Introduction of Clinical Pathways in Orthopedic Surgical Care: The Experience of the Hospital for Special Surgery

Chapter

Abstract

Clinical pathways are structured multidisciplinary care plans which address specific clinical scenarios which help to standardize and coordinate care. Clinical pathways are evidence based incorporating proven best practice but ideally can be adopted to any given hospital environment and culture. Clinical pathways aim to optimize the quality and efficiency of care. These care plans must address pre-hospital preparation, the in-hospital care, and the post-hospital discharge. The patient experience can be optimized leading to improved overall patient satisfaction. The care plan must be focused on the patient experience primarily. Managing patient expectations through pre-hospitalization education and counseling is a key element of success. Adoption of clinical pathways demands physician championship which is best achieved by recording and providing feedback on outcomes following adoption of the new care plans. In high-volume clinical settings adoption of standardized care plans known as clinical pathways can improve patient outcomes and safety and provide for more efficient and satisfying care. The creation of clinical pathways should be based multidisciplinary involving all members of the healthcare team. Each hospital should design clinical pathways based on their unique environment and should be specific to patients undergoing particular medical procedures. Through rigorous planning and following of procedures in clinical pathways, hospitals are able to decrease the incidence of complications and length of stay, improve budget planning, and much more. Following implementation all clinical pathways must be routinely monitored for success and for modification to ensure that best clinical practices are represented and that continuous process improvement is assured.

Keywords

Immobilization Assure Dexamethasone Ondansetron Zofran 

References

  1. 1.
    Pennington JM, Jones DP, McIntyre S. Clinical pathways in total knee arthroplasty: a New Zealand experience. J Orthop Surg (Hong Kong). 2003;11(2):166–73.Google Scholar
  2. 2.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J. 2011;7(1):9–15.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Walter FL, Bass N, Bock G, Markel D. Success of clinical pathways for total joint arthroplasty in a community hospital. Clin Orthop Relat Res. 2007;457:133–7.PubMedGoogle Scholar
  5. 5.
    Husted H, Holm G. Fast track in total hip and knee arthroplasty—experiences from Hvidovre University Hospital, Denmark. Injury. 2006;37S:S31–5.CrossRefGoogle Scholar
  6. 6.
    Healy WL, Iorio R, Ko J, et al. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg. 2002;84:348–53.PubMedGoogle Scholar
  7. 7.
    Pilot P, Bogie R, Draijer WF, Verburg AD, van Os JJ, Kuipers H. Experience in the first four years of rapid recovery; is it safe? Injury. 2006;37S:S37–40.CrossRefGoogle Scholar
  8. 8.
    Pinzur MS, Gurza E, Kristopaitis T, Monson R, Wall MJ, Porter A, Davidson-Bell V, Rapp T. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.PubMedCrossRefGoogle Scholar
  9. 9.
    Larsen K, Hvass KE, Hansen TB, Thomsen PB, Soballe K. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A Before-After Trial of 247 patients with a 3-month Follow-up. BMC Musculoskeletal Disord. 2008;9:59.CrossRefGoogle Scholar
  10. 10.
    Teeny SM, York SC, Benson C, Perdue ST. Does shortened length of hospital stay affect total knee arthroplasty rehabilitation outcomes? J Arthroplast. 2005;20:7.CrossRefGoogle Scholar
  11. 11.
    Peterson MGE, Ciopa-Mosca J, Finerty E, Graziano S, King S, Sculco TP. Effectiveness of best practice implementation in reducing hip arthroplasty length of stay. J Arthroplast. 2008;23:1.CrossRefGoogle Scholar
  12. 12.
    Ganz SB, Wilson Jr PD, Cioppa-Mosca J, Peterson MGE. The day of discharge after total hip arthroplasty and the achievement of rehabilitation functional milestones. J Arthroplasty. 2003;18:4.CrossRefGoogle Scholar
  13. 13.
    Husted H, Holm G. Jacobsen s, predictors of length of stay and patient satisfaction after hip and knee replacement surgery. Acta Orthop. 2008;79:168–73.PubMedCrossRefGoogle Scholar
  14. 14.
    McDonald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev. 2004;1, CD003526.PubMedGoogle Scholar
  15. 15.
    Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W. Patient education before hip or knee arthroplasty lowers length of stay. J Arthroplasty. 2010;25:547–51.PubMedCrossRefGoogle Scholar
  16. 16.
    Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008;33:510–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Choi PT, Bhandari M, Scott J, Doukitis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Sys Rev. 2003;3, CD003071.Google Scholar
  18. 18.
    Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Soballe K. Reduced hospital stay and narcotic consumption and improved mobilization with local and intraarticular infiltration after Hip arthroplasty. Acta Orthop. 2007;78(2):180–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Ekman EF, Koman LA. Acute pain following musculoskeletal injuries and orthopedic surgery: mechanisms and management. Instr Course Lect. 2005;54:21–33.PubMedGoogle Scholar
  20. 20.
    Gómez-Cardero P, Rodríguez-Merchán EC. Postoperative analgesia in TKA: ropivacaine continuous intraarticular infusion. Clin Orthop Relat Res. 2010;468:1242–7.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Larsen K, Hansen TB, Thomsen PB, Christiansen T, Soballe K. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91(4):761–72.PubMedCrossRefGoogle Scholar
  22. 22.
    denHertog A, Gliesche K, Timm J, Muhlbauer B, Zebrowski S. Pathway controlled fast track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating recovery, drug consumption and length of stay. Arch Orthop Trauma Surg. 2012 Aug;132(8):1153-63.
  23. 23.
    Rapheal M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anesth. 2011;58:902–10.CrossRefGoogle Scholar
  24. 24.
    Rotter T, Kinsman L, James E, Machotta A, Goethe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;17(3), CD006632.Google Scholar

Copyright information

© Springer New York 2014

Authors and Affiliations

  • Shivi Duggal
    • 1
  • Susan Flics
    • 2
  • Charles N. Cornell
    • 3
  1. 1.Department of Orthopaedic SurgeryHospital for Special SurgeryNew YorkUSA
  2. 2.Hospital for Special SurgeryNew YorkUSA
  3. 3.Department of Orthopedic SurgeryHospital for Special Surgery, Weill Cornell College of MedicineNew YorkUSA

Personalised recommendations