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Enhanced Management of Orthopaedic Surgery Program

Project Added:
9 October 2015
Last updated:
24 October 2015

Enhanced Management of Orthopaedic Surgery Program

Summary

Coffs Harbour Health Campus (CHHC) implemented an Enhanced Management of Orthopaedic Surgery (EMOS) program that involved pre-operative planning, intra-operative optimisation, post-operative strategies and post-discharge follow-up. 

Aim

To improve patient outcomes following elective knee and hip replacement surgery at CHHC.

Benefits

  • Reduces length of stay.
  • Improves efficiencies in peri-operative services due to appropriate allocation of surgical categories.
  • Reduces day of surgery cancellations due to pre-existing medical conditions.
  • Improves timeliness of surgery cancellations where required.
  • Reduces adverse events post-surgery.
  • Achieves cost savings for surgeries not performed on patients, where it is no longer clinically required.
  • Provides an opportunity for patients to be active participants in their own healthcare journey, to improve patient outcomes and experience.
  • Standardises patient pathways to ensure patients receive the same care.
  • Improves collaboration between patient and multidisciplinary teams.

Project status

Dates

Start: November 2013.

Status

Sustained - The project has been implemented, is sustained in standard business.

Background

Quantitative analysis confirmed that surgical ward activity at CHHC was increasing in the years prior to the development of this program. The high volume of patients admitted to surgical wards for total hip and total knee arthroplasty contributed to this increase.

Enhanced recovery models of care for elective surgery have shown to improve patient outcomes both nationally and internationally. CHHC has implemented enhanced recovery models for colorectal surgery in the past, with success. It was anticipated that the same patient outcomes could be achieved with elective orthopaedic surgery, which may improve National Emergency Access Target (NEAT) and National Elective Surgery Target (NEST) performance.

The EMOS project was an enhanced recovery pathway that comprised the following strategies.

Implementation 

Pre-operative planning and optimisation

  • Pre-operative referrals to multidisciplinary teams.
  • Identification and coordination of comorbidity management, through referrals to specialists and general practitioners.
  • Development of a pre-habilitation program.
  • Management of pre-operative anaemia.

Intra-operative optimisation

  • Pre-operative strategies to minimise surgical stress, including pre-medication, high protein carbohydrate drinks, spinal anaesthesia and tranexamic acid.

Post-operative strategies

  • Local wound infiltration for surgical pain management.
  • Early mobilisation within seven hours.
  • Active patient participation in rehabilitation.

Post-discharge and transfer of care follow-up

  • All patients were phoned 48 hours post-discharge to confirm that they understood post-discharge instructions, appointment follow-up and who to contact if they have concerns.

The partnership between the patient and the multidisciplinary teams was formalised through a patient contract, to ensure all partners were clear on their roles and expectations throughout the episode of care, from the decision to have surgery to post-surgery discharge.

Partnership

  • Centre for Healthcare Redesign

Results

  • 125 patients received unilateral joint replacement surgery, three patients received revision joint replacement and two patients received bilateral joint replacement.
  • Length of stay was reduced by 19%.
  • Time to first mobilisation was improved by 40%.
  • Presentations to the emergency department related to surgery were reduced by 40%.
  • There was a 75% reduction in blood transfusions.
  • The rate of transfers to rehabilitation and/or outlying hospitals for rehabilitation was reduced by 60%.
  • The number of patients who had surgery deferred at pre-admission clinic was reduced by 45%.
  • 14 patients who required urgent surgery had their operation brought forward, 15 patients deferred and 17 patients cancelled their surgery.
  • Estimated cost savings for not proceeding with unilateral joint replacement surgery is approximately $17,800.
  • A physiotherapist is now responsible for the coordination of the program, including:
    • engaging patients
    • coordinating cases
    • achieving goals
    • monitoring patient outcomes
    • educating healthcare workers responsible for providing care within the EMOS program
    • reviewing the program’s supporting tools such as patient contracts, clinical pathways and comorbidity management plans.
  • The EMOS program and tools can be replicated in other health services and settings. Future plans for the program include:
    • a patient education DVD
    • implementation of EMOS in hospitals within the clinical network
    • standardised guidelines for all joint replacement surgery, such as post-operative pain management wound infiltration to support early mobilisation.

Graph of results described above

Lessons learnt

  • Implementation teams can be useful, with champions from each discipline driving implementation within that department (i.e. orthopaedic surgeon, anaesthetist, nursing, allied health). 
  • Clinical staff value executive staff visibility during the implementation phase.
  • It’s important to identify which departments are involved and find sponsors who influence these departments. Mapping key roles can also be an effective process.
  • If implementing early mobilisation, ensure it is part of routine care from the beginning of the project.

Further reading 

  • Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery. Acta Orthopaedica 2008; 79: 168-173.
  • Husted H, Troelsen A, Otte K et al. Fast-track surgery for bilateral total knee replacement. The Journal of Bone and Joint Surgery 2011; 93B: 351-356.
  • Husted H, Holm G. Fast track in total hip and knee arthroplasty – experience from Hvidovre University Hospital Denmark. Injury: International Journal of the Care of the Injured 2006; 37S: S31-S35.
  • Kimmel L, Oldmeadow L, Sage C et al. A designated three day elective orthopaedic surgery unit: First year’s results for hip and knee replacement patients. International Journal of Orthopaedic and Trauma Nursing 2011; 15: 29-34. 
  • McDonald D, Siegmeth R, Deakin A et al. An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom – follow up at one year. The Knee 2012; 19: 525-529.
  • Pilot P, Bogie R, Draijer W. Experience in the first four years of Rapid Recovery; is it safe? Injury: International Journal of the Care of the Injured 2006; 37S: S37-S40.
  • Schneider M, Kawahara I, Ballantyne G et al. Predictive factors influencing fast track rehabilitation following primary total hip and knee arthroplasty. Archives of Orthopaedic and Trauma Surgery 2009; 129: 1585-1591.
  • Wainwright T, Middleton R. An Orthopaedic Enhanced Recovery Pathway.  Current Anaesthesia & Critical Care 2010; 21: 114-120.
  • White J, Houghton-Clemmey R, Marval P. Enhanced Recovery After Surgery (ERAS): an orthopaedic perspective. The Journal of Perioperative Practice 2013; 23: 228-232.

Acknowledgements

  • Beverly Morris – University of California, San Diego Medical Centre.
  • Danella Hackett – Fairfield Hospital.
  • Lara Kimmel – Senior Physiotherapist, The Alfred Hospital.
  • Lesley Thomas – Orthopaedic Nurse Practitioner, The Queen Elizabeth Hospital.
  • Luke Foley – Osteoarthritis Chronic Care Program Coordinator, Port Macquarie Base Hospital.
  • Robyn Speering – Musculoskeletal Manager, Agency for Clinical Innovation.

Contact

Andrew Wong
Physiotherapist
Coffs Harbour Health Campus
Mid North Coast Local Health District
Phone: 02 6656 5277
Andrew.Wong@ncahs.health.nsw.gov.au

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