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Up and at ‘em

Bathurst Base Hospital
Project Added:
24 September 2013
Last updated:
17 October 2014

Up and at ‘em

A trial of early mobilisation in elective orthopaedics in the rural context

By Andrew Muldoon and Catherine Poschich, Western NSW Local Health District

Abstract

2011 heralded a significant shift in the Model of Care for Bathurst Health Service (BHS) Orthopaedic services.  Increasing demands for service, increased waitlist times and inconsistent models of anaesthetic and post-operative service delivery models of care resulted in increased length of stay (LOS) and secondary sequelae of increased pressure area numbers, rehabilitation bed use and inconsistent post-operative analgesic regimes that limited functionality.

With the introduction of activity based funding, a new multi-disciplinary model of care was developed between the Surgical Ward staff and core members of the Allied Health team.  A single blinded randomised control trial was conducted assessing the efficacy of early mobilisation on LOS and secondary sequelae development. 

Results showed a downward trend in average length of stay (ALOS) and pressure ulcer incidence, as well as increased quality of life compared to the current standardised pathways.

Aims

  • Primary: Decrease LOS for joint replacement patients by 20%.
  • Secondary: Increase quality of life outcomes, decrease incidence of pressure areas, consistency in anaesthetic/post-operative analgesia; decrease admissions to Rehabilitation Unit.

Background

2011 strategic planning by the Surgical Ward and Physiotherapy Department in conjunction with hospital Quality and Safety Reviews recognised a need to change the management within existing cultural and clinical ideologies for patients undergoing total hip and knee arthroplasties.

The recruitment of an additional Orthopaedic surgeon further compounded these issues as a direct result of increased demand and surgical numbers.  A systemic needs analysis of waitlist and inpatient data, IIMS reports, clinical and literature reviews of best practice models of care and patient journeys and quality of life reviews showed:

  • Waiting list times and ALOS were increasing with concomitant flow on effects on the patient journey

    Total Days Wait Lower Limb Arthroplasty 2008-2011. Graph shows BHS consistenly higher than national average
    Total Days Wait – Lower Limb Arthroplasty 2008 - 2011

    ALOS - Lower Limb Arthroplasty 2008 - 2011. Graph shows steady increase from just over 5 days to almost 7 days
    ALOS - Lower Limb Arthroplasty 2008 - 2011

  • Increased incidence of pressure ulcers due to increased surgical throughput; type of anaesthetic/post-operative analgesia
    Pressure Ulcer Incidence - Lower Limb Arthroplasty 2009-2011. Graph shows increase from 1 in 2009 to 11 in 2011
    Pressure Ulcer Incidence - Lower Limb Arthroplasty 2009 - 2011

Planning and implementing solutions

A needs analysis and systematic review of current best practice multi-disciplinary models of care was undertaken, which highlighted deficiencies in current practice models of anaesthesia and analgesia.  Group planning sessions and team meetings with key stakeholders of the Anaesthetic Department resulted in modification to ensure consistent anaesthesia and analgesia modalities. 

A Physiotherapy review of current practices at BHS showed current practice met all evidenced standards. However, early mobilisation was recognised as a solution for practice improvement and enhanced patient outcomes.  Limited scientific research surrounds this in elective lower limb arthroplasty patients, despite increasing evidence in other specialities.  The recently released Agency for Clinical Innovation Evidence Review of Primary Total Hip and Knee Replacements showed only two research articles that reviewed early mobilisation (n=261) (Agency for Clinical Innovation, 2012).

An ethically approved (HREC/12/GWHAS/66) randomised single blinded control trial was conducted to analyse the effect of early mobilisation on LOS and quality of life outcomes within a projected cost framework ($600).

Core implementation steps included:

  • Ethical processes were maintained (consent, privacy)
  • Consecutive recruitment and random number allocation to control and intervention
  • Pre and post-operative quality of life (6 weeks post discharge) were assessed using the validated Short Form – 36 (SF-36)
  • LOS was calculated using the i-soft Patient Manager (iPM) system
  • Intervention patients were sat on the side of the bed for a period of five minutes on return to the ward on the day of surgery, while the control received nothing on this day
  • Ongoing Physiotherapy for both groups from day one onwards followed the standard pathway (range of motion and progressive functional mobilisation), with a 'blinded' assessor completing follow-up
  • Discharge occurred when the participant was functionally independent, surgically stable and able to ascend and descend three stairs

Outcomes and evaluation

64 particpants randomised into two groups. Control TKR 15, THR 17. Intervention TKR 23, THR 9. 1 from each group not followed up

Average length of stay

Difference between intervention and control groups:

  • Acute ward 3.45 days (p=0.000) – 42% decrease
  • Rehabilitation Unit 7.06 days (p=0.001) – 58% decrease

Economic per annum benefits/saving equate to:

  • $481,378.50 for acute stay
  • $985,081.80 for Rehabilitation stay
  • Total $1,466,460.30. (1 occupied bed day $2325)

Graph showing reduction in ALOS for intervention group compared to control and previous year
Average length of stay

Quality of life and pressure ulcer incidence

Pressure ulcer development:

  • Control n = 6
  • Intervention group n = 0
    • directly related to consistency in anesthesia/analgesia
    • no epidural patient controlled analgesia (EPCA) or peripheral nerve blocks.

Mean difference in physical outcomes on the SF-36 showed statistically significant increase (p=0.008) in intervention group of 51.8%, compared to 14% increase in control; with no difference in emotional scores (p=0.068). 

Incidentally, the intervention group was independently mobile earlier (2.44 versus 4.75 days) (p=0.002) with minimal Rehabilitation admissions (1/32 versus 13/32) (p=0.002).

2009/10 11 Pressure areas. Intervention: QoL Pre 51, Post 79, Pressure 0. Control Qol Pre 52, Post 59, Pressure 6
Quality of Life and Pressure Ulcer Incidence

Conclusion

This pilot study has provided foundation for the notion of early mobilisation in the elective orthopaedic population.  Results showed a downward trend in ALOS, pressure ulcer incidence and increased quality of life compared to the current standardised pathways.

The early mobilisation project undertaken has now become embedded in the ethos of nursing, allied health and surgeons alike.  A new standard of practice, development of local key performance indicators (reduction in pressure areas, decreased LOS, improved quality of life ) and desire to improve patient care and outcomes, combined with significant cost savings, has ensured top down support for sustainability. 

This process is easily adaptable, safe and cost effective equating to transferability between sites within or external to the Local Health District.  

References

  • Agency for Clinical Innovation, (2012) Musculoskeletal Network NSW Evidence Review Preoperative, Perioperative and Postoperative Care of Elective Primary Total Hip and Knee Replacement Agency for Clinical Innovation, Sydney
  • Burns AWR, Bourne RB, Chesworth BM, MacDonald SJ, Rorabeck CH (2006) ‘Cost effectiveness of revision total knee arthroplasty’ Clinical Orthopaedics and Related Research 29-33
  • Cushnaghan J, Bennett J, Reading I, et al (2009) ‘Long-term outcome following total knee arthroplasty: a controlled longitudinal study’ Annals of the Rheumatic Diseases Vol 68:642-7
  • Khan, F., Ng, L., Gonzalez, S., Hale, T. and Turner-Stokes, L. (2008), ‘Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthroplasty’ Cochrane Database of Systematic Reviews Issue 2 (Art. No.: CD004957. DOI: 10.1002/14651858.CD004957.pub3).
  • Liang, M.H., Cullen, K.E., Larson, M.G. et al (1986) ‘Cost effectiveness of total joint arthroplasty in osteoarthritis’ Arthritis and Rheumatology Vol:29:937-943
  • Naylor JM, Harmer AR, Heard RC, Harris IA (2009) ‘Patterns of recovery following knee and hip replacement in an Australian cohort’ Australian Health Review Vol 33:124-35
  • NSW Government, (nd) NSW 2021. A plan to make NSW Number One NSW Government, Sydney
  • Muldoon, A., (2013) Thesis study for post graduate Masters in Clinical Leadership and Clinical Supervision University of Tasmania Bathurst  

Contacts 


Senior Cardiopulmonary Physiotherapist
Bathurst Health Service
Western NSW Local Health District
Phone: 02 6330 5100


Nurse Unit Manager, Surgical Ward
Bathurst Health Service
Western NSW Local Health District
Phone: 02 6330 5282

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