Sunday, April 24, 2011

How Long Should You Be Hospitalized After Joint Replacement Surgery: Not too short….not too long…..just right

Once upon a time, there was a little girl named Goldilocks.  She went for a long walk in the forest.  Soon, she came upon a house and knocked on the door.  When no one answered, she entered.

On the table in the kitchen there sat three bowls of porridge.  Goldilocks was hungry so she set about tasting the porridge from the first bowl.

“This porridge is too hot!” she exclaimed.   So, she moved to the second bowl and tasted.  “This porridge is too cold, “she declared.  So, she tasted the last remaining bowl of porridge.  “Ahhh, this porridge is just right, “she happily proclaimed and ate it all up.

When it comes to how long a patient remains hospitalized after total hip or knee replacement surgery, the scenario is not unlike the situation faced by Goldilocks in the forest.  Length of stay, the “official” terminology used to describe the measurement of the duration of a single episode of hospitalization, is the period between the time that a patient is admitted to the hospital, to the time that the patient is discharged.  As joint replacement surgery advances in terms of procedural technique and care provided to patients, the surgical outcomes have also dramatically improved.  As the result of improved patient outcomes, the length of stay (LOS) for patients after joint replacement surgery has been declining as well.

Much attention has been given to the cost of hospitalization and the impact of these escalating costs on the American healthcare system.  As a result, the length of time in the hospital or (LOS) for patients has come under close scrutiny and is often a marker associated with hospital finances.  In terms of joint replacement surgery, LOS has been a focus of our program’s efforts for reasons outside of the financial realm.

Patients who are able to be discharged to their homes with adequate support systems in place, and with home physical therapy and nursing services, have been found to achieve the best outcomes associated with their joint replacement procedures. Reduced level of pain, optimum mobility, prompt return to previous level of functioning and activity (motion and function), and the avoidance of surgical wound infection are all associated with discharge to the home.

For the reasons just cited, we encourage our patients to return to their homes for convalescence whenever that is possible.  Preparation and discharge planning for this goal is initiated prior to admission to the hospital for the surgical procedure.  For those patients where this is not an option, arrangements are made for a temporary stay at a facility providing short term rehabilitative services.  Nearly 70% of our patients are discharged directly to their homes.

When it comes to exactly how long a patient should remain in the hospital after joint replacement surgery, we subscribe to the “Goldilocks” philosophy: 
·         The post surgical hospitalization should not be so short that the patient leaves prior to being able to accomplish critical tasks such as independent ambulation with an assistive device or adequate control of pain. (The porridge is too hot).
·         Nor should the patient remain in the hospital so long that advancement in their recovery is thwarted by the restrictions of a hospital environment, or that they are exposed to the risk of infection for longer than necessary.  (The porridge is too cold).
·         The ideal joint replacement patient is leaving the hospital at a time that has “optimized” what the hospital environment, staff, and services can do for them, and further recovery advancement will occur at home or a short term rehab center.  The hospital time (like the porridge) is “just right”.  For most hip replacement patients this is between three and four days, and for knee replacement patients between two and three days. 

At St. Joseph’s the length of time that patients do remain in the hospital has progressively shortened over time due to the advancements in surgery and postoperative  care protocols.

Ave Hip Replacement LOS
Ave Knee Replacement LOS
3.71 days
2.85 days
3.64 days
2.73 days
3.64 days
2.64 days
 (Year to Date)
3.57 days
2.64 days
**national ave hip replacement LOS = 3.7 days in 2008
**national ave hip replacement LOS = 9.1 days in 1992

We are committed to ensuring that patients receive the appropriate care in the hospital for the necessary period of time, and then to assist them in a seamless transition to their homes or the next location of care.

A recent study published in The Journal of the American Medical Association  in April of this year reported on a longitudinal study that described the clinical characteristics and associated outcomes of patients undergoing total hip arthroplasty between 1991 and 2008.  Their findings support the fact that the length of stay in the hospital declined during this time period.  The study also cautions that although the length of stay has decreased, there has also been an increase in the rates of discharge to short term rehabilitative facilities and in re-admission to the hospital.

It is because of the delicate balance between too short and too long a period of time in the hospital that we subscribe to the philosophy of an optimized individual time and recognize that one size does not fit all patients.  Most likely, you will find your discharge time to be when the “porridge is just right”, and that time is collaboratively determined by both you and your doctor.

Cram, P., Lu, X., Kaboli, P.J., et. al. Clinical Characteristics and Outcomes of Medicare Patients Undergoing Total Hip Arthroplasty, 1991-2008.  Journal of the American Medical Association. 2011; 305 (15): 1560-1567.

Sunday, April 17, 2011

Designing for the Future

Momentum continues to build in orthopedic services at St. Joseph’s Hospital.  We launched our orthopedics master planning process this week.  Challenged by a growing orthopedic service, an existing orthopedic unit in an aging physical plant, and the need to integrate our orthopedic plan with other facets of the overall hospital master facility strategic plan, we enthusiastically gathered to initiate the process that will carry our expanding program into the future.
We asked ourselves many candid questions.  What is the future vision for the care delivery model and physical plant environment for joint replacement and other orthopedic patients?  How do we optimize the areas rendering services to orthopedics patients today and in the near future, while the longer term plan is developed and implemented?  These are tough questions with no easy answers.   We are, however, completely committed to advancing the care in a manner that is most meaningful to our patients--from their perspective.  We intend to create a unique patient and family experience that will result in safe, effective, timely, and efficient health care focused on quality outcomes and a high level of patient satisfaction.
To accomplish this we are assembling a multidisciplinary team of individuals closest to our patient processes—physicians, nurses, physician assistants, physical therapists, transporters, nutritional services staff, housekeepers, volunteers, and even past joint replacement patients themselves. The group and many others will work closely together during the next six months to develop short, mid, and long range plans to accomplish our goals for the physical plant and model of care delivery for our patients.
What will this most likely look like?  Dr. Anthony DiGioia has pioneered a patient and family-centered collaborative orthopedic model of care delivery at the University of Pittsburgh Medical Center.  In his experience, focusing on the patient first results in outcomes that cannot be refuted.  The environment in which his patients and their families receive services is an important contributing factor to achieving these desired outcomes.  Our vision for design of the ideal orthopedic center or institute will focus on elements that will support these concepts. 
The design of our orthopedic units will focus on measures to provide a comfortable and at-home feeling for our patients and their families.  Our vision includes a high complement of private rooms that will have in-room amenities such as Internet access, family chairs that convert to beds for overnight stays, small freezers for ice packs, and ample space for easy navigation with crutches, walkers, and canes.  Satellite gym/fitness centers will be on the unit for ease of access and group therapy activities.  Patients and family members will be able to access cafĂ©-style room service for meals at a time that is convenient for them and consistent with their individualized needs.  A family room complete with kitchen and dining areas will support a sense of community and camaraderie amongst the patients and families navigating the surgical and recovery experience together.  The gathering of these individuals promotes the wellness concept associated with the surgical experience and is intended to be inspirational to the recovery process. 
The project promises to be innovative and exciting.  As it unfolds and develops we will provide periodic updates in this blog.  The best is undoubtedly yet to come for orthopedics at St. Joseph’s!

Sunday, April 10, 2011

Satisfaction With Outcome After Hip and Knee Replacement Surgery: "It's Not the Keds"

Think back to your youth when you dreamed of being the fastest runner, the basketball player who could magically became airborne as if tiny springs propelled him higher into the air, or the quarterback who was so agile that he could zigzag around countless enemy linemen attempting to thwart his journey to the end zone.  If you were like so many of us, you enthusiastically badgered your parents until they succumbed to your request for the canvas-top sneakers known simply as “Keds.”  Your expectation was that these magical sneakers would make your athletic prowess soar to legendary heights and transition you into a star athlete.  Sometimes athletic dreams were achieved, but more often than not sports abilities remained unchanged post Keds acquisition.  The reason for this is quite simple.  One’s athletic talents, abilities and motivations are intrinsic to each individual, and are often completely independent from influences outside of one ’s self, i.e. “the Keds.”  The ability of an athlete to achieve amazing feats is internally driven.  Similarly, patient outcomes and the satisfaction associated with how well a patient does after hip and knee replacement surgery is most closely aligned with his/her personal motivations and goals.

Patient satisfaction with the outcome of a hip or knee replacement is very high, with only a small number of patients relating dissatisfaction with the results after the procedure.  Several studies have explored this topic and the findings are quite interesting.  Of even greater interest is the correlation between postoperative patient satisfaction and surgeon satisfaction with procedure outcomes.

Patients and surgeons most likely evaluate surgical outcomes from different perspectives. From the patient perspective, satisfaction results when there is an improvement in pain, lessened joint stiffness, improved physical function, and most importantly, an ability to return to the desired lifestyle and level of activity.  These are all subjective findings.  From the surgeon’s perspective, satisfaction is measured by more objective outcomes such as the absence of complications, radiographic (x-ray) verification of appropriate prosthesis placement and alignment, and a low revision rate.  Although it is true that patients and surgeons have divergent but overlapping criteria of success after joint replacement, commonality does exist in the most important elements.  Return to a desired level of function, reduced pain, and increased mobility are shared endpoints for both patients and their surgeons.

Patients and surgeons might have differing opinions of success after total joint replacement surgery.  
When measuring the success of hip and knee replacement surgery, it is important to recognize these differences.  In addition, patient satisfaction is also most likely influenced by patient expectations (and fulfillment of those expectations) and demographic characteristics such as age and education, gender, and ethnicity.  The expectation of complete pain relief after surgery, as well as the expectation of a low risk of complications, has been found to be the best predictors of improved functional outcomes and overall satisfaction following joint replacement surgery.

Patient expectations may be the single most predictor of patient satisfaction.  When considering hip or knee replacement surgery, keep in mind that patients and surgeons might not share the same definition of success and satisfaction.  It is essential that you discuss your expectations with your surgeon prior to the procedure so that you can ensure that your goals are realistic and attainable after joint replacement surgery.  Expectations are a key to appreciated success.  

So, remember when considering hip or knee replacement surgery, it’s not the Keds that will determine how well you do, it is you.

Noble, P., Conditt, M., Cook K., & Mathis, K.  The John Insall Award:  Patient Expectations Affect
Satisfaction with Total Knee Arthroplasty.  Clinical Orthopaedics & Related Research 2006; 452:35-43.

Brokelman, R. B., Van Loon, D. J., & Rijnberg, W. J.  Patient versus surgeon satisfaction after
           total hip arthroplasty.  The Journal of Bone and Joint Surgery 2003; 85-B; 495-498.