Effects of clinical nursing pathway on the surgical site wound infection in patients undergoing knee or hip replacement surgery: A meta‐analysis

Abstract

To explore the effect of clinical nursing pathway on wound infection in patients undergoing knee or hip replacement surgery. Computerised searches of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database, China National Knowledge Infrastructure databases were conducted, from database inception to September 2023, on the randomised controlled trials (RCTs) of application of clinical nursing pathway to patients undergoing knee and hip arthroplasty. Literature was screened and evaluated by two researchers based on inclusion and exclusion criteria, and data were extracted from the final included literature. RevMan 5.4 software was employed for data analysis. Overall, 48 RCTs involving 4139 surgical patients were included, including 2072 and 2067 in the clinical nursing pathway and routine nursing groups, respectively. The results revealed, compared with routine nursing, the use of clinical nursing pathways was effective in reducing the rate of complications (OR = 0.17, 95%CI: 0.14–0.21, p < 0.001) and wound infections (OR = 0.29, 95%CI: 0.16–0.51, p < 0.001), shortens the hospital length of stay (MD = −4.11, 95%CI: −5.40 to −2.83, p < 0.001) and improves wound pain (MD = −1.34, 95%CI: −1.98 to −0.70, p < 0.001); it also improve patient satisfaction (OR = 7.13, 95%CI: 4.69–10.85, p < 0.001). The implementation of clinical nursing pathways in clinical care after knee or hip arthroplasty can effectively reduce the incidence of complications and wound infections, and also improve the wound pain, while also improving treatment satisfaction so that patients can be discharged from the hospital as soon as possible.

1. INTRODUCTION

Osteoarthritis is a degenerative disease of the joints that primarily involves the hip and knee joints. ¹ According to the World Health Organisation, by 2050, bone and joint diseases may cause disability in nearly 25% of the world's population. ² Degenerative osteoarthritis can be diagnosed by physical examination in nearly 80% of elderly patients aged 60 and above, and 20% of these patients are already suffering from disability. ² Total hip arthroplasty and total knee arthroplasty are effective treatments for end‐stage hip and knee diseases, respectively, and the replacement surgeries can effectively relieve pain, improve joint function, and enhance patients' quality of life. ³ Arthroplasty is an implantable surgery, which causes greater trauma and requires patients to lie down for a long period of time after the surgery, therefore, it is easy to induce a variety of undesirable complications, and high‐quality nursing services can reduce the incidence of complications and promote the recovery of patients. ⁴ If these situations occurring in the perioperative period are not effectively improved and solved, they will inevitably affect the smooth progress of surgery and the postoperative recovery of patients.

With the continuous development of modern medical models, the establishment of standardised, scientific, coherent and continuous quality nursing service is the inevitable trend of nursing development. As a new nursing model, clinical nursing pathway can clarify the strictness and accuracy of nursing work, reduce the blindness and arbitrariness in nursing work, improve the quality of nursing care, and standardise the role of medical behaviour. Clinical nursing pathway refers to the nursing mode of patients during hospitalisation, which is a schedule planner made for patients with the horizontal axis of time and the vertical axis of nursing means such as admission guidance, assessment and diagnosis, examination and medication, treatment and nursing care, dietary guidance and health education. ⁵ In recent years, there have been more and more studies on the application of clinical nursing pathway in the perioperative period of knee and hip arthroplasty, but there is a lack of relevant comprehensive evidence to support it. We therefore conducted this study to investigate the effect of clinical nursing pathway applied to knee or hip arthroplasty patients on their postoperative wound infection, pain and complications via meta‐analysis, so as to provide an effective evidence‐based basis for clinical work.

2. MATERIALS AND METHODS

2.1. Literature search

Computerised searches of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database, China National Knowledge Infrastructure databases were conducted, from database inception to September 2023, on the randomised controlled trials (RCTs) of application of clinical nursing pathway to patients undergoing knee and hip arthroplasty. The following keywords were used for the search: clinical nursing pathway, joint replacement. A combination of subject terms and free words was used for the search.

2.2. Inclusion and exclusion criteria

Inclusion criteria: (1) participants: patients undergoing knee and hip arthroplasty; (2) intervention: patients in the experimental group received clinical nursing pathways, and patients in the control group received routine care; (3) study design: RCTs; (4) outcomes: complications, wound infections, satisfaction, hospital length of stay, wound pain score (evaluated by visual analogue scale). Exclusion criteria: (1) literature of non‐RCTs; (2) studies for which the full text was not available; (3) conferences, abstracts, reviews, animal experiments, or repetitively published studies.

2.3. Data extraction and quality assessment

Literature was screened by two researchers independently according to the inclusion and exclusion criteria, and any disagreements were discussed and resolved with a third researcher. Extracted information included: first author, year of publication, sample size, age and sex. RCTs were assessed for quality using the Cochrane Risk of Bias Assessment Tool version 6.0, including randomisation methods, blinding, allocation concealment, data completeness, publication bias and other biases.

2.4. Statistical analyses

RevMan 5.4 software was employed for data analysis. Dichotomous variables were expressed as odds ratio (OR) and its 95% confidence interval (CI), and continuous variables were expressed as mean difference (MD) and its 95%CI. The I ² and χ ² tests were applied to determine whether there was heterogeneity; if I ² > 50% and p < 0.1, it indicated significant heterogeneity, and a random‐effects model was applied; otherwise, a fixed‐effects model was applied. The robustness of the results was assessed by sensitivity analysis. Potential publication bias was assessed by drawing funnel plots.

3. RESULTS

3.1. Study characteristics

The literature screening process is shown in Figure 1. By searching relevant databases, a total of 431 relevant literatures were obtained, which were imported into Endnote X9, a literature management system, for duplicate screening, and 259 duplicate literatures were removed; secondly, by checking the titles and abstracts of the literatures, 106 literatures that were not relevant to the study were removed; and finally, by reading the full text of the literature, 48 RCTs were finally included. ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ The basic characteristics of the included literature are shown in Table 1, with a total of 4139 patients, including 2072 and 2067 in the clinical nursing pathway and routine nursing groups, respectively. The quality assessment of the included literature is shown in Figure 2.

FIGURE 1.

Literature screening flowchart.

TABLE 1.

Baseline characters of included studies.

Author	Year	No. of patients		Age (years)		Sex (male/female)
		Experimental group	Control group	Experimental group	Control group	Experimental group	Control group
Chen(a)	2021	39	39	56.7 ± 5.9	55.4 ± 6.1	22/17	20/19
Chen(b)	2020	40	40	46.45 ± 7.19	44.21 ± 7.60	23/19	22/20
Chen(c)	2019	69	68	72.19 ± 7.08	72.31 ± 6.17	31/38	29/39
Cheng	2019	40	40	68.78 ± 5.73	67.94 ± 5.34	27/13	25/15
Dang	2015	50	50	54.50 ± 6.27		48/62
Deng(a)	2018	45	45	63.18 ± 3.67	64.02 ± 3.29	23/22	24/21
Deng(b)	2018	40	40	65.59 ± 10.16	65.68 ± 10.21	20/20	22/18
Gan	2016	34	34	52.3 ± 2.6	51.6 ± 3.4	22/12	19/15
Gao	2019	45	45	54.11 ± 2.15	54.24 ± 2.02	27/18	28/17
Guo(a)	2020	30	30	60.12 (49–68)		38/22
Guo(b)	2022	40	40	50.59 ± 5.17	50.43 ± 5.06	24/16	23/17
Hou	2019	44	44	64.71 ± 4.32	64.77 ± 4.38	17/27	20/24
Huang	2017	34	34	74.58 ± 1.62	74.64 ± 1.53	19/15	18/16
Jin	2021	35	35	55.85 ± 1.38	55.99 ± 1.42	28/7	29/6
Li	2009	40	40	63 (46–80)		22/58
Liu(a)	2022	50	50	60–75		25/25	26/24
Liu(b)	2017	41	40	61.7 ± 5.5	61.2 ± 5.2	26/15	26/14
Liu(c)	2016	50	50	71.9 ± 5.8	70.7 ± 5.4	23/27	21/29
Ma(a)	2016	53	53	61.82 ± 8.74	61.45 ± 10.72	28/25	27/26
Ma(b)	2014	45	45	73.5 (61–93)		48/42
Ma(c)	2014	37	37	68.24 + 8.63		46/28
Pan	2019	8	8	73.1 ± 1.3	73.2 ± 1.2	4/4	5/3
Song(a)	2017	48	47	65.1 ± 4.3	65.5 ± 4.0	23/25	20/27
Song(b)	2017	30	30	65.86 ± 3.22		35/25
Sun(a)	2019	30	30	74.1 ± 2.3	73.3 ± 2.6	9/21	11/19
Sun(b)	2011	48	48	70.0 ± 2.6		46/50
Tang	2018	20	20	67.5 ± 5.3	68.9 ± 5.8	12/8	11/9
Wang(a)	2017	42	40	73.2 ± 7.1	77.5 ± 7.2	28/14	25/15
Wang(b)	2022	45	45	68.6	67.8	14/31	18/27
Wang(c)	2016	34	34	64.8	66.5	21/13	24/10
Wu(a)	2019	32	32	77.2 ± 3.4	76.1 ± 3.5	17/15	16/16
Wu(b)	2019	43	43	71.52 ± 6.41	71.67 ± 6.54	24/19	26/17
Xiao	2016	45	45	71.7 ± 5.5	70.9 ± 5.7	23/22	24/21
Xu	2020	48	48	70.50 ± 23.33	71.00 ± 24.01	26/22	28/20
Yang	2017	40	40	54.32 ± 4.35	55.12 ± 4.51	18/22	19/21
Yin(a)	2022	42	42	70.74 ± 8.74	69.84 ± 9.21	17/25	16/26
Yin(b)	2020	55	55	58.2 ± 4.91	59.8 ± 5.24	27/28	29/26
Yi	2017	123	123	35–88		40/206
Yu	2022	40	40	68.95 ± 1.61	69.45 ± 1.58	25/15	23/17
Yuan	2022	50	50	59.35 ± 8.42	58.23 ± 8.31	20/30	22/28
Zhang(a)	2020	51	51	64.71 ± 6.21	63.12 ± 4.69	24/27	23/28
Zhang(b)	2018	44	44	72.15 ± 3.24	71.83 ± 3.16	23/21	24/20
Zhang(c)	2017	36	36	69.45 ± 3.26	69.37 ± 3.18	20/16	19/17
Zheng(a)	2017	40	40	55.2 ± 10.3	56.4 ± 10.1	18/22	20/20
Zheng(b)	2017	50	50	76.3 (62–87)		Not reported
Zhong	2020	40	40	66.88 ± 5.62	65.53 ± 5.44	26/14	25/15
Zhu	2023	42	42	71.23 ± 9.56	71.74 ± 9.23	25/17	24/18
Zhuang	2015	45	45	77.8 ± 7.3		29/61

FIGURE 2.

The risk of bias graph of the included studies.

3.2. Complications

Complications were reported in all RCTs. There were 2072 cases in the clinical nursing pathway group, of which 131 patients had complications, for a complication rate of 6.32%, and 2067 cases in the routine care group, of which 556 patients had complications, for a complication rate of 26.89%. No significant heterogeneity was found (p = 1.00, I ² = 0%), and a fixed‐effects model was applied. In terms of postoperative complications, the clinical nursing pathway group had a significantly lower incidence than the routine care group (OR = 0.17, 95%CI: 0.14–0.21, p < 0.001; Figure 3).

FIGURE 3.

The forest plots of complications.

3.3. Wound infections

Seventeen RCTs reported wound infections. There were 732 cases in the clinical nursing pathway group, of which 13 patients developed wound infections, an incidence of 1.78%, and 731 cases in the routine care group, of which 49 patients developed wound infections, an incidence of 6.71%. No significant heterogeneity was found (p = 1.00, I ² = 0%), and a fixed‐effects model was applied. In terms of wound infection, the clinical nursing pathway group had a significantly lower incidence than the routine care group (OR = 0.29, 95%CI: 0.16–0.51, p < 0.001; Figure 4).

FIGURE 4.

The forest plots of wound infections.

3.4. Hospital length of stay

Twenty‐three RCTs reported the hospital length of stay. About 1022 in the clinical nursing pathway group and 1019 in the routine care group. Significant heterogeneity was found (p = 1.00, I ² = 0%), and a random‐effects model was applied. In terms of the hospital length of stay, the clinical nursing pathway group was significantly shorter than the routine care group (MD = −4.11, 95%CI: −5.40 to −2.83, p < 0.001; Figure 5).

FIGURE 5.

The forest plots of hospital length of stay.

3.5. Satisfaction rate

Sixteen RCTs reported patient satisfaction. There were 701 cases in the clinical nursing pathway group, of which 674 patients were satisfied, with a satisfaction rate of 96.15%, and 701 cases in the routine care group, of which 538 patients were satisfied, with a satisfaction rate of 76.75%. No significant heterogeneity was found (p = 1.00, I ² = 0%), and a fixed‐effects model was applied. In terms of satisfaction rate, the clinical care pathway group was significantly more satisfied than the routine care group (OR = 7.13, 95%CI: 4.69–10.85, p < 0.001; Figure 6).

FIGURE 6.

The forest plots of satisfaction rate.

3.6. Wound pain scores

Six RCTs reported wound pain scores. About 319 in the clinical nursing pathway group and 319 in the routine care group. Significant heterogeneity was found (p < 0.001, I ² = 97%), and a random‐effects model was applied. In terms of wound pain scores, the clinical nursing pathway group was significantly lower than the routine care group (MD = −1.34, 95%CI: −1.98 to −0.70, p < 0.001; Figure 7).

FIGURE 7.

The forest plots of wound pain scores.

3.7. Sensitivity analyses and publication bias

Sensitivity by excluding single studies on a case‐by‐case basis showed that this study was stable and the conclusions were reliable. The funnel plot shows that the position of points in the graph is basically symmetrical, as shown in Figure 8.

FIGURE 8.

Funnel plots. (A) complications. (B) wound infections. (C) hospital length of stay. (D) satisfaction rate.

4. DISCUSSION

Artificial arthroplasty is a common surgical procedure to replace a diseased or injured joint with an artificial prosthesis to achieve the goal of improving joint stability and restoring normal joint function, but the procedure carries a high risk of postoperative complications. ⁵⁴ Intraoperative bleeding is high, often needs to input allogeneic blood, the blood donor's blood cells other than red blood cells are different from the patient's blood, which may produce transfusion reaction, the patient's white blood cell level is reduced, immunity is low, bacterial invasion is prone to wound infection, and the risk of infection around the prosthesis is also significantly higher in the postoperative period, which is very likely to cause loosening of the prosthesis to fall off. ⁵⁵ Therefore, how to reduce the incidence of patient complications, shorten hospitalisation time and reduce hospitalisation costs is an important part of clinical nursing. Clinical nursing pathway is to formulate the nursing process according to the law of occurrence and development of the disease, and to carry out nursing interventions in strict accordance with the nursing pathway, so as to make the nursing more standardised. In the process of formulating clinical nursing pathways, the requirements of evidence‐based medicine are followed, and under the guidance of evidence‐based medicine, diseases are managed in a standardised way, thus regulating the role of medical behaviour, reducing variation, lowering costs and improving the quality of care. ⁵⁶ , ⁵⁷

Our results show that applying clinical nursing pathways to patients who have undergone knee or hip arthroplasty can effectively reduce the incidence of postoperative complications and wound infections, which is consistent with the results of the study by Chen et al., ⁷ which indicates the clinical nursing pathway emphasises practice, and whoever carries out nursing care strictly follows the pathway table, which reduces the arbitrariness of different caregivers in nursing care, and enables healthcare workers to deal with the situation of patients' postoperative wounds that have been exposed for a long period of time in a timely manner, and therefore reduces the risk of postoperative complications and wound infections in the patients. At the same time, the implementation of the clinical nursing pathway can effectively reduce the length of hospitalisation and improve wound pain, which is consistent with the findings of Guo et al., ¹⁵ which suggests that the dietary habits and postoperative recovery details set out in the clinical care pathway can be effectively implemented for patients under the supervision of healthcare professionals, so that patients can receive timely nutritional supplementation after surgery, and patients can recover more quickly. Finally, the implementation of clinical nursing pathway can improve patients' satisfaction with nursing services, which is consistent with the results of Gan, ¹³ which indicating that the clinical nursing pathway can meet the treatment and service needs of patients in a more considerate and subtle way, so that patients can have a better treatment experience.

There are some limitations should be addressed: (1) the sample sizes of the included studies were all small, resulting in a lack of sufficient clinical data for this study; (2) as all the literature included in this study was in Chinese, there was publication bias, which needs to be confirmed by more literature; and (3) the methods of implementing clinical nursing pathways in the included studies were not completely uniform, which may have an impact on the outcome indicators.

5. CONCLUSION

In summary, the implementation of clinical nursing pathways in clinical care after knee or hip arthroplasty can effectively reduce the incidence of complications and wound infections, and also improve the wound pain, while also improving treatment satisfaction so that patients can recover faster and be discharged from the hospital at an early date.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Huang Z, Li Y, Peng J, et al. Effects of clinical nursing pathway on the surgical site wound infection in patients undergoing knee or hip replacement surgery: A meta‐analysis. Int Wound J. 2024;21(3):e14657. doi: 10.1111/iwj.14657

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.