Table 1.
Redesign of the total joint replacement episode.
| Task force constituents: orthopaedic surgery, anesthesiology, case management, rehabilitation services, home care companies, hospital administration, nursing leaders (orthopaedic unit, preoperative, operating room, and postoperative), and hospital quality and data personnel |
|---|
| Preoperative |
| Creation of a Patient Selection Tool: recognize and control known modifiable risk factors, that is, cigarette smoking, chronic narcotic use, morbid obesity, poorly controlled diabetes |
| Patient Medical Optimization: literature-guided three-tiered system (red-yellow-green) using systems-based classification, attempt to move patients to green across all categories; exercise caution when yellow (attempts made to modify, taken on case-by-case basis); red is a hard stop (do not proceed with surgery) |
| Use of Risk Assessment and Prediction Tool (RAPT) for predicting postacute placement: score >9, plan for home discharge; score 6-9, invest preop resources to optimize possibility of home discharge; score <6, plan for postacute care facility |
| Physical Optimization (“prehabilitation” for deconditioning) |
| Chlorhexidine (skin) and Mupirocin (nasal) decolonization |
| Narcotic Protocol, stratified by patient narcotic exposure (narcotic naive, standard, or chronic narcotic user) |
| Engagement of patients by Case Management before admission |
| Documentation of a firm postacute plan before admission (home is default) |
| High-Risk Anesthesia Pathwaya: patients with 2 or more poorly controlled cardiopulmonary disease conditions referred to preoperative “high-risk” clinic to discuss risk and optimization with a high-risk anesthesia provider |
| Joint Replacement Education Programa |
| Acute Care |
| Acute Care pathway changed from 4 days to 2 days |
| Physical therapy started on the day of surgery and twice daily until discharge |
| Use of a physical therapy gym on the orthopaedic unit |
| Preoperative disposition plan is not changed without consulting surgeon |
| Predominant use of regional-only anesthesia (spinal anesthesia with preop regional block, ± home catheter when indicated) |
| Multimodal pain management: acetaminophen, celecoxib, tramadol ± neuromodulating agent |
| No routine Foley catheter use |
| Simplified wound dressings and no routine dressing changes |
| Case management engagement within 12 hours of surgery |
| Discharge teaching by nursing starting on postoperative day 1 |
| Uniform messaging across all services for safe, early home discharge |
| Postacute Care |
| Improved patient engagement and tracking by orthopaedic team via a telephone |
| Preferred Skilled Nursing Facilities and Home care companies with regular communication |
| 7 days per week access to Orthopaedic After Hours Clinic instead of emergency room |
| Nurse navigatora |
| Patient engagement and tracking electronic platforma |
a
This component of the redesign was not active during the study period.