International Society of Orthopaedic Centres

International Society ofOrthopaedic Centres

Length of Stay Project - HamburgApril 2013

Robert CusackSt Vincent’s & Mater Health, Sydney, Australia

International Society of Orthopaedic Centres Length of Stay Project

Day/Month/Year Footnote to go here Page 2

ARTH. KNEE PROC (INCL ACL)

TKR (PRI.)

THR(PRI.)

HEMIKNEE

REV. TKR

REV.THR

BTKR ARTH. SHOUL & / ORSTAB.

HIPSCOPE

BACK / NECK

SPINAL SURG.

R/O FIX . DEV.

HIP / FEMURPROC.

ANKLEA/DES.

TEN. REPAIR

– KLINIK(GERMANY)

2.2(112)

10.2(1498)

9.5(2043)

N/A 14.6(547)

15.2(963)

N/A 3(120)

N/A 7.7(387)

7.5(325)

6.6(36)

N/A 11(76)

N/A

IRCCS – RIZZOLI(ITALY)

2.9(569)

10.7(596)

9.7(1261)

N/A 11(154)

12(239)

N/A 3.8(874)

N/A N/A 12.8(379)

2.1(1492)

N/A 2.1(590)

0(0)

CAMPBELLCLINIC(USA)

0.16(628)

N/A N/A 5.7(3)

N/A N/A N/A 0.17(505)

0.25(6)

0.30(58)

N/A 0.10(244)

0.15(78)

N/A 0.23(217)

ROYAL . HOSPITAL(UK)

0.4(428)

10.5(484)

10.7(643)

N/A N/A N/A N/A N/A N/A N/A 11.6(704)

1.8(362)

5.9(356)

N/A N/A

IRCCS – GALEAZZI(ITALY)

2.3(1445)

5.2(1216)

5.7(878)

N/A N/A 7.6(178)

4.6(40)

1.3(691)

2(1)

4.5(811)

N/A 1.8(652)

N/A N/A N/A

SKANE .(SWEDEN)

1.3(1735)

4.8(546)

4.8(572)

N/A N/A 9.1(165)

6.1(34)

1.4(898)

N/A 5.8(413)

8.6(281)

3.9(4930

9.6(1207)

4.9(423)

N/A

THE MATER (AUST)

0.4(884)

6.6(714)

6.4(686)

5.7(66)

N/A 9.4(71)

7.5(161)

1.35(274)

0.6(78)

1.4(70)

N/A 0.3(221)

0.5(78)

N/A 1.6(72)

HOSP. FOR . SURG (US)

1.86(1243)

3.87(3235)

3.63(3155)

2.49(505)

N/A 5.0(453)

4.51(423)

2.04(1105)

N/A 2.52(764)

N/A 6.97(546)

-(18)

N/A 2.72(207)

SCHULTHESS KLINIK(SWITZ)

3.4(182)

12.1(522)

9.3(761)

N/A 12.7(96)

11.0(147)

N/A 2.9(1370)

N/A 11.1(641)

N/A 10.2(475)

4.5(124)

2.4(482)

N/A

SINT MAARTENS. (NETHER)

1.0(409)

5.0(577)

5.0(465)

4.0(111)

N/A 10.0(235)

5.0(144)

2.0(180)

1.0(30)

2.0(121)

N/A 1.0(388)

4.0(170)

N/A 2.0(80)

LOS results based upon type of procedure

LOS results based upon type of procedure

Current practices utilised affecting LOS


BEST PRACTICE

Factors affecting Length of Stay

Pre-operative classes:Rehabilitation (type of rehabilitation i.e. inpatient):Day of Surgery Admission DOSA (please specify % of orthopaedic patients):Discharge Planning services:Pre Admission Clinic:

BEST PRACTICE

Factors affecting Length of Stay (continued)

DVT/PE screening Clinical Pathways:Mobilisation: Anaesthetic protocols (general, spinal, regional, sedation etc):Pain management: Education - patient/carer/family (advice of LOS and expected discharge date

FACTORS AFFECTING L.O.S

PRE-ADMISSION:Minimum two weeks before admissionAdvantages: Pre op screening of risk factors and co-morbiditiesAppropriate work up of medications and necessary diagnostic testsAvoid cancellations or adverse events during admissionCommence a pre-hab program including muscle training, strength, enduranceOpportunity for education sessions for patient and carer (option on-line)Discharge plans commenced and discussed with patientAnaesthetist not having to see patient prior to surgery on the day of opDisadvantagesPatients have to attend another dayAnaesthetists having to attend another dayNeed to provide physical space to conduct the assessments


DAY OF SURGERY ADMISSION:Effective use of reminder calls prior to admission assist this processAdvantages: Less time in hospital away from home, family or work for patientsLess chance of hospital acquired infection or other adverse events eg falls Cost savings Higher throughput opportunities from increased bed capacity

DisadvantagesPhysical space requirement to admit patients to DOSA CentrePatient and family expectations/satisfaction may not be as highAnaesthetist has to conduct patient review if there has been no pre admission clinic attendancePre op tests may not have been doneAdditional movement of patient belongings to inpatient room


DISCHARGE PLANNING:

Commence at doctors surgery, re-enforced at PAC and continued throughout hospital stay

Involvement of family in discharge planning including equipment needs and home preparation

Having and all areas working to an agreed hospital wide time of discharge

Discharge gains are more effective if discharge metrics are measured in hours not days

Advantages:

Ensures patient and family are adequately prepared for discharge expectations

More likely to achieve expected discharge date and avoid delays

Assists scheduling and resource utilisation

Improved continuity of care and outcomes for patient

Cost savings

Higher throughput opportunities from increased bed capacity

Disadvantages

Needs significant co-ordination on all related aspects eg ward rounds, diagnostic tests, pharmacy, normalising weekends, transport, rehab etc to ensure optimal discharge timing achieved


Early MOBILISATION:Mobilise day of surgery – this includes sitting on the side of the bed / standing by the bed or walking around the bedCommence with 1 session PT on day of surgery, increasing to 3 sessions PT on subsequent daysAdvantages:Reduced risk of DVT’s and PE’sreduced risk of respiratory and GIT complicationsQuicker recovery by patients and able to progress to a rehab program soonerPotential shorter length of stayCost savings


ANAESTHESIA OPTIONS :Use of spinal anaesthetic with or without regional and / or sedation for total joint replacement rather than general anaestheticUse of brachial plexus blocks for upper limb proceduresAdvantages: Less time under general anaesthesia (risks) minimised effects on heart/lung GIT tract/brain. Less fluid retention likelyMuch earlier mobilisation possible on day of surgeryReduced chance of DVT/PEQuicker recoveryShorter length of stayCost savings as less resources usedHigher throughput opportunities from increased bed capacityBetter pain management post-opDisadvantagesAnaesthetist needs to be comfortable with the approach


CLINICAL PATHWAYS:Advantages: Particularly suited to higher volume proceduresAllows standardisation and resulting efficienciesReduced variationPotential higher patient satisfaction as care team offer consistency of servicePotential shorter length of stayCost savings

DisadvantagesDoctors may not feel it allows individual approach for patient


REHABILITATION:Advantages: Faster attainment of short term functional goals / milestonesAccess to an individualised program Higher mean Functional Independence Measures (FIM) in shorter time periodsShorter LOS in the acute and rehabilitation facilities

Disadvantages:Access to external rehabilitation facilities may be delayed due to bed availabilityMay not be able to be followed by other specialists (ie: cardiologists)


PAIN MANAGEMENT:Advantages: Oral pain relief enables mobilisation without causing drowsiness Able to be specified to individual needs Oral medication is less invasive and makes mobilisation easier (ie: no IV poles

or lines)

Disadvantages: One protocol does not suit all patients Oral medication takes longer to reach “peak” dosage Needs to be monitored and tailored off


EDUCATION:Advantages: Ensures patient and family are adequately prepared for hospitalisation

and discharge expectations More likely to achieve expected post-operative goals and avoid delays Education on return to activities of living following hospital discharge Ensures safety whilst hospitalised and on return home following

discharge (ie: falls prevention)

Disadvantages: Lack of information may increase the LOS due to lack of

preparedness by both patient and family Education time requirements directly impact patient

treatment time – if not done pre-admission Additional cost


PRE OP CLASSES:Advantages: Patient undergoing a Pre-hab program will have improved muscle strengthening and range of motion Functional level post-operatively is greater – early return to activityGeneral cardiovascular condition may be greater

Disadvantages: Cost


DVT/PE SCREENING:Risk Assessment to efficiently target patients most in needUse of mobile dopplers rather than transfer to a lab should be

assessedAdvantages: Need for screening could be reduced through the use of mechanical

compression devices, compression stockings, early mobilisation and anti-coagulant therapy

Allows for diagnosis and treatment

Disadvantages: Shown not to be useful until after Day 3 however many facilities have

discharge early than this Diagnosis may require intervention which potentially may impact LOS Additional costs of screening and transport

Key differences in current operations utilised affecting LOS

Hospital for Special Surgery (USA) offers the most types of rehabilitation - inpatient acute and subacute rehabilitation facilities, intensive rehabilitation and standard home rehabilitation programs, outpatient physical therapy and home with no services needed

Pre-admissions –Most completed over the telephoneThe Mater (Aust) provides 90% face to face

Pain Medication – Most used a mix of oral and IV type medicationHospital for Special Surgery (USA) focuses on medication that provides minimum sedation, minimum weakness


Key differences in current operations utilised affecting LOS (cont.)

Anaesthetic Protocols- Most hospitals responded by stating that this was dependant on the type of surgeryThe Mater (Aust) stated that sedation is rarely usedThe Hospital for Special Surgery (USA) stated that only regional anaesthetic is used as much as possible


General discussion and questions

Documents

International Society of Orthopaedic Centres