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Journey to the Finish Line Fast Track Joint Replacements in The QEH
Lesley Thomas
Orthopaedic Nurse Practitioner
Racing to the Challenge
A Celebration of Orthopaedic Nursing
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AT THE STARTERS GATE
BACKGROUND
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BACKGROUND > National Joint Registry predicts 10% annual
growth in demand for hip and knee
Arthroplasty
> By 2016 demand is expected to double and
predicted to occur every decade.
> Finite health budgets and projected demand
increases in all other medical/surgical fields
> Need to work smarter and apply current
world’s best practice.
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CURRENT STATE
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AIM >To develop and implement pathways to discharge home
by Day 4, with Day 5 being acceptable To be the top drawer in the Kitchen
Streamlined!
Not the 3rd drawer down
All over the place!
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OFF AND RACING
How did we do it?
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Using “Lean” thinking to Improve
Care Steps
• Develop a team from across the patient journey
• Map what currently happens
• Staff see big picture & hear each other’s issues
• Eliminate barriers & delays
• Standardise processes
• PDSA
• Monitor performance & feedback to team
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Barriers to Efficient Care
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Action Plan
• Develop ‘Fast-Track’ criteria:
• Education
• Standardization
• Continuity
• Audit and feedback
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KEY CHANGES IMPLEMENTED
Prehabilitation Pre-Admiss Theatre Ward Discharge
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KEY CHANGES IMPLEMENTED
Prehabilitation Pre-Admiss Theatre Ward Discharge
Total Hip Replacement Patient Information Booklet
Please bring this booklet with you when you come for
surgery
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KEY CHANGES IMPLEMENTED
Prehabilitation Pre-Admiss Theatre Ward Discharge
Fast Track Total Knee Replacement Intra- Operative Guidelines
Anaesthesia and The Acute Pain Service
Day of Surgery
Theatre Low dose subarachnoid block (12.5-15mg Bupivacaine)
Intracapsular LA infiltration (Surgeon) prior to prosthesis (300mg Ropivacaine in 150ml Saline with 200microgm Adrenaline)
Parecoxib 40mg (where prescribed following Anaesthetic review)
Paracetamol 1mg Granisetron 1mg
Tranexamic acid 15mg/kg if not contraindicated at prosthesis insertion Call Holding Bay to prep next patient
Please prescribe the following medications on Regular Medication Chart, then
write on APS Chart adjuvants so that they may be appropriately
administered; Celebrex 100mg PO BD x 3 days (where prescribed following
Anaesthetic review) – to commence 24hrs following administration
of Parecoxib in theatre Granisetron 1mg IV BD x 3 doses
Paracetamol 1gm IV/PO QID
Femoral Nerve Catheter Establish block with 20 ml 0.5% PRILOCAINE
Chart Femoral infusion (APS MR35 Prescription form)
0.2% ROPIVICAINE @ 8ml/hr from day of Surgery
0.2% ROPIVICAINE to commence @ 4ml/hr from
0800 on day 2 post-op – please time/date accordingly on
2nd line
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KEY CHANGES IMPLEMENTED
Prehabilitation Pre-Admiss Theatre Ward Discharge
Fast Track Total Hip Replacement Post Operative Guidelines Day 0 Observations
As per observation standards Neurovascular assessment of operated leg – 1/24 for 24 hours Wound assessment (possible drain) as per standard procedure
Hydration & Nutrition
IVT FBC – offer toileting 2/24 due to spinal Diet/fluids as tolerated Check need for a nutritional assessment (see pre-op assessment)
Pain Management
As per APS chart Mobility
Commence hip exercises / dislocation precaution education as per patient booklet.
Sit on edge of bed, stand out of bed, mobilise if able(physio r/v in pm) for both anterior lateral and posterior approach
Other
Anti-coagulants / TEDS as prescribed, if held due to wound ooze consider AV foot pumps. Ensure check pressure points under TED – risk PU.
Commence appropriate aperients Education
Ensure patient knows how to & is performing deep breathing and coughing exercises.
Nurse to review discharge plan with patient &/or family and document.
Patient NOT TO GET UP WITHOUT NURSE/PHYSIO – high falls risk
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KEY CHANGES IMPLEMENTED
Prehabilitation Pre-Admiss Theatre Ward Discharge
Post-Operative Information for Joint Replacement Patients
This information sheet provides answers to frequently asked questions following discharge
from hospital following joint replacement surgery.
Wound closure Most surgeons use a dissolvable suture material which are slowly dissolved and absorbed by the body; they do not need to be removed. You may notice some material exposed at each end of your incision, if this is the case you may just cut them off with scissors. Staples and their removal: If you have metal clips in place, the nurse will provide you with a remover. You need to go to your GP surgery 10 days post op and ask the practice nurse to remove all the metal clips. There is no need to see the GP if you are not having any problems. Caring for Your incision For most people, surgical incisions heal well and require only minimal treatment. To reduce the risk of complications, it is helpful to follow some basic instructions on how to take care of your incision.
THE QUEEN ELIZABETH HOSPITAL
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COMING ROUND THE
BEND
RESULTS
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THR Discharge Outcomes
02468
101214161820
ALOS in - Hip Arthroplasty (DRG IO3)
Av. Length of Stay - All Pts Linear (Av. Length of Stay - All Pts)
Began PDSA Cycles
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TKR Discharge Outcomes
0
2
4
6
8
10
12
ALOS- Knee Arthroplasty DRG IO4 (knee)
Av. Length of Stay - All Pts Linear (Av. Length of Stay - All Pts)
Awaiting new pumps
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FAST TRACK JOINTS ALOS – YEARLY
DATA
2011
2012
2013
TKR 6.99 6.55 5.84
THR 7.80 8.00 6.00
Combined Fast Track Joints 7.40 7.28 5.92
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Patient Satisfaction Survey
n=90
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THE WINNERS CIRCLE
CONCLUSION
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LESSONS LEARNT
> Having an executive champion to
facilitate beauracratic aspects of the
project is essential.
> Need to have a representative from all
major stakeholders on the working party.
• Breaks down the barriers to creating an
integrated pathway.
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Conclusion we can overcome hurdles to make our systems less
complex
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