Three Best Practices for Knee Replacement (Biloine Young @ OTW)
- Manage patient expectations.
- Multidisciplinary teams for complex patients.
- Dedicated nurses in the OR.
When orthopedic surgical teams from five of the elite healthcare systems of the country shared best practices for knee replacement—and then faced pushback on their recommendations—it made medical news.
Or it should have.
Called the High Value Healthcare Collaborative, the group was composed of orthopedic surgical teams from the Cleveland Clinic, Dartmouth-Hitchcock Medical Center, Denver Health, Intermountain Healthcare, and the Mayo Clinic.
Cheryl Clark, senior editor and California correspondent for HealthLeaders Media Online, reported on the three best practices that emerged from a review of 11,000 knee replacements undertaken at the participating institutions. They learned that following the best practices reduced patient’s length of stays, lowered readmission rates and improved outcomes for the hospitals that followed them.
Ivan Tomerk, M.D., an orthopedic surgeon at Dartmouth-Hitchcock who participated in the study, noted that there were significant variations among the five different organizations “even though we were all doing the same knee operation.” Tomek and his colleagues published their findings in the May issue of Health Affairs Journal.
Number One – Managing patient expectations.
The first best orthopedic practice was informing patients how long they would be in the hospital, what to expect the day of surgery, and what to expect afterwards until a relative picked them up to take them home.
“We all think we do this,” Tomerk said, “but as it turned out, one organization spends more time with a multidisciplinary team of nursing staff, physical therapists, and physicians letting their patients know exactly what to expect, and that when they go home, things aren’t going to be perfect”. Following this practice limits the typical length of stay, he says, “Because patients aren’t surprised on day two, for example, that it still hurts them to get out of bed and go to the bathroom.” The practice reduces patients’ anxiety, which improves outcomes.
Tomerk noted that while his own institution, Dartmouth-Hitchcock, offered pre-surgery classes for its knee replacement patients, “they don’t stress a timeline as much as they should.” He believes hospital staff needs to set clear expectations for patients, telling them what points they need to hit before they can go home. Once they understand them, Tomerk said “70% of people hit those by day two.”
Number Two – Multidisciplinary teams for complex patients.
When researchers studied the data they found that 85 – 90% of the knee replacement candidates at the five institutions were either obese or morbidly obese. Many had diabetes, precarious kidney functions or peripheral vascular disease. The one healthcare system that did well with these patients used a multidisciplinary team—that included not just orthopedists but anesthesiologists and internists—who triaged patients preoperatively to identify the ones that could run into trouble. These patients were then singled out for special scrutiny.
“It may turn out that patients would really be better off having surgery three months from now, once they get their blood sugars under control. And if so, doctors would cancel the surgery until that time,” Tomek said. “It was a valuable lesson that if you take the time at the front end, involving internists and affiliated medical staff to enter the discussion about whether the surgery is safe to do, it pays dividends.”
Number Three – Dedicated nurses in the OR.
Everyone understands that it is important for surgeons to be efficient with their time in the operating room, and the study found that experienced surgeons were. But the organization with the shortest operative times was the only one that had a dedicated team of knee replacement surgery nurses. “At most other hospitals, the nurse is in orthopedics one day, in urology the next, and the next day somewhere else. We have to remember that the Honda mechanic fixes it faster than a mechanic who sees a Honda once a year,” Tomek said.
Pushback
When word about certain system processes that improved care was passed around to other participating hospitals, Tomek told Clark, “There was a lot of pushback from surgeons. We’re trying to leverage these results to influence change. It’s an uphill push because in some cases, having a dedicated team is not aligned with what nursing or anesthesiology might want to do. We’re hoping this paper will be a catalyst to say, “Look, this does make a difference.”
Since the results on knee procedures were circulated, 11 other health systems have adopted the approach. They are Baylor Health Care System, Beaumont Health System, Beth Israel Deaconess Medical Center, North Shore-LIJ Health System, MaineHealth, Providence Health & Services, Scott & White Healthcare, Sutter Health, UCLA Health System, University of Iowa Health Care, and Virginia Mason Medical Center.