Objectives:
- Determine length of stay (LoS) for elective Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA), and compare to local hospital LoS key performance indicator (KPI) guidelines.
- Determine what factors cause a “prolonged” LoS (LoS > 4 days as per Tallaght Hospital orthopaedic department guidelines)
Methods:
Twenty seven THA and 19 TKA patients were included in this prospective clinical audit. The audit took place over a 3 month period (March 2017– May 2017). All patients admitted consecutively to a large academic teaching hospital in Dublin over this period were screened for inclusion in this audit. Patients with restricted weight-bearing status and revision arthroplasty surgery were excluded. All patients received routine physiotherapy on the orthopaedic ward throughout their length of stay.
Data was collected by the treating physiotherapists and included; patient demographics, surgery type, weight-bearing status, day 1 post-operative pain using the Numerical Rating Scale (NRS), LoS, reasons for prolonged LoS (> 4 days). An audit assessment form was used to collate the data collected. Data was analysed with Microsoft Excel using descriptive statistics.
Results:
Twenty seven patients received a primary THA and 19 patients received a primary TKA. Average LoS for both THA and TKA patients was 5.9 days, with 55% of THA and 47% of TKA patients having a “prolonged” LoS (>4 days). Length of stay ranged between 2 and 21 days for THA, and 2-13 days for TKA.
The most common reason for “prolonged” LoS for both THA and TKA was delay in transfer to an external rehabilitation or convalescence facility due to lack of bed availability (40% THA, 44% TKA). Other factors prolonging LoS post THA included pain (20%), reduced ROM (20%), reduced power (20%), anxiety (6%) and nausea (6%). Other factors prolonging LoS post TKA included pain (33.3%), queried/confirmed clot (22.2%), reduced ROM (22.2%), reduced power (22.2%), anxiety (11%), nausea (11%) and swelling (11%).
Conclusion:
The current average LoS for both TKA and THA (5.9 days respectively) is longer than the local hospital KPI goal of 4 days. The national orthopaedic guideline (Health Service Executive, 2015) outlines a KPI goal of a 6 day average LoS for elective arthroplasty procedures. Although these results do meet the national orthopaedic KPI, they are not meeting the local hospital orthopaedic KPI LoS goal.
This audit’s findings suggest that there are multiple challenges, including physiotherapy specific challenges such as improving ROM and power, in achieving timely acute hospital discharge of elective TKA and THA patients. The main factor causing “prolonged” LoS in both THA and TKA was time awaiting bed availability in convalescence and rehabilitation centres. This audit highlights the challenge underpinning streamlining of discharge pathways between acute and rehabilitation hospitals. Process mapping of elective arthroplasty physiotherapy and discharge pathways is now necessary to address this service gap.
Ethical approval is not required for clinical audit by the SJH/AMNCH ethics committee.
References :
1). Health Service Executive (2015). National Model of Care for Trauma and Orthopaedic Surgery. Available at: http://www.hse.ie/eng/about/Wh... 06 January 2017)
2.) Pengas, I.P., Khan, W.S., Bennett, C.A. and Rankin, K.S., (2015). Impact of Weekend Physiotherapy Service on the Cost Effectiveness of Elective Orthopaedic Hip and Knee Arthroplasty. The open orthopaedics journal, Suppl 2: M11 (9), p.515.
