Vol. 19 Issue 7
Baptist Hospital's joint replacement program provides a fluid continuum of care
To ensure a smooth transition from inpatient to outpatient, all staff members must collaborate to consider the functional recovery goals and the conditions of discharge for each patient who undergoes joint replacement surgery. Physical therapy is of paramount importance to a patient's recovery and is stressedin varying degreesbefore, during and after this type of surgery.
Setting its joint replacement program apart from others, Baptist Hospital in Nashville, TN, ensures a seamless continuum of care across all segments of a patient's recovery. Members of the inpatient and outpatient departments have worked together to devise an approach that educates the patient and ensures a consistent delivery of care.
"We maintain the continuum of care from pre-operation education through the surgery to inpatient rehab and immediately to an outpatient setting that is often very close to the patient's home," explained Ronnie Ritchie, MSPT, senior physical therapist with Baptist Sports Medicine.
The team at Baptist Hospital has devised an educational approach to address all issues and concerns surrounding the surgery and ensure that patients are at ease with its short-term effects. Post-operation pain management and discharge planning are the biggest concerns identified by patients.
About two weeks before surgery, patients attend a pre-operation classled by case manager Beverly Aldersonto become acquainted with what the joint replacement process will entail. Each individual is given an educational book that covers all concerns and issues that will be encountered from pre-admission to discharge planning.
The physical therapy portion of the class is introduced by Jennifer Etheridge, MPT, rehabilitation supervisor at Baptist Hospital. She addresses the functional progress concerns and exercise plans with the patients. Specifically, she familiarizes the patients with a pre-operative exercise plan that they are instructed to begin that day.
The recommended pre-surgery exercises include isometrics and depending on which surgery, straight-plane exercises to strengthen the hip and the whole lower extremity.
Complying with the exercises and activity level prescribed by a PT is one of the strongest predictors of how patients fare after surgery. Research shows that patients who adhere to a PT program walk on their own considerably sooner, suffer fewer complications during recovery and are significantly more satisfied with the surgery overall.
"When muscles are strengthened before surgery, they respond better after surgery," Etheridge explained. "The muscles act like a shock absorber to the joint and if they recognize what you are trying to do because you have done it prior, they will absorb a little more shock afterward."
The exercises are presented in great detail in the patient manuals to reinforce that which Etheridge has taught in the class. Family members are encouraged to attend the class as well but Baptist Hospital provides a take-home DVD for those who are unable.
It is important that the patient and their loved ones are fully educated because the patient will be returning to the same exercise routine following their inpatient stay. "We encourage our patients to continue the exercises at home that they were given before surgery for progression," Etheridge said. "They are instructed to do the exercises once daily on the days that they work with their PT and twice daily on the off-days."
To address discharge planning concerns, Etheridge, Alderson and a social worker meet with each patient one-on-one to discuss a preliminary plan. This gives patients a chance to think about transportation options to outpatient PT sessions and other issues that need advance planning. Additionally, patients are shown adaptive equipment that they may or may not need. Pain, another large patient concern, is reviewed extensively so there are no surprises post-operation.
The most important PT interventions during the inpatient phase are exercise and gait and transfer training. "Acute care is about making sure patients are safe doing their basic living skills because the majority of our patients discharge to home," Etheridge said. "We do steps, car transfers, tub transfers and lower-body dressing within the first 48 hours or less."
The inpatient unit features 28 private rooms each with a flat-screen TV and DVD player. Five suites have an extra living area with a pull-out sofa for family members and the rest of the rooms can be accommodated with a cot when necessary.
Staffing of therapy personnel in the inpatient joint replacement unit is based on patient volumes. The average length of stay is two to three days but the program is preparing for a transition to a two-day length of stay in the near future.
"Nursing, doctors and pain management are all huge parts of the program," Etheridge said. "The collaborative effort is crucial to what we do. Our patients wouldn't do nearly as well in therapy if it wasn't for the rest of our team."
Baptist Hospital's outcome functions are solid and aggressive. The inpatient PTs see several patients–about one third–on the operative day. Every patient is up by noon the day after surgery at least once if not twice. The night of surgery and the next morning, PTs provide one-on-one bedside therapy sessions to patients.
Following those two sessions, most patients are ready to walk independently in the hallway with an assistive device and attend Therapy Camp. "Most patients are walking 300 to 400 feet independently with an assistive device and completing most of their mobility skills independently in two to three days," Etheridge explained.
The PTs work with an average of 12 patients at once in Therapy Camp and find that the group setting helps speed the recovery process. If patients have complications after surgery and are not progressing as well as other patients, however, the PTs will work with them individually to tweak the therapy to their tolerance.
Every Thursday, a lunch is held on the unit for the Therapy Camp patients. The cafeteria brings up sandwiches and the staff eats with patients who can tolerate it and their families. It's a social, family environment that helps with the patients' progression. "Our approach to care makes it more enjoyable for our patients because we try to have fun," Etheridge said.
The joint program encompasses hip, knee and shoulder replacement but specializes in hip and knee. A team of 20 joint surgeons completes about two knee surgeries for every one hip surgery. The hospital will perform bilateral procedures depending on the physician's preference as well as the medical status of the patient.
The therapy approach is no different for patients who have had a bilateral procedure. All patients are expected to participate in the same level of therapy and mobilize at the same time. "If you can take it, we will give it to you," Etheridge commented. "And we will be as aggressive as possible because you will get better more quickly."
The Outpatient Component
The main reason patients need PT after joint replacement is to return the function they lost when the joint(s) failed. "Most patients have joint surgery because they are losing function in day-to-day activities," Ritchie relayed. "Primarily, we are looking to return that function as quickly and safely as we can."
The time span from inpatient discharge to beginning outpatient is two to three days at most. Because of the program Baptist Hospital has in place, the outpatient PTs know what exercises the patients were instructed to work on at home during the lapse. "I can take that program and add to it as appropriate for each patient in our outpatient setting," Ritchie said.
In the outpatient setting, PTs work with patients on ambulation, balance and coordination skills and educate about how to deal with any swelling that may occur. The main focus, however, is on improving strength as quickly as possible so patients may begin working on more functional activities such as stair climbing.
"We give them a variety of activities to try, such as riding the stationery bike and practicing on the stairs," Ritchie said. "It's a typical progression in terms of strengthening and range of motion."
Patient goals are always taken into consideration and become the forefront of the therapy program. "Our patients' main goal when they come to outpatient is walking independently and getting rid of their assistive device," Ritchie said.
The PTs observe how the patients walk and assess balance and coordination. "Walking is part of our return to function," Ritchie shared. "Patients usually begin therapy with a walker and we assess their gait and safety as they transition off of that and graduate as quickly as possible to a cane or walking independently."
The PTs work hard to restore range of motion soon after patients are discharged from the hospital which is a challenge for patients recovering from either hip or knee replacement. "But we tend to have a few more challenges with our knee patients just inherently from the surgery," Ritchie explained.
The PT approach varies for knee and hip patients. The hip patients generally do not require therapy for as long as knee patients because they regain their range of motion quicker and more easily. There are also a few precautions that PTs need to observe related to limited range of motion. On average, knee patients require six to 10 weeks of physical therapy, and hip patients generally require about four to six weeks.
The outpatient program is centered on patient convenience and a top-of-mind priority is the location of the clinics. Baptist Sports Medicine, a division of Saint Thomas Health Services, provides healthcare, sports medicine and outpatient rehabilitation services in 12 outpatient locations across middle Tennessee.
"From an outpatient standpoint, the most rewarding thing is that I get to be the last point of contact before a patient is discharged and I usually get to see them at their best," Ritchie explained. "When patients have returned to near-full function, it's exciting just to see them return to a life that they've wanted to get back to for quite some time."
Rebecca Mayer is regional editor of ADVANCE and can be reached at firstname.lastname@example.org