Change Management Of Total Joint Arthroplasty

Mark P. Brodersen, M.D.
Mark P. Brodersen, M.D. is an Assistant Professor of Orthopedics for Mayo Medical School and
Consultant, Department of Orthopedic Surgery at Mayo Clinic Jacksonville and St. Lukes Hospital.

Introduction

In 1993 the Department of Orthopedic Surgery at St. Luke's Hospital re-examined the clinical pathway for joint arthroplasty because there was a great deal of inconsistency in how patients were treated and the hospital was losing significant dollars per case. The attending staff paid little attention to the process as evidenced by comments that these things "kind of took care of themselves." Unfortunately, uncertainty on the part of the physician resulted in uncertainty on the part of the patient. This and many other factors resulted in a lack of a cohesive plan for the patient and their family and increased anxiety for everyone. In addition, financial pressures heightened from both the government (Medicare) and managed care.

The reaction to the changes in reimbursement for physician and hospital services can result in a positive or negative experience. At St. Luke's it was decided to look upon these changes as an opportunity not only to decrease costs but also to improve care at the same time. While these goals may seem at odds with each other, the management of resources was addressed in a manner to achieve both goals. This was done by establishing a common clinical pathway for the patient experiencing a total joint arthroplasty.

Method

The first step was to eliminate the old concept of an orthopedic "department" of individuals. An orthopedic practice team was developed which included community and Mayo orthopedists, nurses, an operating room manager, nurse case manager, pharmacist, anesthesiologist, pain management specialist, home health nurse, physician assistant, physical therapist, an administrator, and an outcomes analyst. This group was charged with the management and redesign of the entire continuum of patient care from pre-admission to post discharge.

The initial goal was to create a standardized hospital stay. A standard order form was developed which incorporated cost effective drug use, a seven day per week physical therapy program agreed upon by all surgeons and nursing care protocols for uniform management of fevers, urinary retention, anticoagulation and respiratory care, etc. The order forms were the outgrowth of the clinical pathway approach to patient care. While some hospitals have created hundreds of pathways, it was felt that having multiple pathways would be more confusing than helpful.

A select number of pathways were developed, an upper extremity pathway, a lower extremity pathway and a hip fracture pathway. The hip fracture pathway was developed because of the multiple medical problems that surface in the elderly trauma patient. The order sets were sufficiently broad that they would be used for both trauma and elective surgery patients. Orders were created using the most-cost effective drugs as determined by input from the pharmacy, infectious disease, urology, GI and other services.

Discharge planning was begun preoperatively through the expansion of the case manager's role. A total joint school was started for patient and family education. Those patients that attended this preoperative school consistently experienced shorter lengths of stay than those that have not attended. It seemed that the primary benefit of this school was to give the patient and their family a clear idea of what they will encounter and what their needs and requirements will be upon discharge. Through better understanding of the care interventions, patients and family members could realistically plan their post-discharge care. If they were comfortable with their plans before admission, a major source of anxiety has been relieved allowing the patients to concentrate on recovery.

At the start of this process, nine total joint vendors were used at St. Luke's. Through intensive negotiations, the number of vendors decreased to three and then to one primary vendor. The advantages of having only one primary vendor were significant cost savings for the purchase of prostheses as well as having only one set of instruments for the operating room staff.

Cost reductions were seen as the length of stay decreased from 8 days to 4.5 days. By using standardized order sets, fewer "routine" tests were ordered as well as fewer "routine" radiographs. A demand-matching program was initiated to assure that the prostheses implanted were appropriate for the patients' age and activity level. Operating room case cart standardization streamlined case preparation and turnover in the operating room. Overall, a 33% reduction in total costs has been realized.

Quality Assurance

Obviously cost reduction should not be realized at the expense of patient outcome. The old process of chart review was abandoned and a system of outlier trending was implemented. Sampling of charts was used to monitor implant matching. The last four reviews were at 100% compliance for appropriate prosthesis matching. All unplanned transfers to special care units, readmission within 30 days, returns to surgery within 24 hours, revisions of total joints within six months with the same surgeon, deaths and neuro deficits were trended and routinely bunched for review annually. Blood use and infections were also reviewed and tracked over time. By bundling the cases and looking at the population, trends were identified and practice patterns modified, thus improving patient care. Physician report cards were developed comparing surgeons' costs, operating times and complications. The above changes in practice patterns (reduced length of stay, clinical pathways, etc) have not been accompanied by any increase in adverse outcomes.

The episodic fever pathway resulted in a quality enhancement for patients. A group of 85 total hip patients in 1994 were reviewed for the presence of fever. Tests were ordered to evaluate fever when present and the results of the tests evaluated and correlated with outcome. All 85 patients had a fever and multiple tests were ordered, such as blood cultures, urine cultures, chest radiographs, etc. Few of the tests ever came back positive. As part of the continuous improvement effort a standardized care path was established to evaluate postoperative fever. A follow-up study was done in 1996 that showed a significant reduction in the ordering of unnecessary tests.

Communication

In January 1997, practice team newsletters were developed to communicate specific information to physicians not able to attend the practice team meetings. These newsletters were published monthly and included information on any change in practice, policies, educational opportunities and other noteworthy items. The chair of the practice team sent out periodic letters to all physicians on specific topics. This has managed to keep all physicians informed and has provided opportunities for feedback.

Future Goals

The general goals of total joint replacement surgery are to return a patient to optimal function with as little impact to their life as possible. The better prepared a patient is preoperatively, the smoother the hospital and post hospital course. New preoperative strength testing is being developed. If significant strength deficits can be identified, surgery may be delayed until the patient's physical condition can be optimized. The physical therapy department is currently evaluating the use of a standardized protocol for this strength testing.

The anesthesia department is organized into specialty areas. By having a group of anesthesiologists dedicated to joint procedures, better medical screening tools for hip arthroplasty should be developed. Patients with multiple comorbidities have more complications and longer lengths of stay. Identifying these patients earlier allows their internist more time to decrease medication usage and get the patient in optimum physical and mental condition.

The Total Joint School, though successful, is only meeting the needs of approximately twelve patients per month and the total number of joint surgeries being done per month is more than 50. Many patients are from out of the area and are not able to conveniently return for the Joint School. The practice team is developing a total joint school video that is scheduled for release this summer. The video follows a patient through the surgical process from pre-admission to discharge. The video shows the patient the type of equipment that he/she can expect to see while in the hospital and the personnel that they will encounter. This short video allows the patient to view it many times and to share it with family and friends. The goal is to provide pre-operative education to all total joint patients regardless of geographic location prior to hospitalization.

Conclusion

Standardization of medical care in the area of Total Joint Arthroplasty has yielded the benefits of cost and resource utilization reduction without diminishing the quality of the care product. The goals established at the onset of the project have been accomplished. The program has been recognized by the Jacksonville Business Journal in its "Excellence in Health Care" award. The creation of an orthopedic practice team has allowed the development of a true team approach to the care of the orthopedic patient with all groups having input into the management of the continuum of care. This clinical pathway success for total hip arthroplasty has paved the way for innovative approaches to care management of a select patient population. Most importantly, it has demonstrated the value of a systematic/process oriented approach to care management and its application in a continuous quality improvement effort.

Jacksonville Medicine / September, 1999

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