Changes to rehabilitation after total knee replacement.

BACKGROUND: General practitioners play a vital and increasing part in the perioperative care of patients undergoing total knee replacement (TKR). Rising obesity rates, sports-related injuries and an ageing population are likely to result in a sharp increase in TKR procedures within the next decade, combined with higher cost concerns. Rehabilitation practices that show economic efficiency and produce superior patient outcomes are a major focus of current research. OBJECTIVE: The aim of this article is to provide an evidence-based summary of current rapid recovery protocols following TKR surgery. DISCUSSION: Rapid recovery protocols have been shown to be effective at reducing length of stay, postoperative pain and complications without compromising patient safety. These rapid recovery protocols include same-day mobilisation; blood preservation protocols; self-directed pedalling-based rehabilitation; and individualised targeted discharge to self-directed, outpatient therapist-directed or inpatient therapist-directed rehabilitation. Low-cost self-directed rehabilitation should be considered usual care, with inpatient rehabilitation reserved for the minority of at-risk patients.

Effect of time to first ambulation on recurrence after PELD.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the effect of time to first ambulation on recurrence after percutaneous endoscopic lumbar discectomy (PELD). METHODS: From July 2017 to August 2018, 90 patients with lumbar intervertebral disc herniation underwent PELD surgery. According to the initial walking time, i.e., the time until the patient could walk after the operation, the operations were divided into three groups: early stage, middle stage, and late stage. The follow-up period was 3 months, and complete follow-up data were obtained. The visual analog scale (VAS) and Oswestry disability index (ODI) scores before the operation, at first ambulation, 1 month after the operation, and 3 months after the operation and the recurrence and incidence rates of high magnetic resonance imaging (MRI) signal in the vertebral endplate area were recorded after the operation. RESULTS: The success rate was 100% for these 90 cases. The VAS and ODI scores at the first ambulation after the operation significantly improved compared with those before the operation, and the difference was statistically significant. The improvements in the lumbar VAS and ODI scores of the middle- and late-stage groups were better than that of the early-stage group at 1 and 3 months after the operation, and the differences were statistically significant; however, there was no significant difference between the middle- and late-stage groups. The postoperative recurrence rate and rate of high MRI signal in the vertebral endplate area were significantly higher in the early-stage group than in the other two groups, and the difference was statistically significant. CONCLUSION: The time to first ambulation after PELD is an important factor affecting the curative effect of the operation. Early ambulation may be one of the factors affecting recurrence after PELD.

Can the effects of the mobilization of vulnerable elders in Ontario (MOVE ON) implementation be replicated in new settings: an interrupted time series design.

BACKGROUND: Bed rest for older hospitalized patients places them at risk for hospital-acquired morbidity. We previously evaluated an early mobilization intervention and found it to be effective at improving mobilization rates and decreasing length of stay on internal medicine units. The aim of this study was to conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on surgery, psychiatry, medicine, and cardiology inpatient units. METHODS: A multi-component early mobilization intervention was tailored to the local context at seven hospitals in Ontario, Canada. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. Secondary outcomes were hospital length of stay and discharge destination, which were obtained from hospital decision support data. The study population was patients aged 65 years and older who were admitted to surgery, psychiatry, medicine, and cardiology inpatient units between March and August 2014. Using an interrupted time series design, the intervention was evaluated over three time periods-pre-intervention, during, and post-intervention. RESULTS: A total of 3098 patients [mean age 78.46 years (SD 8.38)] were included in the overall analysis. There was a significant increase in mobility immediately after the intervention period compared to pre-intervention with a slope change of 1.91 (95% confidence interval [CI] 0.74-3.08, P-value = 0.0014). A decreasing trend in median length of stay was observed in the majority of the participating sites. Overall, a median length of stay of 26.24 days (95% CI 23.67-28.80) was observed pre-intervention compared to 23.81 days (95% CI 20.13-27.49) during the intervention and 24.69 days (95% CI 22.43-26.95) post-intervention. The overall decrease in median length of stay was associated with the increase in mobility across the sites. CONCLUSIONS: MOVE increased mobilization and these results were replicated across surgery, psychiatry, medicine, and cardiology inpatient units.

Validation of an extrinsic compression and early ambulation protocol after diagnostic transfemoral cerebral angiography: a 5-year prospective series.

BACKGROUND AND PURPOSE: Access-site complications constitute a substantial portion of the morbidity associated with transfemoral cerebral angiography, yet no standardized protocol exists for femoral closure and practice patterns vary widely. The objective of this single-arm prospective cohort study was to validate the efficacy and safety of a standardized femoral closure strategy for all diagnostic angiography, regardless of antiplatelet regimen. METHODS: A single-arm, prospective study was designed enrolling consecutive patients undergoing diagnostic transfemoral cerebral angiography by a single neurointerventional surgeon from March 2013 - March 2018. The closure protocol consisted of 20 minutes of manual compression to the site of arterial access and 2 hours of bedrest. The primary outcome was hematoma or oozing after manual compression. Demographic, clinic, and laboratory data were collected and analyzed, and patients were stratified by antiplatelet use. RESULTS: Of 525 angiograms, 263 (50.1%) were on patients taking antiplatelet medication, with 66 (12.6%) on dual antiplatelet regimens. Five patients (0.95% of all patients) met the primary outcome: in all five cases, there was no further oozing or enlarging hematoma after the additional compression period. There were not significant differences in primary outcome in groups stratified by antiplatelet use, and there were no instances of delayed hematoma, pseudoaneurysm, or arteriovenous fistula. CONCLUSION: In this single-arm cohort study of 525 consecutive transfemoral angiograms with a standardized extrinsic compression protocol, hemostasis was achieved without complication in >99% regardless of antiplatelet strategy. This protocol is effective and safe for diagnostic transfemoral angiography regardless of a patient's antiplatelet use.

Current Trends in Practice for Early Mobility with the Burn Population.

There is a clinical trend toward "early mobilization" of patients with burn injury, however mobility is not well defined in burn care. Burn injuries result in various extents of injury, body areas affected, and types of skin graft surgeries needed-all of which may influence the type, timing, safety, and outcome of mobilization activities. This study surveyed burn clinicians to determine current mobility practices and the influence of skin graft surgery on clinical decisions to mobilize patients. A 32-question survey was electronically distributed to burn clinicians and included questions about postoperative range of motion (ROM) and out of bed (OOB) mobility practices for various skin graft types and locations. For all types of grafts on all body locations, the average time after skin graft surgery that patients resumed ROM activities was postoperative day (POD) 3.87 (±2.04) while OOB mobility resumed on POD 2.54 (±1.38). There was significantly greater variability for OOB mobility compared to ROM (coefficient of variation [CV] 0.71 ± 0.8 vs 0.5 ± 0.05). Time to postoperative ROM was significantly different depending on the type of skin graft placed with sheet skin grafts resuming ROM the earliest. Time to OOB mobility after surgery was significantly different for different body locations with grafts placed above the waist resuming OOB mobility earliest. This study provides a summary of current mobility practices and serves as a foundation for future studies investigating the optimal timing and practical application of mobility protocols that may influence safety and outcome of burn survivors.

Does implementation of an enhanced recovery after surgery program for hip replacement improve quality of recovery in an Australian private hospital: a quality improvement study.

BACKGROUND: Enhanced recovery after surgery programs may improve recovery and reduce duration of hospital stay after joint replacement surgery. However, uptake is incomplete, and the relative importance of program components is unknown. This before-and-after quality improvement study was designed to determine whether adding 'non-surgical' components, to pre-existing 'surgical' components, in an Australian private healthcare setting, would improve patient recovery after total hip replacement. METHODS: We prospectively collected data regarding care processes and health outcomes of 115 consecutive patients undergoing hip replacement with a single surgeon in a private hospital in Melbourne, Australia. Based on this data, a multidisciplinary team (surgeon, anesthetists, nurse unit managers, physiotherapists, perioperative physician) chose and implemented 12 'non-surgical' program components. Identical data were collected from a further 115 consecutive patients. The primary outcome measure was Quality of Recovery-15 score at 6 weeks postoperatively; the linear regression model was adjusted for baseline group differences. RESULTS: The majority of health outcomes, including the primary outcome measure, were similar in pre- and post-implementation groups (quality of recovery score, pain rating and disability score, at time-points up to six weeks postoperatively). The proportion of patients with zero oral morphine equivalent consumption at six weeks increased from 57 to 80% (RR 1.34, 95% CI 1.13, 1.58). Mean (SD) length of hospital stay decreased from 5.94 (5.21) to 5.02 (2.46) days but was not statistically significant once adjusted for baseline group differences. Four of ten measurable program components were successfully implemented. Antiemetic prophylaxis increased by 53% (risk ratio [RR] 95% confidence interval [CI] 1.16, 2.02). Tranexamic acid use increased by 41% (RR 95% CI 1.18, 1.68). Postoperative physiotherapy treatment on the day of surgery increased by 87% (RR 95% CI 1.36, 2.59). Postoperative patient mobilisation ≥ three metres on the day of surgery increased by 151% (RR 95% CI 1.27, 4.97). CONCLUSIONS: Implementation of a full enhanced recovery after surgery program, and optimal choice of program components, remains a challenge. Improved implementation of non-surgical components of a program may further reduce duration of acute hospital stay, while maintaining quality of recovery. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12615001170516 ), 2.11.2015 (retrospective).

Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial.

BACKGROUND: Immobilisation predicts adverse outcomes in patients in the surgical intensive care unit (SICU). Attempts to mobilise critically ill patients early after surgery are frequently restricted, but we tested whether early mobilisation leads to improved mobility, decreased SICU length of stay, and increased functional independence of patients at hospital discharge. METHODS: We did a multicentre, international, parallel-group, assessor-blinded, randomised controlled trial in SICUs of five university hospitals in Austria (n=1), Germany (n=1), and the USA (n=3). Eligible patients (aged 18 years or older, who had been mechanically ventilated for <48 h, and were expected to require mechanical ventilation for ≥24 h) were randomly assigned (1:1) by use of a stratified block randomisation via restricted web platform to standard of care (control) or early, goal-directed mobilisation using an inter-professional approach of closed-loop communication and the SICU optimal mobilisation score (SOMS) algorithm (intervention), which describes patients' mobilisation capacity on a numerical rating scale ranging from 0 (no mobilisation) to 4 (ambulation). We had three main outcomes hierarchically tested in a prespecified order: the mean SOMS level patients achieved during their SICU stay (primary outcome), and patient's length of stay on SICU and the mini-modified functional independence measure score (mmFIM) at hospital discharge (both secondary outcomes). This trial is registered with ClinicalTrials.gov (NCT01363102). FINDINGS: Between July 1, 2011, and Nov 4, 2015, we randomly assigned 200 patients to receive standard treatment (control; n=96) or intervention (n=104). Intention-to-treat analysis showed that the intervention improved the mobilisation level (mean achieved SOMS 2·2 [SD 1·0] in intervention group vs 1·5 [0·8] in control group, p<0·0001), decreased SICU length of stay (mean 7 days [SD 5-12] in intervention group vs 10 days [6-15] in control group, p=0·0054), and improved functional mobility at hospital discharge (mmFIM score 8 [4-8] in intervention group vs 5 [2-8] in control group, p=0·0002). More adverse events were reported in the intervention group (25 cases [2·8%]) than in the control group (ten cases [0·8%]); no serious adverse events were observed. Before hospital discharge 25 patients died (17 [16%] in the intervention group, eight [8%] in the control group). 3 months after hospital discharge 36 patients died (21 [22%] in the intervention group, 15 [17%] in the control group). INTERPRETATION: Early, goal-directed mobilisation improved patient mobilisation throughout SICU admission, shortened patient length of stay in the SICU, and improved patients' functional mobility at hospital discharge. FUNDING: Jeffrey and Judy Buzen.

Influência da deambulação precoce no tempo de internação hospitalar no pós-operatório de cirurgia cardíaca / Influence of early ambulation in postoperative hospitalization following cardiac surgery

Fundamentos: Apesar do avanço tecnológico que visa a prolongar a qualidade de vida de pacientes submetidos acirurgia cardíaca, esse procedimento ainda é considerado de alta complexidade. A deambulação precoce é uma alternativa para melhorar a capacidade pulmonar, o condicionamento cardiovascular e o aumento do desempenho funcional. Objetivos: Avaliar o impacto da deambulação precoce sobre o tempo de internação na Unidade de Terapia Intensiva (UTI) e hospitalar em pacientes submetidos a cirurgia cardíaca. Métodos: Estudo transversal, realizado com 49 pacientes submetidos à cirurgia cardíaca e admitidos na UTI, no período de outubro de 2014 a abril de 2015. Os pacientes foram estratificados em dois grupos: com e semdeambulação precoce. Deambulação precoce definida como o ato de caminhar até o terceiro dia de internação na UTI. Análise estatística realizada para verificar a existência de modificações no tempo de permanência hospitalare UTI entre os dois grupos de deambulação.Resultados: Foram estudados 49 pacientes, dos quais 55,1% homens, média de idade 55,2±13,9 anos, internados na UTI em decorrência de cirurgia cardíaca no período do estudo. Não se observou correlação estatística entre o ato de deambular precocemente com o tempo de permanência na UTI cardíaca (3,0±1,5 dias vs. 2,8±1,1 dias, p=0,819) e hospitalar (5,4±3,3 dias vs. 5,3±2,6 dias, p=0,903).Conclusão: A deambulação precoce não se associou a um menor tempo de permanência na UTI ou hospitalar.

Background: Despite the technological advances aimed to extend the quality of life of patients undergoing cardiac surgery, such procedure is still deemed a highly complex intervention. Early ambulation is an alternative to improve lung capacity, cardiovascular fitness and increased functional performance. Objective: Assess the impact of early ambulation on the length of stay in intensive care unit (ICU) and in hospital, for patients undergoing cardiac surgery. Methods: Cross-sectional study of 49 patients undergoing cardiac surgery and admitted to the ICU from October 2014 to April 2015. Patients were stratified into two groups: with and without early ambulation. Early ambulation is the act of walking up to the third day of ICU admission. Statistical analysis performed to check for changes in the length of stay in ICU and in hospital between the two groups of ambulation. Results: The study observed 49 patients (55.1% men) with mean age of 55.2±13.9 years, admitted to the ICU due to cardiac surgery carried out during the study period. No statistical correlation was found between early ambulation and the length of stay in cardiac ICU (3.0±1.5 days vs. 2.8±1.1 days, p=0.819) and in hospital (5.4±3.3 days vs. 5.3±2.6 days, p=0.903).Conclusion: Early ambulation is not related to a shorter length of stay in ICU or in hospital.

Environmental impact of accelerated clinical care in a high-volume center.

BACKGROUND: "Fast-track" surgery, involving multimodal care, improves efficiency and short-term outcomes in patients undergoing bowel resection. The sustainability of the benefits and the "drag" effect on non-participating surgeons through changed nursing and resident practice is undetermined. METHODS: 297 consecutive elective colon resections (DRG149) within three study periods (pre-change, immediate post-change, long-term post-change) were retrospectively reviewed. Two surgeons began to "fast-track" their patients in 1999 independently from the other surgeons in the hospital. Surgeons were grouped into "fast-track surgeons," "high-volume surgeons," (>/=10 cases per year) and "low-volume surgeons," (<10 cases per year). Comparisons of duration of stay (DOS), readmission rates, and mortality were made for each of three time periods and surgeon groups. Trends were also compared with unrelated hospital non-colectomy control groups (uncomplicated craniotomy DRG 001 and pancreatic surgery DRG 192) and to a colectomy control group from a statewide database (DRG 149). RESULTS: Mean DOS for colon resection significantly decreased among the "fast-track" surgeons and among all the other surgeons in the hospital, from 6.3 +/- 0.3 days, down to 3.7 +/- 0.1 days. We found no significant difference in mortality or readmission rates between the study periods. 15% of the cases were performed laparoscopically, and the improvements in outcome were independent of surgical technique. Control group analyses demonstrated that the environmental impact on outcome was independent of hospital-wide or regional improvement efforts. CONCLUSIONS: Implementation of a new practice pattern in a shared environment leads to improved outcomes for patients of other surgeons within the same environment. Dissemination and cross-pollination of new methods through resident, nurse, and case manager practice pattern modification creates a favorable force for change and this impact is sustained over a 3-year period.

Early mobilization after aortic valve surgery.

In recent years, the focus in peri-operative care of cardiac patients has shifted from trying to create a stress-free environment to hasten the recovery of patients by providing early extubation, early mobilization, and enteral nutrition. Fast-track cardiac surgery has therefore made a paradigm shift in postoperative care. However, evidence on the safety of early postoperative mobilization in high-risk groups like aortic valve replacement surgery is lacking. Physiological evidence from controlled studies in patients undergoing aortic valve replacement (AVR) showed that heart rate increases and stroke volume falls with maintenance of cardiac output. However, the increase of 50% to 60% of oxygen consumption during mobilization is covered by increased oxygen extraction, resulting in marked mixed venous oxygen desaturation. These physiological changes during postoperative mobilization were also seen in CABG patients. The mobilization pattern was also maintained on the second day after surgery. No serious side effects were observed in the controlled trials of mobilization of AVR patients after cardiac surgery. Over a 13-year period, we have mobilized more than 1200 AVR patients. No serious situations have occurred during or in direct connection to mobilization.