Joint replacement (primary): hip, knee and shoulder

This guideline covers care before, during and after a planned knee, hip or shoulder replacement. It includes recommendations to ensure that people are given full information about their options for surgery, including anaesthesia. It offers advice for healthcare professionals on surgical procedures and ensuring safety during operations. It also offers guidance on providing support and rehabilitation before and after surgery.

Enhancing Nurses' Pain Assessment to Improve Patient Satisfaction.

Patient satisfaction with pain management has increasing importance with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores tied to reimbursement. Previous studies indicate patient satisfaction is influenced by staff interactions. This single-group pre/post design study aimed to improve satisfaction with pain management in older adults undergoing total joint replacement. This was a single-group pre-/posttest design. Nurse (knowledge assessment) and patient (American Pain Society Patient Outcomes Questionnaire Revised [APS-POQ-R], HCAHPS) responses evaluated pre- and postimplementation of the online educational program. Nurse focus group followed intervention. Nurses' knowledge improved significantly (p < .006) postintervention. HCAHPS scores (3-month average) for items reflecting patient satisfaction improved from 70.2 ± 9.5 to 73.9 ± 6.0. APS-POQ-R scores did not change. Focus group comments indicated need for education regarding linkages between pain management and patient satisfaction. Education on linkages between patient satisfaction and pain management can improve outcomes; education on strategies to further improve practice may enhance ability to achieve benchmarks.

Protocol-Based Arthroplasty: Less Is More.

EDUCATIONAL OBJECTIVES: As a result of reading this article, physicians should be able to: 1. State an argument for, and background information on, patient-centered arthroplasty protocols. 2. Describe specific recommendations for designing a simplified arthroplasty care pathway that is reproducible in other institutions. 3. Discuss cost-effectiveness research on the latest value-delivering protocols. 4. Recognize areas of continued research and opportunities for future improvement in protocol development. Total joint arthroplasty is a successful orthopedic procedure that is performed in high volume in the United States and internationally. As economic pressures continue to mount in the US health care system, it will become increasingly important to minimize cost and improve quality and value. At the authors' institution, a protocol-based arthroplasty model is used, in many ways based on simplification of the patient care pathway. The largely evidence-based protocol has its foundation in eliminating unnecessary dogmatic practices, enhancing the patient experience, and achieving cost-effectiveness. The authors believe that a model like this can be applied to joint arthroplasty practices across the country in the future to maximize the value delivered to patients.

Assessment of the Patient-Centered and Family-Centered Care Experience of Total Joint Replacement Patients Using a Shadowing Technique.

In 2030, when baby boomers reach 65 years of age and represent 18% of the population, it is anticipated that 67 million adults will have a diagnosis of arthritis increasing the demand for total hip and knee arthroplasty. With the growing emphasis on patient- and family-centered care, the aim of this project was to assess the patient experience of patients and families throughout the entire spectrum of the total joint replacement service line care at a university regional trauma hospital. A shadowing methodology as defined by the Institute for Health Improvement was utilized. Eight patient/family groups undergoing total joint replacements were shadowed. The mapped care experience included time, caregiver, activity, shadower observations, and impressions. Findings revealed inconsistencies in the delivery of patient- and family-centered care. Communication and interactions were predominantly provider-centric, with a focus on care routines versus the patient and family, and anticipation that care would be medically directed.

Improving transition of care for veterans after total joint replacement.

BACKGROUND: Patients transitioning from hospital to home are at risk for readmission to the hospital. Readmissions are costly and occur too often. Standardized discharge education processes have shown to decrease readmissions. PURPOSE: The purpose of this quality improvement project was to utilize evidence-based practice changes to decrease 30-day all-cause readmissions after total joint replacement. METHODS: Review of literature revealed that improved discharge education can decrease unnecessary readmissions after discharge. A quality improvement project was developed including standardized total joint replacement discharge education, teach-back education methodology, and improved postdischarge telephone follow-up. The quality improvement project was initiated and outcomes were evaluated. OUTCOMES: Improving coordination of the discharge process, enhanced education for patients/caregivers, and postdischarge follow-up decreased total joint replacement readmissions.

The use of tranexamic acid in joint replacement surgery.

Perioperative bleeding is a prevalent risk of elective joint replacement surgery that can lead to allogeneic blood transfusions, delayed discharge, and slowed physical therapy progress. Antifibrinolytics such as tranexamic acid (TXA) have been used in various surgical procedures to reduce bleeding; however, the use of TXA in orthopaedic surgery is not widespread. The purpose of this article is to determine whether the use of TXA in joint replacement surgery reduces total blood loss and lowers the need for allogeneic blood transfusions without adding additional surgical risk and cost. All reviewed meta analyses and systematic reviews analyzed did show a statistically significant reduction in total blood loss and reduction in the need for allogeneic blood transfusions. Therefore, researchers conclude that intravenous TXA use does decrease total blood loss and allogeneic blood transfusion needs. Thus, its use should be included in orthopaedic clinical practice guidelines due to its overall positive effect on outcomes.

Utilizing complexity science to drive practice change through patient- and family-centered care.

Complexity science applied through a 6-step patient- and family-centered care methodology provides a practical framework for achieving meaningful change in organizations. This approach was used to improve the preoperative preparation experience of patients undergoing total joint arthroplasty in an orthopedic specialty hospital.

Enhancing the patient's experience through the total joint replacement continuum of care.

The use of a Total Joint Replacement Pathway provides nurses with a process that guides their professional practice. The pathway begins during the preadmission phase and follows the patients throughout their hospital stay. Relationship-based care is demonstrated by the interdisciplinary care that includes the patient and healthcare team. The goal of this article is to describe the continuum of care for total joint replacement patients at Stamford Hospital from preadmission to discharge. A preoperative class is offered weekly to all patients who are scheduled for elective surgery. Approximately 90% of patients attend the preoperative classes. This article provides a framework for guiding the clinical care of total joint replacement patients. Implementation of this framework will ultimately improve patient care and nursing practice in any surgical setting. Pain management and patient education are 2 core components of nursing practice vital to the success of the Joint Replacement Program and facilitate care of these patients through the continuum.

A comparison between the use of intravenous bags and the Heelift suspension boot to prevent pressure ulcers in orthopedic patients.

The heel is the second most common area where patients develop pressure ulcers (PrUs). Some of the interventions commonly used today to prevent PrUs have not been empirically tested, whereas other interventions have been studied and shown to prevent heel PrUs. Currently, there are no specific studies comparing a pressure-relieving suspension boot with the use of intravenous bags. This quasi-experimental study compared the use of these interventions to determine which intervention was more effective for heel-pressure relief. The target population consisted of a convenience sample of 30 patients admitted to the hospital for hip or knee surgery. Subjects were randomized to intravenous bags or pressure-relieving suspension boots. Daily pressure assessment of heels and the Achilles area was completed using validated pressure scales. Data were analyzed using the SPSS statistical program and were then used to determine the extent to which signs and symptoms of pressure were associated with each intervention. The results demonstrated a significant difference between the pressure-relieving suspension boot and the intravenous bag as heel-pressure-relief methods. Based on the statistical results of this study, the pressure-relieving suspension boot (Heelift; DM Systems Inc, Evanston, Illinois) was the better clinical intervention for patients with decreased mobility.

A review of shoulder replacement surgery.

Shoulder replacement surgery is employed in the treatment of severe shoulder arthritis and following some proximal humeral fractures. Three different replacements are available: hemiarthroplasty (HAS), total shoulder replacement (TSR) and reverse shoulder replacement (RSR). HAS and TSR are indicated in patients with intact rotator cuffs and RSR for cuff deficient older patients. Outcomes are favourable, with the majority of patients having improvements in shoulder pain and function.

Nursing care after a shoulder arthroplasty.

Shoulder arthroplasties are not performed as often as hip and knee arthroplasties. Therefore, the comfort level of caring for these patients may vary amongst nurses. This article will discuss the various types of shoulder arthroplasties, and the postoperative care required for these patients including physical assessment skills, sling management, postural maintenance, activity and range of motion restrictions, and pain management. In addition, the need for a multidisciplinary team approach and discharge planning are discussed. Excellent nursing care, a multidisciplinary approach, and thorough patient education will add to the success of the surgical outcome.

Continuity of care and general wellbeing of patients with comorbidities requiring joint replacement.

AIM: The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement. BACKGROUND: Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis. METHOD: A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005. FINDINGS: Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study. CONCLUSION: Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.

Multidisciplinary patient education for total joint replacement surgery patients.

The purpose of this article is to describe a preadmission, preoperative educational program offered free of charge for patients undergoing total joint replacement surgery at a large teaching hospital located in metropolitan Detroit, Michigan. In establishing the preoperative educational program, a multidisciplinary approach was used to provide a comprehensive learning environment for patients and their families. To evaluate the effectiveness of the program, patients completed surveys at the end of each class. Patients reported that their expectations of the program were met, they were less anxious about their surgery as a result of attending the classes, and the preoperative teaching by the multidisciplinary team was effective. Having a live session that offered an opportunity to ask individual and specific questions to each healthcare professional with immediate feedback proved to be a positive experience for patients. Patients' comments supported the multidisciplinary team's impression that real-time, interactive teaching was highly valued by patients and their caregivers.

The Scandinavian total ankle replacement (STAR).

Ankle joint arthritis is a condition that affects many people. Initial conservative treatment includes nonsteroidal antiinflammatory drugs, soft bracing, and ankle foot orthosis. When conservative management fails, surgical intervention is often considered. Previously an ankle joint fusion has been considered the "gold standard" to treat disabling ankle joint arthritis because early total ankle joint replacements had unacceptably high complication rates. However, early and midterm data have demonstrated that the Scandinavian Total Ankle Replacement (STAR) or Agility Total Ankle may be a reasonable alternative to an ankle joint fusion.

Joint replacement and case management in indigent hospitalized patients.

More than 260,000 total joint replacements are performed every year in the United States. The University of New Mexico Hospital is a publicly held hospital that provides healthcare to many patients who are uninsured and indigent. More than 200 joint replacement surgeries are performed every year at University Hospital, Albuquerque, NM, resulting in an average length of stay of 5.7 days and other patient outcomes. The average cost ranges from $18,000 to $22,000 per procedure, with a reimbursement rate of 61%. Nursing care of these patients can be a challenge and an orthopaedic nurse case manager can effect positive patient outcomes.

Impact of a preoperative education program via interactive telehealth network for rural patients having total joint replacement.

Traditional preoperative education programs have demonstrated the beneficial effects for orthopaedic patients. However, attending preoperative education classes became too difficult for patients, their families, and their friends who traveled great distances from their homes in rural Kentucky. A multidisciplinary continuous quality improvement team from University of Kentucky Chandler Medical Center created a pilot project to provide preoperative education programs for their total joint patients via an interactive telehealth network. The use of telecommunications technology in providing patient preoperative health education was successful in attracting patients from remote areas who otherwise may not have participated. The program has continued for 2 years.