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Implementation of a Clinical Pathway on Primary Joint Arthroplasty: A Process Evaluation

Credits: None available.


Purpose: Variation in clinical practice and lack of organized efficient care process in the care of ortho-joint arthroplasty patients is known to impact negatively clinical outcomes. With variations deemed unacceptable, there is a consensus to standardize processes and procedures such as the utilization of clinical pathways (CP). It is established in the literature that CPs promote safety and improves patient outcomes. The CP implemented for the care of patients undergoing primary ortho-joint arthroplasty was focused on the inpatient stay and discharge process. It was implemented to improve outcomes specifically by decreasing the length of stay, decreasing surgical-related complications, improving patient experience, and decreasing the hospital 30-day readmission rate.

Description: The evidence-based practice (EBP) project was developed and implemented utilizing the plan-do-study-act (PDSA) cycle as a framework. A needs assessment was done to expound on the practice problem. A literature review was done and best practices were screened using the rating system for the hierarchy of evidence adopted by the National Association of Orthopedic Nurses. The implementation was grounded on a collaborative effort among the stakeholders of the program that included nursing, physicians, case management, and physical rehabilitation. A project champion was appointed to be accountable for the care delivery and communication to different stakeholders. Dedicated caregivers, including nurses, case managers, physical therapists, and occupational therapists with specialized training in orthopedic care were identified. A checklist was developed specifying the set of care tasks and milestones. Process metrics were identified to track the progress of the EBP project that included discharge before noon (DBN) on post-op day one, time to PT milestones, patient to SCD milestone, leadership rounding feedback, and discharge instruction audit.

Results: Process metrics were measured and reported to the program stakeholders on two occasions with three-month intervals, phases 1 and phase 2 respectively. Processes were improved following the iterative cycle of PDSA. There was an improvement in process metrics from phase 1 to phase 2. The length of stay of patients decreased from the baseline of 2.2 days to 1.5 days after the 1st phase of the process evaluation and 1.25 days after the 2nd phase. Of the patients who were discharged on post-op day one, the DBN improved from 67% to 78%. The increase in the number of patients seen on post-op day 0 by PT played an important factor in improving the DBN metric. All patients audited were connected to SCD within the 30 minutes of arrival to the unit. Lastly, almost all of the patients verbalized a worthwhile experience in both phases. A few patients verbalized dissatisfaction with dietary-related issues such as late delivery of breakfast trays. A focused group discussion (FGD) was conducted after the first phase of project implementation. Delayed PT sessions on post-op day 1 were attributed to delayed delivery of breakfast trays and intolerable pain in the morning. To address the matter, dietary department was involved in the group. Regular assessment and prompt intervention to pain were put in place, especially the night after post-op day 0.

Evidence-based references
1. Ahbrook, L., Mourad, M., & Sehgal, N. (2015). Communicating discharge instructions to patients, a survey of nurse, intern, and hospitalist practices. Journal of Hospital Medicine, 8(1), 36-41. https://doi: 41 | 10.1002/jhm.1986
2. Ban, A., Ismali, A., Harum, r., Abdul Rahman, A., Sulung, S., & M, A.S. (2012). Impact of clinical pathway on clinical outcomes in the management of COPD exacerbations. BMC Pulmonary Medicine, 12(27). https://doi:10.1186/1471-2466-12-27
3. Gesme, D.H., & Wiseman, M. (2011). Strategic use of clinical pathways. J Oncology, 7(1). https://doi:10.1200/JOP.2010.000193



Credits: None available.

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