A Simplified Pathway for Total Knee Arthroplasty Improves Outcomes

Abstract

Care pathways for total knee arthroplasty (TKA) demonstrate improved quality and utilization outcomes. Standardizing these processes over large systems is difficult due to the variability of practice patterns and the complexity of multistep pathways. A simplified approach to this process focusing on early activity and avoidance of continuous urinary catheters was performed to overcome these perceived barriers for implementing a system-wide care pathway. Data were collected from a total of 6,154 consecutive patients during the time period of 1 year before and 1 year after implementation of a pathway focusing on two key drivers: early activity and continuous urinary catheter avoidance. Patients included were adults admitted for elective primary TKA. A composite score was calculated based on the successful completion of the two key drivers. Outcome measures were tracked before and after implementation. Following implementation of a simplified TKA care pathway, there was a significant increase in the composite score with increases attributable to both increased early activity (p < 0.0001) and continuous urinary catheter avoidance (p < 0.0001). This improvement in composite score was associated with a significant decrease in hospital length of stay (HLOS) (p < 0.0001), costs (p < 0.0001), complications (p < 0.0001), and 30-day readmissions (p < 0.0106). A fixed-effect model analysis demonstrated early activity was associated with improvements in HLOS (p < 0.0001), complications (p = 0.0240), and 30-day readmissions (p = 0.0046). Avoidance of a continuous urinary catheter was associated with improvements in HLOS (p = 0.0001), costs (p < 0.0001), complications (p = 0.0006), and 30-day readmissions (p = 0.0008). A simplified care pathway for TKA focusing on early activity and continuous urinary catheter avoidance is associated with improved complications, costs, HLOS, and 30-day readmissions.

Keywords

knee arthroplasty - quality management

• References

• 1 Barbieri A, Vanhaecht K, Van Herck P , et al. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med 2009; 7: 32
• 2 Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J 2011; 7 (1) 9-15
• 3 Raphael M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth 2011; 58 (10) 902-910
• 4 den Hertog A, Gliesche K, Timm J, Mühlbauer B, Zebrowski S. Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg 2012; 132 (8) 1153-1163
• 5 McDonald DA, Siegmeth R, Deakin AH, Kinninmonth AW, Scott NB. An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom—follow up at one year. Knee 2012; 19 (5) 525-529
• 6 Malviya A, Martin K, Harper I , et al. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 2011; 82 (5) 577-581
• 7 Husted H, Otte KS, Kristensen BB, Ørsnes T, Wong C, Kehlet H. Low risk of thromboembolic complications after fast-track hip and knee arthroplasty. Acta Orthop 2010; 81 (5) 599-605
• 8 Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I'm not sure”. JAMA 2011; 306 (16) 1782-1793
• 9 Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint?. Ann Intern Med 2002; 137 (2) 125-127
• 10 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA ; Healthcare Infection Control Practices Advisory Committee. Guideline for the prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010; 31 (4) 319-326
• 11 Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari M, Zalzal PK. Meta-analysis of navigation vs conventional total knee arthroplasty. J Arthroplasty 2012; 27 (6) 1177-1182
• 12 Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am 2013; 95 (3) 193-199
• 13 Gonano C, Leitgeb U, Sitzwohl C, Ihra G, Weinstabl C, Kettner SC. Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs. Anesth Analg 2006; 102 (2) 524-529