Hip Rehabilitation on the Fast Track

1. Introduction
2. Program Proposal/Development
3. Becoming a National Standard with the Help of an Interdisciplinary Team
4. Which Patients Should Participate?
5. How Do We Measure Success?
6. Challenges
7. Conclusion

Introduction

In 2002, Hospital for Special Surgery (HSS) identified the potential for a Rapid Recovery or "Fast Track" program for certain patients undergoing hip replacement surgery or total hip arthroplasty (THA). This presentation outlines the program's development from its early stages in research, through the establishment of a Joint Commission (JCAHO)-recognized "National Standard" plan of care, and onto the safe, effective, and efficient patient treatment offered today.

Program Proposal/Development

By 2002, many postoperative THA patients progressed at a faster rate than previously seen due to many technical advancements in surgery and anesthesia techniques. HSS recognized this as an opportunity to adapt to the needs of this particular patient population while addressing the hospital’s desire to decrease length of stay. With this goal in mind, the establishment of a Fast Track program was proposed.

The first step towards the development of a Fast Track program was to compare HSS current standard of practice to the national standard following THA. Similar to HSS, other institutions also reported accelerated patient pathways. Reports stated patients were undergoing total hip replacement surgery and being discharged from a hospital within 1.6 days. HSS wanted to re-design a Fast Track program that could meet their goals while providing the same quality care.

A Utilization Management Task Force looked at the implications of a two-day length of stay. The Task Force discovered that surgeons were performing THA on younger and/or more active patients, with current trends focusing on less invasive procedures. Furthermore, there were no outcomes data on the clinical course of patients being discharged on post-operative day #2.

Becoming a National Standard with the Help of an Interdisciplinary Team

An interdisciplinary team reviewed the current standard plan of care for patients undergoing total hip replacement surgery. Necessary changes to the current program were then identified and revised, and it was found that the Fast Track program required the following:

• An update of current education guidelines 
• Modification and establishment of realistic rehabilitation goals for a two- day LOS
• Modification of post-operative pain management 
• Streamlined communication between surgeons, nursing staff, and therapists to meet the needs of this patient population
• Customized current order sets, plan of care and clinical pathway to reflect a two-day LOS.

Addressing these as well as other challenges, the team designed an interdisciplinary plan of care program. An interdisciplinary documentation tool - recognized by The Joint Commission (JCAHO) as the “National Standard” form for interdisciplinary documentation - was developed as well.

Other important developments that resulted from the team's work included:

• A front-loaded pre-op educational program for Fast Track patients, including a class and 1:1 program orientation
• Staff education to review the clinical pathways, physical therapy (PT) guidelines, and patient outcomes
• The addition of rehabilitation and nursing staff to promote the continuum of care, additional therapy, and a nursing ambulation program

Which Patients Should Participate?

Patients for the Fast Track program are recruited in the surgeon's office and have the option to consent to participate in a study. The HSS Institutional Review Board (IRB) reviewed and approved a study to determine if a select group of patients undergoing THA can be discharged from the hospital two days after surgery without any increased complications or adverse affects on the clinical outcome.

A Fast Track protocol was designed to select appropriate patients to go through the correct process as they were admitted into the hospital system. The surgeon would identify the patient as appropriate if he or she met the following criteria:

• Age 65 years old and younger
• Diagnosis of osteoarthritis (OA) (single joint disease in hip), without further complications
• American Society of Anesthesiologists (ASA) II Anesthesia Category or less 
• Body Mass Index (BMI) £30
• Hemoglobin ³13.0, able to donate one unit of autologous blood
• Good support from family/significant other
• Able to ambulate ³ 2 Blocks with or without a cane
• Resides in the tri-state area

The interdisciplinary team is notified when the patients are coming in for surgery, as pre-operative planning is critical for the success of the program. . 

Pre-operative education is a key component in the Fast Track program. It is essential for each patient to have a true understanding of what is entailed, so that he or she is able to make an educated decision about participation in the program. Each Fast Track participant attends a 90 minute class followed by 20 minutes of one-on-one training on individualized Fast Track guidelines.

How Do We Measure Success?

In order for the Rehab staff to measure success and determine if the patients were meeting their goals within the set two-day length of stay, standards were set so that patients must:

• Transfer independently out of bed 
• Ambulate with an appropriate assistive device on level surfaces and stairs 
• Be independent with their total hip replacement precautions as set by the physician 
• Be independent with basic activities of daily living (ADL) and related equipment 
• Be medically and surgically cleared by the team.

Every Fast Track patient would be discharged home with home care services in order to continue working towards independence in ADL activity. In addition, patients would also be provided with an educational video reinforcing how to transfer independently, use an assistive device, perform the home exercises, and recognize precautions they should be aware of. 

A registry was established to track all of the patients enrolled in the program. Certain factors were recorded, including length of stay, variations that were made to the post operative plan of care and, if necessary, reasons why a particular patient's length of stay was longer than two days.

Challenges

The first Fast Track patient was seen in 2004. As the program progressed and an increasing numbers of patients took part, the interdisciplinary team evaluated the delays in discharge to address some of the issues that had arisen. Common challenges that arose and occasionally hindered the patient's rate of progress included:

• Excessive pain or nausea
• A more extensive procedure then originally anticipated
• Excessive post-operative swelling
• Long term effects of the anesthesia 
• Post-operative anxiety

Some patients were motivated and interested but unable to functionally progress as quickly as they wanted to, and some patients decided after surgery that they didn’t want to - or were not ready to - leave in two days.

Conclusion

To date, over 150 patients have enrolled in the Fast Track program. Our average length of stay for 2006, in days, was 2.37. We, as a department and as an institution, are constantly reassessing the program to optimize each patient's chance to achieve their goals. Our physical therapy program is reassessed annually, and we are always looking for ways to improve.

Our intention is that the protocol approved by the IRB for this program will lead to the development of an evidence-based tool that would further measure progress. Ultimately, the Fast Track program has helped the Rehabilitation Department and Hospital for Special Surgery at large to stay at the cutting edge of patient care, and we believe it will continue to do so into the future.