Critical Path Network

Joint replacement CM helps hospital improve outcomes

Surgeries increase, LOS, readmission rates decline 

Hiring a case manager assigned specifically to manage joint replacement patients has paid dividends for St. Mary Medical Center in Langhorne, PA.

The number of total hip and total knee surgeries has increased from 145 in fiscal year 2003 to an expected 260 during this fiscal year.

During the same period, lengths of stay have dropped by 0.3 days, the readmission rate has declined by 1%, patients being discharged to home has increased by 10%, and postoperative deep vein thrombosis (DVT) and infection is down 0.3%.

The hospital started its orthopedic program a year and a half ago and added the case management component in November 2003, collecting baseline measures before the case management program started.

At the same time, the hospital created a dedicated orthopedic unit, instead of scattering orthopedic patients throughout the hospital, wherever a bed was available.

"The increase in the number of cases began just after we created the case management program. We haven’t increased the number of orthopedists. Rather, improving efficiency and putting the patients in one unit has really worked to help our orthopods bring more of their cases to St. Mary," says Steve Meurer, MBA, MHS, PhD, vice president of operations.

Donna McNeill, RN, BSN, orthopedic case manager, starts working with total knee replacement and total hip replacement patients as soon as they make the decision to have surgery. She coordinates the care for hip and knee replacement patients, working closely with the physicians and their office staff and conducting all the preoperative training and orientation for the patients.

McNeill starts the patient educational process as soon as someone is scheduled for surgery. She invites the patients and their families to preoperative classes in the gymnasium, where they meet the physical therapists and occupational therapists and familiarize themselves with the equipment they’ll be using after surgery.

"We show them what to expect and do as much as we can to allay their fears," she says.

In addition to talking with the patients and their families about what to expect during and after surgery, McNeill has compiled educational materials into a binder. Included are frequently asked questions, what to do before surgery, what to expect during and after surgery, signs and symptoms of postoperative problems, and other information. The binder contains preoperative exercises to help patients strengthen their muscles and precautions to take after surgery, and information about how the family should prepare the home for the patient’s discharge, such as moving wires and loose rugs out of the way.

"The patients get so much information that they can’t absorb it at once. That’s why the binder is so important," she says.

McNeill starts the discharge planning process ahead of time so patients will know what options they have after surgery.

"They know they could go home, to a subacute facility, or an acute rehabilitation center, depending on how well they are and what their insurance covers. They’re able to make plans ahead of time so it’s not a shock after surgery," she says.

Many patients prefer to go to home or to an acute rehabilitation unit, an option few insurance companies cover for joint replacement patients.

If a patient wants to pursue the acute rehabilitation option, McNeill does an evaluation and applies for insurance certification ahead of time, reminding the patients that their insurance company may turn down the request.

"I help them realize how many people can go home and do well, and the majority can go home with no problems. A lot of it is knowing what to expect," she says.

McNeill visits patients every day they are in the hospital, reviews the chart, and makes sure the laboratory reports and other information the physicians need are included. She communicates daily with the physical therapist, the occupational therapist, the nursing staff, and the physicians.

"I try to help coordinate things and make sure there are no problems," McNeill adds.

Everyone in the orthopedic department meets once a month to look at what works and what needs improvement.

"The bottom line is to have the patient have a better outcome. We are constantly working to make sure the department runs smoothly," she says.

McNeill has created a form that keeps everyone in the hospital informed when a patient is scheduled for admission. The form includes date of admission, procedure, physician, information on the home environment, past medical and surgical history, and the probability of the patient being discharged to home.

The form is distributed to the home care coordinator, rehabilitation administration, and social worker, letting them know what patients are coming in and what to expect.

"This way, everybody knows about the patient and can get ready for him or her. The home care coordinator starts getting everything the patient will need set up ahead of time so there is no issue with that," she says.

The informational form includes a full evaluation of the patient with information about the home environment. "It gives the therapist a better picture as to what their goals should be. If a patient has to go up seven stairs to get into their home, the therapist will work a little harder on stair climbing than if they have to go up one step," she says.

When McNeill started the case management programs, she visited the home care agencies with one of the orthopedic physicians, told them about the program, and worked with them on a protocol to help them understand the goals of the program.

She created a continuum-of-care notebook that includes space for notes by the hospital’s physical therapists and occupational therapists that the home therapist can review.

"This gives the home therapist information on what the patient can or cannot tolerate so they can continue therapy at the same rate rather than having to ask the patient. We are trying to make sure that the patient goes forward once they leave the hospital," she says.

Community education

McNeill offers free seminars on hip and knee pain to the community. She discusses what can cause joint problems and reviews various treatment options.

"A lot of times, people rely on the advice of their friends with similar problems. I tell them they need to see a specialist because their pain could be caused by a lot of various conditions that have similar symptoms," she says.

The orthopedists who work with the hospital give the people who attend the seminar preferential appointments.

"This program has made the hospital’s orthopedic program more attractive to the doctors and to the community. When the doctors see the program we’ve put in place, they want to bring their patients here. They know that the more educated the patients are, the better the results will be," she explains.

Like all other hospital departments, the orthopedics department participates in St. Mary’s intensive quality improvement program, Meurer points out.

"We have an unwavering focus on measurement and giving a department as much data as possible. We also are adding resources, such as case managers, to help get things done," he says.

One person in the performance improvement department gathers data from all departments at the hospital and develops charts for each of the indicators tracked for that department.

Each department receives a report card each month containing indicators under the topics of quality, service, financial, people, and growth.

The nurse manager or area manager use them to see in what areas the department is meeting goals and where it needs to improve.

The measurement team that supports each department also is involved in the quality improvement process.

The orthopedic program tracks postoperative DVT, postoperative pulmonary embolisms, infection rate, percentage of patients going home, as opposed to a skilled nursing facility or rehab hospital, volume of patients, length of stay, readmission rates, the number of patients that McNeill sees on a daily basis, and patient satisfaction.

"We’re very into patient satisfaction. Just two years ago, the hospital was just below the 50 percentile. Now we are consistently around 90%," she says.

When staff were asked why they believe patient satisfaction scores have increased, most of them said that the hospital is a happier place to work, Meurer adds. "While we have focused on quality and service, we have also focused on the fact that we need to be nice to each other," he explains.