Joint replacement rehab stays on track with path

Plan popular with physicians, therapists, patients

A flexible critical pathway for joint replacement patients has paid dividends for the rehab unit at DuBois (PA) Regional Medical Center.

The combination knee and hip replacement pathway, designed for patients without medical complications who have single joints replaced, combines all the common aspects for total hip replacement and total knee replacement patients. It also has a check-off portion for specific treatments for each diagnosis and the preferences of the orthopedic surgeon. (See copy of pathway enclosed in this issue.)

The document has fit so well with the needs of the patients that there have been no changes since the rehab unit started using it in January 1997. (For details on how the pathway was developed, see article on p. 14.)

Clear-cut and organized’

"Now that we’ve been using the pathway, we have found that it is excellent for all parties involved," says Martin Schaeffer, MD, medical director for the department of physical medicine and rehabilitation. "Everyone knows what they are supposed to be doing. It is very clear-cut and organized, and the patient is getting better care."

Schaeffer spearheaded development of the critical pathway.

Orthopedic surgeons like the pathway because it tells them exactly what will happen to their patients on rehab and how long it will take, he says. Patients are happy because they know what to expect, and it allays fears that they will be incapacitated for a month, Schaeffer says.

The referring physicians find it useful because they can plan patient discharges. The pathway makes also it easier for the rehab hospital to plan admissions and discharges because it sets out the length of stay for these patients. The young therapy staff are also happy with the pathway because it sets out exactly what the patients are supposed to do and when, Schaeffer says.

There hadn’t been a rehab unit in the area, so rehab as a specialty was very unfamiliar. Some of the therapists had experience in outpatient treatment but no inpatient experience, Schaeffer says.

"Because we are a relatively young rehab unit, we have a very young therapy staff. We found that some therapists actually were looking for specific expectations of therapy. The pathway tells them what is expected on each day, and they like that," Schaeffer says.

For example, seasoned therapists know from experience how much joint replacement patients should be able to walk, but the therapists who were just out of school had some uncertainties, Schaeffer says.

"When it was open-ended, these therapists would work with the patients, but they didn’t know what goals to set for each day. The pathway eliminated that problem," Schaeffer says.

Combined diagnoses

Instead of creating a separate pathway for hip replacement patients and knee replacement patients, Schaeffer combined the two.

"Because our unit was so young and new, I didn’t want to introduce two critical pathways at once, so I combined them into a hip and knee replacement pathway," he says.

Much of the treatment is the same for knee replacement and hip replacement patients, Schaeffer says. The physical therapy and occupational therapy treatments overlap to a great extent. Patients receive the same medication, the same education, and the same kind of discharge planning, he adds.

"There is so much overlap that it’s possible to combine the pathways and simplify things," Schaeffer says.

Any differences in treatment procedures are noted on the pathway. For instance, because hip replacement patients generally don’t require treatment on a continuous passive motion (CPM) machine, the physiatrist would simply write "no" in the CPM box. He or she can check off "total knee precautions" or "total hip precautions."

The check-off portion of the pathway includes standard admitting orders with areas for dietary considerations, laboratory orders, wound care orders, and other areas in which the physiatrists or referring orthopedic surgeons have individual preferences.

Two-day segments

Instead of developing a pathway that lists activities and goals day by day, Schaeffer decided to create a range that could accommodate variations in patients’ activeness and motivation.

The eight-day pathway is broken into four segments: Day 1-2; Day 3-4; Day 5-6; and Day 7-8. This allows more motivated and functional patients to progress faster and be discharged earlier.

Because of the flexibility in days, the staff is able to accelerate a patient’s progress on the pathway. For example, if the therapy evaluations show that a patient is on a high functional level, the staff has the option of combining the activities on Day 1-2 with the activities on Day 3-4.

Because of the option for an accelerated pathway, some patients have been discharged as early as Day 4-5 if they have met all the goals for Day 8, Schaeffer says.

Most of the patients are discharged by Day 7, although the pathway goes through Day 8. Patients who stay a day longer are likely to have been admitted on a Friday. DuBois offers limited therapy on weekends.

Sources

For more information on DuBois Regional Medical Center’s critical pathway for joint replacement patients, contact:

Martin A. Schaeffer, MD, Medical Director, Department of Physical Medicine and Rehabilitation, DuBois Regional Medical Center, Suite 300, 145 Hospital Ave., DuBois, PA 15801. Telephone: (814) 375-4660. Fax: (814)375-5206.