clinical practice guidelines for early mobilization hours after … · postoperative orthopaedic...

290 Orthopaedic Nursing • September/October 2010 • Volume 29 • Number 5

Copyright © 2010 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

PurposeThe strategic purpose of this project was to develop a pa-tient-centered total joint replacement CPG to maximizeinterdisciplinary collaboration from all levels of staff.Embedded within the CPG’s purpose was the goal to at-tain earlier benefits of mobilization by transforming thepractice of initiating activity of the joint replacement pa-tient from postoperative Day 1 to the day of surgery.

BENEFITS OF MOBILITY

The benefits of mobility outlined in current nursing text-books indicate that “Early ambulation is the most signif-icant general nursing measure to prevent postoperativecomplications” (Lewis, Heitkemper, & Dirksen, 2004, p.401). The commonly accepted postoperative benefits in-clude a decrease in venous stasis, stimulation of circula-tion, prevention of deep venous thrombosis/pulmonaryembolism, increases in muscle tone, coordination andindependence, and improved gastrointestinal, genitouri-nary and pulmonary functions.

One of the earliest references addressing change inpostoperative activity can be found in the literature dat-ing back to World War II. Dr. Canavarro wrote that priorto his study, routine ambulation began on or about post-operative Days 10–14. He initiated a program in 1946that changed the practice to postoperative Day 1.Today’s clinicians can appreciate the results of Dr.Canavarro’s (1946) early ambulation program, including“a definite reduction of all post-operative complications”by approximately 50% as a breakthrough for modernpractice (p. 181). Dr. Canavarro reported a rapid returnto normal bodily functions with the reduction in med-ication use, rectal treatments, and nursing care. In addi-tion, he wrote, “there is a saving in time and money and

This clinical practice guideline (CPG) is the product of cohe-sive interdisciplinary collaboration. The impact of this projectmerits more than routine attention given the lack of pub-lished nursing literature. The Department of Nursing actedas the catalyst to improve the quality of patient care. Thisinitiative resulted in a pivotal change in the standard of care,updating outmoded orthopaedic nursing practices. Themost significant change improved the time patients begantheir first postoperative activity. Dangling the patient on theday of surgery enhanced the benefits of early activity andreduced the time from 16.8 to 6 hr with no adverse patientconsequences. The CPG also demonstrated excellent post-operative pain management, realizing pain scores below 4(0–10 scale) at multiple time points. In addition, the lengthof stay improved from 4.3 to 2.8 days. The results supportthe value of implementing a CPG.

Postoperative activity following orthopaedicsurgery is a routine intervention initiated by thedisciplines of nursing and physical therapy (PT).This intervention varies between hospital set-

tings, typically prompted by a physician’s order or by an-other structure, such as a predetermined approved proto-col. When exploring postoperative activity in the generaland orthopaedic nursing literature, there is sparse evi-dence outlining nursing’s critical thinking skills associ-ated with decreasing the first postoperative activity fromthe historical 14-day mark to the more current model ofDay 1 or 2 for the joint replacement population. In addi-tion, there were no recent published reports describing acontemporary clinical practice guideline (CPG). As statedby Oermann and Huber (1999),

Our nursing profession needs to be able to iden-tify, measure, and document nursing’s contribu-tions with the same emphasis as that given toother disciplines. Broad outcomes such as mor-bidity and mortality do not address nursing’s con-tributions to patient care. Yet nursing-sensitiveoutcomes, such as pain level, symptom manage-ment, and self-care, often go unexamined. (p. 42)

Another nurse researcher, Meridean L. Maas, furthersuggests that “the emphasis on interdisciplinary care hasobscured nursing’s need to focus on nursing-sensitiveoutcomes” (Oermann & Huber, 1999, p. 42).

Beverly A. Morris, RN, CNP, MBA, Adult Health Nurse Practitioner,Certified, UCSD Medical Center, San Diego, CA.

Maureen Benetti, RN, NP, Orthopaedic Nurse Practitioner, UCSDMedical Center, San Diego, CA.

Hannah Marro, BSN, RN, Charge nurse, orthopaedic unit, UCSDMedical Center, San Diego, CA.

Cynthia Koch Rosenthal, BSN, RN, Patient Education Coordinator,UCSD Medical Center, San Diego, CA.

The authors have disclosed that they have no financial interests to anycommercial company related to this educational activity.

DOI:10.1097/NOR.0b013e3181ef7a5d

Clinical Practice Guidelines For EarlyMobilization Hours After Surgery

Beverly A. Morris ▼ Maureen Benetti ▼ Hannah Marro ▼ Cynthia Koch Rosenthal

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Orthopaedic Nursing • September/October 2010 • Volume 29 • Number 5 291Copyright © 2010 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

a more rapid turnover of patients per bed per month”(Canavarro,1946, p. 181).

An early nursing publication by authors Dumas andLeonard acquaints the reader with an interdisciplinaryresearch project involving nursing, medicine, and psy-chology that evaluated the consequences of change intime to activity (Fitzpatrick & Wallace, 2006). Thisstudy demonstrated a decrease in morbidity and mor-tality after initiating patient ambulation much soonerafter surgery than their previous standard. Similarly,Fitzpatrick and Wallace (2006) reported that the changein time to ambulation from 7 to 10 days to “within hoursafter the operation” provoked anxiety for both patientsand the individuals who cared for them (p. 587). Thisobservation set forth the advent of more structured pre-procedural educational programs for patients.

DIAGNOSIS RELATED GROUPS

Another pivotal change can be derived from the intro-duction of Medicare Diagnosis Related Groups (DRGs)in the late seventies and early eighties. Briefly, DRGs,as a prospective payment plan, defined a specific num-ber of hospital days for patients undergoing specifiedprocedures, and/or a finite amount of reimbursementassociated with each DRG. Prior to their introduction,the length of hospitalization for total joint replacementpatients was ill-defined, varying widely between hospi-tal and surgeon practices, and ranging from 10 to 21days. Postoperative activity began slowly with pre-scribed bed exercises, which may have included the ap-plication of an early form of continuous passive mo-tion. The introduction of DRGs provided a stimulus todevelop formalized rehabilitation programs to maxi-mize DRG benefits.

THE ENVIRONMENT

The University of California, San Diego Medical Center isan academic medical center located in the southern mostaspect of California, immediately adjacent to the borderof Mexico. The University serves a diverse populationthat includes the full spectrum of primary and complexjoint revision surgical procedures. Both the city of SanDiego and the Medical Center encompass a multiculturalpopulation as well as a wide range of socioeconomics.

The Medical Center is a two-hospital system with atotal of 505 beds. Both hospitals admit patients for jointreplacement surgery. The clinical staff can “float” to fillstaffing needs at either facility, although they have afixed work location the majority of the time. It was rec-ognized that the CPG would remove significant variationin practices between the hospital sites related to thesharing of staff.

CLINICAL PRACTICE GUIDELINE

According to the Institute of Medicine, “Clinical practiceguidelines are systematically developed statements to assist practitioner and patient decision about appropri-ate health care for specific clinical circumstances.” Inaddition, the Joint Commission Manual asserts that hos-pitals consider CPGs to improve processes by identifyingcriteria through their appropriate leaders, practitioners,and healthcare professionals (The Joint Commission,2008). Author Stephen Kim and colleagues performed a

literature review in 2003 of 11 clinical pathways con-cluding: “clinical pathways appear successful in reduc-ing costs and length of stay in the acute care hospital,with no compromise in patient outcomes” (Kim, Losina,Solomon, Wright, & Katz, 2003, p. 69).

A typical CPG for any specified indication is devel-oped from existing literature, medical research, theclinical competence contained within each healthcareorganization, and expert opinion. Nursing expertopinion for this CPG project was derived fromNational Association of Orthopaedic Nurses (NAON)presentations extracted from the annual Congress andthe evidence presented from sessions of the TotalJoint Replacement Special Interest Group. For in-stance, Eva Hyde presented an exhibit at the 2007NAON annual Congress detailing the developmentand operational components of a CPG (Hyde, 2007,May). While an excellent resource describing the com-ponents of a CPG, it did not include pre- or postnurs-ing sensitive outcomes.

NURSING NEEDS ASSESSMENT

In addition to developing a CPG, this project exploredchanges in nursing practices from the current standardof care of PT initiating patient ambulation on postoper-ative Day 1. The targeted change in nursing practice fo-cused on dangling the patient on the edge of the bed onthe day of surgery. Interviews with nursing and PT offered insight into the prelaunch CPG practice.Nursing’s reported stance placed focus on the physio-logic effects of general anesthesia and the severity ofpostoperative pain with the assumption that PT wasbetter prepared to deal with appropriate body mechan-ics and managing any possible complications such asthe risk of hip dislocation.

Dangling is a classic nursing intervention to initiateactivity by sitting the patient on the edge of the bed. Theprimary critical judgment gauges the patient’s abilityand tolerance to increase or limit the progression of ac-tivity. While there is no empirical evidence to indicatewhen, and for how long, dangling should occur for thepostoperative orthopaedic patient, an article by PaulaPrice, PhD, reported the results of dangling 55 post—coronary artery bypass graft surgery patients between 8and 15 hr. Dr. Price evaluated the cardiac parameters ofheart rate, blood pressure, and oxygen saturation whiledangling. Although the change in heart rate was shownto be statistically significant, increasing from a baselineof 86 to 93 bmp while dangling, Dr. Price points out thatno results were “clinically significant” because no ad-verse outcomes were observed (Price, 2006).

Orthopaedic surgeons and regional anesthesia hadautonomously incorporated changes into their respec-tive practices without coordination with other disci-plines. This created inconsistencies in the delivery ofcare as well as variations between the two hospital loca-tions. Neither nursing nor PT was able to direct themaximum advantages of physician changes into theirrespective practices to fully benefit the patient. Throughsubsequent discussions, all disciplines involved in deliv-ering care to the joint replacement patient populationagreed that the development of a preoperative patienteducation class and a CPG would benefit the patient and

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serve as a master plan to cluster interrelated, overlap-ping clinical actions.

The nursing staff further revealed apprehension re-garding the risk of dislocation postoperatively and, inparticular, on the day of surgery. In general, or-thopaedic surgeons are not as concerned about this riskas compared to previous years because of continual im-provements in implant design and the surgical proce-dure. Therefore, the surgeons at the medical centeragreed to work in partnership to enhance nursingknowledge of the decreasing rate of hip and knee dislo-cations in order to facilitate the initiation of patient ac-tivity on the day of surgery.

INTERDISCIPLINARY COMMUNICATION

Table 1 outlines the disciplines involved in the develop-ment of the structure and clinical processes. The num-ber of work sessions included interdisciplinary group ac-tivities, one-on-one meetings, education, and thedevelopment of the computerized physician order entry.Nursing representation was present at each of these ses-sions to fulfill the role of patient advocate. The projecthad full support of the nurse managers, chief nursing of-ficer, service line officer, and senior management team.

PAIN MANAGEMENT

Over the past three decades, patients have received post-operative pain management in the form of administra-tion of narcotics such as Morphine Sulfate, Dilaudid, orother potent opioids. Before initiating any mobilization,these powerful narcotics can be administered by meansof a single injection or intravenous/patient controlledanalgesia (IV/PCA). Narcotic complications are wellpublished in the today’s literature. The opioids can alsocause confusion and forgetfulness. These effects mayresult in the joint replacement patient failing to adhereto hip and fall precautions. In light of the limited nurs-ing literature or nursing research examining these is-sues, the interdisciplinary steering committee develop-ing the CPG took these postoperative challenges underconsideration when electing to begin activity on the dayof surgery. The method of measuring pain for the CPGused the well-established scale of a patient self-report of“0” to “10.” A score of “0” was interpreted as no pain,while a patient self-report of “10” was interpreted as theworst possible pain.

CONTINUOUS INFUSION NERVE BLOCKS

Pain management is specifically a measurable nursing-sensitive outcome particularly with the introduction ofcontinuous infusion nerve block (CINB) methodologies.

Approximately 1 year prior to the discussion of a CPG,the Department of Regional Anesthesia launched a con-tinuous infusion local anesthetic nerve block program(CINB). CINB began informally on a case-by-case patientbasis to familiarize surgeons with the technique. Thepain management program included CINBs, and at thattime, the traditional method of managing breakthroughpain using IV/PCA. As CINB is not intended to eliminateall pain, a breakthrough method had to remain availablein conjunction with the nerve block to achieve all the ben-efits of early activity. The logic behind the utilization ofCINB and IV/PCA was twofold: to develop protocols withsuitable anesthetic concentration and dosages to achievean acceptable level of pain/pain suppression, and to bal-ance it with an acceptable level of decrease in motor andsensory function in this patient population while not in-creasing the fall risk.

As the interdisciplinary team evaluated the prelaunchCPG, the patient needs assessment, and the gap analysisin staff knowledge, regional anesthesia continued to re-fine techniques in local anesthetic specifications. In2007, Brian Ilfeld, MD, presented the results of a re-search project at the annual University of California, SanDiego BONES Symposium. Results of CINBs for shoul-der procedures compared ropivacaine 0.2% to IV opi-oids, demonstrating a decrease in nausea from 49% to10% (p � .05%), and vomiting from 27% to 7% (Ilfeld,2007). The CPG factored the increasing success of CINBpain management program into the master plan.

During the interdisciplinary planning meetings, theclinical team decided to discontinue the use of IV/PCAwhenever possible by building a multimodal oral painmanagement program. Subsequently, pain managementconsisted of CINB, a long-acting around-the-clock oralnarcotic, a breakthrough pain oral narcotic availableevery 4 hr, and unless contraindicated, an around-the-clock Cox-2 inhibitor and acetaminophen. Of note, im-mediately postoperatively patients had available a smalldose, limited IV push opioid for breakthrough pain untilthey were tolerating oral fluids and achieving a painscore of 4 or less (�4) with oral as needed management.At the 2006 annual NAON Congress, Pam Cupec, MS,RN, from University of Pittsburgh Medical Center, pre-sented a paper, “What a Relief! Use of Nerve Blocks inOrthopedic Surgery,” reporting their hospital’s proce-dure utilizing [lumbar] plexus catheter nerve blocks. Thecatheters were turned off early in the morning to accom-modate physician rounds and to “attend therapy andsafety considerations. Nerve blocks [were] turned backon after the first morning therapy session” (Cupec, 2006).

The standard of care for the CPG project consisted ofa continuous infusion with no scheduled “off” periodsunless the patient’s assessment demonstrated an overallloss of muscle and/or sensory function of the extremity.Under total muscle or sensory block, at the request ofthe nurse, the anesthesiologist ordered the infusionstopped for 1 hr, at which time the nurse reassessed thepatient. With the return of motor sensory function, the

TABLE 1. INTERDISCIPLINARY DEVELOPMENT SESSIONS

Discipline Sessions

Physicians 12Nurse practitioner 15Rehabilitation services 12Care coordination 12Nursing 85Chief nursing officer 7Senior management team 7Pharmacy 5Information technology 6Patients 53

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pump was turned back on. To prevent potential eventssuch as a patient fall or the loss of sensation that couldlead to skin pressure injury, a motor and sensory assess-ment was performed every 4 hr and when anticipatingmobilization.

MethodsThe CPG is a comprehensive, multidisciplinary team ef-fort conducted as an observational, quality improve-ment project. Approval was reviewed and approvedfrom the internal review board and a waiver of individ-ual informed consent was obtained.

PATIENT QUESTIONNAIRE

The Medical Center participates in Press Ganey cus-tomer service evaluations. Surveys, sent to patients’homes, ask for their perception of their recent experi-ence. The Press Ganey Company then collects theanonymous surveys and analyzes the data for areas ofimprovement (Press Ganey Associates, Inc., 2008).From these blinded Press Ganey questionnaires, it wasnot possible to draw conclusions on relevant issues thatwere patient population specific. The authors could notuse these customer satisfaction surveys to deduce ex-actly what behaviors needed modification to improvethe quality of care specific to the joint replacement pop-ulation. Therefore, a quality improvement question-naire was developed as a one-on-one patient interviewtool that would also serve as a patient needs assessment.

An interview process was developed and administeredon the day of hospital discharge. Individuals were askeda series of 19 questions designed to elicit detailed feed-back. A random sampling of patients undergoing electiveprimary hip or knee replacement, hip resurfacing, or uni-condylar knee replacement was divided into two groupsfor this project (see Figure 1). The prelaunch, or baselinegroup, included joint replacement patients prior to theexistence of the CPG. The responses from this groupserved as a needs assessment in the development of theCPG and the preoperative patient education class con-tent. The prelaunch group subjectively described theirhospital experience and highlighted the aspects of care

most salient for orthopaedic surgical patients and theirfamilies. The second sampling, or postlaunch group, wascomposed of patients having joint replacement surgeryafter the implementation of the CPG.

Utilizing a standard set of questions to stimulate a di-alogue, an independent nurse interviewer, not providingdirect patient care, spoke with patients on the day of dis-charge. Questions explored the patient’s perception ofcommunication between nurse, surgeon, case manager,and physical and occupational therapists. Other ques-tions assessed the quality of pain management, readi-ness for discharge, and the capacity to self-administer aninjectable low-molecular-weight heparin for the preven-tion of deep venous thrombosis at home. During the first3 months before and after the implementation of theCPG, patient interviews were randomly conducted usingthe same questions to gauge changes in quality. To cap-ture the significance of the effect of the CPG, it was crit-ical to remeasure patient satisfaction as well as evaluateeffectiveness and efficiency of clinical activities.

PATIENT EDUCATION

After reviewing charts, the hospital-wide Press Ganeysurvey data and the results of individual patient andnurse interviews, the interdisciplinary team confirmedtheir initial impression that there was room for improve-ment. The interviews enabled the team to draw upon theunique relationship that exists between the patient andthe nurse and speak directly to the gaps in service, indi-cating where the quality of care could be improved. Thisinsight, combined with the concepts presented in theDumas publication regarding anxiety exhibited by boththe patient and caregivers when making changes in prac-tice, provided the nursing team with the framework ofchange theory (Oermann & Huber, 1999).

As a result, the next task was to expand the scope ofthe preoperative patient education program. Because ofthe predictability of the treatment course and expectedoutcomes, a standardized education curriculum wasclearly constructed for total joint replacement surgeries(Prouty et al., 2006). Educating patients and their fami-lies enables them to actively participate in their care andrehabilitation, to assist in goal-setting, and to help toevaluate their progress. In addition to furnishing pa-tients with a sense of control via anticipatory guidance,preoperative education has been shown to contribute toa decrease in length of stay and thus reduced hospitalcosts (Roach, Tremblay, & Bowers, 1995).

The class provided a means for patients to have theirquestions answered as well as clarify any misconcep-tions. Interaction with others having the same surgeryhelped to shape realistic expectations of the procedureand recovery period. The networking also aided familymembers in determining their role as a caregiver in thepatient’s recovery (Prouty et al., 2006). A folder of writ-ten handouts afforded patients the opportunity to re-view content covered in the class at a later time.

Nursing, partnering with PT, occupational therapy,and case management, began to refine the preoperativepatient education class to include the changes in painmanagement and in postoperative activity of danglingthe patient on the day of surgery. The 90-minute class

FIGURE 1. The distribution of surgical procedures that includedprimary hip and knee replacements, hip resurfacing, and uni-condylar knee replacement. No revision or bilateral procedureswere included. CPG = Clinical Practice Guideline.


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also covered other topics such as preparing the homefor a safe recovery. A physical therapist demonstratedexercises to be performed while in the hospital andafter discharge. A variety of medical equipment wasdisplayed including urinary catheters, incentivespirometer, intermittent compression stockings, awalker, and a long-handled grabber. While instructorsdiscussed each piece’s function and proper use, partici-pants were encouraged to handle and practice using thedevices.

Another crucial element added to the class was in-struction on self-injecting of a low-molecular-weight he-parin. A demonstration by the nurse, with an improvisedreturn demonstration by the patient, followed a discus-sion of deep venous thrombosis prophylaxis. There werethree main goals with this key component of the class:(1) to decrease patient anxiety at the time of hospital dis-charge informing them ahead of time that they would beon an injectable medication at home; (2) to explain theimportance of maintaining the regimen at home; and (3)to show how to physically perform the injection.

The patient education class was attended by a broadspectrum of patients including those who spoke Englishas a second language. Primary languages of participantsother than English included Spanish, Chinese,Vietnamese, and Russian. In the majority of sessions, afamily member attended to interpret for the patient. Onall other occasions, the Patient Education Coordinatorwas able to locate a certified interpreter for the patient.The drafts of the CPG were altered into a version knownas the Patient Friendly Guideline. This easy-to-read, de-tailed account of the expected hospital course was avail-able during all phases of preoperative appointments andinpatient stay.

With knowledge, planning, and patient education so-lidified, the team continued to collaborate and incorpo-rate the new best practices into their routines. The teamalso communicated these practices with the patientusing similar language. This ensured that the patientwould receive consistent information from all disci-plines throughout the continuum of care.

NURSING EDUCATION

Frontline staff interviews demonstrated that the major-ity of nurses lacked comprehensive, up-to-date totaljoint replacement specific education or were relying oneducation gained 10 or more years ago. In contrast, theCPG required using updated nursing standards, physi-cian changes in surgical techniques and prostheses, andanesthesiology changes in pain management. Throughthe nursing discussions, barriers to comfort with theproposed changes in the nursing standard of care cen-tered around dangling the patient on the day of surgery,tied to the implications of managing postoperative nau-sea, vomiting, pain, light headedness, and risk of dislo-cation. To assist the nursing staff in overcoming theseconcerns, an educational course was developed in theform of a 3-hr, required attendance program. The didac-tics were presented by the orthopaedic surgeons, nursepractitioners, and nurse educators. Physical and occu-pational therapists performed a one-on-one bedsidescenario competency to reinforce appropriate assess-ments, along with a return demonstration of dangling

the patient on the edge of the bed, and transferring thepatient from bed to a chair.

CPG IMPLEMENTATION

A final CPG document and corresponding physicianorder set were launched in April 2008. The CPG was ini-tially developed in paper format outlining the clinical,step-by-step interventions. In addition, the physicianorder set was integrated into the facilities’ computer-ized physician order entry system (See Appendix A).

ResultsPATIENT NEEDS ASSESSMENT

Patient demographics with the results of the patient in-terview questionnaire are shown in Table 2 for bothCPG prelaunch (baseline) and postlaunch. There was aslight increase in the average age of the postlaunchgroup and in the number of hip resurfacing procedures.This increase reflects a surgeon change within the jointreplacement service line as well as the randomness ofpatient interviews.

Subjective answers were reported using a Likert-typescale and are available in Tables 3 and 4. The Likert-type questionnaire indicated levels of satisfaction witheach statement by choosing one of five options: a ratingof “very poor” equals one (1), “poor” equals two (2),“fair” equals three (3), “good” equals four (4), and “verygood” equals five (5). This rating system mimics thewording from the Press Ganey surveys used by the hos-pital for customer service feedback. The respondents’scores were added together with an arithmetic averageobtained for each statement.

There was a mix of results from the pre- to post-CPGlaunch questionnaire regarding communication be-tween the patient and the clinical team (see Table 3).Nursing demonstrated the most improvement in theirexplanations to the patient. The overall team communi-cations, however, did not improve.

There were several interview questions intended to as-certain the patient’s readiness for discharge (see Table 4).The prelaunch CPG results uncovered the deficits thatwere later targeted to improve patient outcomes. In addi-tion, the CPG set forth the expectation that the inpatienthospital patient teaching would begin on postoperative

TABLE 2. PATIENT INTERVIEW DEMOGRAPHICS

Prelaunch Postlaunch CPG (n � 23) CPG (n � 20)

Age (years)Mean 59.9 60.3Range 25-87 33-81

GenderMale 10.0 19.0Female 13.0 6.0

Surgical procedurePrimary hip replacement 8.0 8.0Primary knee replacement 14.0 6.0Hip resurfacing 1.0 6.0

Note. CPG � clinical practice guideline.

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Day 1. Postlaunch of the CPG demonstrated improve-ment of instructions given on self-injection.

Another question evaluated the patient’s assessmentof pain management. This topic was also revised for thepreoperative patient education class to emphasize theuse of nerve blocks and the multimodal methodology ofpain management. The instructors of the class contin-ued to offer instruction on the use of IV/PCA andepidural pain management for the atypical patient whowas not a candidate for CINBs.

The ability to manage the patients’ pain adequatelyshowed improvement. An increase in this score was im-portant because sufficient pain control while an inpa-tient was necessary for patients to actively participate inall forms of rehabilitation. It was also vital to their self-care after discharge. Of all the patient self-care ques-tions, pain control improved the most.

CLINICAL PRACTICE GUIDELINE AUDITS

Table 5 illustrates patient demographics, attendance atthe preoperative patient education class, and the lengthof hospital stay. Patient activity was randomly auditedand may, or may not, be inclusive of patients in the pa-tient questionnaire survey.

In the postlaunch CPG group, one patient with a his-tory of GERD experienced a complication of postopera-tive ileus. The patient underwent a total knee replace-ment, received a nerve block, and dangled on the day of

surgery; the patient’s length of stay was 9 days. A secondpatient underwent a total hip replacement, received anerve block, dangled on the day of surgery, and thendemonstrated hypotension and hyponatremia on post-operative Day 1. The patient was transferred to a higheracuity unit at this time and remained in the hospital for5 days. Both patients’ data were reported in the primaryanalysis, but in a second analysis of length of hospitalstay they were reported as an outlier, reducing the over-all length of stay from 3.1 to 2.8 days as shown in Table 5.A third patient remained in the hospital for 5 days with-out complication and was therefore included in re-ported results of both analyses.

Table 6 outlines the perceived barriers to dangling onthe day of surgery as presented by nursing and PT. It il-lustrates the number of patients who experienced eithernausea or vomiting. The audit data had to contain cleardocumentation that the problem was resolved or wors-ened. These findings are reported to outline the inci-dence of the perceived barriers to dangling the patienton the day of surgery.

Additional auditing revealed that 7 of the 30 post-launch patients (23%) did not receive prophylactic treat-ment of nausea during surgery. Three of the 30 post-launch CPG patients (1%) received medication for nauseain the postoperative care unit (PACU). Of the eight pa-tients on the unit complaining of postoperative nausea,two patients were treated for vomiting (6%). These twopatients were not dangled on the day of surgery.

In an earlier era, the presence of drains was consid-ered a physician restriction to activity until such time asthe drain was discontinued. In this contemporary time,some large medical centers have eliminated the use ofdrains altogether. However, in this academic center, thedrain remains a consideration on a case-by-case basis.It does not, however, obstruct the patient from danglingon the day of surgery.

Table 7 reflects postlaunch findings of pain scorespostoperatively of patients who were dangled on the dayof surgery. Postlaunch assessments took place: (1) upondischarge from the PACU; (2) on admission to unit from

TABLE 3. PATIENT INTERVIEW QUESTIONS EVALUATING

COMMUNICATION WITH A POSSIBLE SCORE OF 1 TO 5

Average Score

Prelaunch PostlaunchCPG CPG

Question (n � 23) (n � 20)

RN discussed plan of care 4.0 4.1Understood RN explanations 4.1 4.5Understood MD explanations 4.6 4.6Communication between 4.0 3.9

RN and MDCare organized between 4.0 3.9

multidisciplinary team

Note. CPG � clinical practice guideline; RN � registered nurse.

TABLE 4. PATIENT SELF-CARE QUESTION RESULTS,INCLUDING PAIN CONTROL WITH A POSSIBLE SCORE OF 1-5

Average Score

Prelaunch Postlaunch CPG CPG

Question (n � 23) (n � 20)

Preparedness to care for self 3.9 4.1Explanations of discharge medicines 3.7 3.6Instruction on self-injection 3.4 3.7Adequacy of pain control 3.5 4.2

Note. CPG = clinical practice guideline.

TABLE 5. DEMOGRAPHICS OF PATIENTS INCLUDED IN CHART

AUDITS

Prelaunch Postlaunch CPG Chart CPG Chart

Audits Audits (n � 14) (n � 30)

Age (years)Mean 56.2 49.3Range 29-72 33-84

GenderMale 7.0 (50%) 20.0 (67%)Female 7.0 (50%) 10.0 (33%)

Preoperative education classAttended 11.0 (78%) 15.0 (50%)Did not attend 3.0 (21%) 15.0 (50%)

Length of stay (days)Mean without outliers 4.3 2.8Mean with outliers 3.1



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PACU; (3) prior to dangling the patient; (4) reassess-ment after dangling the patient; and (5) PT assessedpain on postoperative Day 1 before beginning ambula-tion. Of a total of 25 patients, 19 patients dangled, 4 pa-tients were admitted to units such as telemetry and in-termediate care unit, and 2 other patients had nauseaand vomiting, The remaining five patients in the post-launch auditing had incomplete data and were not in-cluded in Table 7. Thus, a total of 30 patients were uti-lized in the outcomes. As the dangling activity came outof the development of the CPG, there were no prelaunchCPG dangling pain scores available for auditing. Foroutcome comparison, there is a single pain score shownin the prelaunch CPG group as taken at the time the pa-tient was admitted to the orthopaedic unit.

These scores represented patients achieving safe and ac-ceptable levels for pain management as they were below ascore of 4 (�4), the level that necessitates offering a painmanagement intervention at this institution. Furthermore,even with the small sample size of 30, it demonstrates thatpain was not a barrier to the change in the nursing stan-dard of care. The nursing results of quality pain manage-ment were supported by the results of the patient satisfac-tion interview score previously described in Table 4.

Table 8 outlines the time frame for patients who dan-gled on the day of surgery and the time frame patientsambulated with PT. To be included in the calculation ofthe average number of hours to the first activity, two timepoints were required. They consisted of the time the pa-tient was transferred from the PACU to the orthopaedic

unit, and the time the nurse dangled the patient or thetime PT ambulated the patient.

Nineteen (79%) patients demonstrated an averagetime of 6 hr after transfer from the PACU to the time ofthe first dangling (see Table 8). This demonstrates a 38%reduction in time to the first mobilization of the patient.The majority, 63%, of the patients were dangled by thenight shift. The first time to ambulation by PT on post-operative Day 1 averaged 16 hr.

Outcomes: In summary, launching a CPG estab-lished the following:

• Improvement in the nursing standard of care byeliminating barriers to change.

• Patient mobilization by nursing within 6 hr post-transfer from the PACU.

• Ambulation by PT pre- and postlaunch CPG of 16hr posttransfer from PACU.

• Reduction in length of hospital stays from 4.3 to2.8 days.

• Elimination of IV/PCA with successful CINB andmultimodal pain management program.

• Consistent improvement in pain managementbelow a pain score of 4 (4):• At the time of PACU discharge (pain score 2.1)• Upon admission to the orthopaedic unit from

PACU (pain score: 3.3)• Prior to the intervention of nursing dangling the

patient on the day of surgery (pain score: 2.9)• Reassessment following the intervention of

dangling (pain score: 3.3)• Assessment by PT prior to ambulation on post-

operative Day 1 (pain score: 3.3).• Patient satisfaction interview scores support im-

provements in pain management from aprelaunch CPG score of 3.5 to postlaunch CPGscore of 4.2.

• Areas to be addressed include improvement in in-terdisciplinary communication as reported frompatient interviews.

• The benefits of patient education demonstratedimprovement in:• Preparedness to care for self• Instruction in low-molecular-weight heparin

self-injection

TABLE 6. INCIDENCE OF PERCEIVED BARRIERS TO DANGLING

ON THE DAY OF SURGERY

Incidence

Prelaunch CPG Postlaunch CPG Perceived Chart Audits Chart Audits Barrier (n � 14) (n � 30)

Nausea 35% 27%Vomiting 7% 6%Drains 57% 40%Patient refusal n/a 3%


TABLE 7. PAIN ASSESSMENT SCORES AT FIVE DIFFERENT TIME POINTS WITH A POSSIBLE SCORE OF “0” TO “10”

Prelaunch CPG Chart Postlaunch CPG Chart Audits (n � 14) Audits (n � 30)

Pain assessment time point Average ScoreDischarge from postoperative care unit n/a 2.1Admission to orthopaedic unit 4.7 3.3Before dangling on day of surgery n/a 2.9After dangling on day of surgery n/a 3.3Before physical therapy on postoperative day one n/a 3.3

PercentagePatients with nerve blocks 78.0 83.0Patients dangled on day of surgery n/a 79.0

Note. Pain assessment scores are shown at five different postsurgery time points, utilizing a possible score of “0 to 10” (zero [0] equals nopain; ten [10] equals worst possible pain). CPG � clinical practice guideline.

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• Helpfulness of class• Patients’ understanding RN discussion of the

care plan

The outcomes of the CPG project support the claimthat communications are complex and essential for ef-fective decision-making and continual cooperative part-nerships. This offers growth challenges, yet also re-markable opportunities.

Through interviews, education, and the developmentof a new standard of care by means of a CPG, patientswere mobilized on the day of surgery in a safe manner.Of the patients who were dangled, no secondary adverseevents occurred when initiating the patient’s first post-operative activity within 6 hr of surgery.

Two of the patients audited on the CPG experiencedvomiting. Of these two patients, one was not treated pro-phylactically in the operating room. Neither of these pa-tients was dangled. The limited side effects of nauseaand vomiting may be attributed to the influence ofCINB. One published report supports these events. Itstates that a decrease in the use of systemic analgesia co-incides with a decreased incidence of nausea and vomit-ing (Boyd, Eastwood, Kalynych, & McDonough, 2006).

PAIN MANAGEMENT

The decrease in pain scores below a score of 4 (� 4) pro-vided positive attributes and basis for an expandedstudy of the benefits associated with initiating activitywithin hours following surgery. Even with more aggres-sive activity led by PT on postoperative Day 1, the painscores remained less than 4. Since data were collectedfor the purpose of quality improvement, not research,the authors are not suggesting that this is a statisticallysignificant improvement. Rather, the authors are notingthat CINB, as an intervention, can be associated withimprovements not only in pain management, but mayalso contribute to improved postoperative activity.

PREOPERATIVE PATIENT EDUCATION

Increasing the number of offerings of preoperativepatient education gave more patients an opportunity toattend the classes. This education proactively addressedthe powers of collaboration and patient’s participationin self-care.

EFFECTS OF PHYSICIAN PRACTICE CHANGES

Advancements in physician practices were not transpar-ent to nursing or seamless to the remainder of the clini-cal departments. Next to the patient, nursing would bethe most affected by these changes. The patient andnursing questionnaires, in conjunction with interdisci-plinary meetings, served as a needs assessment, empha-sizing the value of investing in specialty training to de-velop proficiency and alignment with physician practicechanges. Specialty training would also create familiar-ity with new technology including the rapid uptake ofCINBs within the organization.

DiscussionAccording to a recent article published by the Journal ofBone and Joint Surgery, “The benefits of total joint re-placement are the most dramatic of any contemporarysurgical procedures” (Katz, Wright, & Losina, 2004).Achieving such benefits requires synchronized func-tions across multiple disciplines. A patient-focused,total joint replacement CPG was developed to maximizeinterdisciplinary collaboration. Through careful plan-ning, data-mining, and ongoing monitoring, positiveoutcomes have been recognized from the early launchCPG data. The project significantly changed the para-digms governing outmoded nursing practices, drivingimprovements in patient care and nursing outcomes.

Although some of the data showed no change frompre- to postlaunch CPG, these findings are an effectiveevaluation to guide the next generation of this organiza-tion’s CPG with improvements. While advancements inclinical practice outcomes are traditionally measured interms such as morbidity and mortality, today’s market-place also mandates nontraditional outcomes to includepatient satisfaction and interdisciplinary communica-tion. To gauge gaps in customer satisfaction in a highlytechnological, potentially high-risk environment, pa-tients were encouraged by the authors to participate inone-on-one interviews. The patient interviews gener-ated insight into the ripple effects of a large integratedhospital process. The interdisciplinary team used thesefindings to drive change to improve interactions be-tween clinical and system processes, including the de-velopment of a Patient Friendly Guideline.

Advanced practice nurses recognized an opportunityto leverage the utilization of CINB to support initiatingpatient activity on the day of surgery—in effect, alteringthe nursing standard of care. Postoperative pain manage-ment requires a balance between pain relief and un-wanted side effects. It is worth mentioning to readerswho are not familiar with CINB that CINB serves toimprove pain management while eliminating an abun-dance, or overabundance, of injectable opioids and theirside effects. And lastly, the use of the CPG itself may have

TABLE 8. TIME FRAMES FOR PATIENTS DANGLED ON THE DAY

OF SURGERY AND FOR PATIENTS AMBULATED WITH PHYSICAL

THERAPY

Hours

Prelaunch CPG Postlaunch CPG Chart Audits Chart Audits

Time Frame (n � 14) (n � 30)

Admission to orthopaedic unit until time dangled

Mean n/a 6.0Range n/a 1.0–16.5

Admission to orthopaedic unit until time ambulated with physical therapy

Mean 16.8 16.5Range 7.0–22.4 11.0–21.6



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affected positive patient outcomes with respect to painmanagement. Lack of quality postoperative pain man-agement has a wide range of detrimental acute effects onboth traditional and nontraditional outcomes.

While there is no empirical nursing evidence to indi-cate who, when, how, or how long dangling should occurin postoperative orthopaedic patients, the preliminary re-sults of monitoring this practice demonstrates the capac-ity to broaden this tradition. This project embodiedJeffrey Uppington’s concise statement: “They can be ofbenefit when there is uncertainty about care, can helpoverturn outmoded practices and provide reassurances ofthe appropriateness of clinical actions and improve theconsistency of care” (Uppington, 2006, p. 13). Adding toUppington’s statement, the recommendations fromNAON add further clarification to the use of guidelines,stating: “guidelines must be individualized by the profes-sional nurse for each patient and clinical situation”(Whittington, Selman, & Holmes, 2001). Practices,processes, and the initial model CPG developed for thisproject will be updated to reflect findings from internalmonitoring and changes in the care environment. Today’shealthcare settings are challenged by steady introductionsof expanded technologies and treatments. Programs suchas CPGs are critical for helping an organization improvecompetencies needed to coordinate safe practices and ef-ficiencies in care. Initiating activity to within hours ofsurgery benchmarks this CPG as a dynamic evolution anda contribution to quality improvement.

Implications for NursingThe central component to quality improvement is act-ing on what is learned and is a hallmark of learning or-ganizations (Institute of Medicine, 2001). However,findings from quality improvement projects tied withorthopaedic nursing standards of care are seldom pub-lished, resulting in a loss of knowledge to the remainderof the profession. Much can be gained through exami-nation of one’s own organization or learned from the ex-change of ideas and experiences through professionalorganizations. This academic medical center investi-gated the existing literature on CPGs and early mobi-lization, utilizing the little evidence they found as afoundation for the project. As a next step, the authorscompleted an internal needs assessment of both nursingstaff and patients. The insight gained guided the direc-tion and advancement of the institution’s standards andpractices for orthopaedic nurses. Because of limitedsolid evidence describing the structure or methodsused, the authors developed their own early mobiliza-tion process by merging the external evidence with in-ternal assessment results. Nurses can use this project asa template to change their standard of care to produceclinical outcomes or the development of a CPG (seeFigure 2). The solicitation of nursing’s input about as-pects of their daily practice uncovered and challenged“urban-legend” reasoning behind outmoded practices.In this instance, it served to promote change from amore conservative, passive role to one in which nursesand patients were active participants. The results of thisproject support earlier models of CPGs and patient mo-bilization findings throughout the past 60 years.

ACKNOWLEDGMENTS

A special thanks to Patrick Olsen, RN; Sarah Bonome,RN; Nita Uson, RN; Joanne Markart, RN; Sherlita Alfonso,RN; Scott Meyer, MD; Scott Ball, MD; Ed Mariano, MD;Lisa Dacey, MSPT; Lynda Garza, OT; Carolyn Jones-Cullen, RN, and in particular, the staff of both hospitals.Assistance also came from San Diego State Universitynursing students as a senior year change project andSusan A. Schwarz.

REFERENCESBoyd, A. M., Eastwood, V. C., Kalynych, N. M., &

McDonough, J. P. (2006). Clinical perceived barriers inthe use of regional anesthesia and analgesia. Acute Pain,8(1), 23–27.

Canavarro, K. (1946). Early postoperative ambulation.Annals of Surgery, 124(2), 180–181.

Cupec, P. (2006, May). What a relief! Use of nerve blocks intotal joint replacement. Paper presented at the NationalAssociation of Orthopaedic Nurses Congress, Boston, MA.

Fitzpatrick, J. J., & Wallace, M. (2006). Encyclopedia ofnursing research (2nd ed.). New York: Springer.

Hyde, E. (2007, May). Modular nursing orientation path-ways: Organized, standardized, centralized. Poster sessionpresented at the National Association of OrthopaedicNursing Annual Congress, San Jose, CA.

Ilfeld, B. (2007, October). Continuous peripheral nerve blocksfor orthopaedic surgery. Podium presentation at theBonified Orthopaedic Nursing Education Symposium(BONES), San Diego, CA.

Institute of Medicine. (2001). Crossing the quality chasm: Anew health system for the 21st century. Washington, DC:National Academy Press.

Katz, J. N., Wright, J., & Losina, E. (2004). Patient decision-making and total joint replacement [Peer commentary onthe paper “The moving target: A qualitative study of elderlypatients’ decision-making regarding total joint replace-ment surgery” by Jocalyn P. Clark, Pamela L. Hudak,

FIGURE 2. The developmental approach employed by the inter-disciplinary team in designing the Clinical Practice Guideline(CPG), including the “Patient Friendly” version of the CPG.

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Gillian A. Hawker, Peter C. Coyte, Nizar N. Mahomed,Hans J. Kreder, and James G. Wright]. The Journal of Boneand Joint Surgery, Retrieved November 28, 2008, fromhttp://www.jbjs.org/Comments/2004/cp_jul04_katz.shtml

Kim, S., Losina, E., Solomon, D., Wright, J., & Katz, J. (2003).Effectiveness of clinical pathways for total knee and totalhip arthroplasty. Journal of Arthroplasty, 18(1), 69–74.

Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R. (Eds.).(2004). Medical-surgical nursing: Assessment and man-agement of clinical problems (6th ed., pp. 401–407). St.Louis, MO: Mosby.

Oermann, M. H., & Huber, D. (1999). Patient outcomes: Ameasure of nursing’s value. American Journal of Nursing,99(9), 40–48.

Press Ganey Associates, Inc. (2008). Surveys and reports.Retrieved December 26, 2008, from http://www.pressganey.com/cs/our_services/surveys_and_reports

Price, P. (2006). Physiologic effects of first-time sittingamong male patients after coronary artery bypass graftsurgery. Dynamics, 17(1), 12–19.

Prouty, A., Cooper, M., Thomas, P., Christensen, J., Strong,C., Bowie, L., et al. (2006). Multidisciplinary patient ed-ucation for total joint replacement surgery patients.Orthopaedic Nursing, 25(4), 257–261.

Roach, J. A., Tremblay, L. M., & Bowers, D. L. (1995). Apreoperative assessment and education program:Implementation and outcomes. Patient Education andCounseling, 25(1), 83–88.

The Joint Commission. (2008). Synopsis of the 2008 jointcommission standards for acute care hospitals. RetrievedNovember 30, 2008, from www.thejointcommission.org/

Uppington, J. (2006). Guidelines, recommendations, proto-cols, and practice. In G. Shorten, D. Carr, D. Harmon, M.Puig, & J. Browne (Eds.), Postoperative pain manage-ment: An evidenced-based guide to practice (pp. 12–26).Philadelphia, PA: Saunders Elsevier.

Whittington, C. F., Selman, S., & Holmes, S. B. (2001).Guidelines for orthopaedic nursing: Knee arthroplasty.Pitman, NJ: National Association of Orthopaedic NursesMonograph.

For 30 additional continuing nursing education articleson orthopaedic topics, go to nursingcenter.com/ce.


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