enhancing the patient’s experience through the total joint

Copyright © 2012 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

322 Orthopaedic Nursing • November/December 2012 • Volume 31 • Number 6 © 2012 by National Association of Orthopaedic Nurses

Enhancing the Patient’s Experience Through the Total Joint Replacement Continuum of Care

Kathleen R. Parisien ▼ Deborah Valentine ▼ Vicki Hoffman ▼ Janet Penzero

DOI: 10.1097/NOR.0b013e31827424c9

Kathleen R. Parisien, MA, RN, Stamford Hospital, Stamford, CT.

Deborah Valentine, BSN, RN, CCM, ONC , Stamford Hospital, Stamford, CT.

Vicki Hoffman, BA , Stamford Hospital, Stamford, CT.

Janet Penzero, RN, ONC , Stamford Hospital, Stamford, CT.

The authors have disclosed that they have no fi nancial interests to any commercial company related to this educational activity.

The American Academy of Orthopaedic Surgeons (AAOS) estimates that in the United States there are more than 300,000 total knee replace-ments and 193,000 total hip replacements

performed annually (AAOS, 2009a,b). The decision to have elective orthopaedic surgery is often fraught with much anxiety and trepidation. Once a patient has been indicated for elective hip or knee replacement, the pro-cess of coordinating their care begins. Because of the increase in the elderly population, hip replacement sur-geries are considered high-volume, high-cost medical problems (Todaro & Schott-Baer, 2001). A candidate for total joint replacement (TJR) should have evidence of joint damage, persistent pain that is not relieved by nonsurgical management, and clinically signifi cant functional limitation resulting in diminished quality of life (NIH Concensus Development Conference on Total Knee Replacement, 2003). To improve quality of life, the signifi cance of having patients follow the care contin-uum from admission to discharge is spotlighted in The Joint Commission Certifi ed Orthopedic and Spine

The use of a Total Joint Replacement Pathway provides nurses with a process that guides their professional practice. The pathway begins during the preadmission phase and follows the patients throughout their hospital stay. Relationship-based care is demonstrated by the interdisciplinary care that includes the patient and healthcare team. The goal of this article is to describe the continuum of care for total joint replacement patients at Stamford Hospital from preadmission to discharge. A preoperative class is offered weekly to all patients who are scheduled for elective surgery. Approximately 90% of patients attend the preoperative classes. This article provides a framework for guiding the clinical care of total joint replacement patients. Implementation of this framework will ultimately improve patient care and nursing practice in any surgical setting. Pain management and patient education are 2 core components of nursing practice vital to the success of the Joint Replacement Program and facilitate care of these patients through the continuum.

Institute’s Total Joint Replacement Program at Stamford Hospital in Stamford, CT.

The patient is at the center of all care rendered while in the hospital and the decision to have hip or knee replacement is discussed in depth with the physician prior to surgery. During the physician consult, many patients present with arthritis. Consequently, the ortho-paedist will discuss the benefi ts and risks of hip or knee replacement. In addition, the physician explains that the procedure for hip or knee replacement is to substi-tute the diseased joint with an artifi cial one. Afterward, patients are given an opportunity to ask questions regarding surgery and postoperative care. Once the patient is indicated for TJR, the patient’s preferences for care are a priority ( Hawker, 2006 ). Moreover, orthopae-dic surgeons will recommend surgery on the basis of the degree of pain and decreased function.

Once a patient is scheduled for surgery, the patient is referred to the preoperative Total Joint Education Program. The program begins with a comprehensive education class presented by the orthopaedic clinical care coordinator. The coordinator encourages active participation from the patient and family. The goal of the weekly evidence-based class is to educate the patient and family member about the upcoming surgery and provide information that enables the patient to make informed decisions. More than 90% of patients attend the class with the goal of participation being 100%.

The content covered in the class includes informa-tion about hip and knee replacements, preparing for surgery, what to expect while in the hospital, what to expect after discharge, and the pathway to recovery. Patients receive a Patient Education Manual, which outlines the class information. The manual is a valuable

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© 2012 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2012 • Volume 31 • Number 6 323

resource as they prepare for surgery as well as when they return home. In addition to the manual, they re-ceive elastic shoelaces, pain management brochures, and antibacterial cloths to use the morning of surgery. Patients are instructed on infection prevention and en-couraged to get screened for methicillin-resistant Staphylococcus aureus prior to surgery. If patients are unable to come to class, they are given the patient edu-cational material in the preadmission testing area, or it is mailed to them. The mailing is followed by a phone call to verify that the patient understands.

Prior to surgery, patients are given the opportunity to call the clinical care coordinator to answer any ques-tions they may have. It is important to provide preop-erative patient information in order to increase the patient’s knowledge. In addition, there is evidence that preoperative education has a modest yet benefi cial effect on preoperative anxiety (McDonald, Hetrick, & Green, 2009).

Preoperative testing is completed with a patient’s primary care physician or at Tully Health Center’s Pre-Admission Testing (PAT) Center. Patients are contacted by a PAT nurse who provides instructions regarding sur-gical protocols. A preoperative nursing assessment is conducted, as well as initiation of the Total Joint Replacement Clinical Care Pathway, which is part of the patient’s medical record from admission through hospi-tal discharge. The pathway informs the multidisci-plinary team of the patient’s progress and goals. The pathway has interventions that are followed by nursing, physical therapy, and case management until discharge. If the patient is unable to meet the daily goals, the vari-ance is addressed with the healthcare team. The PAT nurse establishes goals with the patient and documents whether or not the patient has attended the total joint education class. In addition, referrals are made to social work or pain management if needed and discharge options and goals are discussed. As the patient is pre-pared for surgery, pain management is considered. The perioperative nurse discusses expectations for TJR sur-gery as well as establishing goals for pain management. The nurse will reinforce education on anesthesia, TJR, and universal protocol, and initiate the Situation Background Assessment Recommendation (SBAR) tool for communication.

Once the patient has undergone surgery, education continues throughout the continuum from periopera-tion to postoperation. Upon arrival to the orthopaedic unit, the registered nurse will identify the patient’s base-line pain and discuss appropriate pain management based on patient feedback. The nurse reviews all equip-ment such as the overhead trapeze, continuous passive motion machine, commode, and walker. During the assessment, the patient is instructed on any drains that are at the operative site (e.g., Hemovac). The nurse will explain how these drains help with recovery time and when the drains will be removed. In addition, a discus-sion on preventing infection will include the use of intravenous antibiotics within 24 hours of surgery along with reinforcing proper hand hygiene. The postoperative education process includes therapeutic communication between the nurse and the patient. Kimmel (2007) states, “In therapeutic communication, the nurse seeks

a response from the patient that is favorable to the patient’s mental and physical health. The therapeutic approach to communication can help the patient to be calm and face the situation in a positive way.”

As part of the clinical pathway, sequential compres-sion devices or venodynes are applied to the legs and anticoagulants are prescribed by the physician. Educating patients about postoperative routines helps reduce the incidence of postoperative complications, specifi cally deep vein thrombosis. Furthermore, post-surgical patient teaching involves the use of the incen-tive spirometer. Lastly, the patient is instructed on positioning and mobility. The goal for the patient is to continue exercising in bed by doing quad sets and foot pumps while awake. The use of the overhead trapeze bar is reinforced so that the patient can be repositioned and maintain hip or knee precautions. In the evening, the nurse assists the patient to dangle at the bedside. These postsurgical interventions help with circulation, respiratory function, prevention of blood clots, and patient comfort.

To meet the needs of TJR patients and to effectively manage their care, standardized order sets and dis-charge instructions were developed at Stamford Hospital. As a result of these order sets, two signifi cant protocols were implemented: pain management and physical therapy. Education is given to the patient on how to rate their pain with the use of the Wong-Baker scale. The tool allows the patient to rate their pain, providing comfort through administration of appro-priate medication. Pain reassessment is key to ensure that the patient’s pain is managed. Chelly, Ben-David, Williams, and Kentor. (2003) suggest that effective pain management in hip procedure patients is associ-ated with a decreased length of stay. The nursing staff provides information to patients in a way that encour-ages them to verbalize pain at an early stage and causes them to take a more active part in the postoperative treatment regimen (Sjoling, Nordahl, Olofsson, & Asplund, 2003). Nevertheless, if a patient’s symptoms are not alleviated using ordered medications, a pain consult is scheduled.

A collaborative approach to communicating with pa-tients includes the use of white boards in patient rooms. The nurse, the physical therapist, and the patient estab-lish goals for each day to ensure that they are ready for discharge on postoperative day 3. For example, on post-operative day 1, the goal would be to get out of bed, ambulate to the hallway, and participate with physical therapy in a group therapy setting. It is also important to know whether the patient was using a cane or walker prior to surgery, this information will give the nurse and the physical therapist an insight of their knowledge of the equipment they will be using to ambulate. Generally, knee pain limits a patient’s ability to perform daily activities including dressing, cooking, or cleaning (Jacobson et al., 2008). Therefore, the postoperative course for patients includes instructions on proper posi-tioning, bed and sitting exercises, and proper transfers on day 1. Postoperative day 2 focuses on range of mo-tion, mobility, climbing stairs, gait, and reinforcement of proper positioning. Postoperative day 3 incorporates the fi nalization of discussions with the case manager



324 Orthopaedic Nursing • November/December 2012 • Volume 31 • Number 6 © 2012 by National Association of Orthopaedic Nurses

Conclusion In summary, Care through the Continuum involves a multidisciplinary team working together to promote quality outcomes (see Figures 1 and 2 ). Preoperative education is instrumental in alleviating anxiety and em-powering patients. In addition, clinical pathways are utilized from preadmission to discharge utilizing the practice guidelines of National Association of Orthopaedic Nurses (NAON), American Academy of Orthopaedic Surgeons (AAOS), National Institutes of Health (NIH), and Surgical Care Improvement Project (SCIP). The pathway assists in guiding evidence-based care to patients. In conclusion, nurses focus on instruct-ing patients about pain management, positioning, enous thromboembolism prophylaxis, medications, and increasing mobility. This supports the patient’s activities of daily living, wound care, and infection prevention.

regarding home equipment needed or referrals to a rehabilitation facility. Ultimately, the goal of increased daily activity is to enhance strength and mobility. Moreover, the patient develops endurance to walk fur-ther and perform exercises several times a day.

As a result of implementing bedside handoff report-ing, hourly rounding and the use of white boards on the orthopaedic unit, Stamford Hospital has seen positive outcomes. The patients’ perception of care during their hospital stay has surpassed the benchmark of 95%. The feedback includes how their pain was managed and their experience from perioperation, postoperation, and day of discharge. This information is obtained through a Perception of Care form that is mailed out to all TJR patients and follow-up discharge calls by the clinical care coordinator. The patient’s feedback informs the Orthopedic Institute what is working and where improvement is needed.

FIGURE 1. In 2005, Stamford Hospital started its comprehensive “Care through the Continuum” for the total joint replacement (TJR) program.

FIGURE 2. In 2005, Stamford Hospital started its “Care through the Continuum” total joint replacement program. In 5 years, we have seen a decrease in the length of stay for total joint replacement patients. LOS � length of stay; TJR � total joint replacement.



© 2012 by National Association of Orthopaedic Nurses Orthopaedic Nursing • November/December 2012 • Volume 31 • Number 6 325

Stamford Hospital’s TJR program has become a com-prehensive, state-of-the-art service that provides a full sequence of coordinated, multidisciplinary care that is designed to support the patient and family through all aspects of the joint replacement process. As a result, the Orthopedic Institute has seen a decrease in the length of stay, an increase in attendance at the patient education class, increased perception of care, and utilization of clinical pathways throughout the continuum.

REFERENCES American Academy of Orthopaedic Surgeons (2009a) . Total

hip replacement . Retrieved October 26, 2009 , from http://orthoinfo.aaos.org/topic.cfm?topic�A00377 .

American Academy of Orthopaedic Surgeons. Total Hip Replacement (2009b). Retrieved October 26, 2009 from http://orthoinfo.aaos.org/topic.cfm?topic�a00377.

Chelly , J. E. , Ben-David , B. , Williams , B. A. , & Kentor , M. L. ( 2003 ). Anesthesia and postoperative analgesia: outcomes following orthopedic surgery . Orthopedics, 26 , 865 – 871 .

Hawker , G. ( 2006 ). Who, when, and why total joint replace-ment surgery? The patient’s perspective . Current Opinion in Rheumatology, 18 , 526 – 530 .

Jacobson , A. , Myerscough , R. P. , Delambo , K. , Fleming , E. , Huddleston , A. M. , Bright , N. , & Varley , J. D. (2008). Patients’ perspectives on total knee replacement . American Journal of Nursing , 108 , 5 , 54 – 63 .

Kimmel , N . ( 2007 ). Therapeutic communication in the nursing profession . EzineArticles . June 5, 2007. Retrie-ved September 25, 2010, from http://ezinearticles.com/?Therapeutic-Communication-in-the-Nursing-Profession&id�594747

McDonald , S. , Hetrick , S. , Green , S. ( 2009 ). Pre-operative education for hip or knee replacement (Review) . The Cochrane Database of Systematic Reviews, Cochrane Collaboration , 3 .

NIH Concensus Development Conference on Total Knee Replacement . ( 2003 ). NIH Concensus on Total Knee Replacements , 20 ( 1 ), 1 – 34 . http://consensus.nih.gov/2003/2003totalkneereplacement117html.htm

Sjoling , M. , Nordahl , G. , Olofsson , N. , & Asplund , K. ( 2003 ). The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain manage-ment . Patient Education and Counseling , 51 , 169 – 176 .

Todaro , T. , & Schott-Baer , D. ( 2001 ). Plan faster, healthier recovery after orthopedic surgery . Nursing Management , 31 , 24 – 26 .

For more than 60 additional continuing nursing education articles on Orthopaedic topics, go to nursingcenter.com/ce.


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