1. Marian Conde University of Central Florida College of Nursing

2. Continuous Passive Motion (CPM) machines used in orthopaedic practice for many years Orthopaedic Unit has spent over $26,000 on disposable CPM parts for 900 total knee replacement (TKR) surgeries Average rental fee for CPM $7.00 per total knee replacement patient per day Decrease reimbursement from government and insurance companies

3. Every total knee replacement patient received a CPM Cost to Orthopaedic Unit $26,000 for 900 TKR patients $7.00 per day for rental of CPM for all TKR patients Aging staff having difficulty putting on and taking off CPMs for patients leading to increased risk for back and shoulder injuries along with the need for multiple staff to tend to the patient several times a day (Tabor, 2013).

4. Early ambulation is the most significant general nursing measure to prevent postoperative complications (Morris, Benetti, Marro & Rosenthal, 2010). Exercise sessions performed day of surgery and each day after for a minimum 30 minutes per session (Bruun-Olsen, Heiberg & Menshoel, 2009) Patients participate in active flexion/extension exercises Preoperative education classes to help prepare patients for surgery and involve them in the plan of care

5. Permission from chosen surgeon to allow a trial to decrease the use of CPMs on his patients Present research data to surgeon on use of CPMs versus no CPM use postoperatively Physical therapist will no longer need to go to patient anesthesia care unit (PACU) to place CPMs on postoperative patients Therapist would increase exercise sessions with patients after surgery

6. Physical assessment completed by physical therapist prior to surgery Patient and coach would attend preoperative class Meet with administration to increase full time equivalents (FTEs) to cover preparation and running of preoperative class Surgeon agreed to trial 50% of his patients CPM versus without CPM

7. Plan-Do-Study-Act (PDSA) cycle for improvement to be used for this project Preoperative education class for TKR patients and their coach Meet with surgeon who will be first to participate in PI plan to reduce/cease use of CPMs

8. Meet with physical therapy department and nursing outline new exercise protocols for patients without receiving a CPM Nursing team educated on new expectations for patients without CPMs Review positive benefits with nursing and physical therapy teams in relevance to CPMs not used

9. Meet with Chief Nursing Officer (CNO), Director of Nursing (DON), Director of Physical Therapy, and finance representative for campus. Meet with surgeon who has agreed to be the champion for the Performance Improvement Plan. Educate nursing staff and physical therapists on exercise and mobility protocol. Form team consisting of nursing, therapy, surgical services, educator, and surgeon to decide on goals and which groups of patients the concentration will be on for a small test of change.

10. Set up preoperative classes for patients and their families to educate. Collect data for range of motion (ROM) measurements for patients without CPMs in acute care setting. Collect data for ROM after discharge upon initial follow-up visit with surgeon, three month visit, and 6 month visit. Report out on data post six months results to major stakeholders. Make changes to exercise and mobilization protocols if not meeting expected outcomes in ROM. Evaluate cost savings.

11. One FTE per month for preparation and execution of preoperative classes. 0.5 to 1 FTE for increased time with patient doing ROM, flexion and extension exercises.

12. Decreased risk of back and shoulder injuries to nursing staff related to lifting of 50 lb. CPM machines numerous times throughout 12 hour shifts. No materials needed to undertake or complete improvement plan. $26,000 to $27,000 on disposable items related to CPMs and rental of $7.00 per day per patient for length of stay for CPM.

13. Patient outcomes during initial postoperative visit to surgeon Patient assessment during 3 month visit and 6 month visit Assessments consist of gait evaluation, extension and flexion of surgical knee Comparison of CPM versus no CPM data collection at initial visit, 3 month, and 6 month

14. Savings to hospital at 3 and 6 month intervals per finance department numbers Decreased number of Workman’s Compensation (WMC) injuries related to lifting of CPMs Success will be proven if the patient has increased flexion, extension & ROM with decreased pain postoperatively at 6 months

15. Bruun-Olsen, V., Heiberg, K., & Menshoel, A. (2009). Continuous passive motion as an adjunct to active exercise in early rehabilitation following total knee arthroplasty-a randomized controlled trial. Disability & Rehabilitation, 31(4), 277-283. doi:10.1080/09638280801931204 Morris, B., Benetti, M., Marro, H., & Rosenthal, C. (2010). Clinical practice guidelines for early mobilization hours after surgery. Orthopaedic Nursing, 29(5), 290-299. Tabor, D. (2013). An empirical study using range of motion and pain score as determinants for continuous passive motion: Outcomes following total knee replacement surgery in an adult population. Orthopaedic Nursing, 32(5), 261-265.