International Society of Orthopaedic Centres Length of Stay Project - Hamburg April 2013 Robert Cusack St Vincent’s & Mater Health, Sydney, Australia

International Society of Orthopaedic Centres Length of Stay Project Day/Month/YearFootnote to go here Page 2 ARTH. KNEE PROC (INCL ACL) TKR (PRI.) THR (PRI.) HEMI KNEE REV. TKR REV. THR BTKRARTH. SHOUL & / OR STAB. HIP SCOPE BACK / NECK SPINAL SURG. R/O FIX. DEV. HIP / FEMUR PROC. ANKLE A/DES. TEN. REPAIR – KLINIK (GERMANY) 2.2 (112) 10.2 (1498) 9.5 (2043) N/A14.6 (547) 15.2 (963) N/A3 (120) N/A7.7 (387) 7.5 (325) 6.6 (36) N/A11 (76) N/A IRCCS – RIZZOLI (ITALY) 2.9 (569) 10.7 (596) 9.7 (1261) N/A11 (154) 12 (239) N/A3.8 (874) N/A 12.8 (379) 2.1 (1492) N/A2.1 (590) 0 (0) CAMPBELL CLINIC (USA) 0.16 (628) N/A 5.7 (3) N/A 0.17 (505) 0.25 (6) 0.30 (58) N/A0.10 (244) 0.15 (78) N/A0.23 (217) ROYAL. HOSPITAL (UK) 0.4 (428) 10.5 (484) 10.7 (643) N/A 11.6 (704) 1.8 (362) 5.9 (356) N/A IRCCS – GALEAZZI (ITALY) 2.3 (1445) 5.2 (1216) 5.7 (878) N/A 7.6 (178) 4.6 (40) 1.3 (691) 2 (1) 4.5 (811) N/A1.8 (652) N/A SKANE. (SWEDEN) 1.3 (1735) 4.8 (546) 4.8 (572) N/A 9.1 (165) 6.1 (34) 1.4 (898) N/A5.8 (413) 8.6 (281) 3.9 ( (1207) 4.9 (423) N/A THE MATER (AUST) 0.4 (884) 6.6 (714) 6.4 (686) 5.7 (66) N/A9.4 (71) 7.5 (161) 1.35 (274) 0.6 (78) 1.4 (70) N/A0.3 (221) 0.5 (78) N/A1.6 (72) HOSP. FOR. SURG (US) 1.86 (1243) 3.87 (3235) 3.63 (3155) 2.49 (505) N/A5.0 (453) 4.51 (423) 2.04 (1105) N/A2.52 (764) N/A6.97 (546) - (18) N/A2.72 (207) SCHULTHESS KLINIK (SWITZ) 3.4 (182) 12.1 (522) 9.3 (761) N/A12.7 (96) 11.0 (147) N/A2.9 (1370) N/A11.1 (641) N/A10.2 (475) 4.5 (124) 2.4 (482) N/A SINT MAARTENS. (NETHER) 1.0 (409) 5.0 (577) 5.0 (465) 4.0 (111) N/A10.0 (235) 5.0 (144) 2.0 (180) 1.0 (30) 2.0 (121) N/A1.0 (388) 4.0 (170) N/A2.0 (80)

LOS results based upon type of procedure

Current practices utilised affecting LOS Day/Month/YearFootnote to go here Page 5 Pre-operative classes. Rehabilitation. Day of Surgery Admission DOSA. Discharge Planning services. Pre Admission Clinic. Clinical Pathways. Mobilisation - day 1 or asap. Anaesthetic protocols - minimise use of sedation. Pain management. Education - patient/carer/family. ENDO – KLINIK (Germany) X√√√X√√X√√ IRCCS – RIZZOLI (Italy) X√√√√√√X√√ CAMPBELL CLINIC (USA) X√√√√√√X√√ IRCCS – GALEAZZI (Italy) X√√√X√√X√√ SKANE UNI. (Sweden) √√√√√√√X√√ THE MATER (Aust) √√√√√√√√√√ HOSP. FOR SPEC. SURG (US) √√√√√√√√√√ SCHULTHESS KLINIK (Switz) X√√√√√√X√√

BEST PRACTICE Factors affecting Length of Stay  Pre-operative classes:  Rehabilitation (type of rehabilitation i.e. inpatient):  Day of Surgery Admission DOSA (please specify % of orthopaedic patients):  Discharge Planning services:  Pre Admission Clinic:

BEST PRACTICE Factors affecting Length of Stay (continued)  DVT/PE screening  Clinical Pathways:  Mobilisation:  Anaesthetic protocols (general, spinal, regional, sedation etc):  Pain management:  Education - patient/carer/family (advice of LOS and expected discharge date

FACTORS AFFECTING L.O.S PRE-ADMISSION: Minimum two weeks before admission Advantages: Pre op screening of risk factors and co-morbidities Appropriate work up of medications and necessary diagnostic tests Avoid cancellations or adverse events during admission Commence a pre-hab program including muscle training, strength, endurance Opportunity for education sessions for patient and carer (option on-line) Discharge plans commenced and discussed with patient Anaesthetist not having to see patient prior to surgery on the day of op Disadvantages  Patients have to attend another day  Anaesthetists having to attend another day  Need to provide physical space to conduct the assessments

FACTORS AFFECTING L.O.S DAY OF SURGERY ADMISSION: Effective use of reminder calls prior to admission assist this process Advantages: Less time in hospital away from home, family or work for patients Less chance of hospital acquired infection or other adverse events eg falls Cost savings Higher throughput opportunities from increased bed capacity Disadvantages  Physical space requirement to admit patients to DOSA Centre  Patient and family expectations/satisfaction may not be as high  Anaesthetist has to conduct patient review if there has been no pre admission clinic attendance  Pre op tests may not have been done  Additional movement of patient belongings to inpatient room

FACTORS AFFECTING L.O.S DISCHARGE PLANNING:  Commence at doctors surgery, re-enforced at PAC and continued throughout hospital stay  Involvement of family in discharge planning including equipment needs and home preparation  Having and all areas working to an agreed hospital wide time of discharge  Discharge gains are more effective if discharge metrics are measured in hours not days Advantages: Ensures patient and family are adequately prepared for discharge expectations More likely to achieve expected discharge date and avoid delays Assists scheduling and resource utilisation Improved continuity of care and outcomes for patient Cost savings Higher throughput opportunities from increased bed capacity Disadvantages  Needs significant co-ordination on all related aspects eg ward rounds, diagnostic tests, pharmacy, normalising weekends, transport, rehab etc to ensure optimal discharge timing achieved

FACTORS AFFECTING L.O.S Early MOBILISATION: Mobilise day of surgery – this includes sitting on the side of the bed / standing by the bed or walking around the bed Commence with 1 session PT on day of surgery, increasing to 3 sessions PT on subsequent days Advantages: Reduced risk of DVT’s and PE’s reduced risk of respiratory and GIT complications Quicker recovery by patients and able to progress to a rehab program sooner Potential shorter length of stay Cost savings

FACTORS AFFECTING L.O.S ANAESTHESIA OPTIONS :  Use of spinal anaesthetic with or without regional and / or sedation for total joint replacement rather than general anaesthetic  Use of brachial plexus blocks for upper limb procedures Advantages: Less time under general anaesthesia (risks) minimised effects on heart/lung GIT tract/brain. Less fluid retention likely Much earlier mobilisation possible on day of surgery Reduced chance of DVT/PE Quicker recovery Shorter length of stay Cost savings as less resources used Higher throughput opportunities from increased bed capacity Better pain management post-op Disadvantages  Anaesthetist needs to be comfortable with the approach

FACTORS AFFECTING L.O.S CLINICAL PATHWAYS: Advantages: Particularly suited to higher volume procedures Allows standardisation and resulting efficiencies Reduced variation Potential higher patient satisfaction as care team offer consistency of service Potential shorter length of stay Cost savings Disadvantages  Doctors may not feel it allows individual approach for patient

FACTORS AFFECTING L.O.S REHABILITATION: Advantages: Faster attainment of short term functional goals / milestones Access to an individualised program Higher mean Functional Independence Measures (FIM) in shorter time periods Shorter LOS in the acute and rehabilitation facilities Disadvantages:  Access to external rehabilitation facilities may be delayed due to bed availability  May not be able to be followed by other specialists (ie: cardiologists)

FACTORS AFFECTING L.O.S PAIN MANAGEMENT: Advantages: Oral pain relief enables mobilisation without causing drowsiness Able to be specified to individual needs Oral medication is less invasive and makes mobilisation easier (ie: no IV poles or lines) Disadvantages:  One protocol does not suit all patients  Oral medication takes longer to reach “peak” dosage  Needs to be monitored and tailored off

FACTORS AFFECTING L.O.S EDUCATION: Advantages: Ensures patient and family are adequately prepared for hospitalisation and discharge expectations More likely to achieve expected post-operative goals and avoid delays Education on return to activities of living following hospital discharge Ensures safety whilst hospitalised and on return home following discharge (ie: falls prevention) Disadvantages:  Lack of information may increase the LOS due to lack of preparedness by both patient and family  Education time requirements directly impact patient treatment time – if not done pre-admission  Additional cost

FACTORS AFFECTING L.O.S PRE OP CLASSES: Advantages: Patient undergoing a Pre-hab program will have improved muscle strengthening and range of motion Functional level post-operatively is greater – early return to activity General cardiovascular condition may be greater Disadvantages:  Cost

FACTORS AFFECTING L.O.S DVT/PE SCREENING: Risk Assessment to efficiently target patients most in need Use of mobile dopplers rather than transfer to a lab should be assessed Advantages: Need for screening could be reduced through the use of mechanical compression devices, compression stockings, early mobilisation and anti- coagulant therapy Allows for diagnosis and treatment Disadvantages:  Shown not to be useful until after Day 3 however many facilities have discharge early than this  Diagnosis may require intervention which potentially may impact LOS  Additional costs of screening and transport

Key differences in current operations utilised affecting LOS Hospital for Special Surgery (USA) offers the most types of rehabilitation - inpatient acute and subacute rehabilitation facilities, intensive rehabilitation and standard home rehabilitation programs, outpatient physical therapy and home with no services needed Pre-admissions – Most completed over the telephone The Mater (Aust) provides 90% face to face Pain Medication – Most used a mix of oral and IV type medication Hospital for Special Surgery (USA) focuses on medication that provides minimum sedation, minimum weakness Day/Month/YearFootnote to go here Page 19

Key differences in current operations utilised affecting LOS (cont.) Anaesthetic Protocols- Most hospitals responded by stating that this was dependant on the type of surgery The Mater (Aust) stated that sedation is rarely used The Hospital for Special Surgery (USA) stated that only regional anaesthetic is used as much as possible Day/Month/YearFootnote to go here Page 20

General discussion and questions