Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Abstract

Background Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. Method A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. Results Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. Conclusion Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Effect of Early Mobilization on Hip and Lower Extremity Postoperative: A Literature Review

“…The length of stay of knee and hip postoperative patientsthat undergo early mobilization appeared to be shorter than in patients did not undergo early mobilization (17,21). Delayed mobilization after pelvic fracture surgery can lead to several complications such as pneumonia, urinary tract infections, thromboembolism and delirium that can prolong length of stay (3).Early mobilization after undergoing THA and TKA shows better functional recovery and hemostasis, which may reduce the length of stay and reduce postoperative complications by hindering physiological effects due to bed rest (22).…”

Effect of Early Mobilization on Hip and Lower Extremity Postoperative: A Literature Review

“…The length of stay of knee and hip postoperative patients that undergo early mobilization appeared to be shorter than in patients did not undergo early mobilization (16,20). Delayed mobilization after pelvic fracture surgery can lead to several complications such as pneumonia, urinary tract infections, thromboembolism and delirium that can prolong length of stay (3).…”

Orthostatic Intolerance-Type Events Following Hip and Knee Arthroplasty

“…Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (http://links.lww.com/JBJS/H368). n Tarcisio F. de Campos, PhD 1,2,3 Nick Vertzyas, MD 4,5 Mitch Wolden, PhD…”

“…However, signs and symptoms of an attenuated baroreceptor and sympathetic nervous system response to changes in posture (e.g., from lying to standing upright and walking) can occur in a number of patients who undergo prescribed postoperative mobilization programs 4,5 . These attenuated baroreceptor and sympathetic responses are clinically referred to as an orthostatic intolerance (OI)-type event 4,5 . The signs and symptoms of an OI-type event can include dizziness, nausea, vomiting, visual disturbances, hypotension, and/or syncope.…”