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A joint replacement pathway developed at DuBois (PA) Regional Medical Center has achieved high levels of physician and staff support by building in a radical degree of flexibility to accommodate different physician practice patterns.
The combination knee and hip replacement pathway, designed for patients without medical complications who have single joints replaced, combines all the common aspects for total hip replacement and total knee replacement patients. But it also contains a section that allows physicians to check off specific treatments for each diagnosis and the preferences of the orthopedic surgeon. (See sample page from the pathway, p. 53.)
Given the physician-friendly nature of the pathway, it’s not surprising that it was spearheaded by a medical director, Martin A. Schaeffer, MD, a physiatrist in the department of physical medicine and rehabilitation at DuBois. Schaeffer knew the pathway couldn’t succeed without the support of the orthopedic surgeons, or orthopods, because they would be responsible for referring the patients to the pathway program.
But accommodating the orthopods proved to be tricky, because each one had a slightly different approach to caring for joint replacement patients. "Basically, the pathway standardizes the treatment of patients once they’re on the rehab unit," Schaeffer says. Prior to that, the orthopod can elect not to put the patient on the pathway and has full autonomy regarding surgical techniques and when the patient should be placed on the rehab unit. Even though the pathway takes effect on the unit, it remains flexible enough to satisfy individual physician preferences.
For example, Schaeffer notes that each orthopod favors slightly different settings for the Continuous Passive Motion (CPM) machine. "That’s okay. We know that for a knee, everyone is going to get a CPM," he says. "But we also know that for Dr. X’s patient, the setting will be zero to 75 the first day, whereas with Dr. P, the setting will start at zero to 110 the first day. We have those kinds of special adaptations."
The difficulty was building in enough flexibility to satisfy the orthopods while still having a pathway that therapists and nurses could make sense of. "We can tell the patients, this is what you’re going to do, yet have it be flexible enough so that we can incorporate individual treatments," he says. "Because, essentially, there would be no way that I could convince three orthopods that they should all start doing their DVT [deep vein thrombosis] prophylaxis the same."
Even with Schaeffer’s attempts to accommodate the orthopedic surgeons’ autonomy, many still took a wait-and-see approach to the pathway, at least at first. Soon, however, it became apparent that patients were enthusiastic about the pathway and were in fact telling their ortho pods how they felt. "The patients told them they really liked it, the care was good, they got out on time, and their leg was fine. So the orthopods kept sending us patients," Schaeffer says. "We had to assure them we were going to incorporate what they wanted and we weren’t going to tell them what to do. Of course, that’s what a lot of physicians normally don’t like about pathways."
Instead of listing activities and goals day by day, Schaeffer decided to create a range that could accommodate variations in patients’ activity and motivation. The eight-day pathway is broken into four segments: days 1-2; days 3-4; days 5-6; and days 7-8. This allows more motivated and functional patients to progress faster and be discharged earlier.
Because of the flexibility in days, staff are able to accelerate a patient’s progress on the pathway. For example, if the therapy evaluations show that a patient is on a high functional level, staff have the option of combining the activities on days 1-2 with the activities on days 3-4.
Most patients are discharged by day 7, although the pathway goes through day 8. Patients who stay a day longer are likely to have been admitted on a Friday. DuBois offers limited therapy on weekends. Because of the option for an accelerated pathway, some patients have been discharged as early as day 4 or 5 if they have met all the goals for day 8, Schaeffer says.
The document has fit so well with the needs of the patients and clinicians that it’s undergone only one minor change since the rehab unit started using it in January 1997. (For details on how the pathway was developed, see related article, this page.)
In addition to being accepted by orthopods and patients, the pathway has won over referring physicians because it allows them to plan patient discharges. The pathway also makes it easier for the rehab hospital to plan admissions and discharges because it sets out the length of stay for these patients. The young therapy staff also are happy with the pathway because it sets out exactly what patients are supposed to do and when, Schaeffer says.
There hadn’t been a rehab unit in the area, so rehabilitation as a specialty was very unfamiliar. Some of the therapists had experience in outpatient treatment but no inpatient experience, Schaeffer says.
"Because we are a relatively young rehab unit, we have a very young therapy staff. We found that some therapists actually were looking for specific expectations of therapy. The pathway tells them what is expected on each day, and they like that," Schaeffer says.
For example, seasoned therapists know from experience how much joint replacement patients should be able to walk, but the therapists who were just out of school had some uncertainties, Schaeffer says.
"When it was open-ended, these therapists would work with the patients, but they didn’t know what goals to set for each day. The pathway eliminated that problem," Schaeffer says.
For more information on DuBois Regional Medical Center’s critical pathway for joint replacement patients, contact Martin A. Schaeffer, MD, medical director, department of physical medicine and rehabilitation, DuBois Regional Medical Center, Suite 300, 145 Hospital Ave., DuBois, PA 15801. Telephone: (814) 375-4660. Fax: (814)375-5206.