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Total Hip Replacement

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Title: Total Hip Replacement


1
Total Hip Replacement
  • Education Workshop (click to go to the desired
    section)
  • Introduction to Workshop/Instructions
  • Evidence-Based Care Program
  • Total Hip Replacement Workshop

2
Introduction
  • This interactive workshop is designed to go along
    with a copy of the pathway. Keep it handy as you
    go through the workshop to engage in the required
    activities.
  • This is a web-based workshop, and thus has links
    throughout each page to enable you to move
    throughout the workshop. Whenever you see words
    underlined like this, you can click on that area
    to go to another section or to find more
    information on a topic.
  • At the bottom of each page are navigational
    buttons to help you move through the workshop.
  • You can go through as much or as little of the
    workshop as you like at a time.
  • If you have any questions about how to use this
    workshop or the individual pathways, feel free to
    ask the Evidence-Based Care Program or your Site
    Champion.

Back to Start of Workshop
3
Evidence-Based Care Program
  • These pathways have been developed as a part of
    the Evidence-Based Care Program, which is
    Schedule 6 in the agreement of the Grey Bruce
    Health Network.
  • The intent is to develop regional pathways and
    other evidence-based tools that flow across all
    hospitals and community services in Grey and
    Bruce (including Grey Bruce Health Services,
    Hanover and District Hospital, South Bruce Grey
    Health Centre, and the Community Care Access
    Centre).
  • It is hoped that these pathways will improve
  • Coordination of care through more communication
    across professions
  • Continuity of care, through increased linkages
    among hospitals and the CCAC
  • Clinical outcomes, through increased usage of
    best practices and
  • Patient satisfaction, through linked expectations
    and increased patient teaching at our agencies.

Back to Start of Workshop
4
Total Hip Replacement Pathway
  • The Total Hip Replacement pathway is intended for
    all patients who are booked for an elective total
    hip replacement.
  • The pathway package includes a clinical practice
    guideline and two stages
  • Acute Stage
  • Pre-Admission package
  • Acute Stage package
  • Community Care Stage
  • Community Care Stage Pathway

Back to Start of Workshop
5
THR Clinical Practice Guideline
  • In most cases, when developing a pathway we
    will come across the most accepted published
    clinical practice guideline for the patient
    population. However, because total hip
    replacements are a procedure, not a condition,
    there were no clinical practice guidelines
    published. Thus a development team from GBHS -
    Owen Sound and GBHS Markdale helped in the
    creation of one based on the available evidence
    and issues we faced for this procedure.
  • The THR clinical practice guideline can be
    found on the GBHN website at www.gbhn.ca

Back to Start of Workshop
Back to beginning of THR section
6
Pre-Admission Package
  • Each elective THR patient is to go to a Pre-Admit
    clinic 2-4 weeks before having surgery. This is
    where our Acute Stage of the clinical pathway
    begins.
  • When the surgeon books a patient, a patient
    education booklet along with the patient pathway
    is given to him/her that day. Thus, when the
    patient arrives in the Clinic, he/she should
    already have these materials. However, if these
    have been lost or were not given, copies are
    available in the Clinic to be sure the patient
    has this information.
  • There are two forms we need the patient to fill
    out before leaving the Clinic. There is the LEFS
    functional assessment tool (see a sample), and
    the Orthopedic Functional Questionnaire (see a
    sample), which are used by the Pre-Admit team to
    determine if CCAC services will be required
    post-operatively.

Back to Start of Workshop
Back to beginning of THR section
7
Pre-Admission
  • During the Clinic, the Acute Stage Clinical
    Pathway is started. It is put on the chart, and
    the appropriate staff initial as tasks are
    completed during the Clinic.
  • There is an algorithm to follow the activities of
    the Pre-Admit Clinic. It can be found by clicking
    here.
  • When the Pre-Admit Clinic is finished, the
    pathway remains on the chart in preparation for
    the day of surgery.

Back to Start of Workshop
Back to beginning of THR section
8
Pre-Printed Orders
  • The pre-printed orders are post-operative orders
    for total hip replacement patients.
  • They can be found in the Operating Room area of
    the hospital and are available at www.gbhn.ca .
    (see a sample)
  • There are also sets of pre-printed orders for
    receiving hospitals that have been developed for
    those patients that are transferred out of GBHS
    Owen Sound (see a sample).
  • These can be found in the medical/surgical units
    in each community hospital and at www.gbhn.ca .

Back to Start of Workshop
Back to beginning of THR section
9
THR Acute Stage Pathway
  • The Acute Stage of the THR pathway is a day-style
    pathway, meaning that each page outlines tasks
    for one 24 hour period, beginning at the start of
    the day shift and ending at the end of the night
    shift. (See a sample)
  • It should be on the chart when the patient
    arrives for surgery, with the pre-admit page
    filled out.
  • The Smiley Face tool is taped to the wall in
    the patients room, and filled in by the
    physiotherapy department as exercise and mobility
    milestones are achieved post-operatively. All
    disciplines can refer to this tool when caring
    for the patient as a quick reference as to the
    abilities of the patient. (see a sample Smiley
    Face Tool)

Back to Start of Workshop
Back to beginning of THR section
10
THR Acute Stage Pathway
  • At the right hand side of the sheet is a place to
    enter the date. There are also three columns,
    these are the time frames for the shifts working
    during that day. Indicate the time you are
    working with the patient in the appropriate
    column.
  • Then, using the column for your shift, initial
    tasks as they are completed, or enter N/A and
    initial if they are not applicable to the
    patient. For example, if it is the night shift
    and you are not doing any patient teaching,
    indicate N/A and initial in the section for
    Psychosocial/Education under Review Patient
    Pathway and Review Total Hip Precautions. (see
    sample)
  • This is repeated for each day of the pathway.

Back to Start of Workshop
Back to beginning of THR section
11
THR Acute Stage Pathway
  • On a daily basis, the Discharge Criteria, the
    last page of the pathway, should be checked and
    dated/initialed if any of the criteria have been
    met. The patient is ready for discharge when
    these criteria have been met.
  • Post-Op Day 1 at the top of the page has one of
    the Performance Indicators for this pathway,
    Antibiotics discontinued within 24 hours of
    surgery. This should be inputted as Met or
    Not Met.
  • Take a look at the pathway by clicking here.

Back to Start of Workshop
Back to beginning of THR section
12
Transferred Patients
  • Approximately 50 of patients in for a THR will
    be transferred to a community hospital following
    surgery. If a patient is transferred to a
    hospital within Grey and Bruce counties, a copy
    the following information must be sent to the
    receiving facility
  • Smiley Face Tool
  • Discharge Criteria
  • Physio Database
  • Teaching Checklist
  • Discharge Planning Tool
  • MAR sheet (and anticoagulant record )
  • The patient should also arrive with the patient
    education materials and patient pathway that can
    be referred to for patient teaching. If not,
    there are extra copies of the education materials
    on each unit.
  • The Acute Stage of the pathway will be continued
    at the new site until the patient is discharged
    and/or the discharge criteria have been met.
  • The Acute Stage Post-op Orders for Transferred
    patients can be used at the receiving facility,
    making any necessary changes depending on the day
    the patient is transferred.

Back to Start of Workshop
Back to beginning of THR section
13
Ongoing Post-Op Care
  • If a patient remains in hospital beyond 5 days
    post-op, regardless of whether he/she was
    transferred or not, the page entitled Ongoing
    Post-Op Care in the pathway can be started.
    These patients may have other comorbidities and
    will remain in hospital for further
    convalescence.
  • This page of the pathway is a phase-type pathway,
    as the patients that remain in hospital longer
    than 5 days are variable and difficult to
    estimate a length of stay. It is expected that
    patients will remain on this stage of the pathway
    until all the discharge criteria are met.
  • There are three columns on the right hand side
    -one for each day the patient remains in
    hospital. Blank copies of this page can be
    inserted if the patient remains beyond the three
    day period.
  • (see sample)

Back to Start of Workshop
Back to beginning of THR section
14
Community Care Stage
  • The Community Care Stage of the pathway is used
    for both outpatient physiotherapy or CCAC
    services following discharge.
  • The Community Care Stage includes the following
    pieces
  • Clinical pathway one page with admission and
    discharge goals, used as a charting tool for
    documentation
  • Client pathway to be given to the patient to
    align expectations
  • Patient Communication Form for the patient to
    bring to follow up appointments with the surgeon.
    Has a list of common questions that the therapist
    and patient need answered
  • LEFS Functional Assessment Tool to be filled in
    by the patient at the end of services. Score can
    be compared to expected goals to determine
    success of therapy.
  • When the patient finishes services either from
    CCAC or Outpatient Physiotherapy, a copy of the
    clinical pathway is copied and sent to the
    Evidence-Base Care Program for evaluation
    purposes.

Back to Start of Workshop
Back to beginning of THR section
15
End of THR Section
  • This is the end of the general information for
    the THR pathway.
  • To get further information by trying the pathway
    on a sample patient, move to the Simulation
    portion of the THR workshop.
  • Test your knowledge of THR by doing the
  • THR quiz.

16
Simulation
  • Try it!
  • Joe has had painful osteoarthritis and his
    surgeon has determined the best solution is a
    total hip replacement. Joe is booked for surgery,
    and given his patient education package,
    including the patient pathway, two months in
    advance. His pre-admit clinic appointment is
    scheduled for two weeks before surgery.
  • Joe arrives to the Pre-Admit clinic, however has
    lost his patient education package. There are
    extra packages in the clinic find out where
    these are stored. Give Joe a new package, and ask
    him to fill out two forms
  • LEFS Functional Assessment Tool
  • Orthopedic Functional Questionnaire
  • Once these are filled out, they are used by
    physio along with the Blaylock Discharge Planning
    Tool to score and determine the most likely
    destination for Joe following discharge.
  • It is determined that Joe is a high needs patient
    and requires an Occupational Therapy Home visit
    before surgery, so the CCAC Case Manager needs to
    be called in to visit Joe before he leaves today
    to assess his needs.

Back to Start of Workshop
Back to beginning of THR section
17
Simulation contd
  • Take a look at the pre-admit clinic algorithm to
    familiarize yourself with the process. (see
    algorithm) and patient flow sheet
  • Joe has four places to go today he will have
    some blood work done, have a nursing orientation,
    a physiotherapy assessment and orientation, and
    an occupational therapy orientation.
  • Take a look at the clinical pathway. The first
    page contains some basic instructions and a
    master signature sheet (If sites have a master
    signature sheet for your facility, this is not
    included in your pathways). Each page needs to
    have a patient ID sticker. The next page for the
    pre-admit clinic to fill in. In the first few
    lines, list any comorbid conditions Joe has, to
    aid health records in coding for Joes condition.
  • On the right hand side of the page is a column.
    At the end of each of these visits, each health
    care provider will initial tasks they completed
    on the first page of the pathway.
  • Review the clinical pathway by clicking here

Back to Start of Workshop
Back to beginning of THR section
18
Simulation contd
  • At the end of the clinic, look at the
    performance indicator for this day of the pathway
    (first row on the page). Joe attended the physio
    portion of the clinic, so this is dated,
    initialed and indicated as Met .
  • Joe should leave with his patient education
    materials, patient pathway, and instructions on
    what to do before surgery. The clinical pathway
    will remain on the chart for when he returns for
    surgery.
  • When Joe returns on the day of surgery, the
    pathway will continue to the next page. It should
    be started in the day surgery department. There
    are post-op pre-printed orders that can be found
    in the OR , the GBHN website and the Order sets
    website.

Back to Start of Workshop
Back to beginning of THR section
19
Simulation contd
  • When Joe finishes surgery, he will spend some
    time in the recovery room and then move to the
    surgical unit. Each care provider that cares for
    Joe will need to fill in the tasks completed
    through this process. Take a look at that page,
    Post-Op Day of Surgery to familiarize yourself
    with the tasks.
  • Once Joe is moved to the surgical unit, the
    Smiley Face Tool needs to be taped to the wall
    in his room. This is used by the physiotherapy
    department to track milestones with respect to
    mobility and exercises. Each milestone will be
    circled and dated as it is achieved. This helps
    all health care providers know Joes status at
    any given time. (see sample)
  • On each page of the pathway, you will notice a
    few consistent tasks. One is under Discharge
    Planning Assess Discharge Criteria Daily.
    Each day, look at these goals the Discharge
    Criteria are the second last page of the pathway.
    If any have been met, initial and date them. Once
    they have been met, Joe should be ready for
    discharge.

Back to Start of Workshop
Back to beginning of THR section
20
Simulation contd
  • Another consistent task is under Psychosocial
    Support/Education. Each day you are asked to
    Review the patient pathway and Review Hip
    Precautions. You can use Joes patient education
    materials and patient pathway to help you with
    this, to ensure Joe understands what is happening
    in hospital, aligning expectations, and he is
    aware of the hip precautions he has following
    surgery.
  • Not all tasks are applicable for all patients, or
    for all shifts. For example, during the night
    shift, you may not be teaching Joe. Thus, under
    Review Patient Pathway, you can indicate N/A
    and initial. This is the case for any tasks that
    are not applicable for Joe. At the end of a day,
    there should be no blank boxes on the pathway
    page.
  • The second indicator we are tracking for this
    pathway is also on this page Antibiotics
    discontinued 24 hours post-op. Joes antibiotics
    were discontinued at 48 hours, it should be
    inputted at Not Met .

Back to Start of Workshop
Back to beginning of THR section
21
Simulation contd
  • Each day, the Discharge Criteria need to be
    assessed to see if they have been met. If they
    have, Joe should be ready for discharge. Lets
    assume Joe has not met the Discharge Criteria by
    the end of 4 days post-op, and so cannot go home.
    He does not have independent transfers yet, nor
    can he ambulate independently on level ground.

Back to Start of Workshop
Back to beginning of THR section
22
Simulation contd
  • Since Joe is from Durham, it is determined he
    should be transferred to the SBGHC Durham
    hospital site. When Joe is transferred, the
    following information needs to go with him to the
    transfer site
  • A copy of the Physio Database
  • A copy of the Teaching checklist
  • Original of the Smiley face tool
  • Copy of Discharge Criteria
  • Copy of Discharge Planning Tool
  • Copy of the MAR sheet (including anticoagulant
    record)
  • When Joe arrives in Durham, the pathway will be
    continued.
  • If Joe remains in hospital beyond 5 days, staff
    in the Durham site will use the Ongoing Post Op
    Care phase of the pathway until Joe has met all
    the Discharge Criteria which are on the last page
    of the clinical pathway.

Back to Start of Workshop
Back to beginning of THR section
23
Simulation contd
  • If Joe remains in hospital beyond the three days
    listed on the pathway page, insert a new Ongoing
    post-op Care page behind this page and continue
    using the pathway until discharge criteria have
    been met or Joe is discharged home.
  • Lets assume that Joe is discharged home, but
    requires outpatient physiotherapy services. In
    this case, the Community Care Stage of the
    pathway begin. See workflow
  • The therapist in the Durham site will use the
    Community Care Stage clinical pathway to aid in
    the care for Joe. She/he will assess him at
    admission to services and at discharge to
    determine if he has met the goals on the pathway.

Back to Start of Workshop
Back to beginning of THR section
24
Simulation Community Care Stage Contd
  • She/he will give Joe the client pathway to help
    explain to Joe what the goals are for therapy.
  • When it is time for Joes follow up appointment
    at 6 and 12 weeks, the Client Communication Form
    will be given to Joe to give to the surgeon and
    get important questions answered about his
    status. He needs to return this form to the
    therapist so therapy can be adjusted accordingly.
  • Finally, when Joe is discharged from outpatient
    services, the LEFS tool will be repeated and
    scored to see how Joe has improved functionally.
    The pathway needs to be completely filled in and
    a copy sent to the Evidence-Based Care Program
  • If Joe were to go to CCAC services, the same
    process would be followed, and started again if
    Joe is transferred to outpatient physiotherapy.

Back to Start of Workshop
Back to beginning of THR section
25
THR Quiz
  1. There are 2 stages to the THR pathway what are
    they?
  2. What are the inclusion criteria for this pathway?
  3. What is the LEFS functional assessment tool? What
    is it used for?
  4. What type of a pathway is this pathway? A) Day B)
    Phase
  5. What is the Smiley Face Tool? Where does it go?
  6. What goes with the patient if he/she is
    transferred?
  7. When is the Ongoing Post Op Care phase used? What
    do you do if the patient remains in hospital
    beyond the first 3 days in this phase?
  8. What is the Community Care Stage used for?

Back to Start of Workshop
Back to beginning of THR section
Answers
26
THR Quiz - Answers
  1. There are 2 stages to the THR pathway what are
    they? Acute Stage, Community Care Stage
  2. What are the inclusion criteria for this pathway?
    Patients undergoing an ELECTIVE total hip
    replacement
  3. What is the LEFS functional assessment tool? What
    is it used for? It is an assessment of the
    patients function before surgery. It is used to
    determine how well the patient progresses
    following surgery. It is filled in at the
    pre-admit clinic and also at the end of
    outpatient physiotherapy
  4. What type of a pathway is this pathway? A) Day B)
    Phase This pathway is both a day and a phase
    pathway. The first four days are a day pathway,
    which means each page is for one day in hospital.
    The Ongoing Post-Op Care phase is a phase type
    pathway, where the patient stays in this phase
    until all variances are resolved.
  5. What is the Smiley Face Tool? Where does it go?
    The Smiley Face Tool should be taped to the
    patients wall and show all health care providers
    how far progressed the patient is with respect to
    mobility and exercise.
  6. What goes with the patient if he/she is
    transferred? The Physio Database should be
    copied, and the Discharge Criteria, the
    Discharge Planning Tool, the MAR sheet (including
    anticoagulant record), the original of the Smiley
    Face Tool should go with the patient along with
    any other documentation that would help in the
    transition of care.

Back to Start of Workshop
Back to beginning of THR section
27
THR Quiz - Answers
  • 7. When is the Ongoing Post Op Care phase
    used? What do you do if the patient remains in
    hospital beyond the first 3 days in this phase?
    This is used if the discharge criteria have not
    been met at 5 days post op and the patient needs
    to stay in hospital longer. It is a phase type
    pathway with one phase, and the patient remains
    on this phase until all discharge criteria have
    been met. If this is longer than 3 days, blank
    photocopied sheets can be inserted and used until
    the variances have been resolved.
  • 8. What is the Community Care Stage used for?
    This is used for outpatient physiotherapy or CCAC
    services the patient receives following hospital
    discharge.
  • If you have had difficulty with any of these
    questions, go back through the material on this
    pathway and/or the general pathway information in
    this workshop, or contact the Evidence-Based Care
    Program

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Back to beginning of THR section
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