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Chew S.X.1, Beh J.Y.1, Pua Y.H.1, Tan I.C.1, Pang H.N.1, Tan M.H.1, Tan M.L.1
1Singapore General Hospital, Physiotherapy, Singapore, Singapore
Background: Singapore General Hospital (SGH) performs approximately 1500 Total Knee Arthroplasty (TKA) surgeries every year and the average length of hospital stay associated with TKA is 5 days. To optimize clinical outcomes, Physiotherapists provide inpatient (post-TKA) rehabilitation. We have previously conducted a study (Pua & Ong 2014) to evaluate the association of early ambulation with length of stay, costs and outcome of TKA patients. We found that as little as a 1-day difference in the day of first ambulation was associated with a shorter length of stay, lower hospitalization costs, and improved knee function. Prior to the project, only 65% of the TKA patients ambulated on Post-Operative Day 1 (POD1). Poor clinical outcome will affect all hospital stakeholders. Furthermore, every delay in ambulation will incur a loss in rehabilitation time which, in turn, would increase LOS and the risk of acquiring a hospital acquired infection (due to a protracted LOS).
Purpose: Limited healthcare resources have prompted strategies to shorten the length of stay (LOS) and improve functional recovery in patients with TKA. This study aimed to develop and evaluate the effectiveness of a quality improvement (QI) intervention in reducing LOS and improving functional recovery in TKA.
Methods: All patients who underwent TKA in SGH during this time period were included for this study. An Ishikawa diagram was used to analyze reasons for suboptimal postoperative care and we developed and implemented a QI intervention. An interrupted time series analysis was used to compare the LOS during a 6-month intervention period with that of a 12-month baseline period preceding implementation. To adjust for secular trends, we used segmented regression analysis. Secondary outcomes included the proportion of patients who walked on postoperative day 1 (POD1) and the proportion of patients who required walking aids with a small base-of-support at hospital discharge.
Results: During the baseline period, 899 of 1434 patients (65%) walked on POD1; during the intervention period, 603 of 739 (82%) patients (P 0.001). At hospital discharge, during the baseline period, 20% of patients required walking aids with a small base-of-support; during the intervention period, 30% of patients (P 0.001). Compared with the baseline period, mean LOS was ~0.5ds shorter during the intervention period (5.1 vs 4.6ds; P 0.001). After adjusting for secular trends, however, the QI intervention was not associated with a significant immediate reduction in LOS (-0.15ds, P=0.68). Segmented regression analysis showed that the proportion of patients who ambulated on POD1 increased by ~2.8% points per month (P 0.01, 95% CI = 2.6 to 14% points) and the QI intervention was associated with an immediate 11%(95%CI, 1% to 22%) absolute increase in the proportion of patients who required only a small walking aid.
Conclusion(s): The QI intervention was not associated with substantial reduction in LOS; however it was associated with greater mobility and functional recovery.
Implications: Early ambulation is associated with greater mobility and functional recovery. It allows TKA patients to return home with walking aids that provide lesser support. Patients can then return to normal gait pattern earlier.
Funding acknowledgements: NA
Topic: Orthopaedics
Ethics approval: This project has been approved by SingHealth Centralised Institutional Review Board. http://research.singhealth.com.sg/Pages/CentralisedInstitutionalReviewBoard.aspx
All authors, affiliations and abstracts have been published as submitted.
