How a quality improvement project following a redesigned clinical pathway reaped benefits beyond the original target population.
The NHS continues to focus on ways to safely reduce length of stay following surgery. High volume surgical pathways are ideal for this accelerated approach. We aimed to evaluate the application of a service improvement methodology to different knee replacement pathways, focusing on length of stay, range of motion and adverse events.
In September 2016 the accelerated pathway for Unicompartmental Knee Replacement (UKR) was introduced and by January 2019 1000 patients had completed it.
By July 2017 the new accelerated UKR pathway was routine practice in our unit but there was no change in rehabilitation for Total Knee Replacements (TKR). They continued with traditional early flexion to limit post-operative stiffness. Early flexion can however lead to increased pain and swelling with delayed mobilisation and discharge.
In July 2018 we introduced an accelerated pathway for TKRs, based on similar principles to our UKR pathway. TKR surgery is not minimally invasive so small changes were required. The main change was that following their day 5 appointment for dressing change and knee flexion exercises all TKRs were routinely referred for out-patient physiotherapy which was not routine for UKRs.
In 28 months 1000 UKRs completed the pathway with 456 patients (45.5%) going home on the day of surgery. LOS reduced from 2.6 to 1.04 days (median of 1 day). There was 1 MUA required. A saving of 1560 bed days and £468,000 was made.
In July 2017, ten months after the introduction of the UKR pathway, 2 (6%) TKR patients went home on day 1, 5 (15%) on day 2 and 26 (79%) stayed in 3 or more days.
Between July 2018 and January 2019 114 TKRs were performed and followed the new accelerated TKR pathway, 1 (1%) went home on day 0, 25 (22%) on day 1, 36 (31%) on day 2 and 52 (46%) stayed 3 or more days.
62 TKR patients went home following the delayed flexion protocol. On day 5 their mean flexion was 70° (range 48-93) and 100° (range 64-125) at 6 weeks. There were 2 readmissions; (i) washout and oral antibiotics and (ii) DAIR. None of the delayed flexion cohort required an MUA. Five (8%) required no further out-patient physiotherapy, 26 (42%) required 1 appointment (3 of these continued their treatment nearer home), 15 (24%) needed 2, 6 (10%) needed 3 and 9 (15%) had more than 3 appointments and 89% of patients said they were “very satisfied” with surgery and “would do it all again”.
By successfully introducing an enhanced recovery pathway for UKRs, without any changes to our TKR pathway, the LOS for TKRs reduced. We feel the reasons for this were the culture change within the hospital encouraging day of surgery mobilisation, the success of one pathway gave all staff the confidence to adopt similar principals for similar procedures. Patient feedback indicated they liked the new pathway.
Cost and savings
The project was funded internally as QIP within existing resources.
The economic analysis from the project regarding length of stay savings are included in our published papers.
We have shown that delaying knee flexion until day 5 post TKR does not have any long term effect on knee flexion. The pathway was safe and acceptable to patients and allows 54% of all the TKRs in this unit to be discharged by day 2.
Top three learning points
No external funding
This work was presented at Physiotherapy UK 2019
Please see the attached Innovations poster below.
For further information about this work please contact Cathy Jenkins.
C. Jenkins, W. Jackson, N. Bottomley, A. Price, D. Murray, K. Barker. Delayed knee flexion is a safe and effective pathway for Total Knee Replacement. Physiotherapy, 108 (2020), pp. 45
C. Jenkins, W. Jackson, N. Bottomley, A. Price, D. Murray, K. Barker. Introduction of an innovative day surgery pathway for Unicompartmental Knee Replacement: no need for early knee flexion. Physiotherapy, 105 (2019), pp. 46-52