Physiotherapy Supported Discharge Service following knee arthroplasty

Purpose

An audit on length of stay (LOS) for total knee replacement (TKR) patients following surgery highlighted that a number of patients were exceeding their predicted date of discharge (PDD), many due to not achieving traditional physiotherapy goals (90⁰ flexion, < 5 ° extension lack and good quadriceps function), despite being safely mobile and medically fit. This exposes patients to risk of harm due to prolonged stay within an acute hospital environment as well as inefficient utilisation of an in-patient bed. A Physiotherapy Supported Discharge Service (PSDS) had previously been piloted for six months. Phase 2 consisted of permanent service resign, continuing the PSDS and service evaluation.

Approach

The pilot study consisted of a post-operative physiotherapy supported discharge service (PSDS) that utilised existing senior in-patient staff (cost neutral). Clinics were established within the existing physiotherapy gym on an orthopaedic ward. Criteria for consideration for PSDS included: post-operative knee arthroplasty patient, independently mobile, functionally independent/have correct level of support at home, pain adequately controlled, patient medically fit for discharge and consenting to referral. They were predominately from the Cardiff and Vale area and were able to make their own way in to the appointment. Clinics ran twice a week, providing appointments of 20 minutes per patient, with a maximum capacity of 12 patients per week. Patients continued to attend for up to two weeks until they had either reached their physiotherapy goals or out-patient physiotherapy had taken over their care.

Outcomes

In total, 158 patients have utilised the PSDS, saving at least 158 bed days over 14 months. 72% of these required only 1 appointment, 22% required 2 appointments and 5% required 3 appointments. Median length of stay reduced by 1.4 days and 57% of patients were discharged by their PDD. Phase 2 showed an increase of 7.3% of patients discharged within their PDD (4 days) and a 12% increase of people requiring only 1 clinic appointment. Fewer patients required 2 or 3 appointments in phase 2. In phase 2, there was an increase in patients who did not attend or could not attend their PSDS appointment-a large number of these were due to more timely out-patient appointments (within 2 weeks of discharge). Patients have consistently reported high satisfaction rates with the PSDS model. On a 0-10 scale, 100% of those patients surveyed rated the PSDS service at 9 or above. All of them said they felt ready to leave hospital on discharge. Common themes of questions were identified including uncertainty of how to book their out-patient appointment, wound issues and clexane queries.

Implications

The PSDS continues to be successful and the trend is one of improvement shown in the results between phases 1 and 2. Further improvement could improve patient flow and theatre utilisation. The aim is to include other post-operative patients.

The PSDS has become a permanent service redesign and is working in collaboration with Enhanced Recovery After Surgery initiatives to further improve the percentage of patients being discharged on or before their PDD, therefore improving patient flow, reducing variation and potential harm.

Fund acknowledgements

This work was not funded.

Additional notes

This work was presented at Physiotherapy UK 2018.