This clinical practice guideline (CPG) is the product of cohesive interdisciplinary collaboration. The impact of this project merits more than routine attention given the lack of published nursing literature. The Department of Nursing acted as the catalyst to improve the quality of patient care. This initiative resulted in a pivotal change in the standard of care, updating outmoded orthopaedic nursing practices. The most significant change improved the time patients began their first postoperative activity. Dangling the patient on the day of surgery enhanced the benefits of early activity and reduced the time from 16.8 to 6 hr with no adverse patient consequences. The CPG also demonstrated excellent postoperative pain management, realizing pain scores below 4 (0-10 scale) at multiple time points. In addition, the length of stay improved from 4.3 to 2.8 days. The results support the value of implementing a CPG.

Our nursing profession needs to be able to identify, measure, and document nursing's contributions with the same emphasis as that given to other disciplines. Broad outcomes such as morbidity and mortality do not address nursing's contributions to patient care. Yet nursing-sensitive outcomes, such as pain level, symptom management, and self-care, often go unexamined. (p. 42)

The strategic purpose of this project was to develop a patient-centered total joint replacement CPG to maximize interdisciplinary collaboration from all levels of staff. Embedded within the CPG's purpose was the goal to attain earlier benefits of mobilization by transforming the practice of initiating activity of the joint replacement patient from postoperative Day 1 to the day of surgery.

Benefits of Mobility

Another pivotal change can be derived from the introduction of Medicare Diagnosis Related Groups (DRGs) in the late seventies and early eighties. Briefly, DRGs, as a prospective payment plan, defined a specific number of hospital days for patients undergoing specified procedures, and/or a finite amount of reimbursement associated with each DRG. Prior to their introduction, the length of hospitalization for total joint replacement patients was ill-defined, varying widely between hospital and surgeon practices, and ranging from 10 to 21 days. Postoperative activity began slowly with prescribed bed exercises, which may have included the application of an early form of continuous passive motion. The introduction of DRGs provided a stimulus to develop formalized rehabilitation programs to maximize DRG benefits.

The Environment

The University of California, San Diego Medical Center is an academic medical center located in the southern most aspect of California, immediately adjacent to the border of Mexico. The University serves a diverse population that includes the full spectrum of primary and complex joint revision surgical procedures. Both the city of San Diego and the Medical Center encompass a multicultural population as well as a wide range of socioeconomics.

The Medical Center is a two-hospital system with a total of 505 beds. Both hospitals admit patients for joint replacement surgery. The clinical staff can "float" to fill staffing needs at either facility, although they have a fixed work location the majority of the time. It was recognized that the CPG would remove significant variation in practices between the hospital sites related to the sharing of staff.

Clinical Practice Guideline

In addition to developing a CPG, this project explored changes in nursing practices from the current standard of care of PT initiating patient ambulation on postoperative Day 1. The targeted change in nursing practice focused on dangling the patient on the edge of the bed on the day of surgery. Interviews with nursing and PT offered insight into the prelaunch CPG practice. Nursing's reported stance placed focus on the physiologic effects of general anesthesia and the severity of postoperative pain with the assumption that PT was better prepared to deal with appropriate body mechanics and managing any possible complications such as the risk of hip dislocation.

Orthopaedic surgeons and regional anesthesia had autonomously incorporated changes into their respective practices without coordination with other disciplines. This created inconsistencies in the delivery of care as well as variations between the two hospital locations. Neither nursing nor PT was able to direct the maximum advantages of physician changes into their respective practices to fully benefit the patient. Through subsequent discussions, all disciplines involved in delivering care to the joint replacement patient population agreed that the development of a preoperative patient education class and a CPG would benefit the patient and serve as a master plan to cluster interrelated, overlapping clinical actions.

The nursing staff further revealed apprehension regarding the risk of dislocation postoperatively and, in particular, on the day of surgery. In general, orthopaedic surgeons are not as concerned about this risk as compared to previous years because of continual improvements in implant design and the surgical procedure. Therefore, the surgeons at the medical center agreed to work in partnership to enhance nursing knowledge of the decreasing rate of hip and knee dislocations in order to facilitate the initiation of patient activity on the day of surgery.

Interdisciplinary Communication

Table 1. Interdisciplinary Development Sessions

Pain Management

Over the past three decades, patients have received postoperative pain management in the form of administration of narcotics such as Morphine Sulfate, Dilaudid, or other potent opioids. Before initiating any mobilization, these powerful narcotics can be administered by means of a single injection or intravenous/patient controlled analgesia (IV/PCA). Narcotic complications are well published in the today's literature. The opioids can also cause confusion and forgetfulness. These effects may result in the joint replacement patient failing to adhere to hip and fall precautions. In light of the limited nursing literature or nursing research examining these issues, the interdisciplinary steering committee developing the CPG took these postoperative challenges under consideration when electing to begin activity on the day of surgery. The method of measuring pain for the CPG used the well-established scale of a patient self-report of "0" to "10." A score of "0" was interpreted as no pain, while a patient self-report of "10" was interpreted as the worst possible pain.

Continuous Infusion Nerve Blocks

Pain management is specifically a measurable nursing-sensitive outcome particularly with the introduction of continuous infusion nerve block (CINB) methodologies.

Approximately 1 year prior to the discussion of a CPG, the Department of Regional Anesthesia launched a continuous infusion local anesthetic nerve block program (CINB). CINB began informally on a case-by-case patient basis to familiarize surgeons with the technique. The pain management program included CINBs, and at that time, the traditional method of managing breakthrough pain using IV/PCA. As CINB is not intended to eliminate all pain, a breakthrough method had to remain available in conjunction with the nerve block to achieve all the benefits of early activity. The logic behind the utilization of CINB and IV/PCA was twofold: to develop protocols with suitable anesthetic concentration and dosages to achieve an acceptable level of pain/pain suppression, and to balance it with an acceptable level of decrease in motor and sensory function in this patient population while not increasing the fall risk.

The standard of care for the CPG project consisted of a continuous infusion with no scheduled "off" periods unless the patient's assessment demonstrated an overall loss of muscle and/or sensory function of the extremity. Under total muscle or sensory block, at the request of the nurse, the anesthesiologist ordered the infusion stopped for 1 hr, at which time the nurse reassessed the patient. With the return of motor sensory function, the pump was turned back on. To prevent potential events such as a patient fall or the loss of sensation that could lead to skin pressure injury, a motor and sensory assessment was performed every 4 hr and when anticipating mobilization.

Methods

The CPG is a comprehensive, multidisciplinary team effort conducted as an observational, quality improvement project. Approval was reviewed and approved from the internal review board and a waiver of individual informed consent was obtained.

Patient Questionnaire

Utilizing a standard set of questions to stimulate a dialogue, an independent nurse interviewer, not providing direct patient care, spoke with patients on the day of discharge. Questions explored the patient's perception of communication between nurse, surgeon, case manager, and physical and occupational therapists. Other questions assessed the quality of pain management, readiness for discharge, and the capacity to self-administer an injectable low-molecular-weight heparin for the prevention of deep venous thrombosis at home. During the first 3 months before and after the implementation of the CPG, patient interviews were randomly conducted using the same questions to gauge changes in quality. To capture the significance of the effect of the CPG, it was critical to remeasure patient satisfaction as well as evaluate effectiveness and efficiency of clinical activities.

Patient Education

Nursing, partnering with PT, occupational therapy, and case management, began to refine the preoperative patient education class to include the changes in pain management and in postoperative activity of dangling the patient on the day of surgery. The 90-minute class also covered other topics such as preparing the home for a safe recovery. A physical therapist demonstrated exercises to be performed while in the hospital and after discharge. A variety of medical equipment was displayed including urinary catheters, incentive spirometer, intermittent compression stockings, a walker, and a long-handled grabber. While instructors discussed each piece's function and proper use, participants were encouraged to handle and practice using the devices.

Another crucial element added to the class was instruction on self-injecting of a low-molecular-weight heparin. A demonstration by the nurse, with an improvised return demonstration by the patient, followed a discussion of deep venous thrombosis prophylaxis. There were three main goals with this key component of the class: (1) to decrease patient anxiety at the time of hospital discharge informing them ahead of time that they would be on an injectable medication at home; (2) to explain the importance of maintaining the regimen at home; and (3) to show how to physically perform the injection.

The patient education class was attended by a broad spectrum of patients including those who spoke English as a second language. Primary languages of participants other than English included Spanish, Chinese, Vietnamese, and Russian. In the majority of sessions, a family member attended to interpret for the patient. On all other occasions, the Patient Education Coordinator was able to locate a certified interpreter for the patient. The drafts of the CPG were altered into a version known as the Patient Friendly Guideline. This easy-to-read, detailed account of the expected hospital course was available during all phases of preoperative appointments and inpatient stay.

With knowledge, planning, and patient education solidified, the team continued to collaborate and incorporate the new best practices into their routines. The team also communicated these practices with the patient using similar language. This ensured that the patient would receive consistent information from all disciplines throughout the continuum of care.

Nursing Education

Frontline staff interviews demonstrated that the majority of nurses lacked comprehensive, up-to-date total joint replacement specific education or were relying on education gained 10 or more years ago. In contrast, the CPG required using updated nursing standards, physician changes in surgical techniques and prostheses, and anesthesiology changes in pain management. Through the nursing discussions, barriers to comfort with the proposed changes in the nursing standard of care centered around dangling the patient on the day of surgery, tied to the implications of managing postoperative nausea, vomiting, pain, light headedness, and risk of dislocation. To assist the nursing staff in overcoming these concerns, an educational course was developed in the form of a 3-hr, required attendance program. The didactics were presented by the orthopaedic surgeons, nurse practitioners, and nurse educators. Physical and occupational therapists performed a one-on-one bedside scenario competency to reinforce appropriate assessments, along with a return demonstration of dangling the patient on the edge of the bed, and transferring the patient from bed to a chair.

CPG Implementation

Another question evaluated the patient's assessment of pain management. This topic was also revised for the preoperative patient education class to emphasize the use of nerve blocks and the multimodal methodology of pain management. The instructors of the class continued to offer instruction on the use of IV/PCA and epidural pain management for the atypical patient who was not a candidate for CINBs.

The ability to manage the patients' pain adequately showed improvement. An increase in this score was important because sufficient pain control while an inpatient was necessary for patients to actively participate in all forms of rehabilitation. It was also vital to their self-care after discharge. Of all the patient self-care questions, pain control improved the most.

Clinical Practice Guideline Audits

Additional auditing revealed that 7 of the 30 postlaunch patients (23%) did not receive prophylactic treatment of nausea during surgery. Three of the 30 postlaunch CPG patients (1%) received medication for nausea in the postoperative care unit (PACU). Of the eight patients on the unit complaining of postoperative nausea, two patients were treated for vomiting (6%). These two patients were not dangled on the day of surgery.

In an earlier era, the presence of drains was considered a physician restriction to activity until such time as the drain was discontinued. In this contemporary time, some large medical centers have eliminated the use of drains altogether. However, in this academic center, the drain remains a consideration on a case-by-case basis. It does not, however, obstruct the patient from dangling on the day of surgery.

Outcomes: In summary, launching a CPG established the following:

* Improvement in the nursing standard of care by eliminating barriers to change.

* Patient mobilization by nursing within 6 hr posttransfer from the PACU.

* Ambulation by PT pre- and postlaunch CPG of 16 hr posttransfer from PACU.

* Reduction in length of hospital stays from 4.3 to 2.8 days.

* Elimination of IV/PCA with successful CINB and multimodal pain management program.

* Consistent improvement in pain management below a pain score of 4 (4):

* At the time of PACU discharge (pain score 2.1)

* Upon admission to the orthopaedic unit from PACU (pain score: 3.3)

* Prior to the intervention of nursing dangling the patient on the day of surgery (pain score: 2.9)

* Reassessment following the intervention of dangling (pain score: 3.3)

* Assessment by PT prior to ambulation on postoperative Day 1 (pain score: 3.3).

* Patient satisfaction interview scores support improvements in pain management from a prelaunch CPG score of 3.5 to postlaunch CPG score of 4.2.

* Areas to be addressed include improvement in interdisciplinary communication as reported from patient interviews.

* The benefits of patient education demonstrated improvement in:

* Preparedness to care for self

* Instruction in low-molecular-weight heparin self-injection

* Helpfulness of class

* Patients' understanding RN discussion of the care plan

Through interviews, education, and the development of a new standard of care by means of a CPG, patients were mobilized on the day of surgery in a safe manner. Of the patients who were dangled, no secondary adverse events occurred when initiating the patient's first postoperative activity within 6 hr of surgery.

The decrease in pain scores below a score of 4 (<=4) provided positive attributes and basis for an expanded study of the benefits associated with initiating activity within hours following surgery. Even with more aggressive activity led by PT on postoperative Day 1, the pain scores remained less than 4. Since data were collected for the purpose of quality improvement, not research, the authors are not suggesting that this is a statistically significant improvement. Rather, the authors are noting that CINB, as an intervention, can be associated with improvements not only in pain management, but may also contribute to improved postoperative activity.

Preoperative Patient Education

Increasing the number of offerings of preoperative patient education gave more patients an opportunity to attend the classes. This education proactively addressed the powers of collaboration and patient's participation in self-care.

Effects of Physician Practice Changes

Advancements in physician practices were not transparent to nursing or seamless to the remainder of the clinical departments. Next to the patient, nursing would be the most affected by these changes. The patient and nursing questionnaires, in conjunction with interdisciplinary meetings, served as a needs assessment, emphasizing the value of investing in specialty training to develop proficiency and alignment with physician practice changes. Specialty training would also create familiarity with new technology including the rapid uptake of CINBs within the organization.

Discussion

Although some of the data showed no change from pre- to postlaunch CPG, these findings are an effective evaluation to guide the next generation of this organization's CPG with improvements. While advancements in clinical practice outcomes are traditionally measured in terms such as morbidity and mortality, today's marketplace also mandates nontraditional outcomes to include patient satisfaction and interdisciplinary communication. To gauge gaps in customer satisfaction in a highly technological, potentially high-risk environment, patients were encouraged by the authors to participate in one-on-one interviews. The patient interviews generated insight into the ripple effects of a large integrated hospital process. The interdisciplinary team used these findings to drive change to improve interactions between clinical and system processes, including the development of a Patient Friendly Guideline.

Advanced practice nurses recognized an opportunity to leverage the utilization of CINB to support initiating patient activity on the day of surgery-in effect, altering the nursing standard of care. Postoperative pain management requires a balance between pain relief and unwanted side effects. It is worth mentioning to readers who are not familiar with CINB that CINB serves to improve pain management while eliminating an abundance, or overabundance, of injectable opioids and their side effects. And lastly, the use of the CPG itself may have affected positive patient outcomes with respect to pain management. Lack of quality postoperative pain management has a wide range of detrimental acute effects on both traditional and nontraditional outcomes.

Figure 2. The developmental approach employed by the interdisciplinary team in designing the Clinical Practice Guideline (CPG), including the "Patient Friendly" version of the CPG.

Acknowledgments

A special thanks to Patrick Olsen, RN; Sarah Bonome, RN; Nita Uson, RN; Joanne Markart, RN; Sherlita Alfonso, RN; Scott Meyer, MD; Scott Ball, MD; Ed Mariano, MD; Lisa Dacey, MSPT; Lynda Garza, OT; Carolyn Jones-Cullen, RN, and in particular, the staff of both hospitals. Assistance also came from San Diego State University nursing students as a senior year change project and Susan A. Schwarz.

References