Total Hip and Knee replacementpathway

So why come to the L&D for yoursurgery? What do we offer?

At the L&D we offer a structuredENHANCED RECOVERY PROGRAMME (ERP)

to support and guide pre-operativepreparation and post operative recovery for

our patients.

Tonight you will be hearing from;

• Myself - Irene Fitt - Clinical Lead EnhancedRecovery

• Aimee Ford - Enhanced Recovery Sister

• Jenny Simpson – Specialist SurgicalPhysiotherapist

• Rita Patel - Hospital at Home Senior Sister

What is Enhanced Recovery?How does it benefit you?

• Providing gold standard care for all patients• Aims to reduce the risk of surgical

complications• Promoting independence• Reduced length of stay in hospital, allowing

you to recover at home

Traditional vs. ERPWhat we did before….

In turn, hospitalstay was

approximately 5days or more!!

In turn, hospitalstay was

approximately 5days or more!!

Resulted in higherrates of DVT,

chest infectionsand other

complications

Resulted in higherrates of DVT,

chest infectionsand other

complications

Large woundsfor everyone

Large woundsfor everyone

Used heavyanaestheticsUsed heavyanaesthetics

Starvedpatients for a

long time

Starvedpatients for a

long time

Kept patientsin bed post

op!

Kept patientsin bed post

op!

No realinformation

givenbeforehand

No realinformation

givenbeforehand

Traditional vs. ERPWhat we do now…..Aim to see all

patients prior tosurgery atHip/Knee

educationalschool

Aim to see allpatients prior to

surgery atHip/Knee

educationalschool

Now you are ableto eat 6 hoursbefore surgeryand even drink

clear fluid up to 2hours before

Now you are ableto eat 6 hoursbefore surgeryand even drink

clear fluid up to 2hours before

Improvedsurgical andanaesthetictechniques

Improvedsurgical andanaesthetictechniques

Patients are upand walking onday of surgery!!

Patients are upand walking onday of surgery!!

Patientsencouraged to

get dressed intoeverydayclothes

Patientsencouraged to

get dressed intoeverydayclothes

Eating anddrinking asap

post op

Eating anddrinking asap

post op

Good painmanagement

Good painmanagement

Multidisciplinary Team (MDT)

approach

Multidisciplinary Team (MDT)

approach

The Surgical Journey

• GP refers to orthopaedicconsultant

• Initial consultation with consultant• Pre-assessment appointment• Patients automatically put onto

ERP• Invited to ERP educational joint

school

Pre-op Educational SchoolsThe aim of the school is to educate patients toplay a very active role in their recovery! Preparation for surgery Fitness for surgery How to help yourself Friend/relative to attend Attendance is part of the ERP MDT speakers 1 hour 15 minute sessions

“I was invited to attenda knee school 4 weeksbefore op date and Ifound this extremely

interesting, it made mefeel more relaxed

about the up comingop on my knee.

7

Information packs

8

Median length of stay2014 = Primary Total Hip Replacement – 5.2 days

2018 = 2 days!

2014 = Primary Total Knee Replacement – 4.7days

2018 = 2.5 days!

Don’t be surprised if you get to go home thevery next day!

9

ERP - Patient feedback

“If you didn’tdo as you weretold , then youwouldn’t be on

to a winner”

“…knowingsomeone wason the end ofthe phone to

contact..”

“The goal chartto follow and theadvice received,

made a bigdifference to the

speed of myrecovery”

“The main benefit was a feeling thateverything was being done to makemy recovery as smooth as possible”

So what do the Therapy team doalong the ERP journey ?

Therapies in Orthopaedics

PHYSIOTHERAPY:• Physiotherapy is a science-based profession

and takes a ‘whole person’ approach tohealth and wellbeing, which includes thepatient’s general lifestyle.

• At the core is the patient’s involvement intheir own care, through education,awareness, empowerment and participationin their treatment.

OCCUPATIONAL THERAPY (OT):• Occupational therapists play a critical role in

helping people of all ages overcome theeffects of disability caused by illness, ageingor accident so that they can carry out everydaytasks or occupations.

• An occupational therapist will consider all ofthe patient’s needs - physical, psychological,social and environmental. This support canmake a real difference giving people a renewedsense of purpose, opening up new horizons,and changing the way they feel about thefuture.

Our Team at the L&D• We cover all the surgical wards - 20, Surgical

Assessment Unit (SAU), 22, 23, Cobham(private ward), and have a service within theHospital @ Home Team.

• We provide a 7 day service.• We see Elective, Emergency and Trauma

patients under Surgery, and Orthopaedics.• Physiotherapy = 6.5• Occupational Therapy = 4• Therapy Assistant, Technical Instructor = 6.5

Elective Joint replacement Surgery

• Total Hip Replacement (THR)• Hip Precautions

• These are in place to reduce the risk ofdislocation of the new joint. Patients aretaught about these at OT pre-assessment, theprinciples are then reinforced at joint school, &following surgery.

Pre-Assessment• Our OT team offer THR patients a pre-assessment in order to

understand their function and home situation. This allows us toprovide equipment and adaptations to be put in place prior tosurgery, to help patients achieve a safe and comfortable recovery.

• All patients attending the Hip/ Knee Schools (and OT pre-assessment) are advised of their exercises, and are encouraged tostart them at home, and to commence straight away after surgery.

Post Operative Protocol• Where patients have had morning surgery, staff will aim

for elective joint patients to be mobilising out of bedDay 0.

• Therapists aim to see patients twice a day from day 1.• Day 1 – Be dressed in own clothes. Transfer out of bed

with walking aids, commence mobility and exercises.Reinforce precautions. In some cases patients willprogress quickly to elbow crutches, be able to completea stair assessment, and go home. Equipment needsidentified and supplied if needed.

• Day 2 onwards (if applicable) – Progressmobility, and exercises, assess on stairs ifneeded for discharge.

• For all patients Discharged up to Day 7post-op, referred to H@H team. If not,Community PT/OT referrals can be made.

So……what isHospital at Home?

Can be described as ‘apopular term for

Acute treatment byhealth care

professionals ofpatients in their own

homes.’

Can be described as ‘apopular term for

Acute treatment byhealth care

professionals ofpatients in their own

homes.’

American concept thathas developed in this

country with everyHospital at Home

Team varying in whatthey offer

American concept thathas developed in this

country with everyHospital at Home

Team varying in whatthey offer

Hospital at Home(H@H)Surgical Team

• 7 day service covering 08.00 – 18:30 (except Sundays are 9-5pm)• Comprises of Nurses, Physiotherapists and Technical Instructors• Areas covered – Hertfordshire, Bedfordshire and Buckinghamshire• Nurses visit the patient the day after discharge from hospital, if

home within 7 days

Specialities managed by the team:• Orthopaedics:

• Elective procedures including THR, TKR and upper limb surgery• Fractured Neck of Femur

• Intravenous (IV) Antibiotics• Pre and Post-op anti-coagulation therapy• SOS calls

Orthopaedics - ElectivePost-op

• Prior to discharge the H@H nurse visits thepatient on the ward to introduce themselves

• Day after discharge the nurses complete firstvisit

• Visits include:Writtenconsent

observations

Writtenconsent

observations

MedicationmanagementMedication

management

woundmanagemen

t

woundmanagemen

t

pressure areachecks

pressure areachecks

Assessment ofequipment/walki

ng aids

Assessment ofequipment/walki

ng aids

GeneralAdviceGeneralAdvice

exercises,mobility andstair practice

exercises,mobility andstair practice

• Patients are visited daily or alternate daysdepending on the needs of the patient

• Removal of clips Day 12-14• Referred to Physiotherapist – will visit you at

home to progress exercises, walking aids,outdoor mobility & car transfers

• Remain under the care of the H@H team for6 weeks post op with telephone support

• Orthopaedic Hub referrals if required forissues with the wound

• Referral to Ambulatory Care for suspectedDeep Vein Thrombosis (DVT/blood clots)

“Not having to stayin hospital was

brilliant. The nursesand physiotherapistwere very helpful”

“The kindness of thenurses and the

wonderful help fromthe physiotherapist

in helping mewalking and

strengthening myknee”

“First classservice”

“Nurses andphysio werevery helpful,encouraged

me to try andrebuild my

confidence”