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Managing postoperative TKA pain with therapy

Samantha Beckman OTD

Kelly Fairfield PT

OBJECTIVES

Past procedures and therapy protocols

Need for change/new Medicare guidelines for reimbusement

Evidence supporting change

Tracking outcomes

Present therapy processes

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Time for change• Jennie McCarthy’s presentation “Tackling the Opioid Epidemic:

Optimizing Pain Management in Orthopedics”

• Evidence (in practice and research)

• Basic desire to see successful outcomes and have patients be happy about that, rather than “hotel lakeside”

How it was

Joint camp

Meals and exercise groups together

“Stations” for tasks

Expecting a 3 day stay

Confusion re: d/c planning

Waiting for RN to get pain under control via meds prior to attempting to move

All focus was on keeping patients comfortable

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How they did

Refusal to move from bed due to pain

Knees buckling/hypotension/nausea

Inconsistent outcomes

Confusion at time of d/c

However, they were happy about their experience as far as customer service went

OPIOIDS TRENDS

2001 Joint commission designated pain as the 5th vital sign

Opioid crisis

US vs International opioid usage/abuse

Growing cause of death in the US

More postoperative complications

Studies indicate use of opioids for 12 weeks results in 50% of patients continuing to use them 3 years later

“ PROLONGED OPIOID USE IS THE MOST COMMON COMPLICATION OF SURGERY”

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OXFORD STUDY 2019

34,792 Total Joint Patients

Hip 38%, Knee 58%, 4% Shoulder

6,043 (17%) opioid user preoperative

Increased length of stay

Non home discharger

30 day readmission

35% higher site infection

44% higher surgical revision

64% lower rate of narcotic cessation

HIGHER MEDICAL SPENDING

A LARGER RETROSPECTIVE COHORT STUDY OF ADMINISTRATIVE CLAIMS DATA

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Department of Orthopaedic Surgery from Massachusetts General Hospital and Harvard Medical School

389 Total Hip Arthroplasty

76 preoperative opioid users

237 preoperative non opioid users

Patient Reported Outcome Measures before and after surgery

STAY IN HOSPITAL LONGER

D/C TO REHAB

LOWER PATIENT OUTCOME SCORES

A STUDY FROM 2019 ANNALS OF TRANSLATIONAL MEDICINE JOURNAL

408 TKA

185 pod 0 45%

221 POD 1 54%

SIGNIFICANT DIFFERENCE

LOS

HOME VS REHAB D/C

70% pod 0 D/C HOME VS 58% POD 1

“Early mobilization decrease LOS in hospital and optimization d/c to home.”

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INTERNATIONAL EVIDENCE

CDC estimated prescription drug abuse is the fastest growing premature death in the USA, resulting in 33,000 a fivefold increase sine 2001

“ TJA recipients consuming a greater amount of preoperative medication particularly narcotics, were more likely to be discharged to a rehab facility and readmitted compared to those who were taking less medications”

Chronic opioid users have increase ER visits, readmissions, postoperative stiffness, periprosthetic infection, and aseptic loosening

“ Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization.”

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What we tried

Consistent messaging

o “it’s very normal to have pain after surgery”

o “we will take it slow and easy”

o “we are right here to help you”

o “we are going to get up now”

o “GET to go home” vs “HAD to stay” and redirect “they’re kicking me out”

Preoperative joint class-referring back to information they already heard

Setting expectations right away

Emphasizing that we are following their surgeon’s recommendation

WE STOPPED ASKING FOR A PAIN RATING

Strategies

Environment- shades up, lights, calm voice, including family member, explaining each step and setting patients at ease

Mental History: noting anxiety, depression, fibromyalgia , psych history

Past Medical History: BMI, diabetes, oxygen needs, complex history, stroke, inactivity prior, preoperative narcotic usage

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We noticed a trend developing:

IDEAL PROTOCOL Expected length of stay 1 day

Optimizing BMI

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Decided to track our outcomes

1. LOS

2. D/C

3. PAIN MEDICATION

4. IV PAIN MEDICATION

5. CLASS

6. ASK FOR PAIN RATING AFTER A COUPLE WEEKS

7. TIME GOT UP AFTER SURGERY WITH OT/PT

8. RAPT score

What we looked at to determine

COVID hit, had to reset some protocols/practices with caseload and staffing changes

Resumed tracking once surgeries were allowed

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2

0

8

7

0

7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ideal Other

July 2020 IV Narcotic Use in Knee Replacement Patients

Yes No

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0

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67

0

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2625

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NUMBER OF PO PAIN MEDICATION

Doses of PO Pain Medications in Patients who received IV narcotics

Ideal Other

What it looks like now

Refusal to participate is very rare

Unsuccessful evaluation/treatment also very rare

Discharges are smooth and organized, rarely change from initial plan

Patients are up within 6 hours of surgery

Treatments are individualized and efficient

We make every effort to get patients out by noon POD 1

o Need nurses on board/scheduled appropriately/joints cohorted

o Need ortho on board/rounding and discharge orders in

o Pharmacy on board for meds to beds

o Work with CPM vendor so we’re not waiting for them

o Set patients up to expect that time, and that’s a good thing (=success!)

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PHRASES “TAKE AWAYS”

Our bodies are made to be in motion

Pain is a good reminder to you not to over do

“Its completely normal” to have pain

Everything is fixed now you can put weigh on it

Your muscle/tendons are really angry right now because they are trying to figure out how to work with your new parts, therefore you have pain

Lets try it before the IV pain meds because that causes more problems etc

Focus on your breathing

You have a brand new perfect joint, it will get better

Its going to hurt for a little while but then this pain will go away

Ice is your friend

We will go slow and if its too much we will stop

IT TAKES A TEAM!

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References

Peratikos MB, Weeks HL, Pisansky AJB, Yong RJ and Stringer EA. Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States: A Large Retrospective Cohort Study of Administrative Claims Data. Pain Medicine, 2020; 21(3): 521-531

Ohnuma R, Raghunathan K, Moore S, Setohuchi S, Ellis AR, Fuller M, Whittle J, Pyati S, Bryan WE, Pepin MJ, Bartz RR, Haines KL and Krishnamoorthy V. Dose-Dependent Association of Gabapentinoids with Pulmonary Complications After Total Hip and Knee Arthroplasties. Journal of Bone and Joint Surgery, 2020; 102:221-9

Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P and Ljungqvist O. Consensus Statement for Perioperative Care in Total Hip Replacement and Total Knee Replacement Surgery: Enhanced Recovery After Surgery Society Recommendations. Acta Orthopaedica, 2020; 91(1): 3-19

Pizzi LJ, Bates M, Chelly JE and Goodrich CJ. A Prospective Randomized Trial of an Oral Patient-Controlled Analgesia Device Versus Usual Care Following Total Hip Arthroplasty. Orthopedic Nursing, Jan/Feb 2020; 39(1):37-46

Rajamaki TJ, Puolakka PA, Hietaharju A, Moilanen T and Jamsen E. Use of Prescription Analgesic Drugs Before and After Hip or Knee Replacement in Patients with Arthritis. BMC Musculoskeletal Disorders, 2019; 20:427

Shakya H, Wang D, Zhou K, Luo ZY, Dahal S and Zhou ZK. Prospective Randomized Controlled Study on Improving Sleep Quality and Impact of Zolpidem after Total Hip Arthroplasty. Journal of Orthopaedic Surgery and Research, 2019; 14:289

Bonner BE, Castillo TN, Fitz DW, Zhao JZ, Klemt C and Dwon YM. Preoperative Opioid Use Negatively Affects Patient-reported Outcomes After Primary Total Hip Arthroplasty. Journal of the American Academy of Orthopedic Surgeons, 2019; 27:e1016-e1020

Zhao J and Davis SP. An Integrative Review of Multimodal Pain Management on Patient Recovery After Total Hip and Knee Arthroplasty. International Journal of Nursing Studies, 2019; 94-106

References

Lemay CA, Saag KG and Franklin PD. A Qualitative Study of the Postoperative Pain Management Educational Needs of Total Joint Replacement Patients. Pain Management Nursing, 2019; 20: 345-351

Wilson R, Pryymachenko Y, Audas R and Abbott JH. Long Term Opioid Medication Use Before and After Joint Replacement Surgery in New Zealand. New Zealand Medical Association Journal, 2019; 132: 33-48

Anoushiravani AA, Kim KY, Roof M, Chen K, Oconnor CM, Vigdorchik J and Schwarzkopf R. Risk Factors Associated with Persistent Chronic Opioid Use Following THA. European Journal of Orthopaedic Surgery and Traumatology, 2020; 30: 681-688

Deen JT, Stone WZ, Gray CF, Prieto HA, Iams DA, Boezaart AP and Parvatanei HK. Revision Arthroplasty Does Not Require More Opioids Than Primaries: a Review of Prescribing Practices After Implementation of a Structured Perioperative Pain Management Strategy, 2020; 35: 2173-2176

Yakkanti RR, Miller AJ, Smith LS, Feher AW, Mont MA and Malkani AL. Impact of Early Mobilization on Length of Stay After Primary Total Knee Arthroplasty, Annals of Translational Medicine. 2019 Feb; 7(4)

Chua MJ, Hart AJ, Mittal R, Harris IA, Zuan W and Naylor JM. Early Mobilization After Total Hip or Knee Arthroplasty: a Multicentre Prospective Observational Study. PLoS ONE; 2017: 12(6)

Russo MW, Parks NL and Hamilton WG. Perioperative Pain Management and Anasthesia, A Critical Component to Rapid Recovery Total Joint Arthroplasty. Orthopedic Clinical Nursing, 2017; 48: 401-405

Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, Gerlinger TL, Buvanendran A and Valle CJD. The James A Rand Young Investigator’s Award: Large Opioid Prescriptions are Unnecessary After Total Joint Arthroplasty: A Randomized Controlled Trial. The Journal of Arthroplasty, 2019; 34: S4-S10

Thomas W Wainwright, Mike Gill, David A Mcdonald, Robert, Middleton, Mike, Reed, Opinder, Sahota, Piers, Yates, and Olle Ljungqvist. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Acta Orthopaedica 2020 (1): 3-19.

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