Nursing in fast-track total hip and knee arthroplasty: A retrospective study

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Abstract

Aim

To describe the increased activity in total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2002 to 2012 in a single orthopaedic department, the organisation of fast-track and its consequences for nursing care.

Methods

Retrospective, descriptive design. Data collection; from the hospital administrative database, local descriptions of fast-track, personal contact and discussion with staff.

Results

The number of operations increased threefold from 351 operations in 2002 to 1024 operations in 2012. In 2012, THA/TKA patients had a postoperative mean LOS of 2.6/2.8 days. Nurses had gained tasks from surgeons and physiotherapists and thus gained more responsibility, for example, for pain management and mobilisation. Staffing levels in the ward in 2002 and 2012 were almost unchanged; 16.0 and 15.8 respectively. Nurses were undertaking more complicated tasks.

Conclusion

Nursing care must still focus on the individual patient. Nurses need to have enough education to manage the complex tasks and increased responsibility. To prevent undesirable outcomes in the future, there is a need to pay attention to the nursing quality in balance with the nursing budget. It may, therefore, be considered a worthwhile investment to employ expert/highly qualified professional nurses in fast-track THA and TKA units.

Introduction

This paper considers the major changes in nursing care after fast-track was implemented for total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a Danish orthopaedic department. The organisation of fast-track in THA and TKA varies significantly between departments in different countries (Hjort Jakobsen et al, 2014, Kehlet, 2013). It consists of a standardised programme with improved multimodal strategies including opioid sparing pain management (Husted, 2012a, Kehlet, 2013, Specht et al, 2011), early and increased mobilisation and improved information and nutrition (Kehlet and Dahl, 2003). With a focus on dialogue and education, patients are motivated to play an active role in their own treatment, care and rehabilitation. Fast-track approaches in total joint replacement have developed considerably during the past 10 years and it has had an influence on nurses' roles and responsibilities. In Denmark length of stay (LOS) has decreased from about 10 to 11 days in 2000 to 4 days in 2009 (Husted et al., 2012b). For THA this trend has continued as one Danish clinic reported a median LOS of 1 day in 2011 (Mikkelsen et al., 2014) and several multicentre studies reported a median stay of 2 days (Jorgensen and Kehlet, 2013). In Denmark patients are discharged to their own home. It is very unusual for patients to go to a family member's home after discharge and the country does not use rehabilitation centres for THA and TKA patients.

The advantages of fast-track are well documented from both socio-economic perspectives (Andersen et al, 2009, Hunt et al, 2009, Larsen et al, 2009) and from the perspective of improved outcome for patients (Dowsey et al, 1999, Kehlet, 2013, Kehlet, Wilmore, 2008) including reduced incidence of complications (Husted et al, 2010b, Husted et al, 2010c, Savaridas et al, 2013). Furthermore, the readmission rate is reported not to be higher in a fast-track setting compared with a conventional setting (Husted et al., 2010b).

Hospitals are a target when stakeholders want to save money. Health system reforms have reduced inpatient beds and the fast-track concept, with its shortening of LOS down to about 2 days, is considered to be of benefit when the health system is trying to do more with less. A consequence of shortening LOS in hospital is that nursing care will be considerably intensified. This might raise concerns about the quality and safety of care. Recently, a study about nurse staffing and education and hospital mortality in nine European countries concluded that nurse staffing cuts to save money adversely affects patient outcomes (Aiken et al., 2014).

Scheel et al. (2008) described the conflict between the ‘system world’, controlled in a political context with a focus on reduction of cost burden, and on the other hand the ‘life world’, which is focused on the patient and nursing care. A dominance of the system world may result in nursing care being ignored and forgotten. Political dominance has resulted in consequences in relation to nursing care and Scheel et al. (2008) points out an urgent need for investigation in this area (Scheel et al., 2008).

Although the notion of fast-track is not new, the organisational consequences for nursing care of fast-track in THA and TKA have not been described. This study, therefore, aimed to describe, in a retrospective manner, the increased activity in THA and TKA from 2002 to 2012 in an orthopaedic department, the organisation of fast-track and its consequences for nursing care. Even though the study was an informal local inquiry in a specific department, it has relevance to other departments elsewhere in Denmark and in other countries.

Section snippets

Methods

The study had a descriptive design. We retrospectively considered and described the surgical activity and the organisational consequences for nursing of fast-track care in THA and TKA after the fast-track programme was implemented in 2002 until 2012. The study was conducted in one ward in a Danish regional hospital with 310 beds and 2100 employees with a catchment area of 303,000 citizens. The hospital continuously collected data on surgery, patient information and organisation and recorded

Increased activity and decreased LOS

In the orthopaedic department discussed here, fast-track for THA and TKA has led to a significant increase in activity; the number of operations increased threefold from 351 operations in 2002 to 1024 operations in 2012 (Table 1). The number of beds was 24 during the entire period. For all arthroplasty patients in the ward including elective, acute, primary and revision surgery patients, the LOS decreased. The LOS of all THA patients decreased from mean 8.6 to 3.3 days and for TKA patients from

Patients in the ward

When fast-track was implemented in the department in 2002 all THA and TKA patients were allocated to the same ward and initially only the “best” patients were included in the programme. From 2005 there was no selection of patients, thus all THA and TKA patients were included in fast-track. During summer, Christmas time and other holiday periods (up to 15 weeks per year), the two orthopaedic wards in the department had to take turns to close the ward. Thus a small number of THA and TKA patients

Pain management

A standardised protocol for pain management in the ward made it possible for the nurses to handle most of the pain treatment themselves. When patients still had pain after the nurses had tried with non-pharmacological interventions and conventional analgesics within the protocol, the surgeon or an anaesthesiologist were asked for assistance. Most of the patients self-administered and kept their own oral analgesia, but the nurses advised the patients about when to take the medicine and the

Nurses with specialist responsibilities

Because all patients following THA and TKA were cared for in the same ward, the nurses' specialist skills were enhanced and they had greater experience within the area. The ward manager identified two registered nurses to take specific specialist responsibilities, one for THA and one for TKA. The two nurses had many years of experience of the orthopaedic field especially of THA and TKA nursing care. They were in charge of fast-track care in the ward as well as induction of new staff. Every

Task shifting

Compared with 2002 the nurses in the ward in 2012 had taken on more tasks from surgeons, leaving them with more time to focus on surgery. In the ward the nurses and physiotherapists have joint responsibility for discharging the patients when they were ready to go home according to predefined discharge criteria. Thus, more patients were discharged before and during weekends because the surgeons did not need to be present. A discharge checklist was developed and the surgeons wrote a postoperative

Staffing levels

Staffing levels in 2002 and 2012 in the ward were almost unchanged at 16.0 and 15.8 respectively (Table 2). The NHPPD during the study period ranged from 5.5 to 6.8 (Table 2). However, the resources were used differently in 2002 and 2012 (Table 3). Distribution of nurse staffing during the week changed over time because of new demands on nursing care. In order to prepare patients for going home 1 or 2 days after surgery increased nursing resources were planned during weekdays in the evening (

Discussion of methods and limitations

The study had a retrospective, descriptive design, where staffing level data were collected from an existing database. More effective data could have been collected by prospective recording of nurse staffing in the ward alongside the patient activity at the same time point. A predefined framework for evaluation of clinical practice was not used in this study and if such a framework had been used the study would have demonstrated greater rigor. Finally, this study examined data from only one

Conclusion

Our study showed markedly increased THA and TKA surgery activity with the same nursing budget in the ward during the decade. The advantages of the increased effectiveness were improved exploitation of health care financial resources and the advantages for the patients were reduced waiting lists, reduced complications and less need to stay in hospital.

Concerning nursing care, it is important to be aware of the continuing development of fast-track in THA and TKA means that nurses are taking on

Recommendations

  • 1.

    Identify relevant tasks within THA and TKA fast-track and to assess to what level of registered nurses or licensed nurse practitioners are competent the tasks.

  • 2.

    Focus on employing expert, specialist and high-qualified nurses to handle the demands of complexity in fast-track settings.

  • 3.

    Ensure that the nurses working within fast-track in orthopaedic departments have the required education.

  • 4.

    Perform further research regarding patient experiences in fast-track total hip and knee arthroplasty.

  • 5.

    Perform

Conflict of interest statement

There is no conflict of interest in the preparation of the manuscript.

Funding source

No funding was applied for in the preparation of the manuscript.

Ethical approval

The Danish Data Protection Agency approved the study (J.nr. 2012-41-0326). The regional ethical committee found that a formal approval was not required.

Acknowledgement

Authors wish to acknowledge the two consultants from Vejle Hospital, Denmark; Kirsten Winther-Rasmussen and Hans Jørn Refsgaard Jørgensen for supporting us with data from the hospital administrative database.

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