Dataset Information

Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.

ABSTRACT:

Objective

Early mobilisation is recommended following total hip arthroplasty (THA) or total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). We sought to determine the proportions of patients that first mobilised on post-operative day 0 (POD 0) and factors associated with earlier time to mobilisation.

Methods

A prospective cohort study was conducted involving patients with hip or knee osteoarthritis who had undergone primary unilateral THA (n = 818) and TKA (n = 989) at 19 Australian hospitals. Patient-related (e.g. age, gender, body mass index), treatment-related (e.g. hospital site, presence of indwelling catheter) and mobilisation-related variables were collected on standardised forms. Time was measured by post-operative days, where POD 0 was defined as the day of surgery ending at midnight. Multivariate Poisson regression analysis identified associations between patient- and treatment-related covariates and time to mobilisation.

Results

Inter-hospital variation was evident, but overall, only 9.4% of THA and 5.6% of TKA patients mobilised on POD 0. For THA patients, earlier time to mobilisation was associated with hospital site and absences of an indwelling catheter and acute complications. For TKA patients, earlier time to mobilisation was associated with hospital site and absence of donor blood transfusion.

Conclusions

Few THA and TKA patients mobilise POD 0, although some hospitals appear more aggressive with their mobilisation attempts than others. Treatment-related factors, not patient-related, are associated with post-operative day of mobilisation, indicating the potentially pivotal role of service providers in promoting early mobilisation to improve health outcomes and reduce rates of VTE.

SUBMITTER: Chua MJ

PROVIDER: S-EPMC5487040 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Publications

Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.

Chua Matthew J MJ Hart Andrew J AJ Mittal Rajat R Harris Ian A IA Xuan Wei W Naylor Justine M JM

PloS one 20170627 6

<h4>Objective</h4>Early mobilisation is recommended following total hip arthroplasty (THA) or total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). We sought to determine the proportions of patients that first mobilised on post-operative day 0 (POD 0) and factors associated with earlier time to mobilisation.<h4>Methods</h4>A prospective cohort study was conducted involving patients with hip or knee osteoarthritis who had undergone primary unilateral THA (n = 818) and TKA (n = 98 ...[more]

PMID: 28654699

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Project description:BACKGROUND:Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice. METHODS:From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was 'days alive and at home up to 30 days after surgery' (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30?days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice. RESULTS:Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3-5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25-27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%). CONCLUSION:Quality of recovery measured by a median DAH30 of 26?days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if 'buy-in' from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative. TRIAL REGISTRATION:The study was registered with ClinicalTrials.gov ( NCT03540667 ).

Project description:BACKGROUND:Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. METHOD:A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12?weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. RESULTS:Five hundred twenty consecutive patients (n?=?278, Before; n?=?242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p?=?0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p?<?0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p?<?0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12?weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. CONCLUSION:Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Project description:BackgroundTotal joint replacements are high-volume and high-cost procedures that should be monitored for cost and quality control. Models that can identify patients at high risk of readmission might help reduce costs by suggesting who should be enrolled in preventive care programs. Previous models for risk prediction have relied on structured data of patients rather than clinical notes in electronic health records (EHRs). The former approach requires manual feature extraction by domain experts, which may limit the applicability of these models.ObjectiveThis study aims to develop and evaluate a machine learning model for predicting the risk of 30-day readmission following knee and hip arthroplasty procedures. The input data for these models come from raw EHRs. We empirically demonstrate that unstructured free-text notes contain a reasonably predictive signal for this task.MethodsWe performed a retrospective analysis of data from 7174 patients at Partners Healthcare collected between 2006 and 2016. These data were split into train, validation, and test sets. These data sets were used to build, validate, and test models to predict unplanned readmission within 30 days of hospital discharge. The proposed models made predictions on the basis of clinical notes, obviating the need for performing manual feature extraction by domain and machine learning experts. The notes that served as model inputs were written by physicians, nurses, pathologists, and others who diagnose and treat patients and may have their own predictions, even if these are not recorded.ResultsThe proposed models output readmission risk scores (propensities) for each patient. The best models (as selected on a development set) yielded an area under the receiver operating characteristic curve of 0.846 (95% CI 82.75-87.11) for hip and 0.822 (95% CI 80.94-86.22) for knee surgery, indicating reasonable discriminative ability.ConclusionsMachine learning models can predict which patients are at a high risk of readmission within 30 days following hip and knee arthroplasty procedures on the basis of notes in EHRs with reasonable discriminative power. Following further validation and empirical demonstration that the models realize predictive performance above that which clinical judgment may provide, such models may be used to build an automated decision support tool to help caretakers identify at-risk patients.

Dataset Information

Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.

Objective

Methods

Results

Conclusions

Publications

Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.

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