PICOT Introduction
Total joint replacement surgery such as, hip or knee replacements, are commonly performed orthopedic surgeries. When undergoing an elective orthopedic surgery, patients receive education regarding expectations before, during, and after surgery. This can help alleviate anxiety and help patients understand the process of recovering from orthopedic surgery. An important aspect of total joint replacement surgery is ensuring a quick and safe recovery. In a study conducted, research showed that patients who ambulated with trained staff, early ambulation intervention accelerated the recovery time for patients post total joint replacement (Lisevick, et al., 2020). Early ambulation for post total joint replacement surgery patients has a positive impact in helping patients achieve a healthy and quick recovery.
Background
The PICOT discussion that was formed around this topic is: When it comes to total joint replacement surgical patients, how does early ambulation post-surgery compared to no intervention, have a positive outcome with recovery during patient treatment? Early ambulation after total joint replacement surgery is a great way to helping patients recover and offset post-surgical complications. Some examples of how ambulation assists in patient recovery are: decreased risk of blood clot formation, quicker recovery time, decreased pain, decrease GI problems, and decreased risk of urinary retention. A study conducted stated that patients who ambulate earlier after having total joint replacement surgery have a decreased chance of developing complications such as venous thromboembolism (VTE), gastrointestinal issues, pneumonia, and urinary retention (Lisevick, et al., 2020). When hospital stays and readmissions are decreased then so are healthcare costs. Not ambulating this population can lead to patients developing a secondary complication associated to surgery such as VTE and can increase the length of thier hospital stay thus impacting costs. Early ambulation may also increase patient satisfaction, as early ambulation can help speed up their recovery time, decrease chances of post-surgical complications, and help patients find a comfortable level of independence. This issue is important to my practice because on a medical-surgical orthopedic unit, it is imperative that a patient’s plan of care includes safety and ambulation if permitted.
Foreground
The patient population are post-surgical patients that have undergone total joint replacement surgery such a total knee replacement or hip replacement. The intervention is ambulating patients post total joint replacement surgery. The comparison is early ambulation to no ambulation at all and what impacts it has on patient outcome. The outcome is the result of early ambulation and its ability to help post total joint replacement surgical patients heal and reduce chances of post-operative complications. The time frame is within post op da zero to discharge. Some barriers to early ambulation for post-surgical orthopedic patients are lack of time to walk patients, physical therapy unavailable when patients are ready to ambulate, patient pain level, and patient motivation. In an article regarding patient mobility post total joint replacement surgery, they state that benefits of early ambulation are clear. Physical activity strengthens joints and muscles, and movement is associated with shorter hospital stays (Halpern, 2017).
Literature Review
The first research article used to support my PICOT question is Lisevuick et al. (2020), which is an article discussing the importance of early ambulation in Total Joint Replacement surgical patients. The goal of the study was to create a program to help increase ambulation in post TJR patients on post op day 0. The study discussed in the research article aimed to compare the effectiveness of the MT model developed by researchers compared to traditional Physical Therapy model in the early ambulation of patients with total joint replacement. The study included 11,777 patients that had a Total Joint Replacement. Following the MT program, number of Post Op Day 0 ambulation, Post Op Day 0 ambulation distance, and total distance ambulated all increased while time-to-first ambulation decreased. Some barriers involved in the study were patients not ambulating post op day 0 after TJR surgery and patient pain level. The study was conducted to evaluate the effectiveness of a program created to help post op total joint replacement patients ambulate Post Op Day 0. They determined that this program helps improve patient outcomes and reduce barriers to walking patients by not solely relying on physical therapy. There are not many risks identified with this study but limitations. The limitations involved barriers to patients not ambulating post op day zero. A major barrier one being pain. This is would be highly useful in my practice. Physical Therapy is not always able to get to patients as soon as we need them. Having a program that trains other members of the interdisciplinary team such as nusring aids to get patients up and walking would be very beneficial. Aids on the unit were already being assigned meetings with PT to learn how to safely ambulate appropriate patients in a timely manner.
In the next article used during research for my PICOT question, Nishijima et al. (2020), discusses how early mobilization contributes to the reduction of complications and the improvement of the physical status in the perioperative period. In this study the researchers used a total of 398 patients who performed first ambulation at POD 1, 220 patients first ambulation at POD 2, and the remaining 100 patients first ambulation until POD 3 or later. They used this information to see how early post-surgical ambulation reduced the occurrence of post-surgical complications. The results of the study suggested it would be beneficial to ambulate patients at least by POD 2 to optimize postoperative short-term outcomes. Patients who waited POD 3 or more were most susceptible to post-operative complications. The study was conducted to evaluate the effectiveness of ambulating patients prior to post op day 2 after surgery. They determined that patients had less post-surgical complications when walked before Post Op 2 compared to those who walked after. Some barriers that they study faced was pain. Some patients were in too much pain to ambulate or were instructed by physician not to ambulate. This study is important in nursing practice in general because early ambulation post-surgery is very important for improved patient outcomes and for lowering risks post – operative complications. This relevant to nursing practice since its early ambulation has proven to have positive benefits on patients post-operatively especially when it comes to TJR.
Heiden et al (2021), focused on evaluating mortality after hip fracture surgery relating to early postoperative ambulation. A group of 485 patients initially identified, 218 met the inclusion criteria. Overall mortality rates were 6.4% at 30 days and 18.8% at 1 year. Two-thirds of patients ambulated in the first 3 postoperative days versus one-third who did not. Patients who did not ambulate had both significantly increased 30-day mortality. The study was done to test the effectiveness of ambulation prior to post op day 2. The study was done to test the effectiveness of ambulation prior to post op day 2. The results showed that early ambulation decreased mortality. Some barriers of the study included the frailty of the patients. This study is relevant as hip surgery performed on patients than >65 is not uncommon. It is beneficial to test the effectiveness of ambulation prior to Post Op Day 2 and its ability to decrease mortality. This research is relevant and can be put into practice since TJR patients over 65 years are at risk for more complications. Having a plan in place to decrease complications is important in order to ensure quick and safe recovery.
Article from Dehorney & Ashcraft, (2018), discusses the importance of a joint camp to help patients with TJR to recover and decrease rehospitalization. The goal of the joint camp was to decrease length of stay of patients who received TJR surgery and decrease the number of patient rehospitlized in a thirty day period. Two major cost concerns related to joint replacement surgery are patient length of stay and 30-day hospital readmission rates. A quality improvement project was implemented to evaluate the impact of a joint replacement program on patient readmissions and hospital LOS. A total of 1425 patients older than 50 years participated. At the end of the project period, readmission rates decreased from 6.19% to 2.8% and average LOS decreased from 5.87 days to 2.7 days (Dehorney & Ashcraft, 2018). The Joint Camp was stared at a rural north Texas medical center. This hospital was a 300 bed hospital. The Joint Camp consisted of preoperative education classes, interprofessional collaboration and postoperative follow-up (Dehorney & Ashcraft, 2018). One of the important factors used in the Joint Camp was physical therapy. Physical therapy was performed in the hospital on post op day 0. Patients continued to receive individualized physical therapy exercises to meet their needs. Some limitations to this study were the small sample of patients over fifty used to test the effectiveness of the Joint Camp. The study lacks participants that are younger and also needs to be conducted for longer period of time to see its true impact. The unit at my hospital did have a Joint Camp. There was a specific physical therapy room where patients worked with PT on exercises to increase patient recovery and independence. Patients also were required to take a class prior to their elective surgery to received education on their procedure and expected outcomes post-operatively. This program is very beneficial to help patients have a clear understanding on the importance of physical therapy and early ambulation and the expected outcomes after TJR surgery.
Jones, Davidson, & Cline, (2022) research article discusses the effect of pre-operative education prior t hip or knee replacement on immediate postoperative outcomes. The Joint Commission (2017) estimates that 700,000 people undergo a hip or knee arthroplasty in the United States each year. (Jones, Davidson, & Cline, 2022). The study was conducted on an orthopedic floor at a community hospital in southwestern Pennsylvania. All patients who underwent a total hip or knee arthroplasty in the year 2018 and met inclusion criteria were included in the study. Classes were taught by a rotation of four experienced orthopedic nurses with input from a physical therapist, occupational therapist, and orthopedic navigator. This study used a descriptive, retrospective chart review design. The goal of this study was to compare immediate postoperative outcome post TJR based on educational session attendance. The results showed that patients who had total knee replacements that attended the educational course had a ambulation distance that was statistically significant (M = 131.34 ft) than nonparticipants (M = 97.22 ft). Length of stay was statistically significant (p < .001) with preoperative class participants having a shorter LOS (M = 1.97 days) than nonparticipants (M = 2.10 days). With patients who underwent TJR of the hip, also had an ambulation distance that was statistically significant (p < .001) with preoperative class participants having greater ambulation (M = 146.13 ft) than nonparticipants (M = 111.38 ft). This study concludes that the educational program provided helped patients have improved ambulation and shorter length of stay. This kind of education would be beneficial and is typically provided to help enhance patient outcomes post TJR surgery. Postoperative PT performance is clinically relevant as it plays a role in determining discharge disposition. Physical therapy performance helps determine whether the patients can safely return home after surgery or whether they require an SNF for more surveillance (Jones, Davidson, & Cline, 2022). Some limitations on the study conducted were because of the retrospective design of this study, participants could not be randomized and this may have led to biases in the study.
Model for Implementation
The model that would beneficial in incorporating this change is the IOWA model. The IOWA model provides guidance in making decisions about clinical practices that impact healthcare outcomes (Melnyk & Fineout-Overholt, 2019). This model uses several steps such as identifying the issue, clinical applications, stating the purpose, topic priority, and more (Melnyk & Fineout-Overholt, 2019).). This model was developed by nurses incorporating successful strategies learned when undertaking research utilization projects (Buckwalter et al., 2017). These steps assist nurses or clinicians in applying evidence-based practice into their clinical practice. The pros of using the IOWA model that it is a practical framework that utilizes a step by step process to help identify the problem and break down the steps to implementing clinical practice change. Another benefit of the IOWA model is that it uses polit testing. This allows for potential issues to addressed prior to implementing clinical changes. A con of using this model is the time needed to conduct the extensive research. This model has many steps to help ensure that the best practice is identified but can be an issue if prompt changes are needed.
Cultural and Ethical Considerations
There are cultural considerations that impact the implementation of this program in the hospital setting. I believe the unit and staff’s ability to accept and be open to change will impact the participation needed to see results. Staff are typically working under pressure and taking on more workload than usual especially with staff shortage, and this can impact staff’s motivation to work with patients on ambulating out of bed. There will need to be leadership and staff cooperation as well as encouragement to implement this change.
Implementation
When using the IOWA model for implementation of change the evaluation process can consist of designing a pilot study to correct errors prior to clinical implementation. A control group can be utilized to monitor the benefits and potential risks of this program. A group of nursing aids can be selected to receive training from physical therapist to help ambulate standard risk patients on post op day zero (Lisevick et al., 2020). Some possible outcomes that could occur is staff or patient resistance. Staff will need to be on board with the implementation of this change for the program to making an impact. Having a meeting to encourage nurse managers and charge nurses is crucial. Also hosting mandatory meeting for nursing aids to work with physical therapy to learn techniques and safety measures. Physical therapy can also stress the benefits and importance of their participation in ambulating patients post op day zero. Patient resistance and pain level can also be a barrier. If pain is not managed it can interrupt patient motivation to ambulate. Patient fall risk level may also be a barrier to nursing aids walking patient post op day zero. If a patient is a high fall risk as determined by the nurse, physical therapy evaluation and treatment will be necessary.
An ambulation program can be cost effective as it aims to reduce patient length of stay, patient readmission, and conserving resources (Lisevick et al., 2020). Some recommendations for implementing this change is to host a mandatory meeting with nursing mangers, charge nurses, and physical therapy. This will allow staff to be introduce to the new change and discuss any concerns or barriers. Implementing a mobility program on a orthopedic unit in which nursing aids ambulate post-op TJR patients when PT is not available would be a beneficial program for both patients and staff.
Conclusion
Patients who receive joint replacement surgery have improved post-operative outcomes, less chance of readmission, and decreased hospital costs when they ambulate in a timely manner. Early ambulation post-surgery compared to no intervention, has a positive outcome with recovery and decreasing the chance of suffering post-operative complications. Implementing a program that trains nursing aids to safely ambulate appropriate patients would be beneficial on medical/surgical orthopedic unit. Models for implementation such as the IOWA model is a great tool to design a plan for beginning a new program. Implementing best practices and making changes that best serve patients is an important aspect of healthcare. When best practices are utilized, such as early ambulation post TJR, patients are able to receive the best care and are more likely to have a quick recovery.
References
Dehorney, Ivana, DNP, RN, Ashcraft, Pamela & PhD, RN. (2018). Effect of Joint Camp on Patient Outcomes Following Total Joint Replacement. Journal of Nursing Care Quality, 33, 279-284. Retrieved from https://doi.org/10.1097/NCQ.0000000000000290
Halpern, Lucy. (2017). Early Ambulation Is Crucial for Improving Patient Health. AJN, American Journal of Nursing, 117, 15. https://doi.org/10.1097/01.NAJ.0000520240.29643.e2
Heiden, J. J., Goodin, S. R., Mormino, M. A., Siebler, J. C., Putnam, S. M., Lyden, E. R., & Tao, M. A. (2021). Early Ambulation After Hip Fracture Surgery Is Associated With Decreased 30-Day Mortality. Journal of the American Academy of Orthopaedic Surgeons, 29(5), e238–e242. Retrieved from https://doi.org/10.5435/JAAOS-D-20-00554
Jones, Eric, Davidson, Lynda & Cline, Thomas. (2022). The Effect of Preoperative Education Prior to Hip or Knee Arthroplasty on Immediate Postoperative Outcomes. Orthopaedic Nursing, 41, 4-12. Retrieved from https://doi.org/10.1097/NOR.0000000000000814
Lisevick, Alexa, Kelly, Stephanie, Cremins, Michael, Vellanky, Smitha, McCann, Grace, LeBlanc, Kathy, et al. (2020). Mobility Technicians: A Viable Solution to Early Ambulation of Total Joint Replacement Patients. Orthopaedic Nursing, 39, 333-337. Retrieved from https://doi.org/10.1097/NOR.0000000000000698
Melnyk, B. M. & Fineout-Overholt, E. (2019). Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. 4th ed.
