Each year, more than 1 million hip and knee replacement surgeries are performed in the United States, making them among the more common surgical procedures. And, like any surgery, they carry risks of infection, blood clots and transfusions.
But at MultiCare, where physicians perform more than 1,000 total hip and knee replacements annually, a group of doctors and nurses has worked over the past 18 months to reduce surgical complications, standardize procedures systemwide and improve the patient experience from pre- to post-op.
The result: progress in all three risk areas and a patient readmission rate cut in half, to 2.5 percent.
And it‘s only the beginning. The Total Joint Work Group is part of MultiCare‘s Surgery Collaborative – one of six clinical collaborative efforts among medical and administrative personnel from facilities around the system.
Tasked with identifying ways to streamline care, improve patient outcomes and reduce costs, the collaboratives – Critical Care, Surgery, Women‘s, Cardiac, Medicine and Pediatric – are divided into work groups that drill down to the day-to-day delivery of health care. By targeting needs, collecting data, and, in many cases, changing routines and processes, efforts such as the Total Joint Work Group are demonstrating success.
“What we‘re really driving toward is to eliminate unnecessary clinical practice variation that leads to inconsistencies in patient care,” said Dr. Rob Tamurian, an orthopedic surgeon at MultiCare Allenmore Hospital in Tacoma and a leader of the Total Joint Work Group. “The goal is to have all of our patient experiences, regardless of where they‘re having a hip or knee replaced, be consistent at all our facilities.”
By combing through MultiCare‘s surgery data and researching trends and best practices nationwide, the Total Joint Work Group set out to reduce:
• The rate of VTE in post-op patients
• The likelihood of post-op infection, specifically related to MRSA
• The number of transfusions among patients receiving a hip or knee replacement
The aim to reduce transfusions reflects an overall goal toward transfusion-free medicine, Dr. Tamurian said. Members of the Work Group used a collaborative, evidence-based approach based, in part, on Dr. Tamurian‘s own pilot of a medication protocol.
The procedure – to administer a specific medication immediately prior to and following a hip or knee replacement – reduced transfusion rates from the first quarter of data-tracking. After three quarters of consistent declines, even as Dr. Tamurian‘s surgery rate increased, the Work Group evaluated the data, discussed and established guidelines and opened up the procedure to other surgeons.
Before the new protocol, Dr. Tamurian said, MultiCare‘s hip- and knee-replacement transfusion rates were on par with facilities around the country: between 25 and 30 percent of cases. Using the new procedure, transfusion rates are down to 1 to 5 percent of cases – aiming, of course, to get to zero.
“I haven‘t transfused a knee in over a year,” Dr. Tamurian added.
In establishing goals, such as reducing transfusions or SSI, the Work Group tried to focus on areas where doctors and nurses could make an initial, direct impact, then expand to other areas as time goes on, said Dr. Paul Degenfelder, an orthopedic surgeon at Good Samaritan Hospital in Puyallup.
For example, the group decided to examine patient infection rates after surgery – to become, Dr. Tamurian said, “a devoted watchdog, evaluating every infection, finding out if any steps along the way were missed.”
Nationwide, an estimated 1 to 7 percent of patients undergoing knee or hip replacement end up with a post-op infection, so the Work Group determined that all joint-replacement patients should be screened for MRSA. That process is part of the best-practice guidelines for pre-op and involves not only physicians but also nurses and pharmacy staff.
Patients who test positive for MRSA are to receive an antibiotic before and after surgery. Such a process “gives us the best chance of minimizing adverse effects,” Dr. Degenfelder said, and will provide clear procedures and data sets with which to assess.
From here, the Work Group expects to come up with a new set of goals, likely focused on the patient population prior to surgery, Dr. Degenfelder said. The Work Group might pull in more primary care providers, cardiologists and sleep specialists, for instance, to establish standards for identifying appropriate candidates for surgery.
Such collaborative efforts take time, study, and cooperation and compromise among professionals with different backgrounds, and from different facilities. That can feel like a culture shift, Dr. Degenfelder said. But it‘s for the benefit of the entire MultiCare system.“It‘s sometimes difficult, but the only way to do it is through collaboration,” said Dr. Degenfelder, who volunteered to help lead the Work Group. “It‘s eye-opening, if anything. We‘re swapping notes and learning from each other.”