Following total knee replacement (TKR), patients are not only required to be functionally and medically safe for discharge but also achieve set exercise goals before being allowed home.
These set exercise goals are:
· 90 degree knee flexion.
· A straight leg raise with < 5 degree quadriceps lag.
· Inner range quadriceps with < 5 degree quadriceps lag.
These goals are set by the operating Consultants.
A recent audit on length of stay (LOS) highlighted that out of 38 patients, 32 (84%) had exceeded their predicted date of discharge (PDD). Of these 32 patients, 19 (59%) had exceeded their PDD as a result of not achieving their exercise goals by this time, despite being deemed functionally and medically safe. Further audit over a 12 week period highlighted an additional 38 TKR patients remaining in hospital after being deemed functionally and medically safe in order to achieve the set exercise goals. This equated to 65 additional bed days over the 12 week period, approximately 5 additional bed days per week. With a standard overnight stay costing £400 per night, this equated to £26,000 over the 12 week period and therefore potentially £104,000 a year.
It was suggested that providing a physiotherapy service to allow TKR patients to go home once functionally and medically safe but without achieving their exercise goals could facilitate discharge for these patients without compromising the quality of their care or outcomes
A Physiotherapy supported Discharge Service is currently being piloted for 6 months. The service design utilises the current in-patient orthopaedic physiotherapy team to run a clinic style supported discharge service. This allows these patients to be discharged home once functionally and medically safe but without achieving their set exercise goals. The patients attend the clinic up to twice a week until they achieve their exercise goals or out-patient physiotherapy can take over their care.
The pilot is to run from January 2017 until June 2017. Patient outcome measures, length of stay, therapy time and patient satisfaction will be collected.
The anticipated outcomes of the pilot are that LOS for TKR patients will reduce (currently 5 days) without compromising care and at no additional cost. There will be a cost saving in bed days and improved patient satisfaction due to facilitated supported discharge. To date, 38 patients have been through the service with 17 (44%) being discharged on or before their PDD. Average LOS has reduced to 4.5 days for this group of patients. The majority of patients (71%) only required one clinic appointment to achieve their set exercise goals.
Despite showing an improvement in LOS, the anticipated outcomes of the service have not yet been fully realised. Reasons for this are thought to be reluctance to discharge patients early and awareness of the service availability. The pilot will continue until June 2017 when full data analysis will be undertaken.
If the pilot study is successful, Physiotherapy Supported Discharge Service for TKR patients would be permanently implemented and potentially expand the service to other patient groups.
Top three learning points
- Knee arthroplasty patients do not need to have an extended hospital stay to achieve exercise goals.
- Changing service design is important to accommodate the needs of the patient and service.
- Need to increase physio’s confidence to discharge patients early once medically fit.
This work was not funded
Presented at Physiotherapy UK 2017.