Total Hip Replacement

1
Total Hip Replacement

• Education Workshop (click to go to the desired
  section)
• Introduction to Workshop/Instructions
• Evidence-Based Care Program
• Total Hip Replacement Workshop

2
Introduction

• This interactive workshop is designed to go along
  with a copy of the pathway. Keep it handy as you
  go through the workshop to engage in the required
  activities.
• This is a web-based workshop, and thus has links
  throughout each page to enable you to move
  throughout the workshop. Whenever you see words
  underlined like this, you can click on that area
  to go to another section or to find more
  information on a topic.
• At the bottom of each page are navigational
  buttons to help you move through the workshop.
• You can go through as much or as little of the
  workshop as you like at a time.
• If you have any questions about how to use this
  workshop or the individual pathways, feel free to
  ask the Evidence-Based Care Program or your Site
  Champion.

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3
Evidence-Based Care Program

• These pathways have been developed as a part of
  the Evidence-Based Care Program, which is
  Schedule 6 in the agreement of the Grey Bruce
  Health Network.
• The intent is to develop regional pathways and
  other evidence-based tools that flow across all
  hospitals and community services in Grey and
  Bruce (including Grey Bruce Health Services,
  Hanover and District Hospital, South Bruce Grey
  Health Centre, and the Community Care Access
  Centre).
• It is hoped that these pathways will improve
• Coordination of care through more communication
  across professions
• Continuity of care, through increased linkages
  among hospitals and the CCAC
• Clinical outcomes, through increased usage of
  best practices and
• Patient satisfaction, through linked expectations
  and increased patient teaching at our agencies.

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4
Total Hip Replacement Pathway

• The Total Hip Replacement pathway is intended for
  all patients who are booked for an elective total
  hip replacement.
• The pathway package includes a clinical practice
  guideline and two stages
• Acute Stage
• Pre-Admission package
• Acute Stage package
• Community Care Stage
• Community Care Stage Pathway

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5
THR Clinical Practice Guideline

• In most cases, when developing a pathway we
  will come across the most accepted published
  clinical practice guideline for the patient
  population. However, because total hip
  replacements are a procedure, not a condition,
  there were no clinical practice guidelines
  published. Thus a development team from GBHS -
  Owen Sound and GBHS Markdale helped in the
  creation of one based on the available evidence
  and issues we faced for this procedure.
• The THR clinical practice guideline can be
  found on the GBHN website at www.gbhn.ca

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6
Pre-Admission Package

• Each elective THR patient is to go to a Pre-Admit
  clinic 2-4 weeks before having surgery. This is
  where our Acute Stage of the clinical pathway
  begins.
• When the surgeon books a patient, a patient
  education booklet along with the patient pathway
  is given to him/her that day. Thus, when the
  patient arrives in the Clinic, he/she should
  already have these materials. However, if these
  have been lost or were not given, copies are
  available in the Clinic to be sure the patient
  has this information.
• There are two forms we need the patient to fill
  out before leaving the Clinic. There is the LEFS
  functional assessment tool (see a sample), and
  the Orthopedic Functional Questionnaire (see a
  sample), which are used by the Pre-Admit team to
  determine if CCAC services will be required
  post-operatively.

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7
Pre-Admission

• During the Clinic, the Acute Stage Clinical
  Pathway is started. It is put on the chart, and
  the appropriate staff initial as tasks are
  completed during the Clinic.
• There is an algorithm to follow the activities of
  the Pre-Admit Clinic. It can be found by clicking
  here.
• When the Pre-Admit Clinic is finished, the
  pathway remains on the chart in preparation for
  the day of surgery.

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8
Pre-Printed Orders

• The pre-printed orders are post-operative orders
  for total hip replacement patients.
• They can be found in the Operating Room area of
  the hospital and are available at www.gbhn.ca .
  (see a sample)
• There are also sets of pre-printed orders for
  receiving hospitals that have been developed for
  those patients that are transferred out of GBHS
  Owen Sound (see a sample).
• These can be found in the medical/surgical units
  in each community hospital and at www.gbhn.ca .

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9
THR Acute Stage Pathway

• The Acute Stage of the THR pathway is a day-style
  pathway, meaning that each page outlines tasks
  for one 24 hour period, beginning at the start of
  the day shift and ending at the end of the night
  shift. (See a sample)
• It should be on the chart when the patient
  arrives for surgery, with the pre-admit page
  filled out.
• The Smiley Face tool is taped to the wall in
  the patients room, and filled in by the
  physiotherapy department as exercise and mobility
  milestones are achieved post-operatively. All
  disciplines can refer to this tool when caring
  for the patient as a quick reference as to the
  abilities of the patient. (see a sample Smiley
  Face Tool)

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10
THR Acute Stage Pathway

• At the right hand side of the sheet is a place to
  enter the date. There are also three columns,
  these are the time frames for the shifts working
  during that day. Indicate the time you are
  working with the patient in the appropriate
  column.
• Then, using the column for your shift, initial
  tasks as they are completed, or enter N/A and
  initial if they are not applicable to the
  patient. For example, if it is the night shift
  and you are not doing any patient teaching,
  indicate N/A and initial in the section for
  Psychosocial/Education under Review Patient
  Pathway and Review Total Hip Precautions. (see
  sample)
• This is repeated for each day of the pathway.

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11
THR Acute Stage Pathway

• On a daily basis, the Discharge Criteria, the
  last page of the pathway, should be checked and
  dated/initialed if any of the criteria have been
  met. The patient is ready for discharge when
  these criteria have been met.
• Post-Op Day 1 at the top of the page has one of
  the Performance Indicators for this pathway,
  Antibiotics discontinued within 24 hours of
  surgery. This should be inputted as Met or
  Not Met.
• Take a look at the pathway by clicking here.

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12
Transferred Patients

• Approximately 50 of patients in for a THR will
  be transferred to a community hospital following
  surgery. If a patient is transferred to a
  hospital within Grey and Bruce counties, a copy
  the following information must be sent to the
  receiving facility
• Smiley Face Tool
• Discharge Criteria
• Physio Database
• Teaching Checklist
• Discharge Planning Tool
• MAR sheet (and anticoagulant record )
• The patient should also arrive with the patient
  education materials and patient pathway that can
  be referred to for patient teaching. If not,
  there are extra copies of the education materials
  on each unit.
• The Acute Stage of the pathway will be continued
  at the new site until the patient is discharged
  and/or the discharge criteria have been met.
• The Acute Stage Post-op Orders for Transferred
  patients can be used at the receiving facility,
  making any necessary changes depending on the day
  the patient is transferred.

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13
Ongoing Post-Op Care

• If a patient remains in hospital beyond 5 days
  post-op, regardless of whether he/she was
  transferred or not, the page entitled Ongoing
  Post-Op Care in the pathway can be started.
  These patients may have other comorbidities and
  will remain in hospital for further
  convalescence.
• This page of the pathway is a phase-type pathway,
  as the patients that remain in hospital longer
  than 5 days are variable and difficult to
  estimate a length of stay. It is expected that
  patients will remain on this stage of the pathway
  until all the discharge criteria are met.
• There are three columns on the right hand side
  -one for each day the patient remains in
  hospital. Blank copies of this page can be
  inserted if the patient remains beyond the three
  day period.
• (see sample)

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14
Community Care Stage

• The Community Care Stage of the pathway is used
  for both outpatient physiotherapy or CCAC
  services following discharge.
• The Community Care Stage includes the following
  pieces
• Clinical pathway one page with admission and
  discharge goals, used as a charting tool for
  documentation
• Client pathway to be given to the patient to
  align expectations
• Patient Communication Form for the patient to
  bring to follow up appointments with the surgeon.
  Has a list of common questions that the therapist
  and patient need answered
• LEFS Functional Assessment Tool to be filled in
  by the patient at the end of services. Score can
  be compared to expected goals to determine
  success of therapy.
• When the patient finishes services either from
  CCAC or Outpatient Physiotherapy, a copy of the
  clinical pathway is copied and sent to the
  Evidence-Base Care Program for evaluation
  purposes.

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15
End of THR Section

• This is the end of the general information for
  the THR pathway.
• To get further information by trying the pathway
  on a sample patient, move to the Simulation
  portion of the THR workshop.
• Test your knowledge of THR by doing the
• THR quiz.

16
Simulation

• Try it!
• Joe has had painful osteoarthritis and his
  surgeon has determined the best solution is a
  total hip replacement. Joe is booked for surgery,
  and given his patient education package,
  including the patient pathway, two months in
  advance. His pre-admit clinic appointment is
  scheduled for two weeks before surgery.
• Joe arrives to the Pre-Admit clinic, however has
  lost his patient education package. There are
  extra packages in the clinic find out where
  these are stored. Give Joe a new package, and ask
  him to fill out two forms
• LEFS Functional Assessment Tool
• Orthopedic Functional Questionnaire
• Once these are filled out, they are used by
  physio along with the Blaylock Discharge Planning
  Tool to score and determine the most likely
  destination for Joe following discharge.
• It is determined that Joe is a high needs patient
  and requires an Occupational Therapy Home visit
  before surgery, so the CCAC Case Manager needs to
  be called in to visit Joe before he leaves today
  to assess his needs.

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17
Simulation contd

• Take a look at the pre-admit clinic algorithm to
  familiarize yourself with the process. (see
  algorithm) and patient flow sheet
• Joe has four places to go today he will have
  some blood work done, have a nursing orientation,
  a physiotherapy assessment and orientation, and
  an occupational therapy orientation.
• Take a look at the clinical pathway. The first
  page contains some basic instructions and a
  master signature sheet (If sites have a master
  signature sheet for your facility, this is not
  included in your pathways). Each page needs to
  have a patient ID sticker. The next page for the
  pre-admit clinic to fill in. In the first few
  lines, list any comorbid conditions Joe has, to
  aid health records in coding for Joes condition.
• On the right hand side of the page is a column.
  At the end of each of these visits, each health
  care provider will initial tasks they completed
  on the first page of the pathway.
• Review the clinical pathway by clicking here

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18
Simulation contd

• At the end of the clinic, look at the
  performance indicator for this day of the pathway
  (first row on the page). Joe attended the physio
  portion of the clinic, so this is dated,
  initialed and indicated as Met .
• Joe should leave with his patient education
  materials, patient pathway, and instructions on
  what to do before surgery. The clinical pathway
  will remain on the chart for when he returns for
  surgery.
• When Joe returns on the day of surgery, the
  pathway will continue to the next page. It should
  be started in the day surgery department. There
  are post-op pre-printed orders that can be found
  in the OR , the GBHN website and the Order sets
  website.

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19
Simulation contd

• When Joe finishes surgery, he will spend some
  time in the recovery room and then move to the
  surgical unit. Each care provider that cares for
  Joe will need to fill in the tasks completed
  through this process. Take a look at that page,
  Post-Op Day of Surgery to familiarize yourself
  with the tasks.
• Once Joe is moved to the surgical unit, the
  Smiley Face Tool needs to be taped to the wall
  in his room. This is used by the physiotherapy
  department to track milestones with respect to
  mobility and exercises. Each milestone will be
  circled and dated as it is achieved. This helps
  all health care providers know Joes status at
  any given time. (see sample)
• On each page of the pathway, you will notice a
  few consistent tasks. One is under Discharge
  Planning Assess Discharge Criteria Daily.
  Each day, look at these goals the Discharge
  Criteria are the second last page of the pathway.
  If any have been met, initial and date them. Once
  they have been met, Joe should be ready for
  discharge.

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20
Simulation contd

• Another consistent task is under Psychosocial
  Support/Education. Each day you are asked to
  Review the patient pathway and Review Hip
  Precautions. You can use Joes patient education
  materials and patient pathway to help you with
  this, to ensure Joe understands what is happening
  in hospital, aligning expectations, and he is
  aware of the hip precautions he has following
  surgery.
• Not all tasks are applicable for all patients, or
  for all shifts. For example, during the night
  shift, you may not be teaching Joe. Thus, under
  Review Patient Pathway, you can indicate N/A
  and initial. This is the case for any tasks that
  are not applicable for Joe. At the end of a day,
  there should be no blank boxes on the pathway
  page.
• The second indicator we are tracking for this
  pathway is also on this page Antibiotics
  discontinued 24 hours post-op. Joes antibiotics
  were discontinued at 48 hours, it should be
  inputted at Not Met .

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21
Simulation contd

• Each day, the Discharge Criteria need to be
  assessed to see if they have been met. If they
  have, Joe should be ready for discharge. Lets
  assume Joe has not met the Discharge Criteria by
  the end of 4 days post-op, and so cannot go home.
  He does not have independent transfers yet, nor
  can he ambulate independently on level ground.

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22
Simulation contd

• Since Joe is from Durham, it is determined he
  should be transferred to the SBGHC Durham
  hospital site. When Joe is transferred, the
  following information needs to go with him to the
  transfer site
• A copy of the Physio Database
• A copy of the Teaching checklist
• Original of the Smiley face tool
• Copy of Discharge Criteria
• Copy of Discharge Planning Tool
• Copy of the MAR sheet (including anticoagulant
  record)
• When Joe arrives in Durham, the pathway will be
  continued.
• If Joe remains in hospital beyond 5 days, staff
  in the Durham site will use the Ongoing Post Op
  Care phase of the pathway until Joe has met all
  the Discharge Criteria which are on the last page
  of the clinical pathway.

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23
Simulation contd

• If Joe remains in hospital beyond the three days
  listed on the pathway page, insert a new Ongoing
  post-op Care page behind this page and continue
  using the pathway until discharge criteria have
  been met or Joe is discharged home.
• Lets assume that Joe is discharged home, but
  requires outpatient physiotherapy services. In
  this case, the Community Care Stage of the
  pathway begin. See workflow
• The therapist in the Durham site will use the
  Community Care Stage clinical pathway to aid in
  the care for Joe. She/he will assess him at
  admission to services and at discharge to
  determine if he has met the goals on the pathway.

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24
Simulation Community Care Stage Contd

• She/he will give Joe the client pathway to help
  explain to Joe what the goals are for therapy.
• When it is time for Joes follow up appointment
  at 6 and 12 weeks, the Client Communication Form
  will be given to Joe to give to the surgeon and
  get important questions answered about his
  status. He needs to return this form to the
  therapist so therapy can be adjusted accordingly.
• Finally, when Joe is discharged from outpatient
  services, the LEFS tool will be repeated and
  scored to see how Joe has improved functionally.
  The pathway needs to be completely filled in and
  a copy sent to the Evidence-Based Care Program
• If Joe were to go to CCAC services, the same
  process would be followed, and started again if
  Joe is transferred to outpatient physiotherapy.

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25
THR Quiz

1. There are 2 stages to the THR pathway what are
   they?
2. What are the inclusion criteria for this pathway?
3. What is the LEFS functional assessment tool? What
   is it used for?
4. What type of a pathway is this pathway? A) Day B)
   Phase
5. What is the Smiley Face Tool? Where does it go?
6. What goes with the patient if he/she is
   transferred?
7. When is the Ongoing Post Op Care phase used? What
   do you do if the patient remains in hospital
   beyond the first 3 days in this phase?
8. What is the Community Care Stage used for?

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Answers
26
THR Quiz - Answers

1. There are 2 stages to the THR pathway what are
   they? Acute Stage, Community Care Stage
2. What are the inclusion criteria for this pathway?
   Patients undergoing an ELECTIVE total hip
   replacement
3. What is the LEFS functional assessment tool? What
   is it used for? It is an assessment of the
   patients function before surgery. It is used to
   determine how well the patient progresses
   following surgery. It is filled in at the
   pre-admit clinic and also at the end of
   outpatient physiotherapy
4. What type of a pathway is this pathway? A) Day B)
   Phase This pathway is both a day and a phase
   pathway. The first four days are a day pathway,
   which means each page is for one day in hospital.
   The Ongoing Post-Op Care phase is a phase type
   pathway, where the patient stays in this phase
   until all variances are resolved.
5. What is the Smiley Face Tool? Where does it go?
   The Smiley Face Tool should be taped to the
   patients wall and show all health care providers
   how far progressed the patient is with respect to
   mobility and exercise.
6. What goes with the patient if he/she is
   transferred? The Physio Database should be
   copied, and the Discharge Criteria, the
   Discharge Planning Tool, the MAR sheet (including
   anticoagulant record), the original of the Smiley
   Face Tool should go with the patient along with
   any other documentation that would help in the
   transition of care.

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27
THR Quiz - Answers

• 7. When is the Ongoing Post Op Care phase
  used? What do you do if the patient remains in
  hospital beyond the first 3 days in this phase?
  This is used if the discharge criteria have not
  been met at 5 days post op and the patient needs
  to stay in hospital longer. It is a phase type
  pathway with one phase, and the patient remains
  on this phase until all discharge criteria have
  been met. If this is longer than 3 days, blank
  photocopied sheets can be inserted and used until
  the variances have been resolved.
• 8. What is the Community Care Stage used for?
  This is used for outpatient physiotherapy or CCAC
  services the patient receives following hospital
  discharge.
• If you have had difficulty with any of these
  questions, go back through the material on this
  pathway and/or the general pathway information in
  this workshop, or contact the Evidence-Based Care
  Program

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