Download Total Knee or Total Hip Replacement Surgery

Care Process Model
J U LY
2016
D EAVNEALGOEPMMEENNTT OAFN D D E S I G N O F
M
Total
Knee orModels
Total Hip Replacement
Care Process
2 015 U p d a t e
Surgery
This care process model (CPM) was created by the Musculoskeletal Clinical Program to maintain Intermountain Healthcare’s
leading edge in joint replacement surgery and improve patient outcomes by enhancing best practices, promoting patient safety,
improving patient satisfaction, and assuring cost accountability and regulatory compliance.
The CPM follows the sequential processes and expert advice for the perioperative
management of total joint replacement surgeries (total knee arthroplasty, total hip
arthroplasty) and summarizes current medical literature and national practice guidelines.
Intermountain’s care management system for total joint replacement also includes:
• Education materials and programs for providers and patients
• Data systems that help providers and facilities gauge their success in patient outcomes
• Multidisciplinary coordination of perioperative patient care
Why Focus ON TOTAL JOINT REPLACEMENT SURGERY?
• Joint replacement is an increasingly common and high-cost procedure.
Knee and hip replacement surgeries performed in the U.S. more than doubled between
2000 and 2010, to over 671,000 knee replacements and over 300,000 hip replacements
annually.DOT The Utah average price for each procedure is just over $36,700 for knees
and $34,400 for hips;BCBS surgical complications further add to these costs.
• Medical facilities are under scrutiny for procedural costs and outcomes.
The Centers for Medicare and Medicaid Services (CMS) will begin a bundled payment
program in 2016 that will reward and penalize selected facilities for quality and cost
outcomes for joint replacements. Several Intermountain hospitals will be required to
participate. In addition, the general public and providers are increasingly aware of
hospital performance ratings, patient outcomes, and publicly reported measures.
• Collaboration and communication between perioperative teams and care
specialists ensure all patients system-wide get the best evidenced-based
care. This CPM promotes optimal patient outcomes through consistent care based
on expert consensus and evidence-based best practices.
• Patient engagement is critical to improving satisfaction and meeting
patient expectations. Patients who participate in preoperative education have
better functional outcomes.IBR Patient education should stress pain management,
early mobility and physical therapy compliance, and preparing for discharge to home,
which has been linked to reduced hospital readmissions.JUB As a result, providers
and patients should partner to ensure appropriate care utilization, including setting
realistic expectations for discharge at multiple points in the care process and the
importance of a health coach.
Where this CPM fits in the care pathway Assessment
and
Diagnosis
of
Joint Pain
Conservative
Care for
Joint
Pain
Conservative
Care
Management
Management
of
Management
of
Total
Joint
of Joint
Joint
Replacement
Preservation
Revision
Surgery
Surgery
Preservative
Care
Joint
Replacement
WHAT’S INSIDE?
ALGORITHMS . . . . . . . . . . . . . . . . . . . . . . . . . . 2
–– Pre-admission. . ................................
2
–– Surgical
and Post-operative
Management................................... 4
–– Discharge Disposition....................... 10
PRE-OPERATIVE PATIENT/COACH
EDUCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
COMPLICATIONS RISK
MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . 6
POST-OPERATIVE PHYSICAL
THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . 9
PROVIDER RESOURCES . . . . . . . . . . . . . . 10
PATIENT EDUCATION
RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
MEDICATIONS. . . . . . . . . . . . . . . . . . . . . . . . . 12
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GOALS AND MEASUREMENTS
As a result of implementing this CPM,
Intermountain aims to:
• Improve patient safety and decrease
complications related to morbidity and mortality
(blood use, infections, DVTs/PEs, medication
errors, skin integrity, and falls)
• Reduce:
–– Unplanned readmissions within 30 days
–– Variations in cost and quality of care (via
transparent data reporting)
• Increase:
–– Number of patients/health coaches receiving
optimized pre-operative education
–– Number of patients discharged to home
(via measuring discharge outcomes)
–– Patient early mobility and functionality in less
than 6 hours after leaving PACU
–– Patient satisfaction, meeting or exceeding
75th percentile for HCAHPS
• Ensure regulatory compliance in terms of
medical necessity/appropriate use criteria, VBP
Throughout this CPM, the icon at right
indicates an Intermountain measure.
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
J U LY 2 0 1 6
ALGORITHM 1: PRE-ADMISSION
ALGORITHM NOTES
Patient to be scheduled for surgery
(a) Medical necessity criteria
Indicates an Intermountain measure
Medical records should contain detailed
information to support replacement as
reasonable and necessary (see Orthopedic
VALIDATE medical necessity
Surgeon Documentation of Medical
Necessity for Total Joint Replacement).
Medical necessity documentation should
demonstrate that one or more of the
following criteria for advanced joint disease
have been met:CMS
• Radiographic-supported evidence
• Pain or functional disability
• Documented history of unsuccessful
conservative therapy in the patient’s
pre-procedure record
If conservative therapy is not appropriate, the
medical record must clearly document why
such approach is not reasonable.
•
•
•
Patient meets criteria for
medical necessity (a)
It is very important to help the patient plan ahead for their surgery and life after surgery.
Review the available patient education materials (see page 11) and resources for using
teach back strategies (at right and in the Teach Back Best Practice flash card).
Key points to stress in care provider discussions with patients appear in the checklist
below (details about each checklist item can be found in the patient education toolkit,
Your Guide to Joint Replacement).
…… Arrange for a recovery coach and caregiver for a week or two (could be the same person)
…… Set up your home for accessibility and comfort:
REFER to Surgeon
no
–– Allow plenty of space around furniture to move around easily with a walker or crutches.
–– Place a study chair with arms within reach of a table (not a recliner).
–– Make seating easy to get into and out of (add pillows as necessary).
–– Prepare the bathroom to prevent falls (see Bathroom Safety fact sheet).
–– Remove household tripping hazards (throw rugs, loose carpet/flooring, electrical cords, clutter).
COMPLETE pre-surgical scheduling and education tasks
•
(b) Pre-op physical therapy
Pre-operative physical therapy offers a variety
of benefits for optimizing patient surgical
and rehabilitation outcomes. It is important
to share with patients these benefits of preoperative physical therapy:
• Doing recommended pre-operative
exercises — Research indicates a link
between strengthening exercises prior to
surgery and decreased risk of discharge
to rehab as well as a positive impact on
post-surgical function.HOL, ROO, MIZ
•
Losing weight — Each pound of
weight loss reduces pressure on the
knee or hip joint by 4 pounds.MES Thus,
a patient who loses 10 pounds before
surgery experiences a decrease of
40 pounds of pressure on the joint,
which improves wound healing time and
decreases the risk of bed sores.
•
•
ENSURE appropriate implants identified and ordered.
RECOMMEND smoking cessation: Educate patient on resources for quitting smoking to
prevent post-surgical complications, especially surgical site infections.SOR
ARRANGE joint optimization therapy: If appropriate, arrange presurgical physical therapy
(mobility training and conditioning; crutch, gait and stair training). (b)
IDENTIFY recovery coach/caregiver: Identify coach (significant other, child, other family
member, friend).
PROVIDE patient/family education: Use system-wide tools to discuss initial transition
plan to home and postoperative pain management and ambulation; include health coach as
a participant in joint pre-op class (or video) with the patient; discuss pre-op skin preparation
processes and other infection prevention measures (see page 3).
–– Allow for small pets (put a bell on the collar to know when the pet is underfoot or keep in a separate
area of the house for a week or two).
…… Keep from overdoing
•
•
•
ORDER Labs, EKG, clearances.
CONSIDER SCREENING for MRSA.
RECONCILE medications.
DETERMINE infection prevention measures, skin prep protocols, discharge/transition plan.
ASSESS VTE risk and elect VTE thromboprophylaxis measures
Patient meets pre-admission
criteria for surgery?
no
What is teach-back? — Teach-back is a
way to confirm that patients understand what
we tell them using open-ended questions that
invite the patient and family to “teach back”
the information to us. It’s not a test of the
patient’s knowledge — it’s a test of how well
we explained something.
REFER to
specialist for
comorbidity
management
yes
VERIFY skin preparation
• MAKE pre-surgery call to inform/remind patient about pre-op
nutrition: No food or drink after 11:00 p.m. (unless otherwise instructed).
• INITIATE medication history
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
When can I use it? — Use early in the
care process and at each decision point
or transition, especially when families or
caregivers are present. Make sure caregivers
participate in the teach-back process to
ensure they understand key information.
1.Explain or demonstrate a concept, using
simple lay language.
Tips: Avoid covering too much at one time,
explaining no more than 2 or 3 concepts at a
time. Slow down and take pauses. If you’re
giving the patient printed information,
mark or highlight key areas of the handout
or booklet as you explain.
necessary while you’re recovering.
–– Store kitchen and bath items so that you don’t bend below the waist, reach, or lift.
Work with your healthcare providers to prepare for a safe surgery and recovery
……Things to do A FEW WEEKS before surgery:
–– Attend a pre-surgery class — and bring your recovery coach.
–– Pre-register with the hospital.
–– Complete your advance directive — and share it with the hospital or your doctor (for more information,
see the Advance Care Planning booklet and Advance Health Care Directive card)
…… Things to do in THE WEEK before surgery:
–– Give the hospital your health history information.
–– Review your insurance coverage, including co-pay, covered expenses, and hospital-required payments
due prior to surgery; contact insurance company and hospital staff with questions and concerns.
–– Expect a pre-surgery phone call — for your arrival time and last-minute instructions (discuss special needs).
–– Prevent constipation.
–– Do not shave the area of your body where your surgery will be performed for 5 days before surgery
to avoid infection.
…… Things to do THE DAY before surgery:
–– Shower in the morning and the evening using the soap or cleansers your doctor has recommended
–– Do not shave the area of your body where the surgery will be performed.
•
Who can use it? — Everyone who
explains anything to a patient or family.
What are the steps?
(wash thoroughly; do not scrub; dry gently; do not use lotion, cream, or powder)
SCHEDULE surgery and notify patient
of admission time and location.
understanding medical information is a
common reason for readmissions. Teachback is a proven tool for improving patient
understanding.
–– Make sure your home is clean and orderly before you go to the hospital so that cleaning won’t be
–– Discuss all your medications, both prescribed and over the counter, with your healthcare providers.
CONDUCT pre-admission assessment
•
USING TEACH-BACK STRATEGIES
–– Stock up on meals and supplies to avoid running errands during recovery.
–– Have a physical exam and pre-admission tests.
•
2 PATIENT / COACH EDUCATION
Why is it important? — Not
yes
•
Getting minimum recommended
aerobic exerciseCDC — Exercising
150 minutes a week (swimming, water
aerobics, walking, etc.) improves a
patient’s aerobic capacity, which will
make it easier to come out of anesthesia
and reduce the need for supplemental
oxygen. Counsel patients that this
150 minutes equates to 30 minutes (not
all at once) a day for 5 days a week (perhaps exercising for as little as 10 minutes
3 times during the day).
For information on specific home exercises,
access the Intermountain Home Exercise
Program database.
PRE-OPERATIVE
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
–– Use a bed on the main floor (avoid stairs).
•
•
USE history and physical (see Patient History and Patient Exam forms)
REFER to CMS guidance on medical necessity documentation (a)
SUBMIT required paperwork
J U LY 2 0 1 6 –– Pack a small suitcase of personal items.
–– Take only those medications recommended by your doctor for before surgery. Do NOT take any blood-
thinning medications.
–– DO NOT eat or drink anything after 11:00 p.m. the night before surgery (unless otherwise instructed).
…… Things to do THE MORNING of your surgery
–– Shower in the manner described above.
–– Take ONLY the medications your doctor or nurse instructed you to take the day of surgery.
–– Arrive at the hospital at the scheduled time.
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
2.Ask the patient/caregiver to repeat
the information in their own words or
demonstrate the process.
Tips: Own the responsibility (“I want to
see whether I explained this well”). Ask
the patient to tell you how he or she would
explain the information to a spouse or
family member. Avoid yes/no questions.
3.Identify and correct misunderstandings.
Tips: Show empathy and caring as you
correct. Avoid making the patient feel
they’ve failed a “test.” Don’t repeat the
entire explanation or demonstration again
unless it’s necessary — just focus on areas
that need clarification.
4.Ask the patient/caregiver to explain or
demonstrate again, to show improved
understanding.
Tips: Own the process again. “Let’s see if
I cleared that up.” Avoid yes/no questions
(such as “do you understand now?”).
5.Continue this loop until you’re convinced
the patient/caregiver understands
the concept.
Tips: Be patient — this process is worth
the time it takes. Continue to be gracious
in the process — patients can worry about
judgment or wasting your time.
3
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
J U LY 2 0 1 6
ALGORITHM 2: SURGICAL AND POST-OPERATIVE MANAGEMENT
Patient admitted for surgery
no
Patient compliant with pre-admission process?(a)
Indicates an Intermountain measure
MEDIATE
patientspecific
barriers and/or
reschedule
yes
MOVE patient to pre-op
•• PERFORM pre-operative process (b).
•• COMPLETE Universal Protocol Checklist (c) and Surgical Care Improvement Process (SCIP) (d).
ADMINISTER INTEROPERATIVE
MEDICATIONS (see medication tables
on pages 12–15).
USE Ortho Hip or Knee Replacement Peri-op Order Set/ANES adult peri-operative order set in iCentra — Key Points:
Pain Management: Use Intermountain/TOSH Pain Scale (see page 10); administer post-op PACU medications (see pages 12–15).
• Monitoring: Follow the Modified Aldrete Scoring System; monitor core temperature, HR, BP; assess for respiratory distress (see page 6); monitor risks
associated with blood transfusion, if indicated (see page 6).
• Imaging: X-ray to confirm implant placement.
• Criteria for transition to surgical floor: Follow the Modified Aldrete Scoring System; active PSO; order durable medical equipment (DME) in iCentra.
• Patient must be classified as in-patient for full reimbursement, even if discharged the same day.
no
Patient meets criteria for transfer to surgical floor?
MEDIATE
patientspecific issues
yes
MOVE patient to floor and PERFORM surgical floor tasks
•
•
•
Set realistic pain management
goal: Use Intermountain TOSH Pain
Scale (pages 9–10); administer post-op
floor medications (pages 12–15).
Review care plan with patient/recovery
coach.
Use appropriate interventions:
Medications, repositioning, icing,
elevation, etc. (see Chronic Non-Cancer
Pain CPM).
Assess and reassess: See Chronic
Non-Cancer Pain CPM.
FACILITATE mobilization
•
Optimize early mobilization via:
–– Patient getting out of bed
within 6 hours after arriving
at floor.MAL
–– PT assessment scheduled
within 24 hours post-op
(page 8).
–– Daily PT therapy sessions
held (page 8).
–– OT evaluation and treatment,
as indicated.
EDUCATE/PLAN care transition
•
•
•
•
Use the Discharge Destination
Algorithm (page 7).
Sign patient choice and durable
medical equipment (DME) forms.
Ensure ADL teaching (OT/RN/PT).
Use in-room TV for exercise and
education reminders.
MONITOR other risks
Evaluate labs, including PT/INR if
patient taking warfarin (Coumadin®)
and renal function if taking a direct
oral anticoagulant (e.g., apixaban,
rivaroxaban).
• Assess for respiratory distress/
other complications (see page 6).
• Conduct respiratory incentive
spirometry and training (see
•
Incentive Spirometry Pediatric
Adult Procedure).
CONDUCT interdisciplinary team review
no
Patient meets discharge criteria?
TREAT/REFER
as needed
yes
DISCHARGE and FOLLOW UP per 30-day, post-op care guidance
4 (a) Pre-admission process
(d) SCIP Core Measures
Review pre-admission preparation, which ideally included having
the patient (and identified health coach as appropriate):
Core measures for reducing surgical complications include
(remember as ABCs):
•• Attend a joint replacement class or viewing DVD.
•• Participate in teachback method with care providers (see page 3).
•• Have the treatment plan reviewed with pharmacist, case manager, and
nurse (and physical therapist, occupational therapist/home evaluation,
as needed).
•• Meet recommended medical clearance criteria for all systems and
comorbidities (hematocrit, HbA1c, INR, mobility, BMI, active MDRO infection,
chronic pain, etc.).
•• VERIFY health history/medical clearance (i.e., MDRO, OSA, cardiac
insufficiency, diabetes, and other comorbidities).
•
•
ALGORITHM NOTES
•• EDUCATE patient and health coach: Perform hospital orientation;
review and verify understanding of post-operative pain management,
ambulation, health coach role, and transition plan.
After Surgery, MOVE patient to PACU and PERFORM post-anesthesia care
MANAGE pain
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
(b) Pre-operative process tasks
MOVE patient to surgery
PERFORM SURGERY ACCORDING TO:
• Order sets in iCentra (e) • SCIP measures (d)
• Anesthesia requirements • Physician preferences
J U LY 2 0 1 6 ©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
•• ORDER medication: Consult with pharmacist; administer pre-op
medications (antibiotics, anti-inflammatories, blood thinners). See pages
12–15 for medication details.
•• FINALIZE medication history.
•• OBTAIN or VERIFY health care directives (living will, power of
attorney, POLST).
•• REVIEW and COMPLETE physician pre-op orders.
•• FACILITATE anesthesia consultation.
•• VERIFY surgery site marking.
(c) Universal protocol checklist (surgical time out)
The surgical time-out process involves all surgical team members,
including the physician involved with the care of patients, and is performed
just before starting the procedure. See Timeout Policy for more
information. The checklist validates that the team:
•• Used active communication
•• Verified correct patient using 2 approved identifiers
•• Validated that consent form was accurately completed and signed
•• Agreed on the procedure(s) to be performed
•• Agreed on the correct site of procedure
•• Performed direct visualization of correct site marking (by procedural
team) following prep and draping
Antibiotic
1. Prophylactic antibiotics initiated within 1 hr.
(2 hrs. for Vancomycin) prior to incision
for CABG, cardiac, total hip, total knee,
hysterectomy, colon, some vascular, PEG.
2. Prophylactic antibiotic consistent with current
guidelines.
3. Prophylactic antibiotics discontinued within
24 hrs.*
Beta
Blockers
4. Surgery patients on beta blocker prior to
admission, continue beta-blocker therapy
during peri-operative period (24 hrs. before
incision to discharge from PACU).
Blood
Glucose
5. Cardiac surgery patients with controlled
6:00 am blood glucose (≤ 200 mg/dL) for first
2 post-operative days.*
Body Temp
6. Surgical patients should be warmed during
surgery or have at least one recorded body
temperature equal to or great that
96.8 degrees F within 30 min. prior to the
end of anesthesia to 15 min. after anesthesia
end time.
Circulation
– VTE
prophylaxis
7. Surgery patients with recommended venous
thromboembolism (VTE) prophylaxis, ordered
anytime from hospital arrival to 48 hrs. after
Anesthesia End Time.
8. Surgery patients who received appropriate
venous thromboembolism (VTE) prophylaxis
within 24 hrs. prior to anesthesia start time.
Catheter
D/C’d
9. Surgical patients with urinary catheter
removed on post-op day 1 or post-op day 2
with day of surgery being day zero.*
Surgical
Site Hair
Removal
10.Surgery patients with appropriate surgical site
hair removal. Appropriate: hair removal with
clippers, depilatory, or no hair removal.
* Starred measures are initiated in the OR but completed on inpatient units.
(e) Ortho joint replacement peri-op order set in iCentra — key points
MEDICATIONS: Prophylactic antibiotics, VTE prophylaxis, antibiotic irrigants, local anesthetics (see pages 12–15 for medication details).
BLOOD UTILIZATION: May or may not reduce the need for transfusion or Cell Saver.®
VTE RISK FACTORS — (Points)
Do not use for all patients (see page 6).
High risk = >4 pointsKUC
• ANTICOAGULATION PROTOCOLS: Based on risk stratification, using the VTE computerized risk alert
tool, which identifies VTE risk factors and assigns a weighted score (in points) for calculating VTE risk
Cancer — (3)
score. Any score of > 4 points indicates that a patient is at high risk for VTE.
Prior VTE (ICD codes) — (3)
(See info at right and User’s Guide: VTE Computerized Risk Assessment Tool).
Hypercoagulability (factor V Leiden, etc.) — (3)
• ANESTHESIA: See the ORTHO Knee Replacement and/or ORTHO Hip Replacement powerplans in
Major surgery (>60 minutes) — (2)
Powerchart in iCentra for guidance on pain management/nerve block, anesthesia type/medication choice
Bed rest (nurse charting) — (1)
and dosage. Use regional anesthesia whenever appropriate.HOR
Age >70 — (1)
• TRANEXAMIC ACID (TXM): Use weight-based dosing (10 mg/kg) vs. standard dose.
Obesity (BMI >29 kg/m2) — (1)
For high-risk patients (e.g., personal or family history of DVT or PE) inject 2 mg intra-articularly.
Hormone replacement therapy or oral
See the ORTHO Knee Replacement and/or ORTHO Hip Replacement powerplans in
contraceptives — (1)
Powerchart in iCentra.
• OR EFFICIENCY: Turnover time, anesthesia time.
•
•
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
5
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
J U LY 2 0 1 6
COMPLICATIONS RISK MANAGEMENT
Rapid response for respiratory distress
Most patients experience sedation at the beginning of opioid therapy and whenever dose
is increased significantly. Clinically significant respiratory depression is a risk factor for all
patients receiving opioids for the first time and typically occurs when there is a decrease
in rate and depth of respirations from baseline. Respiratory distress can be prevented by
careful opioid titration and close monitoring of sedation and respiratory status.
TABLE 1. Transfusion
Monitoring for unintentional opioid oversedation
Transfusion Populations
Indications
Assess heart rate, respiratory rate/effort, blood pressure, level of consciousness, pupil size,
oxygen saturation, and gastrointestinal status. Watch for arrhythmia, seizure, or inadequate
ventilation and need for bag mask ventilation. Using the NAMDU Scale (see table 2
below), the goal is to maintain a level of sedation of N or A. Notify physician or licensed
Guidelines
HCT <21% /
Hbg <7 g/dL
All age groups
HCT <24% /
Hbg <8 g/dL
Any of the following, with
no explanation other than
anemia:
• Tachycardia or
tachypnea
• Shortness of breath or
dyspnea
• Orthostatsis and/or
syncope
HCT <27% /
Hbg <9 g/dL
• Neonate
• Marrow suppressive
therapy
HCT <30% /
Hbg <10 g/dL
To reduce
cardiac stress
in severe CHF
• Shock with global tissue
ischemia, manifested by
hemodynamic instability
and/or elevated lactic
acid >4 mmol/L in
adults or >2 mmol/L in
neonates
• Local ischemic disease
of heart or brain
• Infants with cyanotic
heart disease
independent practitioner when NAMDU goal is not met OR when patient experiences:
• Oversedation
• Respiratory rate outside designated parameters, decrease in respiratory effort
• Pinpoint pupils
• Bradycardia, apnea, desaturations
• Deteriorating patient status despite interventions (e.g., verbal or physical stimulation)
Degree
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
ALGORITHM: DISCHARGE DESTINATION
Intermountain Healthcare’s goal for most patients is to discharge to a safe and supportive home environment, which is associated with
lower post-operative complication and hospital readmission rates.JUB Patient education and standardization of rehabilitation protocols may
shape patient expectations and aid in this transition of care from hospital to home.
Patient to be discharged
Is patient willing and able to participate in therapy?
Implement patient arousal measures and administering oxygen and a reversal agent such
as naloxone (Narcan®). CAUTION: Rapid administration, excessive dosage, or the use
of naloxone in opioid-dependent patients can cause hypertension, seizure, tachycardia,
ventricular arrhythmias, pulmonary edema, or cardiac arrest.
For more information, see Intermountain’s Unintentional Opioid Oversedation Newborn
Pediatric Adult Protocol for assessment, reportable conditions, patient care management,
education, safety, and complications.
Transfusion Risk
Risks associated with red blood cell (RBC) transfusions are a major consideration and
are proportionally related to the volume of blood given. The most serious risks are
Transfusion-Related Acute Lung Injury (TRALI), ABO-incompatible transfusions, and
bacterial contamination of blood products (platelets high risk).
As a result, RBC transfusion thresholds have become more restrictive. Table 1 at left
details Intermountain’s recommended transfusion guidelines. Consider using autologous
blood transfusions (Cell Saver®) to minimize associated risks. If unavailable, consider
blood bank/donor transfusions.
DETERMINE DISCHARGE APPROACH based on ambulatory capabilities
Patient ambulating at >201 feet
Patient ambulating at 51–200 feet
Patient ambulating at <50 feet
Patient has a willing and committed caregiver available AND is safe
to discharge to home (based on therapy recommendations)?
yes
Is patient
homebound? (b)
no
yes
DISCHARGE
to home with
Home Health
(see page 8 for
information)
DISCHARGE
to home with
outpatient
therapy (see
page 8 for
information)
EVALUATE if patient qualifies for
inpatient rehab (either must be met)
OPTION 1: BOTH must apply:
Level of assist > MODERATE
• Patient able to complete >3
hours of therapy 5 times/wk
•
no
EVALUATE if patient qualifies for
skilled nursing facility (SNF)REF
yes
Insurance-covered care requires skilled nursing
(or rehabilitation staff) to manage, observe,
and evaluate treatment plan (e.g., intravenous
injections, physical therapy). Medicare will
only cover skilled care when there is:CMS1, 2
•• Therapy recommendation to discharge to SNF
•• Required IV antibiotic therapy
•• Evidence that patient requires moderate or
greater assistance (>2 persons) with transfers
•• No available outpatient therapy or problematic
transport to outpatient facility
Assessment Findings
Neurological / Behavioral
Airway / Breathing / Circulation
N
no sedative effect
awake and responsive: requires no stimulation
airway / ventilatory function unaffected; maintains BP / HR
A
anxiolysis — minimal
sedation
dozing, sleeping; responds to verbal / environmental stimulation,
(e.g., patient stirs when you enter the room), cognition /
coordination may be impaired
airway / ventilatory function unaffected; maintains BP / HR
M
moderate sedation —
­
“conscious sedation”
responds purposefully to verbal / physical stimuli; sleepy and
returns to sleep without stimuli, unable to maintain conversation /
may be slurring words
maintains airway / ventilatory function / BP / HR
D
deep sedation*
depressed consciousness, requires repetitive strong / painful
stimulation to arouse; somnolent
patient may require airway / ventilatory support; BP / HR
usually maintained
U
anesthesia —
unconscious, requires
intervention
unconscious, not arouseable to painful stimulus
patient may be hypotensive / bradycardic; airway /
ventilatory support required
(a) Alternate transition planning
strategies
DISCHARGE
to
in-patient
rehab
facility
Does patient meet criteria for
authorized discharge to skilled
nursing facility (SNF)?
Explore other safe transitions that may or may not
be covered by the patient’s insurance, such as:
•• 24/7 sitters
•• Custodial care
•• Assisted living/facility for non-skilled care
(b) Homebound Patients
•• Are confined to home due to a medical condition
•• Are heavily dependent on another person to be
able to leave the residence
•• May leave home only occasionally for short
durations or for necessary health care visits
OPTION 2: Patient
has other skilled needs
requiring >3 hours of
skilled therapy/day
Patient qualifies for
discharge to rehab?
no
ALGORITHM NOTES
yes
no
DISCHARGE
to SNF as
“authorized”
DISCHARGE to SNF
as “self pay,” OR use
alternate transition
planning strategies (a)
EVALUATE if patient qualifies
for long-term acute care
hospital (LTACH)
ALL must apply:
• Level of assist = MAXIMUM.
• Patient has other skilled needs requiring
>6.5 hours of skilled care/day
• Patient needs LTACH care for >30 days
Patient qualifies for
discharge to LTACH?
yes
no
DISCHARGE
to LTACH
DISCHARGE
using Alternate
Transition
Planning
Strategies (a)
Indicates an Intermountain measure
* CAUTION: Deep sedation is an indication of impending respiratory depression or arrest.
6 Discharge using alternate transition planning
strategies. (a)
no
yes
Patient care management for respiratory distress
TABLE 2. NAMDU Newborn Pediatric Adult Tool
Score
J U LY 2 0 1 6 ©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
7
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
HIP REPLACEMENT
POST-OP
PRECAUTIONS
Anterior approach* —
Caution patient to NOT:
• Extend the hip
–– No stepping backwards with
surgical leg
–– No excessive separation of leg
• Cross the legs (at knees or ankles)
• Externally rotate leg
• Lie down without a pillow between legs
–– Use pillow when lying flat and rolling
onto side
–– Only lie on surgical side or back
(not stomach)
Posterior approach —
Caution patient to NOT:
• Bend the hip past a 90-degree angle
–– No leaning forward to reach or get
up from a seated position
–– Knees must not be higher than hips
when seated or lying down
• Cross the legs (at knees or ankles)
• Twist
–– No turning knees and toes in or out
–– Use small steps to the side for turning
• Reach with elbows inside knees
* For anterior revisions, patient should have
assistance for any abduction.
KNEE REPLACEMENT
POST-OP
PRECAUTIONS
Caution patient to:
• Avoid falls by:
–– Always using handrails when going
up and down stairs
–– Wear low-heeled or flat shoes
–– Avoid ice or snow
–– Avoid wet or waxed floors
–– Remove throw rugs and small objects
that could be tripping hazards
• Keep a pillow under the ankle when
lying down to help achieve full
extension; DO NOT put a pillow under
the knee on the affected leg
• NOT kneel and put weight on the
affected knee.
8 J U LY 2 0 1 6
POST-SURGICAL PHYSICAL THERAPY
Inpatient occupational and physical therapy consults
Following surgery (typically during 24 hours post-op), a physical therapist will meet
with the patient to conduct an initial assessment and create a post-op physical therapy
(PT) plan. Patients who have had a spinal block should have full return of sensation
and motor control for 30 minutes prior to initiation of PT assessment/intervention.
The PT assessment typically includes:
• Reviewing medical history
• Identifying patient discharge disposition goals (see ambulation guidelines in the
Discharge Destination algorithm on page 7)
• Conducting lower extremity strength testing, such as:
–– For knees: weight-bearing heel raise, knee flexion and extension
–– For hips: hip flexion, extension, abduction, adduction, internal and external rotation;
quad, hamstring
• Assessing balance and fall risk (via single-leg stance test, comparing operative vs. nonoperative side)
• Analyzing gait (walking with and without assistive device); daily ambulation goals
are typically >100 feet by end of post-operative day 1 and >200 feet by end of postoperative day 2.
• Conducting functional testing (e.g., timed up-and-go test which correlates fall risk as
well as stair climb test and 5 repetitions of sitting to standing)
• Assessing range of motion, such as:
–– For knees: lower extremity range of motion; dorsiflexion, knee flexion and extension
–– For hips: hip flexion, extension, abduction, adduction, internal rotation and external
rotation (IF NOT an anterior hip surgery)
The resulting plan will focus primarily on achieving optimum discharge disposition
goals, particularly those associated with discharge to home. In daily visits during the
hospital stay, the physical therapist will guide the patient to do range-of-motion and
strengthening exercises as well as to use TED hose, and do ADLs, such as getting
in and out of chairs and bed as well as a car, dressing, showering, and using stairs (if
required at home). The goal of these PT sessions is to help the patient transition to
home and outpatient physical therapy, if indicated.
Outpatient physical therapy (as indicated)
During an initial outpatient physical therapy session, patient evaluation will build on
the assessment and planning done during the patient’s hospital stay, focusing on the
patient’s ultimate activity goals (active sports vs. activities of daily living/occupational
goals). The physical therapist works with the patient to set interim goals, which will
be reevaluated and reset every 30 days. At each subsequent visit, the physical therapist
re-evaluates at least one therapy component (e.g., ROM, strength, balance, etc.) and
prioritizes, personalizing activities for the patient’s goals and progress.
J U LY 2 0 1 6 T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
PAIN MANAGEMENT
There are a number of pain management issues related to post-operative recovery,
including setting realistic pain management goals and using caution with
older adults.
Discuss pain management goals with each patient in terms of ADLs and physical
therapy, long-term activity goals (e.g., skiing vs. walking the dog), and level of
comfort that optimizes healing.
For geriatric patients, consider avoiding NSAIDS and certain narcotics (due to
issues with creatinine clearance) and avoid muscle relaxants. Additionally, delirium
can result from either over- or under-treatment of pain in older adults. Refer to
the medications tables on pages 12–15 for prescribing information about pain
medications.
Using the booklet, Managing Your Pain with an Orthopedic Procedure, be sure to talk
with patients about:
PATIENT REMINDERS ABOUT
PAIN MEDICATIONS
Use teach-back strategies (see sidebar on
page 3) with patients taking pain medications
to emphasize key safety guidelines. Caution
patients that NOT following these guidelines
could result in serious complications or death.
• Take medications exactly as prescribed.
• NEVER take medications more often than
prescribed.
• NEVER take other medications (not even
Tylenol®) or drink alcohol without physician’s
permission.
• NEVER take illicit, illegal, or recreational drugs
while taking pain medication.
• Only take medications that were prescribed
for YOU and store them in a safe place.
• Safely taking pain relief medications (see guidelines at right)
• Dealing with potential side-effects of pain medications (constipation, drowsiness,
confusion, and difficulty breathing)
• Managing pain without medication (heat/cold therapy, relaxation or meditation,
massage, spiritual or emotional counseling)
• Dispose of unused pain medication properly,
either by consulting a pharmacist or (if
available) by taking leftover pills to the local
police department for disposal.
See useonlyasdirected.org/drop-offlocator/ for additional Utah locations.
• Avoiding addiction
For more information, see Management of Chronic Non-Cancer Pain CPM and the
Tapering Opioid Pain Medication Clinical Guideline.
Wong-Baker FACES Pain Rating Scale
0
No hurt
2
Hurts
little bit
4
Hurts
little more
6
Hurts
even more
8
Hurts
whole lot
10
Hurts worst
© 1983 Wong-Baker FACES ® Foundation, www.WongBakerFACES.org. Used with permission.
Originally published in Whaley & Wong’s Nursing Care of Infants and Children. © Elsevier Inc.
Currently, Intermountain uses the validated Wong-Baker FACES Pain
Rating Scale for assessing a patient’s pain following surgery.
Release criteria for patients participating in outpatient physical therapy includes
independent gait for length of time/distance established in initial goals and a
facilitated transition to a long-term exercise situation (gym membership, walking
group, recreation center classes, home exercise plan, etc.)
When outpatient physical therapy is indicated, emphasize home exercise compliance
by delineating with the patient what to do daily at home versus at an outpatient
clinic. Compliance is key to reducing outpatient visits and improving outcomes.
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
No duele
Duele un poco
Duele un
poco más
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
Duele un
mucho
Duele mucho
más
Duele el
máximo
9
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
BEST PRACTICE FLASH CARDS
PROVIDER RESOURCES
Providers can now
access flash cards
for:
A D U LT B E S T P R A C T I C E F L A S H C A R D
Joint Replacement Surgery
Reference
Link
PRE-OP/SURGICAL MANAGEMENT
Patient admitted for surgery
REVIEW pre-admission preparation
Pre-op education conducted
Treatment plan reviewed by pharmacist, case manager, nurse, etc.
• Medical clearance criteria met
•
•
• Joint Replacement
Surgery (covers
perioperative
management)
yes
no
J U LY 2 0 1 6 T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
PATIENT EDUCATION
To find this CPM, clinicians can go to intermountainphysician.org/clinical/
musculoskeletal/Pages/home.aspx and select the CPM listed under the heading,
“Care Process Models” as shown below.
MEDIATE
barriers and/or
reschedule
PERFORM surgery
COMPLETE
pre-op process,
Universal
Protocol
Checklist, SCIP
FOLLOW order sets in iCentra, SCIP measures,
anesthesia requirements, and physician preferences
• USE medication guidance (see CPM pages 12–15)
to administer interoperative medications
•
FOLLOW peri-op order set/ANES adult perioperative order set in iCentra for:
pain management , monitoring, imaging
TRANSITION to surgical floor (Modified Aldrete Scoring System; active PSO);
order DME
MEDIATE
specific issues
no
Criteria met
for surgical floor
transfer?
yes
An array of
materials including
a toolkit and fact
sheets to help,
including:
• Provide brief decision advice or quick
reference information
Intermountain’s patient education toolkit, Your Guide to Total Joint
Replacement, is as a single-source reference binder for joint
• Contain algorithms or tables that aid in
decision making for diagnosis, treatment,
and management
• Link to the CPM or guideline they support
The Flashcard App
Be sure you have your username and
password.
Printed Flashcards
At iprintstore.org, providers can order
packs of 10 flash cards (all the same topic,
on 4-inch by 6-inch cardstock printed on
both sides).
Replacement Binder
Exercises
• Total Hip Exercises
• Total Knee
Clinicians can order Intermountain patient education booklets and fact sheets for distribution to their patients from Intermountain’s online
library and print store at iprintstore.org.
Best practice flash cards:
This app is available as part of the Physican
Container App, which can be downloaded
from the App store on your phone (or via
iTunes from an Apple device). Just search
for “Intermoutain Healthcare,” and scroll
down to “Intermountain Physician” and
“Get” the app.
• Joint
Intermountain patient resources
TRANSFER
©2016 Intermountain Healthcare. CPM086fca - 05/16 Reference: CPM086
Not intended to replace physician judgment with respect to individual variations and needs.
There are a number of other CPMs and clinical guidelines that may be informative
for care providers in relationship to total joint replacement surgery and patient postsurgical care. These resources include:
replacement patients to use throughout their experience. The toolkit
includes interactive checklists, time lines, and tips for preparing
for surgery, understanding what to expect in the hospital, and
optimizing recovery at home. This binder can be ordered from
iPrintStore as MSK005 Joint Replacement Binder. The binder can then
be personalized for the patient by adding customized materials to these sections:
• From My Surgeon ­— a place to include surgeon-specific handouts and discharge
instructions
• About My Facility — a place to include information about a particular hospital (e.g.,
maps, menus, TV stations, etc.)
• Management of Chronic Non-Cancer Pain CPM
• My Joint Replacement ­— a place to include information about the joint to be
• Substance Use Disorder CPM
replaced (precautions, pre-op and post-op physical therapy, etc.).
• Tapering Opioid Pain Medication Clinical Guideline
• LiVe Well — a place to add physician- or facility-preferred LiVe Well materials that
meet specific patient needs (e.g. for weight management, smoking cessation, etc.).
• Choosing a Direct Oral Anticoagulant (DOAC) Clinical Guideline
• Clinical Recommendations for Prescribing Naloxone Clinical Guideline
Cost is a little more than $2 per pack.
Standardized content from the toolkit without these sections can also be viewed as a
single pdf at Your Guide to Joint Replacement.
Current pre-operative classes held throughout Utah reflect the standardized content
in the toolkit. These classes are free to the public. Patients can see a full calendar of
classes offered and register online at intermountainhealthcare.org/JointReplacementClass.
Krames patient resources
CLINICAL GUIDELINE
J U LY 2 0 16
Clinical Recommendations for
Prescribing Naloxone in the Outpatient Setting
Opioid overdose is currently the leading cause of injury death in Utah,
with more than 10 Utahns dying each week from an overdose. Opioid
overdose occurs when a person takes more opioids than their body can
handle, causing their breathing to slow or stop completely. Naloxone can
be expected to work in 3 minutes after administration as evidenced by
restored breathing.
This guideline was created by a multidisciplinary team based on recently published
literature (see bibliography on page 4). It outlines recommendations for prescribing
naloxone (see table 2 on page 2) to patients as well as family and friends of those at risk
for opioid overdose. See page 3 for key messages for patient and family education.
CONTRAINDICATIONS
Hypersensitivity to naloxone hydrochloride
ADVERSE REACTIONS
INDICATIONS (See sidebar for contraindications and adverse reactions)
•
Naloxone hydrochloride is an emergency opioid antagonist that is FDA-approved for
the treatment of opioid overdose. Naloxone is NOT a controlled substance and can be
prescribed without liability according to Utah Code (see sidebar page 2)
•
RISK-BASED PRESCRIBING RECOMMENDATIONS
Recommendations are based on two levels of risk — increased risk and some identified
risk — which are detailed in table 1 below. Prescribing options include an intranasal kit, an
intramuscular (IM) kit, Narcan® nasal spray, and an auto injector (EvzioTM).
TABLE 1. Risk
CHARACTERISTICS OF THOSE AT RISK
RISK
LEVEL
•
•
May precipitate opioid withdrawal, which
can be life threatening in neonates
Adverse CV effects if abrupt postoperative
reversal of opioid depression (typically in
those with preexisting CV disorders or
who take drugs with similar adverse CV
effects)
Increased blood pressure, musculoskeletal
pain, or headache
Nasal dryness, edema, congestion, and
inflammation
Categories and Prescribing Recommendations
Increased Risk
(Offer kit to all)
Some Identified Risk
(Consider offering kit)
Individuals who are:
Individuals who have:
• Known or suspected illicit or non-medical opioid • Prescriptions for:
users (including heroin)
– High opioid doses (50 morphine milligram equivalents per day or higher — see table 3 on page 2)
– Methadone
• Diagnosed with substance use disorder or use
non-medical injectable drugs
– Long-acting opioids
– Opioids for chronic pain management
• Recipients of emergency medical care for acute
opioid poisoning
– Rotating opioid regimens
• Receiving medication-assisted therapy for opioid • A prescription for any opioid* AND:
– Children in the home
use disorder (taking buprenorphine or entering
a methadone maintenance treatment program)
– Known or suspected use above prescribed doses
– Breathing impairment related to sleep apnea, smoking, chronic obstructive pulmonary disease,
• Likely to witness an opioid overdose (e.g., a first
asthma, or other respiratory illness or obstruction
responder)
– Renal dysfunction or hepatic disease
– Known or suspected, concurrent use of alcohol, benzodiazepine, sedative/hypnotic,
antidepressants
– Age greater than 65 years old or cognitive impairment
– Difficulty accessing emergency medical services (not in proximity to a hospital)
• Been released from opioid detoxification or mandatory abstinence program
• Lost opioid tolerance and are likely to restart an opioid (recent release from a correctional facility)
*ASAM, AMA, etc. recommend co-prescribing
©2016 INTERMOUNTAIN HEALTHCARE. All rights reserved.
10 Patient
Information:
Patient education is a critical element in joint replacement surgery associated with
enhanced patient outcomes and satisfaction. Patients need to know the goals of the
program, understand its steps and what they need to do, and feel motivated to
participate. Several patient education resources are available to help you educate
patients about knee and hip replacement.
MANAGE PACU care
•
•
• Discharge Planning
Patient compliant with
pre-admission process?
J U LY 2 0 1 6
page 1 of 4
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
KODI - Personalize & Print
In addition, Krames StayWell offers some brief Health Sheets on
orthopedic surgeries. Access these using the Krames On Demand link
on the Intermountain Patient Education Library page and in the Cerner
EMR patient education library.
To find and print Krames Health Sheets at your desktop:
1. Open the Patient Education Library page by typing PEN in your
address bar (within the firewall).
Page 1 of 1
90144
After Hip Replacement: Using Your Crutches or Cane
Getting around at home
When you’re ready, you may progress from a walker to crutches or a cane. Before you stop using your
walker or any other walking aid, be sure to check with your surgeon or physical therapist that it is safe
to do so.
KODI - Personalize & Print
Using crutches



Page 1 of 1
With crutches in place, lean on your hands, not your armpits. The
top of the crutches should be just below, not in, the armpit.
Move your operated leg and crutches forward at the same time.
Keep the operated leg lined up with the crutches.
Look straight ahead, and step through the crutches with your good
leg.
90064
To turn, take small steps. Don’t twist.
• Understanding Knee Replacement
After Hip Replacement: When to Call Your Surgeon

KODI - Personalize & Print
HealthSheets:
Using a to
cane
After your hip replacement surgery, it’s important
follow all of your surgeon’s instructions. If you have
 Hold the cane in the hand opposite
questions, call your doctor.
the hip replacement unless told
otherwise.
Once home, call your surgeon right away if you
have:
 Put all your weight on your good leg.
 Trouble breathing or chest pain
Find your balance. Move the cane
 An increase in hip pain
and your operated leg forward.
 Pain or swelling in the calf of the leg
 Support your weight on both the cane
 Unusual redness, heat, or drainage at the and
incision
operated
Page 1 leg.
of 1 Then step through
site
with your good leg, putting all your
 Fever of 100.4˚F (38˚C) or higher
weight on your foot. Then start the
next step.
• Understanding Hip Replacement
Preventing infections
Easing
An infection in your body can harm the new
joint. into
So, activity
be sure to call your surgeon or primary care
doctor
As you
getifstronger,
slowly increase the
83562
you think you have an infection. Also, call if you
amount of activity you do around your
Understanding Hip Replacement
schedule a medical or dental procedure. You
may
need
home.
Start
by getting your own glass of
to take antibiotics
to help
infection.
water
and
doing
household chores like
The hip joint is one of the body’s largest weight-bearing
joints.
It is aprevent
ball-and-socket
joint.
This
helps
you’ll be able to move on
the hip remain stable even during twisting and extreme ranges of motion. A healthydusting.
hip jointSoon
allows
to advanced
activities,
suchPA
as19067.
using All
therights
stairs.
you to walk, squat, and turn without pain. But
when a hip
is damaged,
is likely
to hurt Line
when
youYardley,
© 2000-2015
Thejoint
StayWell
Company, it
LLC.
780 Township
Road,
reserved. This
move. When a natural hip must be replaced,
a prosthesis
used. as a substitute for professional
information
is notisintended
medical
care. Always
followLLC.
your780
healthcare
professional's
© 2000-2015
The StayWell
Company,
Township
Line Road, Yardley, PA 19067. All rights reserved. This
instructions.
information is not intended as a substitute for professional medical care. Always follow your healthcare professional's
instructions.
https://www.kramesondemand.com/PrintController.aspx?PrintDocuments=True
A Healthy Hip
A Problem Hip
A Prosthesis
In a healthy hip, smooth
cartilage covers the ends of the
thighbone, as well as the pelvis
where it joins the thighbone.
This allows the ball to glide
easily inside the socket with
little friction. When the
surrounding muscles support
your weight and the joint moves
smoothly, you can walk
painlessly.
In a problem hip, the worn
cartilage no longer serves as a
cushion. As the roughened
bones rub together, they
become irregular, with a
surface like sandpaper. The
ball grinds in the socket when
you move your leg, causing
pain and stiffness.
An artificial ball replaces the head
of the thighbone, and an artificial
cup replaces the worn socket. A
stem is inserted into the thigh
bone to keep the ball in place.
These parts connect to create your
new artificial hip. A plastic liner is
placed between the metal ball and
cup to create a smooth surface for
comfortable movement once you
have healed.
© 2000-2015 The StayWell Company, LLC. 780 Township
Line Road, Yardley, PA 19067. All rights reserved. This
https://www.kramesondemand.com/PrintController.aspx?PrintDocuments=True
information is not intended as a substitute for professional medical care. Always follow your healthcare professional's
6/10/2015
6/10/2015
instructions.
https://www.kramesondemand.com/PrintController.aspx?PrintDocuments=True
6/10/2015
2. Click the Krames On-Demand button.
3. Type “Total Joint Replacement” in the search bar. The applicable
materials appear.
Pertinent Krames materials will also appear in the Cerner EMR.
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
11
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
J U LY 2 0 1 6
MEDICATION DETAILS
Local
Anesthetics
Usual
dosing
tranexamic acid (Cyklokapron)
10 mg/kg to 15 mg/kg (1 g to 1.2 g) varies; pre-op/
intra-op
Generic: Tier 1, $
epinephrine (Adrenalin)
Spinal/Nerve Block: 0.2 mg (in combination with
other agents)
Generic: Tier 1, $
lidocaine (Xylocaine)
Varies
Generic: Tier 1, $
bupivacaine — plain
(Marcaine, Sensorcaine)
bupivacaine — liposomal
(Exparel — restricted)
Plain: Varies
Generic: Tier 1, $
Liposomal: 266 mg intra-op infiltration
Brand: Tier 3, $$$$$
ropivacaine (Naropin)
Varies
Tier*, Cost †
Precautions
•• Liposomal formulation must be
diluted in NS
•• Toxicity on chondrocytes in
intra-articular injections
Brand: Tier 1, $
Tier*,
Cost †
Benefits and Precautions
Antihistamines/
Opioid AgonistAntagonists
Vasoconstrictors
Medication name:
generic (Brand)
Usual
dosing
diphenhydramine
(Benadryl)
25 mg to 50 mg every
4 hours
Generic:
Tier 1, $
•• Anticholinergic effects may be enhanced in elderly population
•• Caution for sedation and dizziness in all adult populations
nalbuphine (Nubain)
1 mg every 30 minutes;
DNE 3 mg/4 hours
Generic:
Tier 1, $
•• May be used as adjuvant therapy with opioids
•• On national shortage – may not be available for use
Antacids/H2 Blockers
TABLE 3. OR-Use Only: Oral Agents and Non-insulin Injectable Medications
Medication
name: generic
(Brand)
calcium carbonate
(Tums)
500 mg to 1000 mg four
times daily
Generic:
Tier 1, $
•• May decrease the absorption of other medications
famotidine
(Pepcid)
20 mg to 40 mg twice daily Generic:
Tier 1, $
magnesium/
aluminum/
simethicone (Maalox)
15 mL to 30 mL four times
daily
gabapentin
(Neurontin)
300 mg to 1200 mg pre-op Generic:
Tier 1, $
•• Dose reductions in patients with decreased creatinine clearance
pregabalin (Lyrica)
75 mg to 150 mg pre-op
Brand:
Tier 3, $$$
•• Dose reductions in patients with decreased creatinine clearance
•• Schedule V Controlled Substance
ibuprofen (Motrin)
200 mg to 800 mg every
6 hours (max)
Generic:
Tier 1, $
•• 200 mg tablets available OTC
•• Do not use for patients with chronic kidney disease
•• Contains Black Box Warning associated with increased risk of adverse
events with prolonged use
•• May impair bone healing
naproxen (Naprosyn)
250 mg to 500 mg
twice daily (max)
Generic:
Tier 1, $
•• 220 mg tablets available OTC
•• Do not use for patients with chronic kidney disease
•• Contains Black Box Warning associated with increased risk of adverse
events with prolonged use
•• May impair bone healing
ketorolac (Toradol)
30 mg to 60 mg pre-op
15 mg to 30 mg every
6 hours (max)
Generic:
Tier 1, $
•• Do not use for patients with chronic kidney disease
•• Dose reduction to 15 mg in patients > 65 years of age
•• Contains Black Box Warning associated with increased risk of adverse
events beyond 5 days use
•• May impair bone healing
celecoxib (Celebrex)
100 mg to 200 mg
twice daily (max)
Brand:
Tier 3, $$$
•• Contains Black Box Warning associated with increased risk of adverse
events with prolonged use
•• May impair bone healing
•• Use with caution with patients with known sulfonamide allergy
diazepam (Valium)
2.5 mg to 5 mg every
6 hours
Generic:
Tier 1, $
•• Not recommended in patients >65 years old due to prolonged half-life in this
population, leading to increased sedation and fall risk
•• Schedule IV Controlled Substance
zolpidem (Ambien)
2.5 mg to 10 mg at
bedtime
Generic
Tier 1, $
•• Avoid 10 mg dose in women and all patients >65 years old due to risk of
excessive sedation and adverse effects
•• Schedule IV Controlled Substance
Class
Anticonvulsants
(Adjuvant Therapy
Pain Management)
NOTE: Table 3 (below) details those medications that should only be administered in the operating room. Table 4 (below and
continued on pages 13–15) details all other oral agents and non-insulin injectable medications used throughout the patient’s
continuum of care for total joint replacement surgery. For all tables, the legend for tier and cost information appears on page 15.
Bleeding
Prevention
TABLE 4. Oral Agents and Non-insulin Injectable Medications
12 Usual
dosing
Tier*,
Cost †
acetaminophen
(Tylenol)
1000 mg pre-op
325–1,000 mg every 6
hours (max)
Generic:
Tier 1, $
acetaminophen
(Ofirmev) —
Restricted
1000 mg pre-op
650–1,000 mg every 6
hours (max)
meclizine
(Antivert)
25 mg pre-op
12.5 mg to 25 mg every
8 hours
Generic:
Tier 1, $
•• May show benefit in patients with extensive intra-op manipulation
•• Anticholinergic effects may be enhanced in elderly population
•• Caution for sedation and dizziness in all adult populations
ondansetron
(Zofran)
4 mg pre-op
4 mg to 8 mg every 6
hours
Generic:
Tier 1, $
•• Best when used at preventing instead of treating post-op nausea and vomiting
•• 8 mg dosing has shown little benefit over 4mg dosing for post-op nausea and
vomiting
•• Caution when used with other medications that cause QT prolongation
prochlorperazine
(Compazine)
5 mg to 10 mg every 6
hours (max)
Generic:
Tier 1, $
•• Anticholinergic effects may be enhanced in elderly population
•• Caution for sedation and dizziness in all adult populations
promethazine
(Phenergan)
6.25 mg to 25 mg every 4
hours to 8 hours (max)
Generic:
Tier 1, $
•• May have opioid-sparing effect
•• Anticholinergic effects may be enhanced in elderly population
•• Caution for sedation and dizziness in all adult populations
•• Contains Black Box Warning associated with tissue necrosis –
Intermountain Policy requires dilution in 100 mL and administration over 5 – 10
minutes
scopolamine
(Transderm Scop)
1.5 mg pre-op
Brand:
Tier 3, $$
•• Anticholinergic effects may be enhanced in elderly population
•• Caution for sedation and dizziness in all adult populations
Generic:
Tier 1, $
Benefits and Precautions
•• May have opioid-sparing effect
•• Oral and rectal formulations are over-the-counter (OTC) and inexpensive
•• Intravenous formulation is listed as restricted formulary status, expensive and
non-inferior to oral and rectal routes of administration
•• Use with caution for patients with chronic liver disease or alcoholism
Brand name: •• Caution when using with combination products containing acetaminophen
(DNE 4 gm/day)
Tier 3, $$$$$
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
Nonsteroidal Anti-inflammatory Drugs
(NSADIS)/COX-2 Inhibitors
Medication
name: generic
(Brand)
Muscle Relaxants
Sedatives
Antiemetics/Antivertigo
Analgesic/Antipyretics,
Non-Salicylate
Class
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
TABLE 4. Oral Agents and Non-insulin Injectable Medications (continued)
This section gives detailed information on medication — oral agents and non-insulin injectables — for the surgical management of
patients undergoing total hip replacement surgery. AAOS, ASAH, DEI, FAL, JAC, MIC
Class
J U LY 2 0 1 6 ©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
•• High doses may cause confusion in elderly patients or patients with decreased
creatinine clearance
•• Not recommended for patients on dialysis due to aluminum and magnesium
accumulation
13
J U LY 2 0 1 6
TABLE 4. Oral Agents and Non-insulin Injectable Medications (continued)
Medication name:
generic (Brand)
Usual
dosing
hydrocodone/APAP (Norco)
2.5 mg to 20 mg every Generic:
6 hours (max)
Tier 1, $
Anticoagulants
Corticosteroids
Long-Acting Opioids
Short-Acting Opioids
hydromorphone (Dilaudid)
14 IV: 0.1 mg to 1 mg
every 15 minutes to
1 hour
PO: 2 mg to 4 mg
every 6 hours
Tier*,
Cost †
Generic:
Tier 1, $
Class
Benefits and Precautions
•• Caution when using with products containing acetaminophen (DNE 4 gm/day)
•• Use with caution in elderly patient or in hepatic or renal dysfunction
•• Schedule II Controlled Substance
•• Less histamine release (uticaria) as compared to morphine
•• Use with caution in elderly patient or in hepatic dysfunction – high risk of
accumulation and respiratory depression
•• Schedule II Controlled Substance
morphine (Morphine/
Astramorph)
IV: 2 mg to 10 mg
Generic:
every 1 – 4 hours
Tier 1, $
Spinal: 0.2 mg to
0.5 mg pre-op/intra-op
•• Use with caution in elderly patient or in hepatic or renal dysfunction
•• Higher risk of histamine release (urticaria) than other opioids
•• Schedule II Controlled Substance
oxycodone — with or
without APAP (Percocet /
Roxicodone)
2.5 mg to 20 mg every Generic:
6 hours (max)
Tier 1, $
•• Use with caution in elderly patient or in hepatic or renal dysfunction
•• Caution when using with products containing acetaminophen (DNE 4 gm/day)
•• Schedule II Controlled Substance
Tramadol — with or
without APAP) (Ultram/
Ultracet)
25 mg to 100 mg
every 6 hours (max)
•• Use with caution in elderly patient or in hepatic or renal dysfunction
•• Can increase seizure risk when used in combination with other products that
decrease seizure threshold
•• Can increase risk of serotonin syndrome, especially in patients taking
antidepressants
•• Schedule IV Controlled Substance
Generic:
Tier 1, $
15 mg to 30 mg
pre-op
15 mg to 45 mg every
8 hours to 12 hours
Generic:
Tier 1, $
•• Not recommended for chronic use in orthopedic population
•• Schedule II Controlled Substance
oxycodone (Oxycontin)
10 mg to 20 mg
pre-op
10 mg to 30 mg every
8 hours to 12 hours
Generic:
Tier 1, $
•• Not recommended for chronic use in orthopedic population
•• Schedule II Controlled Substance
dexamethasone
(Decadron)
IV: 4 mg to 10 mg pre- Generic:
op/intra-op
Tier 1, $
Nerve Block: 2 mg
(in combination with
other agents)
•• May prolong wound and bone healing
warfarin (Coumadin)
1 mg to 12.5 mg daily
x 10–35 days
Generic:
Tier 1, $
•• Predictable dose adjustments made through INR testing
•• Bleeding reversed by Vitamin K
•• Grade 1b CHEST Guidelines for VTE prevention
•• Multiple drug-drug and drug-food interactions
•• Patient subjected to frequent INR testing
enoxaparin (Lovenox)
30 mg twice daily x
10–35 days (begin
12 hours before or
after surgery)
Generic:
Tier 1, $
•• Grade 1b CHEST Guidelines for VTE prevention – PREFERRED AGENT
•• No laboratory testing required
•• Black Box Warning for epidural or spinal hematomas in patients
anticoagulation with LMWH and receiving neuraxial anesthesia or spinal puncture
rivaroxaban (Xarelto)
•• Grade 1b CHEST Guidelines for VTE prevention
10 mg daily x 10–35
Brand:
days (begin 6-10 hours Tier 2, $$ •• No laboratory testing required
after surgery)
•• No reliable reversal agent exists
apixaban (Eliquis)
•• Grade 1b CHEST Guidelines for VTE prevention
2.5 mg twice daily x
Brand:
10–35 days (begin
Tier 2, $$ •• No laboratory testing required
12 hours after surgery)
•• No reliable reversal agent exists
aspirin (Ecotrin/
Bayer)
325 mg twice daily x
10–35 days
morphine (MS Contin)
Generic:
Tier 1, $
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
TABLE 4. Oral Agents and Non-insulin Injectable Medications (continued)
Laxatives/Stool Softeners/Enemas
Class
J U LY 2 0 1 6 Antibiotics
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
Medication name:
generic (Brand)
Usual
dosing
Tier*,
Cost †
Benefits and Precautions
polyethylene glycol
(Miralax)
17 g daily
Generic:
Tier 1, $
•• Non-stimulant laxative
•• Available OTC without prescription
senna — with or without
docusate sodium
(Senokot/Senokot-S)
8.6 mg to 34.4 mg
daily to twice daily
Generic:
Tier 1, $
•• Available OTC without prescription
docusate sodium — with
or without senna
(Colace/Senokot-S)
50 mg to 100 mg daily Generic:
to twice daily
Tier 1, $
•• Available OTC without prescription
magnesium hydroxide
(Milk of Magnesia)
15 mL to 30 mL daily
Generic:
Tier 1, $
•• Available OTC without prescription
•• Not recommended for patients with chronic kidney disease
bisacodyl (Dulcolax)
5 mg to 10 mg daily
Generic:
Tier 1, $
•• Available OTC without prescription
mineral oil enema (Fleet
Mineral Oil)
133 mL daily
Generic:
Tier 1, $
•• Available OTC without prescription
cefazolin (Kefzol, Ancef)
2 g (if < 120kg) to
Generic:
3 g (if > 120kg) pre- Tier 1, $
op and every 8 hours x
24 hours
clindamycin (Cleocin)
900 mg pre-op and
every 8 hours x 24
hours
Generic:
Tier 1, $
•• For patients with beta-lactam allergy
•• CMS will not pay for antibiotic unless documentation for beta-lactam allergy is
noted
vancomycin
1 g (if < 100kg),
1.25 g (if > 70kg, but
< 100kg), 1.5 g (if >
100kg) pre-op and
every 12 hours x
24 hours
Generic:
Tier 1, $
•• For patients with beta-lactam allergy AND MRSA colonization or high risk MRSA
•• CMS will not pay for antibiotic unless documentation for MRSA is noted
* Tier: Tier 1 = $5–10 copay; Tier 2 = $30–35 copay; Tier 3 = $50–60 copay (based on typical SelectHealth 2010 RxSelect benefit design; some benefit designs
may differ).
† Cost: Estimated monthly cost based on usual dose. $=$1–$25; $$=$26–$75; $$$=$76–$150; $$$$ = $150–$300; $$$$$ = >$300. Generic used for tier and
price comparisons unless otherwise noted.
•• Grade 1b CHEST Guidelines for VTE prevention
•• Available OTC without prescription
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
15
T O TA L K N E E O R H I P R E P L A C E M E N T S U R G E R Y
J U LY 2 0 1 6
REFERENCES
This CPM presents a model of best care
based on the best available scientific
evidence at the time of publication. It is
not a prescription for every physician or
every patient, nor does it replace clinical
judgment. All statements, protocols,
and recommendations herein are viewed
as transitory and iterative. Although
physicians are encouraged to follow
the CPM to help focus on and measure
quality, deviations are a means for
discovering improvements in patient care
and expanding the knowledge base. Send
feedback to:
Joan Lelis, Operations Director
Musculoskeletal Clinical Program
Intermountain Healthcare
([email protected])
AAOS Aaos.org. AAOS clinical practice guidelines. 2015. Available at: http://www.aaos.org/guidelines/?ssopc=1.
Accessed July 14, 2016.
ASAH Asahq.org. American Society of Anesthesiologists - standards & guidelines. 2015. Available at:
http://www.asahq.org/quality-and-practice-management/standards-and-guidelines. Accessed May 17,
2015.
BCBS Blue Cross Blue Shield. A Study of Cost Variations for Knee and Hip Replacement Surgeries in the
U.S. Available at: http://www.bcbs.com/healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf.
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CDC Centers for Disease Control and Prevention. How much physical activity do adults need? Available at:
http://www.cdc.gov/physicalactivity/basics/adults/. Accessed December 23, 2015.
CMS Center for Medicare and Medicaid Services, Department of Health and Human Services. Documenting
medical necessity for major joint replacement (hip and knee). Available at: https://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
SE1236.pdf. Accessed December 23, 2015.
CMS1 Center for Medicare and Medicaid Services, Department of Health and Human Services. Skilled nursing
facility (SNF) billing reference. Available at https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/downloads/snfspellillnesschrt.pdf. Accessed March 18, 2016.
CMS2 Center for Medicare and Medicaid Services, Department of Health and Human Services. Medicare
program: Comprehensive care for joint replacement payment model for acute care hospitals furnishing
lower extremity joint replacement services. Available at http://www.regulations.gov/#!documentDetai
l;D=CMS-2015-0082-0395. Accessed March 18, 2016.
DEI
CPM DEVELOPMENT TEAM
MSKCP Total Joint Development Team
Deitelzweig S. Preventing venous thromboembolic events after total hip arthroplasty: New developments
in clinical practice. Hospital Practice. 2012;40(2):79-87. doi:10.3810/hp.2012.04.973.
DOT Dotinga R. Number of hip replacements has skyrocketed. Web MD. http://www.webmd.com/arthritis/
news/20150212/number-of-hip-replacements-has-skyrocketed-us-report-shows. Published February
12, 2015. Accessed July 22, 2015.
Medical Director: Nate Momberger, TOSH
FAL
Central Region: Jeremy Gilliland, LDSH
Josh Hickman, LDSH
Crystal Sovereen, LDSH
Keri McAffee, TOSH
Adam King, IMC
HOL Holstege MS, Lindeboom R, Lucas C. Preoperative quadriceps strength as a predictor for short-term
functional outcome after total hip replacement. Arch Phys Med Rehabil. 2011; 92(2):236-241.
doi: 10.1016/j.apmr.2010.10.015.
North Region: Tom Calton, McKay-Dee
Bryan King, Logan
Allyssa Burr, Logan
Evelyn Chapman,
McKay-Dee
Falck-Ytter Y. Prevention of VTE in orthopedic surgery patients. Chest. 2012;141(2_suppl): e278S.
doi:10.1378/chest.11-2404.
HOP Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, et al. ASRA practice advisory: Regional
anesthesia in the patient receiving antithrombotic or thrombolytic therapy. Reg Anesth Pain Med. 2010;
35(1):64-101.
IBR
Ibrahim MS, Khan MA, Nizam I, Haddad FS. Peri-operative interventions producing better functional
outcomes and enhanced recovery following total hip and knee arthroplasty: An evidence-based review.
BMC Medicine. 2013;11:37.
JAC
Jacobs JJ, Mont M, Bozic K, et al. American Academy of Orthopaedic Surgeons clinical practice guideline
on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty.
J Bone Joint Surg Am. 2012;94(8):746-747. doi:10.2106/jbjs.9408.ebo746.
Southwest Region: Ed Prince, DRMC
Emily Lowe, DRMC
JUB
Jubelt LE, Goldfeld KS, Chung W, Blecker SB, Horwitz LI. Changes in discharge location and readmission
rates under Medicare bundled payment. JAMA Intern Med. 2016;176(1):115-117.
PKMC-Heber: KUC Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, et al. Electronic alerts to prevent venous
thromboembolism among hospitalized patients. N Engl J Med. 2005;352(10):969-977.
South Region: Adam Bergeson, UVH
Terrell Winterton, UVH
Jordan Falor, UVH
Charles Lind, PKMC
Nicolle Miller, PKMC
Jen Brown, PKMC
MSKCP Medical Director: Hugh West
MSKCP Operations Director: Joan Lelis
MSKCP Data Manager: Ben Layne
MSKCP Data Analyst: Jackie Lee
Medical Writer: Kathi Whitman, Patient and
Provider Publications
MSKCP Administrative Assistant: Helen Messina
MAL Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, Reed MR. Enhanced recovery
program for hip and knee replacement reduces death rate. Acta Orthop. 2011;82(5):577-558.
MES Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and
obese older adults with knee osteoarthritis. Arthritis Rheum. 2005;52(7): 2026-2032.
MIC Micromedexsolutions.com. Micromedex products: 2015. Available at: http://www.micromedexsolutions.
com/micromedex2/librarian/. Accessed December 1, 2015.
MIZ
Mizner RL, Petterson S, Stevens J, Axe, MJ, Snyder-Mackler, L. Preoperative quadriceps strength predicts
functional ability one year after total knee arthroplasty. J Rheumatol. 2005;32(8):1533-1539.
ROO Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, et al. Effect of preoperative exercise on measures
of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis Rheum.
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©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications CPM086 - 07/16