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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. Published January 21, 2015. Accessed July 22, 2015. 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. 2006;55(5):700-708. SOR Sorensen LT. The clinical impact of smoking and smoking cessation: a systematic review and metaanalysis. Arch Surg. 2012;147(4):373-383. doi:10.1001/archsurg.2012.5. 16 ©2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications CPM086 - 07/16