West Gippsland Healthcare Group1
In 2018/19 in Victoria it took 301 and 265 days for 90% of patients to be admitted for elective Total Knee and Total Hip replacement surgery respectively, and 4.6% and 2.7% (respectively) waited for more than 365 days.
Studies have shown that patients with lower preoperative function and pain did not improve postoperatively to the same levels as those with higher preoperative function. The longer a patient waits for their surgery, the greater the potential for functional decline and deconditioning which also leads to a longer postoperative recovery.
What you did?
A multidisciplinary working group was formed to implement a Prehabilitation Program, ensuring all stakeholders were involved from the beginning. This included:
- designing how the program would be delivered (Pre-admission Clinic/Nursing, Physiotherapy, Occupational Therapy, Dietetics, Diabetes Education, Allied Health Assistance),
- the reporting and clinic set-up to maximise funding,
- referral processes and communication across disciplines and units,
- developing forms and templates for documentation, and
- embedding evaluation into the program.
Program delivery commenced in August 2018 which included a 4 week physiotherapy exercise program and OT education sessions. Input from a Dietitian or Diabetes Educator was determined by screening embedded in the referral tool.
Regular meetings continued with multidisciplinary clinical team meetings discussing ‘ready for care’ issues, and ‘process’ meetings allowing for evaluation and continuous improvement.
Following 12 months of program delivery 3 people did not progress to surgery, with 2 more waiting to ensure benefits are sustained. Improved efficiencies have been reported on the Surgical Unit, with patients ready to participate and more prepared for discharge. The program helped to improve how patients managed daily activities prior to surgery in 92%, mobility in 86% and the management of their weight or nutrition in 54%.
Between 60-80% of patients either improved or maintained status quo in outcome measures (10mwt, TUG, HOOS/KOOS score) taken prior to the program and prior to surgery.
Ongoing review has resulted in quality improvements including the introduction of a ‘Booster Group’ and expanded malnutrition screening.
Future directions and practice implications:
Now two and a half years down the track, the Prehab team will be doing a full review of outcome measures used. Implementation of a delirium/frailty screen within pre-admission is planned.
Thorough planning prior to implementation is vital, with input from all stakeholders. Ongoing, regular ‘process’ meetings have been extremely beneficial to ensure continuous improvement in response to feedback from both staff and patients.
Sally is a Senior Clinician Physiotherapist with 19 years of experience in public hospitals. She has worked in all clinical areas, as well as Clinical Education and Quality and Safety.