scholarly journals The journey to total hip or knee replacement

2012 ◽  
Vol 36 (2) ◽  
pp. 130 ◽  
Author(s):  
Julie Lynette Walters ◽  
Shylie Mackintosh ◽  
Lorraine Sheppard
Keyword(s):  
Joint Replacement ◽  
Elective Surgery ◽  
Public Hospitals ◽  
Patient Journey ◽  
Total Hip ◽  
Joint Replacement Surgery ◽  
Replacement Surgery ◽  
Patient Pathway ◽  
Total Knee ◽  
Insight Into

Objectives. Despite the incidence of joint replacements in Australia, there is a paucity of information regarding how patients progress from their referral to their surgery. The aim of this study was to describe a patient pathway from referral to receipt of total hip replacement (THR) or total knee replacement (TKR) surgery in South Australian public hospitals. Methods. Patient perspectives of the pathway to THR and TKR surgery were obtained via a postal survey (n = 450) and hospital employee perspectives were attained via semi-structured interviews (n = 19). Survey data were analysed using descriptive statistics and interview data were analysed thematically. Results. A typical patient pathway to THR and TKR surgery can be divided into two distinct phases; referral-to-initial appointment (9–24 months), and initial appointment-to-surgery (12–15 months). This gives an overall waiting period between 2 and 3 years for THR or TKR surgery. Conclusions. Waiting times for THR and TKR surgery reported in this study were longer than other reports in the literature. Current Australian health policy does not consider the first (and longest) phase of the patient pathway. Excluding this initial phase could be generating an erroneous perception of the patient pathway to THR or TKR surgery, possibly leading to poorly considered health reforms. What is known about the topic? Meeting the demand for elective surgery services in public hospitals is an ongoing challenge for governments and health systems alike. The persistent mismatch between supply and demand has resulted in the development of waiting lists for elective total hip replacement (THR) and total knee (TKR) replacement surgery in Australia. Current state-level health policies such as the Policy Framework and Associated Procedural Guidelines for Elective Surgery Services in South Australia or the Elective Surgery Access Policy in Victoria, outline a generic pathway consisting of a few linear steps that occur immediately before receipt of surgery, without consideration of the early stages of the journey. Aside from these types of policies, we were unable to identify any published literature outlining the patient journey from referral to receipt of THR or TKR surgery. As such, our understanding of the issue is inadequate due the paucity of existing research evidence. What does this paper add? Our current understanding of the patient journey to THR and TKR surgery is limited to the perspective of the policy-makers, whose focus is the organisation of waiting lists and the systematic progression of an individual through the elective surgery system. This perspective reinforces the assumption that it is a simple, linear process and may lead to erroneous judgements regarding the impact that the patient pathway has on an individual and the time it takes to progress along that pathway. This study presents the patient pathway from the perspective of individuals working within the systems responsible for delivering THR and TKR surgery and from patients who have received a joint replacement in a South Australian public hospital. As such, this paper provides new insight into the length, impact and features of the entire patient journey, rather than a snap-shot of the final stages. What are the implications for practitioners? This study is the first step towards better understanding of the patient pathway to joint replacement surgery in Australian public hospitals. Greater understanding of the complete pathway and identification of areas of congestion within the pathway, as evidenced by longer waiting periods, offers insight into areas with the potential for effective reforms. Should the patient pathway be significantly altered, the experience of practitioners responsible for the interim and postoperative management of patients undergoing THR and TKR surgery will also be changed. Additionally, practitioners currently frustrated by the long delays experienced by their patients who are in need of elective surgery in Australian public hospitals, could have that frustration abated by system improvements that reduce the length and complexity of the pathway to joint replacement surgery.

scholarly journals Ultra Low-Dose Naloxone and Tramadol/Acetaminophen in Elderly Patients Undergoing Joint Replacement Surgery: A Pilot Study

2009 ◽  
Vol 14 (2) ◽  
pp. 103-108 ◽  
Author(s):  
Ngozi N Imasogie ◽  
Sudha Singh ◽  
James T Watson ◽  
Debbie Hurley ◽  
Patricia Morley-Forster
Keyword(s):  
Pilot Study ◽  
Elderly Patients ◽  
Joint Replacement ◽  
Standard Therapy ◽  
Randomized Clinical Trials ◽  
Intrathecal Morphine ◽  
Total Hip ◽  
Joint Replacement Surgery ◽  
Replacement Surgery ◽  
Total Knee

OBJECTIVE: A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid-sparing drugs in elderly patients undergoing lower extremity joint replacement surgery.DESIGN: Ten patients 70 years of age or older undergoing either total knee (n=7) or total hip (n=3) arthroplasty were treated prospectively. Each patient received two tablets of tramadol/acetaminophen (Tramacet; Janssen-Ortho Inc, Canada) preoperatively and every 6 h postoperatively, as well as a naloxone infusion started preoperatively at 0.25 μg/kg/h and continued up to 48 h postoperatively. In addition, standard intraoperative care was provided with 0.2 mg of intrathecal morphine, 1.4 mL of 0.75% bupivacaine, and an intra-articular infiltration of 100 mL of 0.3% ropivacaine and 30 mg of ketorolac, as well as standard postoperative morphine via patient-controlled analgesia orders and celecoxib 200 mg twice daily for five days.OUTCOME MEASURES: Compared with seven historical controls, also 70 years of age or older, who had undergone either a total knee (n=4) or total hip (n=3) arthroplasty, postoperative opioid use was reduced by 80%. Except for transient nausea and vomiting in 40% and 20% of patients, respectively, the 10 patients on tramadol/acetaminophen and naloxone tolerated the new regimen without difficulty.CONCLUSION: Consequently, a randomized, double-blinded clinical trial comparing standard therapy versus standard therapy plus these two drugs seems warranted. In such a trial, it would require approximately 20 subjects per treatment arm to detect a 80% decrease in morphine use.

scholarly journals Anti-Phospholipid Antibodies in Patients Undergoing Total Joint Replacement Surgery

Thrombosis ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-5 ◽  
Author(s):  
Melissa Simpson ◽  
Michael J. Sanfelippo ◽  
Adedayo A. Onitilo ◽  
James K. Burmester ◽  
William Hocking ◽  
...  
Keyword(s):  
Joint Replacement ◽  
Total Joint Replacement ◽  
Patient Specific ◽  
Preoperative Period ◽  
Joint Replacement Surgery ◽  
Replacement Surgery ◽  
Increased Risk ◽  
Patients At Risk ◽  
Total Knee ◽  
Arthroplasty Procedure

Background. Patients undergoing joint replacement remain at increased risk for venous thromboembolism (VTE) compared to other types of surgery, regardless of thromboprophylactic regimen. The pathophysiologic processes rendering this group of patients at risk for VTE are multifactorial. Procedure-specific and patient-specific exposures play a role in the postoperative development of VTE, including the development of anti-phospholipid antibodies (aPL). Methods. We measured three aPL (anti-cardiolipin, anti-β2 glycoprotein, and lupus anticoagulant) in 123 subjects undergoing total knee or hip arthroplasty to describe the presence of these antibodies preoperatively and to describe the rate of postoperative seroconversion among those people who were negative preoperatively. Postoperative antibodies were measured at day 7, 14, and 21. Results. The prevalence of aPL antibodies in the preoperative period was 44%, positive subjects were more likely to be smokers (P=0.05) and were less likely to have undergone a previous arthroplasty procedure (P=0.002). Subjects seroconverted in a 21 day postoperative period at a rate of 79%. Conclusions. These pilot data suggest that the prevalence of aPL in this population both preoperatively and postoperatively is higher than previously expected. Further studies are needed to describe aPL in a larger population and to establish their clinical significance in populations undergoing joint replacement surgeries.

scholarly journals Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals

2013 ◽  
Vol 37 (2) ◽  
pp. 166 ◽  
Author(s):  
Julie L. Walters ◽  
Shylie F. Mackintosh ◽  
Lorraine Sheppard
Keyword(s):  
Knee Replacement ◽  
Elective Surgery ◽  
Waiting Times ◽  
Waiting Lists ◽  
Public Hospitals ◽  
Barriers And Facilitators ◽  
System Function ◽  
Knee Replacement Surgery ◽  
Replacement Surgery ◽  
Total Knee

Objectives. Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip- and total knee-replacement surgery in South Australian public-funded hospitals. Methods. Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework. Results. System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy. Conclusions. Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful. What is known about the topic? Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn’t clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform. What does this paper add? This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip- and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region- or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered. What are the implications for practitioners? All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians should experience a more streamlined approach to referral for and receipt of elective surgery in public hospitals. The consistency with which barriers and facilitators were identified across the four hospitals involved in this research supports the generalisability of the results. This further suggests that although specific to hip and knee replacement, many of the same barriers and facilitators could be in place across numerous surgical and non-surgical disciplines.

scholarly journals Preexisting Cognitive Impairment and Mild Cognitive Impairment in Subjects Presenting for Total Hip Joint Replacement

2011 ◽  
Vol 114 (6) ◽  
pp. 1297-1304 ◽  
Author(s):  
Lisbeth A. Evered ◽  
Brendan S. Silbert ◽  
David A. Scott ◽  
Paul Maruff ◽  
David Ames ◽  
...  
Keyword(s):  
Cognitive Impairment ◽  
Mild Cognitive Impairment ◽  
Alzheimer Disease ◽  
Hip Joint ◽  
Joint Replacement ◽  
Verbal Learning ◽  
Hip Joint Replacement ◽  
Total Hip ◽  
Joint Replacement Surgery ◽  
Replacement Surgery

Background The prevalence of preexisting cognitive impairment (PreCI) is documented before cardiac surgery, but there is less information before noncardiac surgery. In addition, the prevalence of mild cognitive impairment, defined by different cognitive criteria and subjective complaints, and which may progress to Alzheimer disease, is unknown in these subjects. Because anesthesia and surgery have been implicated in Alzheimer disease pathology, we prospectively measured PreCI and mild cognitive impairment in subjects scheduled for total hip joint replacement surgery in an observational study. Methods One hundred fifty-two subjects 60 y of age and older who were scheduled for total hip joint replacement surgery underwent assessment, including neuropsychologic testing, 1 week before surgery. Test results were compared with published norms. PreCI was defined as impairment in two or more of seven cognitive tests, for which impairment in an individual test was defined as ≥ 2 SD below norms for that test. Amnestic mild cognitive impairment (aMCI) was defined as impairment ≥1.5 SD below norms for results of the immediate and/or delayed Auditory Verbal Learning Test plus a subjective complaint. Results Subjects performed worse compared with normative data on five of seven neuropsychologic tests. Thirty (20% [95% CI, 13-26%]) subjects were classified as having PreCI. Thirty-four (22% [95% CI, 16-29%]) were classified as having aMCI. Ten (7%) subjects were classified as having both PreCI and aMCI, representing 33% of the 30 subjects with PreCI. Conclusions The prevalence of aMCI in subjects scheduled for total hip joint replacement surgery is similar to that in the general community. PreCI and aMCI tend to identify different subjects. Because aMCI is known to progress to Alzheimer disease, future studies that track cognition before and after anesthesia and surgery should document the presence or absence of aMCI so that the rate of conversion to Alzheimer disease after anesthesia and surgery can be compared with the rate in the nonsurgical population.

scholarly journals A prospective study on the risk of glove fingertip contamination during draping in joint replacement surgery

2014 ◽  
Vol 96 (6) ◽  
pp. 434-436 ◽  
Author(s):  
D Makki ◽  
K Deierl ◽  
A Pandit ◽  
S Trakru
Keyword(s):  
Prospective Study ◽  
Joint Replacement ◽  
Dominant Hand ◽  
Coagulase Negative Staphylococci ◽  
Joint Replacement Surgery ◽  
Replacement Surgery ◽  
Total Knee Replacements ◽  
Hip Replacements ◽  
Total Knee ◽  
A Prospective Study

Introduction The aim of this prospective study was to investigate the risk of contamination of surgical gloves during preparation and draping in joint replacement surgery. Methods During 46 hip and knee replacement procedures, the gloves of orthopaedic consultants (n=5) and registrars (n=3) were assessed for contamination immediately after draping by impression of gloved fingers on blood agar. Contamination was evaluated by the surgeon’s grade, the type of procedure, the role of the assistant and the dominance of the hand. Results A total of 125 pairs of top gloves were examined (79 pairs from registrars and 46 pairs from consultants). Bacterial contamination was isolated on 19 pairs (15.2%) (16 pairs from registrars and 3 pairs from consultants, p=0.04). Coagulase negative staphylococci were the main isolates and contamination was considered low in all cases (1–5 colonies). Contamination was seen more on the dominant hand (16 gloves from dominant hands and 6 from non-dominant hands, p=0.04), on the index finger and thumb. More contaminated gloves were seen in hip arthroplasty procedures (16 pairs from total hip replacements vs 3 pairs from total knee replacements, p=0.02). Conclusions Contamination of glove fingertips during draping in joint replacement procedures is more likely to occur among junior surgeons, in hip rather than knee arthroplasty procedures and on the dominant hand. It is therefore essential that surgeons of different grades replace gloves used in draping to avoid exposing patients to the risk of infection.

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