Docstoc

CLINICAL PATHWAY TOTAL HIP REPLACEMENT

Document Sample
CLINICAL PATHWAY TOTAL HIP REPLACEMENT Powered By Docstoc
					                         CLINICAL PATHWAY
                       TOTAL HIP REPLACEMENT


  Expected LOS: 4 days



                                             Clinical Pathways are not considered a substitute for professional judgement.

     Phase:            Physician's Office                         Physio/OT Preop Class                    Pre-Surg Assessment Clinic

     Date:
PATIENT          Patient introduced to plan of care    Patient/family will be knowledgeable of preop    Patient/family will be knowledgeable
OUTCOMES         Surgery booked                        preparations and postop care.                    of pre & postop care.
                 Appointments to be made by            Patient to fill out questionnaire,               Verbalizes acceptance with d/c plans
                 patient:                              providing information about home                 PO day 4
                 - Blood Conservation Clinic           environment, current list of                     Verbalizes understanding of active




                                                                                        CE
                 - Pre-Admission Clinic                equipment used, family supports,                 role in hospital and need to modify
                   (up to 28 days preop)               and activity level.                              activities at home
                 - Preop Physio/OT
                   (2-3 weeks preop)                   Clinical Indicator #1:
                                                       Attended preop physio/OT class?
                                                       Yes _____ No _____ (initial)




                                                                             N
                                                       If NO, reason: ______________________


TEACHING         Physician initiates pathway with      Patient brings preop package                     Patient brings preop package.
                 patient/family.                       Review the following information:                Preop video viewed.
                                                        RE
                 Patient is given preop package        Patient pathway booklet                          Patient Pathway reviewed
                 Patient to book history & physical    Exercises, walking with equipment                (Hemovac, CSM, anticoagulation
                 with family physician within 28       (walker and/or crutches), practicing             tests & meds, use of heel
                 days prior to surgery or internal     stairs, general safety, clothing and             protectors bilaterally, LOS)
                 medicine arranged by surgeon          footwear                                         Patient/family learning needs
                 Book Geriatrician appointment         Pain management                                  identified & addressed
                 if indicated                          DB&C, F&A exercises                              Patient reminded to notify other
                                                       Hip precautions and application to ADL,          ancillary physicians eg:
                                        FE

                                                       functional transfers, home set up/               cardiologist, endocrinologist
                                                       safety and accessibility


DISCHARGE        ELOS reviewed - 4 days                ELOS reviewed -4 days                            ELOS reviewed - 4 days
PLANNING                                               Vendor's list provided and required              Review and contract with pt/family:
CRITERIA                                               equipment needs in home prior to                 Need to arrange for a caregiver to
                   RE



                                                       discharge on POD 4                               stay with pt up to 2 wks or until pt
                                                       List of equipment (mobility aid,                 feels support is no longer needed.
                                                       bathroom safety equipment, dressing              Alternately, pt may choose to stay
                                                       aids, walker / crutches or cane)                 at the home of a family member
                                                       Follow-up according to CCAC (PT                  where support can be provided.
                                                       pathway) and/or outpatient PT                    Identify barriers for discharge
                                                       appointment                                      Provides information on
                                                       Patient to arrange for Transhelp or              resources for orthopedic respite
                                                       other means of transportation
                                                       (family or friends) for appointments


  Pathway
                                                                                                                                               40506 D HR (Jan/2009) Page 1 of 7




Reviewed with
                  _______ Yes          _______ No             _______ Yes         _______ No              _______ Yes         _______ No
Patient/Family
    (Initial):
Patient/Family          YES            NO                         YES           NO                               YES           NO
Satisfied with
  Progress?           if NO, see progress notes                 if NO, see progress notes                      if NO, see progress notes

Signatures:                          Initials                                  Initials                                      Initials
                  _________________ ________                _________________ ________                    _________________ ________
                  _________________ ________                _________________ ________                    _________________ ________
                  _________________ ________                _________________ ________                    _________________ ________


                                                                                              CLINICAL PATHWAY - TOTAL HIP REPLACEMENT
                   CLINICAL PATHWAY
                 TOTAL HIP REPLACEMENT




                                      Clinical Pathways are not considered a substitute for professional judgement.


        Phase:           Physician's Office                 Physio/OT Preop Class                   Pre-Surg Assessment Clinic

        Date:

                                                              INTERVENTIONS:
Assessments      Consent(s) initiated in office         Questionnaire completed by              Data Base completed, including
                                                        patient or family member                assessment for delirium, dementia,
                                                        Assess for appropriate assistive        cognition, hx of post op nausea and
                                                        devices and equipment needs             vomiting (PONV) & other surgical risk




                                                                                 CE
                                                                                                factors.
                                                                                                Consents reviewed
                                                                                                CCAC home assessment prn

Consults         Internal Medicine if indicated         Physiotherapist (PT)                   Preop Anaesthesia consult as
                 Geriatrician if indicated              Occupational Therapist (OT)            indicated according to:
                                                                                               Level of risk, anxiety, lack of




                                                                     N
                                                                                               knowledge.

Tests                                                                                           CBC, lytes, urea, creat
                                                                                                Chest xray, ECG
                                                    RE
                                                                                                +/- xray of affected hip
                                                                                                +/- PT, PTT, INR
                                                                                                +/- Sickle Cell test
                                                                                                +/- Group & Reserve


Treatments                                              Patient to attend physiotherapy -       Review pts role in actively
                                                        occupational therapy class              participating in care pathway
                                   FE

Medications      Discontinuation of ASA,                                                        Reconcile medications and meds
                 NSAIDS, warfarin (Coumadin),                                                   to take a.m. of surgery.
                 clopidogrel (Plavix) and herbal                                                Review d/c ASA, NSAIDS,
                 meds 7 days prior to surgery                                                   warfarin (Coumadin), ticlopidine (Ticlid),
                 and ticlopidine (Ticlid) 14 days                                               clopidogrel (Plavix) and herbel meds
                 RE



                 prior to surgery as directed by                                                COX-2 agents day prior to surgery
                 physician                                                                      if applicable
                                                                                                Review potential need for home INR
                                                                                                monitoring

Nutrition                                                                                                 ONE DAY PREOP
                                                                                                NPO after midnight.

Activity/                                               Review activity and safety as
Safety                                                  per PT/OT class content
                                                                                                                                             40506 D HR (Jan/2009) Page 2 of 7




Elimination                                                                                     Assess bowel routine/function



Pain                                                    Review pain management as               Review pain management
Management                                              per PT/OT class content                 Consider prophylaxis for PONV
                                                                                                with dexamethasone or
                                                                                                ondansetron if 2 or more risk
                                                                                                factors




                                                                                        CLINICAL PATHWAY - TOTAL HIP REPLACEMENT
                         CLINICAL PATHWAY
                       TOTAL HIP REPLACEMENT




                                            Clinical Pathways are not considered a substitute for professional judgement.

                         Day of Surgery                               Day of Surgery
      Phase:                                                                                                       Postop Day 1
                        Surgical Check-in                                Postop

      Date:

PATIENT          Patient will be prepared for         Patient/family will be informed of               HR, BP +/- 20% pre-op value
OUTCOMES         surgery                              postop condition __________                      RR +/- 10% pre-op value +/- O2
                 Verbalizes understanding of          HR, BP +/- 20% pre-op value                      Afebrile




                                                                                         CE
                 postop care & hip precautions        RR +/- 10% pre-op value +/- O2                   CSM within normal range
                                                      Temperature less than or equal to 38.4
                                                      Patient will verbalize pain control,             Patient will:
                                                      pain score less than or equal to 4 _____
                                                      Verbalizes understanding of postop               Verbalize pain control __________
                                                      care & hip precautions                           Transfers with assistance to/from
                                                                                                       bed/chair __________




                                                                            N
                                                                                                       Ambulates greater than or equal to 1
                                                                                                       and prn __________
                                                                                                       Achieves functional mobility targets
                                                                                                       as per PT P&P
                                                                                                       Follows hip precautions and
                                                       RE
                                                                                                       demonstrates proper positioning

TEACHING         Review information as per patient    Orient to room, nursing unit AND                 Review:
                 and family needs                     care routines __________                         Post op care, pain management,
                 Review length of time in PACU:       DB&C __________                                  monitoring, positioning, activity,
                 - Approximately 2 + hours            F&A exercises __________                         diet, elimination, dressings, drains,
                 Review pathway and activity          PCA/epidural __________                          catheter, IV and medications.
                 participation while in hospital      Repositioning __________                         DB&C, F&A exercises
                                        FE

                                                      Review drain, IV __________                      Teaching complete __________
                                                      CSM __________                                   Begin Self administration of sc
                                                      Dressing __________                              injections if applicable _________
                                                                                                       Ambulation / Exercises (PT)
                                                                                                       ADLs and functional transfers with
                                                                                                       hip precautions (OT)
                    RE



DISCHARGE                                             Planned discharge date is written on             ELOS reviewed 4 days
PLANNING                                              bedside communication board                      Pt and family informed of postop
CRITERIA                                                                                               condition
                                                                                                       Discuss any outstanding discharge
                                                                                                       needs if applicable
                                                                                                       Outpatient PT referral if applicable


  Pathway
                                                                                                                                               40506 D HR (Jan/2009) Page 3 of 7



Reviewed with
                   _______ Yes        _______ No            _______ Yes         _______ No               _______ Yes          _______ No
Patient/Family
    (Initial):
Patient/Family          YES           NO                        YES           NO                                YES            NO
Satisfied with
  Progress?           if NO, see progress notes               if NO, see progress notes                       if NO, see progress notes

Signatures:                          Initials                                Initials                                       Initials
                  _________________ ________              _________________ ________                     _________________ ________
                  _________________ ________              _________________ ________                     _________________ ________
                  _________________ ________              _________________ ________                     _________________ ________



                                                                                             CLINICAL PATHWAY - TOTAL HIP REPLACEMENT
                   CLINICAL PATHWAY
                 TOTAL HIP REPLACEMENT



                                    Clinical Pathways are not considered a substitute for professional judgement.

                          Day of Surgery                         Day of Surgery
        Phase:                                                                                                Postop Day 1
                         Surgical Check-In                          Postop
        Date:
                                                               INTERVENTIONS:
Assessments      Reconfirm consents and Data Base      VS q2hx4, then q4h x 3 and prn OR        VS q4h OR as per APS
                 Vital signs                           as per APS PCA or Neuraxial orders       PCA/Neuraxial orders
                 Complete preop checklist              CSM q4h                                  CSM and pain score q4h
                                                       Pain score, sedation score/sensory       Fluid balance
                                                       & motor if spinal anesthetic             Bowel sounds q8h
                                                       Falls / delirium assessment              Dressing site




                                                                                     CE
                                                       Fluid balance q4h                        +/- Hemovac output q8h
                                                       Bowel sounds q8h                         Call surgeon if Hgb less than 80
                                                       +/- Hemovac output q4h - notify          Falls / delirium assessment
                                                       surgeon if greater than 300 mL/4h

Consults                                               PT/OT                                    PT/OT
                                                       RT prn                                   Internist prn
                                                       Acute Pain Service prn                   RT prn


Tests            MRSA results
                 Other tests as ordered/or as
                                                                       N
                                                       X-ray operative hip in PACU
                                                       As per physician specific orders
                                                                                                Acute pain service prn

                                                                                                CBC, lytes, urea, creat +/- PT/INR if
                                                                                                on warfarin
                                                       RE
                 per protocol (e.g. Diabetic)                                                   Other tests as ordered or as per
                                                                                                protocol (e.g. Diabetic)

Treatments       Warm blankets                         Warm blankets                            IV as per physician orders, decrease
                                                       IV as per physician order                TKVO if po intake is greater than
                                                       O2 as per orders/protocol                400 mL/8h and urine output greater
                                                       DB&C, F&A, q1h while awake & prn         than 30 mL/h x 8h.
                                                       Falls and delirium interventions if      O2 as per orders/protocol
                                  FE

                                                       applicable                               DB&C, F&A q1h while awake & prn
                                                                                                Falls and delirium interventions
                                                                                                if applicable

Medications      Identify meds taken a.m. of surgery   Antiemetics/PONV prophylaxis             Antiemetics/PONV prophylaxis
                 Pre op medications as ordered         as per orders                            as per orders
                                                       Antibiotics & VTE prophylaxis            Antibiotics & VTE prophylaxis
                 RE



                                                       as per orders                            as per orders
                                                       Other medications as per surgeon         Other medications as per surgeon

Nutrition        Reconfirm & reinforce NPO             Sips to DAT as per patients              DAT as per pts specified diet
                                                       specified diet

Activity/                                              Overhead bars on bed                     Weight bearing status as ordered
Safety                                                 Assist to sitting position               Up in chair/side of bed for meals
                                                       Weight bearing status as ordered         as tolerated
                                                       Stands at bedside with assistance        Ambulates greater than or equal to 1
                                                       Reposition q2-4h and prn                 with gait aid as per PT
                                                       If spinal, safety precautions            BR by commode/walker with assist.
                                                                                                                                        40506 D HR (Jan/2009) Page 4 of 7




                                                       Heel protectors bilateral                Exercises / ROM (PT)
                                                                                                Hip precautions

Elimination                                            Bedpan/urinal/commode                    Bedpan/urinal/commode
                                                       Catheterize as per orders                Catheterize as per orders
                                                                                                Initiate bowel routine
Pain                                                   PCA or epidural                          PCA or epidural
Management                                             OR                                       OR
                                                       IV/po analgesia as ordered
                                                                                                IV/po narcotics
                                                       If pain or PONV not controlled,          APS to assess route of analgesia
                                                       notify MD
                                                                                                +/- D/C PCA/Epidural as per orders


                                                                                         CLINICAL PATHWAY - TOTAL HIP REPLACEMENT
                         CLINICAL PATHWAY
                       TOTAL HIP REPLACEMENT



                                             Clinical Pathways are not considered a substitute for professional judgement.

      Phase:              Postop Day 2                                    Postop Day 3                               Postop Day 4 D/C Goals
        Date:
PATIENT          VS stable (see day 1) ________        Patient will:                                        Patient will:
OUTCOMES         Afebrile, CSM normal ________         Verbalize pain control ________                      Verbalize pain control ________
                 Patient will:                         Participate in ADL, progress to                      Complete ADL's independently (with
                 Verbalize pain control ________       independence ________                                assistive devices) _______
                 Ambulates greater than or equal       Up for meals ________                                Verbalize understanding of
                 to 1 and prn ________                 IV d/c & tolerating DAT ________                     teaching requirements ________
                 Achieves functional mobility          +/- Hemovac drain d/c if output less than            Hip exercises independently (PT)
                 targets as per PT P&P                 300 mL/4h ________                                   Understands hip precaution
                 Follows hip precautions and           Walks greater than or equal to 2 x to BR             application to all activities (OT)




                                                                                             CE
                 demonstrates proper positioning       with gait aid ________                               Safe functional transfers
                 Verbalizes understanding of pain      Verbalize understanding of teaching                  (e.g. vehicle, tub, etc.)
                 management and bowel routine          requirements ________
                                                       Demonstrates self adm of sc injections ______        Has had a BM ________
                                                       Use assistive ADL devices (OT)

TEACHING         Review:                               Review:                                              Review:




                                                                                N
                 Post op care, pain management,        Post op care (day 2)                                 Self administration of sc injections
                 monitoring, positioning, activity,    Self administration of sc injections if applicable   if applicable ________
                 diet, elimination, dressings,         Danger signals (DVT/PE, UTI, wound infection)        Danger signals (DVT/PE, UTI,
                 drains, catheter, IV and              Medication side effects/interactions                 wound infection) ________
                 medications.                          Coping strategies for home                           Meds - side effects/interactions ______
                                                         RE
                 DB&C, F&A exercises                   Staple removal, follow-up MD                         Pain management ________
                 Importance of VTE prophylaxis         Teaching complete ________                           Wound care ________
                 Teaching complete ________            Ambulation/Exercises (PT)                            Bowel routine ________
                 Begin Self administration of          ADLs and functional transfers with hip               Coping strategies for home ________
                 sc injections if applicable ______    precautions (OT)                                     Staple removal, follow-up
                 Ambulation / Exercises (PT)           Hip precautions                                      MD appointments ________
                 ADLs and functional transfers                                                              CCAC home visit ________
                 with hip precautions (OT)                                                                  Pt has information booklets ________
                                         FE

                 Hip precautions                                                                            Ambulation / Exercises (PT)
                                                                                                            ADLs and functional transfers with hip
                                                                                                            precautions (OT)

DISCHARGE        ELOS reviewed 4 days                  ELOS reviewed 4 days                                 Independent with basic self care _____
PLANNING         Notify CCAC of expected d/c date      Update bedside communication board                   Follow-up appt. arranged (staple
                   RE



CRITERIA         (POD 4);                              with d/c time and transportation arrangements        removal 7-14 days) ________
                 indicate first home PT visit within   Follow up appointments are booked and                RX for analgesia & anticoagulation ___
                 24 hrs of arrival home & if wound     given to pt/family                                   Ambulates independently
                 care required                         Confirm CCAC order on chart and plans                Climbs stairs if applicable
                 Confirm discharge arrangements        complete                                             Hip precautions followed
                 complete                                                                                   Equipment arranged
                 Out pt PT referral arranged if        If patient meets criteria for rehabilitation,        CCAC-PT / outpatient PT arranged /
                 applicable                            initiate transfer process
                 Plans in place for INR monitoring                                                          OR     Arrange orthopedic respite
                 if d/c on warfarin                                                                         OR     Transfer Rehab (see criteria)
                                                                                                                                                      40506 D HR (Jan/2009) Page 5 of 7



  Pathway
Reviewed with
                  _______ Yes          _______ No              _______ Yes           _______ No                  _______ Yes       _______ No
Patient/Family
    (Initial):
Patient/Family
                        YES            NO                          YES             NO                                 YES           NO
Satisfied with
  Progress?           if NO, see progress notes                  if NO, see progress notes                          if NO, see progress notes

Signatures:                          Initials                                  Initials                                             Initials
                  _________________ ________                _________________ ________                           _________________ ________
                  _________________ ________                _________________ ________                           _________________ ________
                  _________________ ________                _________________ ________                           _________________ ________



                                                                                                 CLINICAL PATHWAY - TOTAL HIP REPLACEMENT
                   CLINICAL PATHWAY
                 TOTAL HIP REPLACEMENT



                                     Clinical Pathways are not considered a substitute for professional judgement.

        Phase:                  Postop                              Postop                                    Postop
                                 Day 2                               Day 3                                Day 4 D/C Goals
        Date:
                                                              INTERVENTIONS:
Assessments      VS/CSM q8h                           VS/CSM q8h                            Wound status
                 Fluid balance q8h until IV d/c'd     Wound status                          Bowel status
                 Bowel status                         Bowel status                          Pain score
                 Pain score                           Pain score                            Skin integrity
                 Skin integrity                       Skin integrity                        S&S of DVT
                 Call surgeon if Hgb less than 80     S&S of DVT                            Assess mobility for safe discharge home




                                                                                    CE
                 Falls / delirium assessment          Assess mobility for safe discharge    Assess understanding of hip precautions
                                                      home



Consults         CCAC                                 CCAC
                 Pharmacy if applicable               Pharmacy if applicable

Tests            CBC, lytes, urea, creat as
                 ordered +/- PT/INR
                 Other tests as ordered or as per
                 protocol (e.g. Diabetic)
                                                                     N
                                                      Monitor INR if on warfarin
                                                      Other tests as ordered or as
                                                      per protocol (e.g. Diabetic)
                                                                                            Home monitoring of INR if on warfarin
                                                     RE
Treatments       IV as per physician orders,          D/C IV as per orders                  Daily dressing change
                 decrease TKVO if po intake is        Dressing change: clean with N/S,      DB&C, F&A exercises
                 greater than 400 mL/8h and           strip dressing                        Hip exercises (PT)
                 urine output is greater than         Cont. DB&C, F&A exercises
                 30 mL/h x 8h or d/c as per orders    Hip exercises (PT)
                 Cont. DB&C, F&A exercises
                 Falls and delirium interventions
                                  FE

                 if applicable
                 Hip exercises (PT)


Medications      Antiemetics/PONV prophylaxis        As per orders                          Pt's own medications returned if
                 as per orders                       Review medication side                 applicable
                 Antibiotics & VTE prophylaxis as    effects/interactions for new           Rx given (as per orders)
                 RE



                 per orders                          medications (e.g. warfarin,            Review medication side effects/
                 Other medications as per surgeon    codeine)                               interactions for new medications

Nutrition        DAT as per pts specified diet       DAT as per pts specified diet          DAT as per pts specified diet

                 Up in chair/side of bed for meals   Progress to independent                Shower (+/- waterproof dressing) with
Activity/        as tolerated                        ambulation with gait aid (PT)          assistance
Safety           Ambulate with gait aid              Progress to independent functional     Independent ADL's and functional transfers
                 (assistance as required) as         transfers                              Indenpendent ambulation with gait aid (PT)
                 per PT                              Participate in ADL's                   Manages stairs safety if applicable
                                                                                                                                            40506 D HR (Jan/2009) Page 6 of 7




                 Participate in ADL's                Demonstrate use of assistive           Achieves approximately 45 degrees hip flexion
                 Hip precautions                     devices for dressing/undressing        and 15 degree abduction or an appropriate
                                                     Begin stairs if applicable             level of hip joint function to go home

Elimination      Up to BR with assistance            Progress to independent use of         Independent use of washroom
                 Bowel routine                       washroom                               Bowel routine
                                                     Bowel routine, if no BM give           Assess for BM
                                                     suppository/enema prn

Pain             D/C PCA/Epidural as per orders      Oral analgesia q4-6h regularly,        Oral analgesia prn
Management       Oral analgesia q4-6h regularly,     coordinated with activity
                 coordinated with activity



                                                                                       CLINICAL PATHWAY - TOTAL HIP REPLACEMENT
                     CLINICAL PATHWAY
                   TOTAL HIP REPLACEMENT




Regular Rehabilitation (must have 2 or more of the following):
- Elderly Mobility Scale (EMS) score between 0-13 on day 4 post op
- Decreased exercise tolerance such that patient would not be able to tolerate CCAC Physiotherapy
- Other medical conditions contributing to slow recovery
- Patient does not have support/assistance from family and/or friends available and Orthopedic
  Respite not an option
- Patient must be willing to participate in therapy and agree to transfer




                                                                             CE
Estimated Length of Stay:
- Discharged from Acute: LOS 4 days
- Regular Rehab: Rehab LOS 5-7 days




                                                                   N
                                                  RE
                                  FE
                RE




                                                                                                                       40506 D HR (Jan/2009) Page 7 of 7




                                                                                CLINICAL PATHWAY - TOTAL HIP REPLACEMENT

				
DOCUMENT INFO