A review of the total knee replacement pathway:

Integrated care is quality care

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Quality in Health

A review of the total knee replacement pathway:Integrated care is quality care

Shipra Gupta a, Gaurav Loria b,*, Nipun Choudhry c

a Manager, Quality Systems, Apollo Health City, Indiab Group Coordinator, Quality Systems, Apollo Hospitals, Indiac Dy. Chief Medical Administrator, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India

a r t i c l e i n f o

Article history:

Received 18 November 2014

Accepted 19 November 2014

Available online xxx

Keywords:

TKR

Quality care

Prophylaxis

* Corresponding author.E-mail address: gaurav_l@apollohospitals

http://dx.doi.org/10.1016/j.apme.2014.11.0070976-0016/Copyright © 2014, Indraprastha M

Please cite this article in press as: Gupta SApollo Medicine (2014), http://dx.doi.org/

a b s t r a c t

A Total Knee Replacement (TKR) Pathway (adapted from the Credit Valley Hospital, Can-

ada) is in place at the Apollo Health city facility since 2011. We re-visited the pathway

design and the priority grid that led to its adaptation. We analyzed the data with the aim to

analyze repetitive and unique trends and evaluate the performance of the pathway. Even

with the increased volume the patient satisfaction rose from 56% at the time of pathway

implementation to 77% at the end of the evaluation period of 45 months. The Average

Length of Stay reduced by 27% from 7.94 to 5.78 days (the difference between the initial and

final recorded values), in the same evaluation time period. The methodology of evaluation

of the pathway was adapted from the Leuven Clinical Pathway Compass 5 way approach.9

Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

The health care industry is at an inflection point. The amal-

gamation of Clinical best practices (e.g. Goal based patient

care approach) with management techniques of improving

efficiency, will lead to higher standards of care. It is estimated

that every year the United States sees 44,000 and 98,000 people

negatively affected from medical errors.1

The Integrated Care Pathways (ICP's) are good examples of

standard guidelines which match the needs of the local pop-

ulation, based on the best practices and learning from the

experience of individual patients. Additionally, ICP's records

the deviation in care from the planned care in the form of

variances.2

.com (G. Loria).

edical Corporation Ltd. A

, et al., A review of the to10.1016/j.apme.2014.11.

Health care systems are prone to variation. Trends in the

industry are often evidence based, each patient being

different, medical evidence is not widely documented or

standardized and the most important fact that treatment

process is riddled with uncertainties.3e8

61% of patient hospitals admit in the Low and Middle In-

come countries which include India covered their hospitali-

zation cost out of their own pocket (WHO Database, Global

Health Expenditure Database, 2012). This puts immense cost

burdens on patients who undergo treatments especially sur-

geries. The best alternative which addresses the concerns of

costs and quality are again, Integrated Care Pathways.

This article aims to highlight a case of the Total Knee

Replacement Pathway implementation at a super-specialty

setup. The article covers why the pathway was

ll rights reserved.

tal knee replacement pathway: Integrated care is quality care,007

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e52

implemented, what were the steps taken to ensure it was

accepted by the clinical care providers and an analysis of what

were the results of it.

1.1. Objectives of a surgical clinical pathway8

1. Selecting a treatment plan which themajority of Care-plan

implementers follow and abide by.

2. Clear responsibility segregation at each level of care thus

defining measurable parameters for example Average

Length of Stay.

3. Defining goals at each care level which helps in role-

awareness and keeping the patient and the family atten-

dants on the same page.

4. Collection and analysis of data and trend, which help in

continuous improvement with updated patient condition

logs.

5. Consolidating information in a standard format helps the

staff understand the goal-based approach of treatment and

their role.

We analyzed the Total Knee Replacement pathway at

Apollo Health City, which was implemented in the year 2011.

Our objective was to analyze whether the pathway was ful-

filling the above objects in sufficient measure.

1.2. Clinical pathway development

The care process organization triangle (based on Donabedian

and including the terminology used by Pawson & Tilley,

Mitchell, Batalden, Heskett et al, and Teboul).

According to the above paradigm, the solution which re-

sults is based on which situations are most conducive for the

working of a particular organization.19,20,21,22

Based on the above methodology the answers to the

following were to be determined:

1. To assess the differences in perceptions of the Health Care

providers on the care protocols.

2. To access whether the care process supported by the

pathway will yield to a better implementation and docu-

mentation compliance.

Please cite this article in press as: Gupta S, et al., A review of the toApollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.

3. To assess the specific parameters which would rate the

efficacy of the pathway be compliant.

A survey was conducted among the Doctors and Nurses

(Total N ¼ 35) of the Orthopedics department, where the

following were determined. Based on the survey conducted

among thehealthcare providers the followingwere the results:

1. A clinical pathway being interdisciplinary the involvement

of all care providers was essential.

2. The Structure of the pathway would require the most delib-

eration,once inplace itneedsa trial runto test for itsworking.

3. The Context and the design of the program would require

situations specific to the health care setup for example:

Patients suffering from chronic knee pain pre-operation

suddenly may feel the urge to quickly ambulate, where

early mobilization is aided.

4. The process needs to be a structured one, with due

weightage for complications example Surgical Site In-

fections (SSI's) and Deep Vein Thrombosis (DVT) prophy-

laxis were to be assessed at all care levels with an impetus

on Infection Control.

The Total Knee Replacement Pathway was adapted from

the Credit Valley Hospital, Canada. The implementation of the

pathway was done following the steps:

1. Followed an Evidence-based Method was used to examine

the gaps in our care process analyzing health care data.

2. Involving a multidisciplinary team to cater to the different

aspects of care (Surgeon, Anesthetists, Nurses, Dietitians,

Physiotherapist, Social Worker and as need be others).

3. Defining the patients who would fulfill the criteria.

4. Review practices and modify the base document based on

our practices and patient mix.

5. Development and Pilot run of the Pathway.

6. Ongoing evaluation.

1.3. Selection of indicators10,17,18

The scoring on a priority grid helped us identify the impor-

tance of implementing a pathway using the following

parameters:

1. Patient population affected e This was done by identifying

the patient volumes which would benefit from a pathway

implementation.

2. Relevance to identifiedpatientpopulation,diagnosis, disease

e Since a surgery involves high involvement in the patient

care plan and the hospital stay is affected by the process.

3. Resources available to provide care e Being a tertiary care

setup and skilled surgical teams place us on the favorable

end of patient choice spectrum.

4. PatientRiskeBasedonthepatient in-flowhowmanypatients

will benefit immensely from the pathway being in place.

5. Patient OutcomeeAs a direct reflection of patients being at

the epicenter of the care process.

6. Cost to implement e Any factors which directly improve

patient care, without escalating costs of implementation

beyond the cost-benefit grid.

tal knee replacement pathway: Integrated care is quality care,007

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e5 3

7. Patient needs/expectations: Being at the centre of the care

process. the patient feedback scores reflect the efficacy of

the care process.

8. Impact on Quality Care e Being interdisciplinary and

multidisciplinary in nature, the quality care process was to

be directly proportional to improved care plans.

9. Impact on Safety e Being a safe hospital, and following the

International Patient Safety Goals without fail was to be

achieved 100% of the times.

Based on the scoring the adaptation of the clinical care

pathway ranked on the top priority of implementation.

2. Managing change

As a change management exercise the following were taken

care of:

1. A pre-training session for all involved in the patient care

plan.

2. A core-group which has been a part of JCI Trainings to

further the training in their respective departments.

3. A score-card devised to monitor regular progress and

address the cause of deviation.

4. Data from the pilot was used to identify the process vari-

ations and close any gaps.

5. A TKR Committee was established which met every

quarter to discuss the progress of the pathway and address

any issues faced.

3. Results & discussion

The pathway has been in place for over 45 months at the time

of publication. To analyze the pathway the standard tool of

The Leuven Clinical Pathway Compass was used.9e16

The tool is designed to evaluate the impact of a clinical

pathway.

Please cite this article in press as: Gupta S, et al., A review of the toApollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.

The compass operates with 5 major indicators9:

1. Clinical Domain e The compliance data aimed at

addressing the clinical and the functional parameters for

the patient.

2. Service Domain e Measuring patient satisfaction has been

an important goal in signifying the success rate of the

pathway implementation.

3. Team Domain e The co-ordination between teams, a

difficult parameter to monitor, was seen as a result of

completion of each part of the pathway.

4. Process Domain e The data was analyzed in the pre and

the post training, any variations were addressed in the

dedicated quarterly pathway meeting with all the

stakeholders.

5. Financial Domain e the Volume of the satisfied patients

(with exclusion of natural growth in numbers) and the

Average length of the patient, which helped us further our

bed-turns specific to orthopedic patients, were measured.

The trend analysis was done on the pre and the post

implementation phase of the pathway implementation. The

initial 3 months have been not included to exclude the change

management process. (See Graphs 1.1 and 1.2) (Tables 1.1 and

1.2)

As the results show, the tangible increase in the satisfac-

tion of patients is a result of improved coordinated services

between departments.

1. Patient Satisfaction improved significantly, where 56% of

the patients at the time of implementation gave Excellent

and Very Good scores to the services of the TKR Team. At

the end of the evaluation period of 45 months, the per-

centage had risen to 77%, with a parallel rise in the number

of average discharges per week.

2. Patient Length of Stay in the Hospital showed considerable

improvement as well. A decrease in 27% with the initial

7.94 days (at the time of implementation) stay now reduced

to 5.78 days, per discharge.

3. Percentage compliance to surgical Site marking improved

over the duration from not being captured to 99.4% of the

Graph 1.1 e Comparative of the average length of patient

stay over the 45 months of implementation.

tal knee replacement pathway: Integrated care is quality care,007

Graph 1.2 e Patient volumes vs the patient feedback trends.

Table 1.1 e Comparative of the Clinical Pathway Indicators e Pre-pathway Implementation and Post-PathwayImplementation Compliance Percentage (first three months i.e. January to March 2013 were not included to smoothenadaptation).

Clinical pathway indicators Pre-pathwayimplementation

compliancepercentage

Post-pathwayimplementation

compliancepercentage

Percentage of patients on whom site marking has been done Not measured 99.4

Percentage of patients who received DVT prophylaxis post surgery 90 99

Average length of stay 7.94 6.12

Number of patients who developed surgical site infection 3 0

Number of patients who developed complications (other than surgical site infection) 1 0

Percentage of patients who were discharged alive after TKR 95 100

Table 1.2 e Comparative data since the inception of the pathway, parameters are measured with open and closed medicalrecords compliance.

Parameters January 2013eMarch 2013

April 2013eJune 2013

July 2013eAugust 2013

Sept 2013eNovember 2013

December 2013eFebruary 2014

March 2014eMay 2014

June 2014eAugust 2014

Patients discharged 78 99 106 68 90 95 76

ALOS 7.94 6.20 6.22 5.76 6.92 5.82 5.78

Percentage compliance to

surgical site marking

82 85 98 98 100 100 100

Percentage of patients who

received DVT prophylaxis

post surgery

84 96 100 100 100 100 100

Number of patients who

developed surgical site

infection

1 2 0 0 0 0 0

Number of patients who

developed complications

(other than surgical site

infection)

0 1 0 0 0 0 0

Percentage of patients who

were discharged alive

after TKR

100 100 100 100 100 100 100

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e54

Please cite this article in press as: Gupta S, et al., A review of the total knee replacement pathway: Integrated care is quality care,Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.007

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e5 5

times accurate marking before the patient was shifted to

the Pre-Anesthesia Check.

4. DVT prophylaxis improved from 90 to 99%, it also helped

track at all care levels, even in the wards if a complication

developed due to a missed dose of prophylaxis or not.

5. The percentage of patients who were discharged alive

remained the standard at 100%.

4. Conclusion

An integrated care pathway, when implemented in conjunc-

tion with the local needs requires to be completed. Clinical

pathways are indeed quality tools to evaluate the variations of

care if any. The clinical pathway for TKR which has been a

combined effort of the entire care plan, with the priority grid

matrix has enabled the real value of the pathway to be

highlighted.

Conflicts of interest

All authors have none to declare.

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