INTRODUCTION
For many years, evidence has supported early mobil-
ity for knee and hip total joint replacement (TJR)
patients to decrease physical complications and
hospital length of stay (LOS) (Bernasek, Thatimatla,
Levering, & Haidukewych, 2013; Brennan & Parsons,
2017; Christelis et al., 2015; Gwynne-Jones, Martin,
& Crane, 2017; Ibrahim, Alazzawi, Nizam, & Had-
dad, 2013; McCann-Spry, Pelton, Grandy, & Newell,
2016). Prompted by this evidence, hospital capac-
ity issues and financial mandates, staff on a 30-bed
orthopedic unit specializing in total knee and hip
surgery began an initiative to decrease length of stay.
This article shares how evidence, interprofessional
collaboration and patient engagement were integrat-
ed to not only decrease LOS, but also enhance the
total patient experience at Lehigh Valley Hospital
(LVH) in Allentown, Pennsylvania.
LITERATURE REVIEW
The literature review focused on early mobilization
for knee and hip TJR patients and the impact on
LOS. The most pivotal interventions identified were
a physical therapy (PT) session on post-operative day
zero (POD 0) and an interdisciplinary, multimodal
approach to postoperative care of TJR patients.
Length of stay for TJR patients was decreased in
one Michigan health network by 0.5 days using a
multimodal approach consisting of patient and pro-
vider education, risk assessment prediction, and early
mobilization on the day of surgery (McCann-Spry,
Pelton, Grandy, & Newell, 2016). These authors also
suggest earlier removal of indwelling catheters to
improve ambulation.
Several articles described an enhanced recovery after
surgery (ERAS) program which reduced LOS for
both knee and hip TJR patients. Ibrahim, Alazzawi,
Nizam, and Haddad (2013) conducted an evidence-
based review on ERAS programs and found many
effective interventions, including pre-operative
patient education, multimodal pain control, and ac-
celerated rehabilitation. A study by Gwynne-Jones,
Martin, and Crane (2017) evaluated outcomes of an
ERAS program whose foci were preadmission edu-
cation, appropriate anesthesia, discharge planning,
and early mobilization beginning POD 0. Average
length of stay was decreased and patient satisfaction
was increased for both the total knee and hip patient
populations.
In a study evaluating enhanced recovery programs
in the United Kingdom, Brennan and Parsons (2017)
set out to identify best practice measures and areas
for improvement. Recommendations were made
for patients in the orthopedic population regarding
pain control, oral hydration, and early mobilization.
Christelis et al. (2015) examined the benefits of an
ERAS program on LOS and quality of care when ap-
plied to total knee or total hip arthroplasty patients.
Studying 709 patients, the authors determined the
ERAS program was instrumental in reducing LOS in
total knee and total hip replacement patients. Poor
discharge planning was identified as the main limita-
tion in this study.
Raut, Mertes, Muniz-Terrera, and Khanduja (2012)
investigated the effect of baseline factors such as
age, pre-operative mobility and use of mobility aids,
on LOS for knee and hip TJR patients over age 75.
Early mobilization was found to be a significant
postoperative intervention to decrease LOS for this
population. Study limitations included poor docu-
mentation accuracy, risk for statistical error, and
varying discharge criteria. In a study by Bernasek,
Thatimatla, Levering, and Haidukewych (2013), full
weight-bearing for knee and hip TJR patients was
directly correlated to a decreased LOS as opposed to
partial weight-bearing limitations. This manuscript
adds to the literature in two ways—it recommends
additional tactics compared to those in other pub-
lished studies and not only focuses on decreased LOS,
but also patient satisfaction with their hospitaliza-
tion experience.
INTERVENTION TACTICS
Lehigh Valley Hospital orthopaedic staff began
interventions aimed at LOS reduction in 2012. Ad-
ditional tactics continued to be added for continued
decreased LOS and increased patient satisfaction
through 2016. Patient age ranges were 55-85, with an
almost equal distribution of males and females. The
primary reason for surgery was osteoarthritis with
the accompanying pain and mobility limitations.
Issue 73, 2 2018 Pennsylvania Nurse 5