Figure 1. Average length of stay (LOS) for total knee and hip replacement patients
Average Length of Stay (LOS) for Total Knee and Total Hip Replacement Patients
5.00
Pre-
Interventions
Pts OOB by
11:00 am
POD 1
4.00
Pts OOB POD 0
Anesthesia
m odifications and
intra-operative
antiemtic
Urinary catheter
rem oval upon
voiding
sensation or by
11:00 pm POD 0
3.00
2.00
1.00
Avg LOS
CY 11 CY 12 CY 13 CY 14 CY 15 CY 16 CY 17
4.85 4.26 3.13 2.92 2.64 2.07 1.82
Mobility Anesthesia Modifications and Pain Control
Prior to 2012, PT staff were responsible to assess and
then assist patients out of bed (OOB) their first time
after surgery on post-operative day one (POD 1).
The standard was changed in 2012 to include nurs-
ing staff assisting patients OOB POD 1 by 11:00 am,
even if they had not yet been evaluated by PT. Edu-
cation on the benefits associated with early mobiliza-
tion was provided to both staff and patients. This
education occurred at a pre-operative joint class prior
to hospital admission and was later reinforced during
the immediate and ongoing post-operative period.
For calendar year (CY) 2013, LOS was significantly
reduced compared to the two prior years. (Refer to
Figure 1.) Often patients on the defined LVH patient unit expe-
rienced post-operative nausea and vomiting, delaying
mobility and lengthening their recovery. Interpro-
fessional discussion between nursing, surgery and
anesthesia staff prompted anesthesia modifications,
moving from general anesthesia to conscious sedation
and monitored anesthesia care with a regional block.
In addition, an antiemetic was added to the regimen
intra-operatively.
In 2014, as evidence showed the value of earlier
patient mobility than POD 1 (Ibrahim, Alazzawi,
Nizam, & Haddad, 2013), either nursing or PT was
identified as responsible to get patient OOB on POD
0. The intent was for communication and collabo-
ration between both PT and nursing to ensure the
initiative was met. The PT staff revised their work
schedules to be available into the evening hours to see
the patient in the post-anesthesia care unit or inpa-
tient unit and support the nursing staff.
Issue 73, 2 2018 Pennsylvania Nurse 6
These changes produced less post-operative nausea
and vomiting and enhanced pain control. Additional
strategies to control pain were incorporated into the
standard care plan and included a combination of
oral short- and long-acting narcotics, adjuvant medi-
cations such as muscle relaxants, and cold therapy.
Urinary Catheters
Prior to 2016, urinary catheters were removed at
6:00 am on POD 1. Following catheter removal, a
large majority of patients had difficulty voiding.
This resulted in a voiding late in the afternoon and at
times, a urology consult, impacting timely discharge.
Nursing initiated discussions with surgeons to de-
velop a nurse managed protocol for catheter removal
post-operatively by 11:00 p.m. POD 0. Interestingly,