Joint Centre speeds surgeries

Patients undergoing hip and knee replacement surgery at Thunder Bay Regional Health Sciences Centre used to spend as many as eight days in hospital recovering from their operation, and that didn't count time spent in rehab at St. Joseph's Care Group.

Today, the average hospital stay for arthoplasties in Thunder Bay has been slashed to four days and more than 50 per cent of patients return home to convalesce.

The dramatic improvement in efficiency is attributed entirely to the hospital's establishment of a Total Joint Centre and the introduction of a total knee and hip clinical pathway in July 2007, according to Cheryl Anderson, the centre's utilization co-ordinator.

"Every patient that comes in for a hip or knee replacement is started on a pathway that designates his or her progress through the hospital from the time they're admitted to the time they're discharged," she said.

Specialized education resources and exercise instructions provide them with information about the procedure, what to expect after the operation and what they will require at home, "so they know prior to coming in what's going to happen to them."

The centre consists of 10 beds located in one surgical unit and is staffed by nurses, physiotherapists and occupational therapists with the knowledge and experience necessary to offer hip and knee replacement patients the best possible level of care.

In the pre-op screening process, patients are divided into three categories corresponding to the length of stay and level of care they will require. Patients in the fast stream can expect to be discharged anywhere from two to four days following surgery.

Patients falling into the average stream are generally released on the fourth day, "but if someone has heart problems and no help at home, we'll usually send them to rehab on day two and they could be there for a week or two," said Anderson.

Patients are generally encouraged to stand at the edge of their bed and put weight on their prosthesis the night of the procedure. The next day, they're in a chair and taking steps with their walker.

Fewer complications

"We're pushing them a lot harder than we did 10 or 15 years ago," said Dr. Claude Cullinan, one of six orthopedic surgeons at the hospital. "We know that they can get moving a lot faster and, more importantly, we know that the faster they get moving, the fewer complications there are, especially with regard to blood clots.

"The nurses and therapists also feel more comfortable pushing their patients to get moving because they have seen patients before them do it."

Cullinan, who underwent fellowship training in hip and knee replacement surgery at Toronto Western Hospital, usually performs three or four procedures a day, depending on bed availability and whether or not there are any revision arthoplasties scheduled.
Artificial hip and knee joints generally last for 15 years, after which they have to be replaced.

"Revision work tends to take a little longer," explained Cullinan, "because it's not just putting in a new implant. It's taking out an old one and putting in a new one in a setting of bone loss and more scar tissue, so it's much more complicated."

Wait times

Funding to establish the Total Joint Centre was provided by the Ministry of Health and Long-Term Care as part of a province-wide initiative to reduce wait times for hip and knee replacement surgeries.

Wait times at Thunder Bay Regional Health Sciences Centre are improving, but are still in excess of the provincial target.

"Lately, the biggest thing that's been affecting our throughput is the lack of beds," said Cullinan. "The hospital administration is working hard to make sure we have beds available, but sometimes there's nothing you can do. The ALC (alternate level of care) issue impacts on all in-patient surgery."

According to the Ministry of Health's wait time web site, patients requiring hip replacement procedures at Thunder Bay Regional can expect a wait of 207 days, which corresponds exactly with the provincial average. The wait for knee replacement surgery is 261 days, slightly better than the provincial average. (See accompanying table.)

Orthopedic surgeons are seeing an increasing number of referrals from primary care physicians because people are more active and wearing out their joints faster, said Cullinan.

"There's no doubt that there's a trend for a continued increase in demand for both hip and knee replacements, so we want to be able to get ahead of the game, start focusing our resources and get better at what we're doing."

Most patients undergoing arthoplasties are 75 and older, but it's not unheard of for younger people to require joint replacement surgery, especially if they had childhood hip diseases.

According to Cullinan, members of the First Nation community in northwestern Ontario experience a high incidence of developmental dysplasia of the hip, a condition characterized by an abnormal formation of the hip joint. In these cases, surgery is sometimes performed on patients in their 30s and 40s.

New lease on life

Arthoplasties offer patients a new lease on life.

"Many of them have constant pain day and night," said Cullinan. "They have difficulty sleeping. They have great difficulty mobilizing and many of them come into our offices with crutches, canes and walkers."

Following surgery, many of them are able to resume playing golf and tennis. Physicians warn them against participating in more demanding sports, but some of them ignore the advice.

"I would consider hip and knee replacement patients some of the most grateful patients I deal with," said Cullinan. "That's why I chose to do this. They're extremely satisfying procedures to perform. The pain is gone so fast and their function is so much better than it was before surgery."

www.health.gov.on.ca/transformation/wait_times/wait_mn.html