BWH's evidence-based knee replacement process is based on research by the Care Improvement Team, led by orthopedic surgeon Dr. John Wright (center).

As a concerned friend or relative of a patient who recently had a joint replaced, you might be tempted to ask: “How was your surgery?” But research findings from our Department of Orthopedic Surgery suggest that you should be just as concerned about how they were treated before and after surgery.

Brigham and Women’s Hospital (BWH) now uses a standardized approach to total knee replacement that guides how patients should be treated from the time they arrive at the hospital for a consultation to the care they receive after being discharged. This new evidence-based approach is based on the work of the Care Improvement Team, led by orthopedic surgeon Dr. John Wright. After researching prospective changes to conventional knee replacement practices, the team tested selected changes and evaluated their effects. Changes found to have had a significant impact were incorporated into a new knee replacement process, which is now the standard protocol for all knee replacement surgeries at BWH.

“A lot of people say, ‘patients are all different, they have different needs,’ and while that’s true to an extent, patients are more alike than they are different,” explains Dr. Wright. “One of the beauties of standardizing the care is that 95 percent of the care happens automatically and because of that you can really focus on the 5 percent of the care the patient needs individually.”

This shift to a new, standardized process has led, in turn, to significant, measurable changes in patient outcomes. The following are a few comparisons between patient outcomes from 2007, before the new approach was implemented, and 2010, when the new approach was in effect.

  • The distance that a patient could walk on the first day after surgery in 2010 averaged 85 feet. In 2007, the average was only 55 feet.
  • When asked to assess the severity of their pain (on a 1-10 scale, with 10 being the most severe), patients from 2007 reported an average pain experience of 7.5 on the first day after surgery and 6.5 on the second day. Patients from 2010, however, reported an average of less than five for both the first and second days after surgery.
  • From 2007 to 2010, the average number of days that patients stayed in the hospital after their surgery decreased from 3.25 to 2.5. During that same period, the percentage of patients who went straight home instead of going to a rehabilitation facility increased from 40 percent to 60 percent.

Here are a few of the key process changes that have led to improved outcomes:

  • Emphasizing patient education – Every patient attends a class that helps them prepare mentally and physically for the procedure and stresses the importance of adhering to pre- and post-surgery practices (e.g., proper nutrition and exercise) that will improve their recovery. “Setting expectations is very important,” explains Dr. Wright. “Eliminating the fear of the procedure and setting appropriate goals beforehand has a significant impact on a patient’s commitment to recovery.”
  • Long-acting pain medications – Patients are now given long-acting pain medications immediately before surgery, instead of short-acting pain medications immediately after surgery. Long-acting meds, which can work for up to 12 hours, produce fewer side effects than short-acting meds and provide steady, continuous relief for a patient after surgery. Short-acting meds administered after surgery, on the other hand, provide only intermittent relief and are used only for breakthrough pain (an intense spike in pain).
  • Regional anesthesia – Surgery, in most cases, is performed with regional anesthesia and sedation rather than general anesthesia. Thus, patients are awake, and in less pain, immediately after surgery. This, in turn, leads to a quicker recovery.
  • Get moving – The former post-operative standard of care was to use a continuous passive motion machine, during which a patient’s knee would be moved for them by a machine. Dr. Wright’s research team, however, demonstrated that this technique actually increased the amount of pain and slowed recovery. Patients now participate in active physical therapy as soon as possible. “We’ve found that when we get patients up and about more quickly, their pain scores have been lower than before,” says Dr. Wright. “And they also gain their range of motion and mobility much quicker.”

To learn more about how Dr. Wright’s team developed improvements to knee replacement care, read our recent white paper, Improving Patient Outcomes for Joint Replacement: A White Paper on Groundbreaking Research from Brigham and Women’s Hospital, or watch the video below.

– Chris P

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