Transforming Ontario's Health Care System Care Stories

Prepping Patients for Successful Outcomes

Manjul Bhatnager went shopping for shoes one size bigger than usual prior to her knee replacement operation. It was part of the preparation advice she received from Toronto East General Hospital (TEGH), where her surgery took place in May 2013.

"I was given valuable advice for after the operation. An information handbook told me what to expect before, during and after surgery," Bhatnager said. The day following her surgery, 70-year-old Bhatnager was walking to the bathroom by herself. Day two she was working with a hospital-based physiotherapist walking the length of the corridor and climbing stairs. By day three, she was ready for discharge.

Within days she received a call from a TEGH coordinator to see how she was coping. Bhatnager said "It was comforting to get the call and she called back a few times to see how I was doing. I really appreciated it."

Bhatnager's pre-op and post-op experience highlights TEGH's approach to improving the outcomes of hip and knee replacement patients. The hospital significantly increased the percentage of patients discharged directly home and reduced lengths of stay, while not increasing readmission rates over the first three quarters of 2012-13.

"About a year and a half ago we were sending approximately 60 per cent of our patients home directly and 40 per cent to rehab," explained Carmine Stumpo, Vice President, Programs. "With the new supports offered, in the 3rd quarter of 2012-13 we were sending 94 per cent of hip and knee patients directly home - a phenomenal rate."

At the same time, length of stay for these patients was reduced to an average of 3.8 days - lower than the provincial target of 4.4 days. "TEGH continues to monitor quality and safety indicators such as readmission rates and will identify ongoing opportunities for improvements in care," Stumpo added. TEGH has exemplified their commitment to reducing acute length of stay for key Quality-Based Procedures, including hip fractures, by embedding a focus on HSFR as part of this year's Quality Improvement Plan.

TEGH President and CEO Rob Devitt explained that the hospital targeted quality outcomes and then systematically examined all aspects of care necessary to achieve the desired goals.

"The beauty of Health System Funding Reform (HSFR) is that it identifies province-wide, the clear measurable outputs of an episode of care," he added.

Particular focus was put on the pre-op and post-op component of the patient experience. "Before the patient enters the hospital it is important to set the expectation that they will be discharged directly home after four days and we map out what those days will look like," Devitt explained. TEGH also fostered better coordination with physiotherapy services in the community post discharge.

All hip and knee replacement patients are provided with a comprehensive information booklet and asked to attend two pre-op sessions about a month prior to their procedure. In one session an occupational therapy/physiotherapy assistant reviews the process and demonstrates recovery exercises. The second session is a three to four hour clinic where patients meet one-on-one with health care professionals including a pharmacist, a registered nurse, a medical internist and others to talk about all aspects of their care. "We talk about the equipment they will need at home and suggest they get it before their surgery. We inform them about options for accessing physiotherapy and about arranging transportation to these appointments," said Esther Cabrera, who provides support to patients prior to and following their surgery.

Within 24 to 48 hours after discharge, Cabrera phones patients to see how they are doing and to detect any potential problems early on. "I talk to them about the effectiveness of their pain medication. I ask if they are running a fever and if this is an issue I arrange to bring them back to see the surgeon in the fracture clinic, rather than leaving it and they end up coming back to ER." Cabrera follows up with patients again about a week later.

The pre-op and post-op focus has been essential to increasing the percentage of patients discharged directly home and reducing lengths of stay. Dr. Peter Weiler, Chief of Orthopedics, explained that he tries to see knee joint replacement patients in the orthopedic clinic between two and three weeks post-op, instead of the previous follow-up time of six weeks. This helps ensure that the patient's wound can be checked and that out-patient physiotherapy has been arranged and is accomplishing rehabilitation goals. "Patients feel more comfortable knowing that they are being monitored, so that potential problems can be identified and dealt with sooner," Dr. Weiler said.  "We want what's in the best interest of patients."

The increased focus on reduced lengths of stay and successfully discharging patients from hospital directly home is well worth the effort Devitt said. "The less time you spend in a place like a hospital bed, the better. If you're at home, you're in familiar surroundings. It's a safer place to be and will lead to faster recovery and quicker return to a more normal life."

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