Transforming Ontario's Health Care System Care Stories

Putting Hip and Knee Patients First with Quality Based Procedures – Thunder Bay Regional Health Sciences Centre

"I have my mobility back and my life back and you began it all." A grateful patient recently shared this sentiment in a thank-you card sent to Caroline Fanti, lead physiotherapist with the Thunder Bay Regional Health Sciences Centre's hip and knee surgical program. The patient, who Fanti saw a couple of years ago, still marvels at the fact that she was assessed by the advanced practice physiotherapist and met with a surgeon on the same day. "You are a very caring woman who facilitated a critical and positive change in my life," the note concludes.

Patients have been the key beneficiaries of an approach implemented by the Thunder Bay hospital over the past few years to streamline its hip and knee replacement surgical program. "It has really been about empowering patients," explains Dr. David Puskas, Chief of Orthopaedic Surgery. "The message is: You're not sick. You're a well person, who had a reconstructive procedure."

The results of the hospital's efforts? A 54 per cent increase in patients being discharged after hip or knee surgery directly home in the third quarter of fiscal 2013-14, compared to the same quarter in 2010-11 – 89.5 per cent versus 58.2 per cent. Length of stay in the hospital for these patients also declined over the same period from an average of 4.6 days to 3.75 days.

Hospital executive Dr. Rhonda Crocker Ellacott is reassured when she sees the targets and benchmarks followed by the hospital also reflected in the Ministry of Health and Long-Term Care's Quality-Based Procedures Clinical Handbook for Primary Hip and Knee Replacements.

"We believe we're doing well every day, and having a best practice standard of care helps to reinforce the work we're doing," says Ellacott.

The hospital's Regional Joint Assessment Centre – set up a number of years ago – provides centralized intake for hip and knee patients across Northwestern Ontario and has reduced wait times for referrals from about nine months to within six weeks. A significant percentage of the hospital's patients travel hours from home to attend the centre, where a physiotherapist initially assesses them. If they are candidates for surgery, they can be examined by a surgeon on the same day. This benefits patients who live a great distance away. Patients can have their hip or knee replacement done within two to three months, instead of 18 months to two years. The multi-disciplinary nature of the assessment centre, with a range of professionals working collaboratively, set the tone for the hospital team's continued efforts to improve outcomes for hip and knee surgical patients.

In January 2012, the hospital set out to create greater consistency in the care pathway of these patients. "We saw the need to streamline to ensure there was a consistent clinical pattern. Previously there were different streams and there wasn't a clear set of criteria for patients being discharged to a rehab facility, instead of directly home," says Crystal Edwards, Manager of 3A Surgical Unit that cares for hip and knee replacement patients.

Good communication across the patient journey is a key best practice that the hospital has embraced.

"Preparing patients well through pre-op classes and ensuring they know what to expect from the beginning have led to better outcomes in discharging patients directly home and reducing length of stay," Ellacott says. "The approach is very collaborative. Surgeons are working closely with physiotherapists and we are engaging patients and families more in their care."

The changes in the hospital's approach have also had a positive impact on bringing the care team closer together. "Everyone is on the same page. The team has been empowered. A physiotherapist can approach a surgeon and make recommendations. Trusting relationships have been built," explains Ron Turner, Director of Surgical and Ambulatory Care Services.

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