Pathways for the Episode of Care

Jorge A. Padilla, MD

Hayeem Rudy, BA

James Slover, MD, MS

INTRODUCTION

Given the rising costs of healthcare in recent decades, increasing emphasis is being placed on transitioning to a system of value-based care, where patient-centered outcomes are maximized and expenditures are minimized. To this end, healthcare organizations have sought to design innovative methods for delivery of care. Standardization is one strategy for increasing efficiency. Clinical pathways for the delivery of care to patients with a given diagnosis have been used to improve resource utilization, workflow efficiency, and quality of care through an increase in standardization.

A clinical pathway is a standardized system designed for patients with a specific clinical diagnosis, which establishes a pragmatic plan for the sequence, timing, and delivery of care throughout the entire episode.¹,²,³ Clinical pathways are a multidisciplinary approach, designed to optimize patient-centered care, with emphasis on evidence-based medicine.²,³ They may take the form of protocols, algorithms, care continuums, practice parameters, integrated care pathways, care maps, and guidelines. In recent years, improvement in standardized clinical pathways has been one of the principle driving forces for cost containment and quality enhancement initiatives as they organize the procedures and optimize the use of resources that would otherwise be uncoordinated and wasteful.⁴ Standardized pathways provide the patient and the care team with direction and predictability that will ultimately assist patients navigate in the direction of the planned health outcome. This chapter discusses standardized clinical pathways for the episode of care (EOC) in total knee arthroplasty (TKA), a surgical procedure with significant opportunity for standardization and evidence-based practice.

VALUE AND CLINICAL PATHWAYS

TKA is widely recognized as an efficacious treatment method for patients with degenerative disease of the knee, uncontrollable pain, and unacceptable physical function. In 2014, TKA was among the procedures with the most substantial inpatient expenditures, contributing largely to the economic unsustainability of the current US healthcare system.⁵,⁶ Despite its success, a substantial number of TKA patients have suboptimal outcomes or complications, and inefficiencies in care delivery are prevalent. As the framework for healthcare shifts from a volume-based model to a value-based one, physicians and healthcare institutions must align their efforts to integrate evidencebased medicine into clinical practice for the purpose of creating added value. Standardization of care in the form of clinical pathways has been demonstrated as a robust approach for achieving these goals in orthopedic surgery.

Standardized pathways can be designed to reliably incorporate important quality metric measures and patient-reported outcomes, which have been emphasized by the Centers for Medicare and Medicaid Services (CMS).⁷,⁸,⁹ Adherence to standardized clinical care pathways provides uniformity among cases in a fashion designed to improve communication, decrease error, improve patient outcomes, and reduce outcome variation. The benefits of creating a standardized clinical care pathway for the EOC relating to TKA are myriad.⁴,¹⁰ Standardization creates a streamlined workflow for physicians and care providers to follow throughout the continuum of care and allows for effective planning. Well-designed standardized care pathways promote interdisciplinary collaborative practice, which has been demonstrated to effectively reduce waste by obviating circuitous and oftentimes unnecessary variations in the delivery of care that inefficiently consume healthcare resources.²,⁸,⁹,¹¹ The predictability of standardized care pathways also allows for more precise cost tracking for healthcare organizations, improving decision-making regarding the distribution of resources.²,¹¹,¹² Clinical pathways have been found to be most advantageous for high-volume procedures that lack substantial unexpected events, such as TKA.²,¹³

DEVELOPING PATHWAYS

The process of developing a standardized clinical care pathway begins with the assembly of a multidisciplinary panel comprised of stakeholders and caregivers who will participate in reviewing and refining of evidenced-based practices for incorporation or exclusion in the pathway.¹⁴,¹⁵ The members of the panel may include orthopedic surgeons, anesthesiologists, internists, hospital administrators, nurses, social workers, patients, and safety and quality leaders. The panel must set a goal for the pathway and identify current practices and the potential areas for improvement of the current care delivery model. For each individual component (e.g., procedure or test), the panel reviews and discusses evidence-based
practices and implementation strategies. The panel then develops a track with detailed steps that will guide clinicians and caregivers across the care continuum. Routine tests or procedures deemed unnecessary by the panel are discarded from the standardized pathway. After finalizing the pathway, an implementation plan should be developed to test the feasibility and impact on overall hospital costs and patient outcomes.

The multidisciplinary effort allows for incorporation of diverse input and may provide mechanisms for dissemination of the pathway to caregivers as well. It is important to recognize that the pathway is continuously evolving, and as medical technology and evidence advances, the pathway will change. Therefore, it remains important to periodically and critically reevaluate the pathway to update it to reflect new evidence and clinical practices. We offer a summarized iteration of our 2-day TKA clinical care pathway as an example and discuss certain important elements of its current iteration in this chapter (Table 49-1).

THE EPISODE OF CARE

The EOC can be broadly defined as the collection of services provided to a patient to completely treat a discrete clinical condition. Time components of the EOC may include the preoperative, acute care, and the post-acute care period (Fig. 49-1).² For example, the Comprehensive Care for Joint Replacement (CJR), an alternative payment model (APM) for the EOC associated with total joint arthroplasty (TJA), developed by the CMS, defines the EOC as all services provided beginning upon admission for a Medicare Severity Diagnosis Related Group (MS-DRG) 469 or 470 and ending 90 days post discharge.¹⁶

Care coordinators are an early innovation that may play an important role in future care pathways for total knee replacement in the acute care period and beyond, as they help manage the patient’s entire EOC and are responsible for achieving a smooth transition through the preoperative, acute care, and postoperative care periods.¹⁵ The presence of care coordinators facilitates interdisciplinary communication between providers and patients throughout the continuum of care, which has been shown to contain the overall expenditures of TKA by preventing unnecessary use of resources in the hospital and after discharge.¹⁵,¹⁷ Care coordinators achieve this by addressing the patients’ needs and expectations during the preoperative period and ensuring the delivery of essential services throughout the entire EOC.¹⁵,¹⁸ However, they are associated with additional cost, and coordination through leverage in technology and other innovative mechanisms are likely to proliferate in the future as a means to reduce these costs while simultaneously increasing care coordination. Perhaps the most valuable contribution from care coordinators is the facilitation of post hospital care, a common barrier to even the most well-intentioned discharge plans.

Preoperative Period

The preoperative period is a significant time for patients who may feel overwhelmed at the prospect of undergoing surgical intervention. To manage this, it has been demonstrated that standardizing preoperative patient education programs improve patient understanding and satisfaction, as well as specific factors such as discharge disposition, the rate of postoperative complications, and inpatient hospital length of stay (LOS).¹⁹,²⁰,²¹,²²,²³,²⁴,²⁵ An increased rate of discharge to home instead of discharge to an inpatient facility with a preoperative education program has also been reported.¹⁹ Other studies substantiate these findings and further demonstrated a reduced rate of short-term postoperative falls following the implementation of a standardized patient education protocol.²⁵ In addition to effectively addressing the information needs of a patient, a properly designed preoperative patient education program can help manage and organize the postoperative care and discharge planning.¹⁹,²¹,²²,²³,²⁴,²⁵,²⁶ Patients who are properly educated about the intervention and their role in the recovery process have also been demonstrated to take a more proactive role in their rehabilitation.²⁰ All of these factors enhance patient experience, streamline costs, and improve outcomes. Other studies evaluating the effects of preoperative education as part of standardized care pathways in TKA have had similar positive results, which makes the importance of beginning to address recovery during the preoperative period absolutely clear.²¹,²²,²³,²⁴

The preoperative period also serves as a time when the health of patients with multiple medical comorbidities and psychosocial difficulties can be adequately optimized for surgical intervention and improved recovery. Previous studies have reported worse outcomes following TKA in patients who failed to receive proper medical treatment for their comorbidities prior to surgery.²⁷ A multidisciplinary preoperative assessment and meticulous health optimization program has been shown to reduce morbidity and mortality following TKA.²⁸ Bernstein et al demonstrated significantly higher quality of care and lower resource utilization in patients who underwent a preoperative optimization protocol as part of a standardized pathway in hip and knee arthroplasty.²⁹ However, overuse of routine preadmission testing may lead to unnecessary expenditures, and therefore, preoperative evaluations and testing must be carefully scrutinized. For example, one analysis investigated the effects of obviating routine preoperative studies including urinalyses, prothrombin time, partial thromboplastin time, and international normalized ration measurements and demonstrated increased cost savings with no impact on clinical and patient-reported outcomes following TKA.¹⁵ Incorporating preoperative assessment and medical optimization into a standardized clinical pathway in TKA, careful evidence-based evaluation of the value of preoperative test with elimination of those that do not provide value can improve resource utilization, interdisciplinary collaboration, and workflow efficiency.³⁰,³¹,³²,³³

TABLE 49-1 Two-Day Total Knee Arthroplasty Clinical Care Pathway

	Preoperative Period	POD 0	POD 1	POD 2
MD/NP	Medical clearance Anesthesia clearance Discharge planning	Monitor HGB/HCT Monitor O₂ Sat, and vitals Pain management Dressing/drainage	Assess physiological stability of patient Fluid balance and electrolytes Monitor HGB/HCT and determine the need for blood transfusion Prescription for anticoagulation treatment Adequate pain meds and reassessment Assess wound Initiate bowel regimen Inform patient of D/C between 10 and 11 Finalize anticoagulation plan	Check HGB/HCT Medicine reconciliation Scripts Discharge orders Check for equipment Instructions for follow-up of surgical and primary MD for anticoagulation and medication management
Nursing	Preadmission testing admit assessment Class or DVD	Routine vitals monitoring as per standard Pain management assessment as per standard Continuous passive motion Cryotherapy OOB 30 min	Obtain anticoagulation prescription Routine vitals monitoring as per standard Pain management assessment as per standard Continuous passive motion Cryotherapy Instructions of new medications and side effects 24-h notice given Encourage incentive spirometer Encourage oral fluids/advance diet as tolerated OOB all meals for 1 h Mobilize per PT	Pain management assessment as per standard Continuous passive motion Cryotherapy Complete anticoagulant teaching Inform patient they may receive survey Complete instructions on new medications and side effects Routine postop monitoring Bathing independent in bathroom with assistive devices LE dressings with aids as needed Instructions on signs and symptoms of infection Activity at home OOB all meals Bowel regimen ongoing for home Follow-up visits Inform patient may receive discharge call
CM	Guided patient services preadmission completed 1-2 wk before surgery Preoperative counseling regarding discharge needs and expectations		Complete psychosocial assessment with discharge planning and insurance review Confers with PT for activity level and progress Reviews and confirms discharge plan and transport needs with patient and/or caregiver Refers to home care/subacute/acute rehab Finalizes transport mode with patient or caregiver Performs admission UR Confirm selected anticoagulant Receives script for anticoagulant and begins process if an injectable Follow-up of anticoagulant for availability, accessibility, and affordability	Performs discharge UR Reviews and finalizes discharge plans and transport with patient and/or caregivers Reviews and finalizes services, equipment, and transportation with patient and/or caregivers
PT	Bed mobility	Moderate assist	Minimal assist/independent	Independent
	Supine ↔ sit	Dependent/maximum assist	Minimal assist/independent	Independent
	Sit ↔ stand	2 person/maximum assist	Minimal assist/independent	Independent
	Ambulation	0-5 ft maximum/moderate assist with AD	40-100 ft up/down supervised	40-100 ft up/down supervised
	Stairs		4 steps up/down minimal assist in afternoon	4 Steps up/down independent
	CPM	As per MD protocol	As per MD protocol	As per MD protocol
	Active and/or passive ROM	As tolerated by patient	0°-75°	0°-90°
OT	Toilet transfer		Moderate assist in AM. Minimal assist in PM.	Minimal assist/independent in AM. Independent in PM.
	Toileting		Minimal assist in AM. Supervision in the PM.	Supervision/independent in AM. Independent in PM.
	Dressing		Maximum/moderate assist with equipment in AM. Minimal assist with no equipment in PM.	Minimal assist with no equipment in AM. Supervision/independent with no equipment in PM.
CM, care manager; HCT, hematocrit; HGB, hemoglobin; O₂ Sat, oxygen saturation; OOB, out of bed; OT, occupational therapy; POD, postoperative day; PT, physical therapy.