Adapting Physical Therapy Practice for the “Short-Stay” Total Joint Arthroplasty Patient: A Commentary

Outpatient Total Joint Replacement

The removal of total knee arthroplasty (TKA) and total hip arthroplasty (THA) from the Centers for Medicare and Medicaid Services (CMS) “inpatient only” list has resulted in a movement toward outpatient total joint arthroplasty (TJA), defined as surgery requiring a length of stay (LOS) of less than 24 hours for patients who qualify. Improvements in surgical techniques, anesthesia protocols, and clinical pathways have resulted in shorter recovery times, reducing typical hospital LOS to 2 to 4 days, which includes some patients with same-day discharge (SDD) [42,51]. Outpatient TJA programs require careful patient selection and screening, facility and staff preparation, and streamlined instrumentation [2].

For TJA patients who do not require an overnight stay, SDD is a cost-effective option [39,50], but it requires consolidated patient management. A TJA patient assigned to the SDD care pathway will have a clinical experience that may include fewer throughput touchpoints and discharge directly from the perioperative area, rather than an acute care unit. The SDD care pathway requires unique staff workflows, such as enhanced and expedited coordination for postoperative care [19]. Health care organizations have been working to condense care while continuing to ensure patient safety and efficacy of interventions. Physical therapists are among the providers who have had to pivot in response to the changing regulatory climate, challenging conventions of practice both clinically and operationally.

Evolving Physical Therapy Care Provision

To adapt to the requirements of outpatient TJA surgery, physical therapists must work with patients earlier in their post-surgical course. Early mobilization during the postoperative period—traditionally within 24 hours of surgery—is a highly supported intervention for those undergoing TJA to facilitate a shorter stay and is generally considered safe [9,22]. Although the optimal time for early mobilization has not been established, mobilization should occur “as soon as possible following surgery” [48]. For SDD patients, timing is typically based on their progression through recovery phases in the post-acute care unit (PACU), and therapists may mobilize patients in the PACU within 1 to 2 hours of the anesthesia stop, after the patient has met established criteria.

To adapt to the expedited timeline, physical therapy (PT) departments must modify their clinical practices to continue to ensure safe service provision. Establishing the patient’s readiness for early mobilization is essential. Early in the postoperative period, patients may still be experiencing the lingering effects of anesthesia. Thus, motor, sensory, and vital sign screening is essential to establish objective criteria for patient readiness. Temporary motor weakness surrounding the knee has been associated with certain types of anesthesia and has been found to relate to knee buckling that can result in falls and other injuries during upright activities [6,17,45]. Orthostatic hypotension is common after surgery and may also result in falling [3,17]. A standing blood pressure measurement to screen for orthostatic hypotension and a “trial” of marching in place to screen for knee buckling help establish patient readiness for walking. Having a second set of hands for those considered high risk helps to prevent falls during early mobilization.

Physical therapists seeking to expedite care and mobilize patients early in the PACU after TJA must find the sweet spot between timeliness of care and patient readiness for mobilization. A workflow in which nurses screen patients prior to mobilization can improve efficiency by preventing physical therapists from having to return twice if patients are not yet optimized. To get the timing right for postoperative PT, effective communication with PACU nursing staff is essential. Novel electronic medical record (EMR) tools, such as dashboards or readiness indicators within the EMR may help to reduce the need for frequent verbal handoff between PACU nurses and physical therapists. Further study of outcomes related to early mobilization is needed, to understand both its benefits and risks.

The abbreviated hospital course that outpatient TJA patients experience requires expedited and highly coordinated collaboration between health care providers. The development of highly refined workflows, in which clinicians work together in predictable ways, are most likely to result in the shortest patient stay, reducing cost to organizations. The development of efficient and effective communication tools is essential for successful coordination between surgeons, nurses, social workers, care managers, physical and occupational therapists, other licensed independent practitioners, and various consultants on the care team. Time-sensitive communication about milestone achievement is essential to move patients along the care pathway. Communication about patient progress via session note documentation may not be rapid enough to meet the requirements of short-stay TJA—even it occurs in real-time immediately after sessions. To facilitate communication, health care organizations should utilize varied and overlapping modes of communication, including large group discussions (multidisciplinary rounds), EMR dashboards, secure chat, and care team huddles.

Thus, the communication demands placed upon team members working with short-stay TJA patients are high and require an increasing portion of physical therapists’ time. Electronic medical record secure messaging is an efficient means of communication that has been embraced by care teams managing TJA patients. Although there are many benefits of secure messaging [20,34], there are also several challenges to using chat for patient management communication. Risks include the development of alarm fatigue, the liability associated with critical communications, and communication errors that may occur [10]. Physical therapy departments would be wise to develop guidelines for the use of secure chat to safeguard patients against harm and reduce redundancy in communication. Furthermore, they must be accepting of the high volume of communication required by this approach to care and would benefit by focusing on improving the efficiency of note-writing.

The Evolving Role of the Physical Therapist

The physical therapist’s role in caring for the TJA patient during the post-surgical period has evolved over the last decade. Instead of traditional rehabilitation interventions, short-stay demands require that the multidisciplinary team focuses on achieving milestones for discharge home, family training, and equipment provision. Many outpatient TJA patients may only receive a single PT session rather than multiple sessions. Consequently, physical therapists are challenged to assess impairments and provide interventions and education in a more efficient manner. Decisions must be made with haste and in collaboration with the multidisciplinary team. Targeted communication with surgeons occurs frequently and is essential to address medical or pain management barriers to participation. Failure to reach ambulation goals may delay discharge for those planning an SDD [38]. Therefore, the role of the physical therapist is integral for progressing the patient along the clinical pathway, either through fast-tracking for additional sessions or by training caregivers to aid those who have not yet reached mobility goals. Creation of a precise communication that is universally accepted by all team members and strict criteria for discharge is crucial for effective patient management.

Although it has changed, the role of the physical therapist within the interdisciplinary team continues to have value for achieving organizational goals. In addition to being the “early mobilizers” during the postoperative period, physical therapists assume other roles that contribute to favorable outcomes and patient satisfaction. Therapists may provide activity guidelines, prescribe exercises, give advice about home management, and facilitate continuum of care within the health care system. This therapist-patient interaction is a critical element of care provision and may include filling information gaps, allaying patient concerns, and reducing anxiety about what may occur after surgery. Physical therapists spend considerable time with patients during visits and impact their experience and satisfaction with their care.

As postoperative inpatient PT use has decreased, physical therapists may utilize encounters during the preoperative period to provide interventions which may enhance outcomes. Considering the large volume of information the patient may receive postoperatively, it may be essential to capitalize on opportunities for education in the preoperative period [14,16,23]. Use of group or in-person preoperative visits for education is common [12,13,18,25,26,40,41,43] and has been found to relate to reduced PT service utilization [41] and reduced LOS [13,26,40,41,43]. Group or individual classes are often staffed by physical and/or occupational therapists, who use the time to pre-teach mobility tasks and exercises, discuss equipment options, provide activity recommendations, and gain information about each patient’s needs. In light of the movement toward virtual communication [37], virtual educational sessions are being trialed for this purpose, and have the potential to reduce barriers to care [4,28]. It is unclear if virtually administered preoperative “joint class” sessions are as efficacious as in-person sessions in terms of the LOS benefit.

Physical therapists may also play a role in assessing patient candidacy for outpatient TJA during the preoperative period. Red flags may include evidence of poor baseline mobility, a lack of caregiver support after surgery, home environment barriers, patient preference, or the presence of unrealistic expectations regarding care. Early identification of patients who are not well-suited for the specific demands of outpatient TJA are communicated back to the surgical team by the physical therapist and may impact the surgeon’s decision for surgical class. It has been previously established that patients classified as “functionally dependent” [33,35] or “inactive” [36] prior to their surgery required a longer hospital stay than those who were independent or mildly active prior to their TKA or THA surgery. Similarly, those deemed “functionally dependent” were less likely to achieve SDD [24]. Performance on the Timed Up and Go [30] and the 10-Meter Walk [8] tests have been associated with both the speed of recovery after surgery [5,11,27,47] and LOS [31,32] but have not been investigated in relation to candidacy for outpatient TJA or SDD, more specifically. Although the theoretical rationale exists for the relationship of patient mobility on short-stay TJA, there is no well-established tool to determine candidacy. Physical therapists are experts in assessment of mobility in those with osteoarthritis and are well-suited to participate in decisions pertaining to LOS and surgical class during the preoperative period; yet they are not always consulted. Future investigation should focus on establishment of a user-friendly mobility measurement tool.

During the preoperative visit, physical therapists may help prepare patients for the rigor of outpatient TJA. Therapists can inform patients of what to expect during the postoperative period and provide information on predicted LOS. For most TJA patients, the care required during the postoperative period has significantly reduced. However, patients may still expect a prolonged stay for recuperation and recovery—the kind of extensive rehabilitation that occurred in the past. Alignment of patient and family expectations with the care team’s discharge plan has been demonstrated to relate closely to patient satisfaction with care [7,25,44] and is therefore essential for successful execution of the short stay. Utilizing pre- and postoperative visits, therapists help patients to have confidence in their abilities and feel safe leaving the hospital environment on the day of surgery.

Evolving Management of the PT Department

To accommodate the needs of this population, significant adaptation in managing a team of physical therapists has been required. Physical therapy teams providing service to this population are required to adapt alongside the other care disciplines at a pace of change that can be both exciting and challenging. Operational structures, including staff numbers, staff schedules, staff and supervisor duties, data collection practices, clinical practice guides, note documentation, communication procedures, and staff training must continue to evolve in response to the shorter timeframe of care. Therefore, departments providing care to this population should become comfortable with change.

The high demands on staff working with outpatient TJA patients may result in a reduction in the conventional staff-to-bed ratios that PT departments have utilized in the past. Organizations must understand that the portion of clinician time utilized for communication and coordination of care for this population is higher than for other populations. Staff or manager attendance in the more frequently occurring team meetings must be accounted for in staffing models. Patients may require more frequent or lengthier visits to accomplish the mobility milestones required for a safe discharge home. Additional supervisory staff might be required to support the demands of the larger teams caring for this population.

The need for both early- and late-day care provision challenges PT departments to re-organize the workforce to provide maximal coverage during peak hours. Late-day surgery continues to challenge teams who seek to achieve SDD. Late surgery has been associated with delayed PT intervention [49], which poses an obstacle to discharge. To meet this challenge, many PT departments have extended their hours of operation, enabling more patients to receive early mobilization despite late surgery. Similarly, early morning PT visits may facilitate a discharge before noon for outpatient TJA patients who remained overnight. It can be challenging to retain staff assigned to late shifts, as hospital PT departments have not traditionally required employees to work late into the evening. A transition toward longer work shifts on fewer working days is one strategy that may be more agreeable to clinicians while also satisfying departmental needs [15]. Shifting staff schedules to include regular weekends is also essential to ensure high-quality and efficient care 7 days per week.

The work of PT supervisors has also evolved. Frequent modifications to patient assignments—which are reflective of the needs of the patients and the goals of the health care organization—require supervisors’ attention each hour of the day. They must be focused on the timeliness of the PT visits provided by their team. Development of efficient team workflows for assignment and patient prioritization is paramount to providing timely care. Attendance in more frequently occurring rounds consumes several hours of the supervisor’s time each day. With the spreading of staff schedules into the evening and across the weekend, the requirement of providing staff supervision has likewise expanded and may require supervisors to also work longer days or on staggered shifts. Indeed, adaptation to outpatient TJA requires significant management team resources in interdisciplinary program development, planning, and execution.

Management of the PT department includes detailed data collection and analysis. Unique to this care service, analyses of staff productivity are based upon time of day and day of the week, rather than simply by provider. Analysis of historical volume data related to day of the week and time of surgery are compared with the surgical schedule, expected volume of each patient type, and predicted discharge timeframe for patients. Information is gathered on an ongoing basis, so that, staff schedules may be re-evaluated and adapted to match. Stratification models for patient selection for outpatient surgery and for SDD exist [1,21,24,29,46] but may not yet be integrated into the pre-surgical decision-making process for all providers. Improving the accuracy of the patient classification during the preoperative period would enhance the ability of PT departments to meet the unique care demands of this population.

In response to regulatory changes in TJA procedures, PT has evolved to include innovations in clinical care, more efficient communication processes, and expanded preoperative involvement. The role of the physical therapist should not be underestimated as essential for ensuring patient safety and satisfaction.

Supplemental Material

sj-docx-1-hss-10.1177_15563316231212183 – Supplemental material for Adapting Physical Therapy Practice for the “Short-Stay” Total Joint Arthroplasty Patient: A Commentary

Supplemental material, sj-docx-1-hss-10.1177_15563316231212183 for Adapting Physical Therapy Practice for the “Short-Stay” Total Joint Arthroplasty Patient: A Commentary by Susan Camillieri in HSS Journal®