Hip replacement clinical pathway
The Local Health Authority of Verbano - Cusio – Ossola (VCO), Piedmont, covers about 172,429 inhabitants, 37,205 (22%) of which are aged over sixty. Hospitalization is granted by three hospitals with a total number of acute care beds of 522.
The Piedmont Region has developed an Institutional Accreditation system which involves implementation of care pathways with simultaneous verification of the structural, organizational and technological requirements at Department level.
The good practice herein described is about the re-engineering process of the care pathway for elective hip replacement according to the requirements for the Institutional Accreditation of the Piedmont Region.
The State of the Art
According to the procedure adopted by the Italian Register of the Orthopaedic Prosthetic Implants (RIPO), a form with the patient’s personal details, and information about the disease that need surgery, antibiotic and antithromboembolism prophylaxis, the possible use of bone grafts, possible complications in the perioperative period, must be filled in for each hip or knee replacement. Trade name, batch production of each component and the type of bone cement used are also to be recorded, using self-adhesive labels attached to the implants.
The outcome of surgery (and therefore its effectiveness) is monitored using as an endpoint the implant removal.
Taking cue from the above, it was considered to be useful to check the possibility of including items proposed by the Registry (RIPO) in the macro-management model of care of Hip Replacement.
In VCO Orthopaedics Departments most implants are cementless, used at both femoral and acetabular level. Only in special cases cemented or hybrid and custom made protheses or anatomical implants are used.
Type of surgical procedure performed:
Based on the accreditation requirements of the Piedmont Region, a clinical audit was conducted at VCO, to put in writing, through flow diagrams, operating procedures, treatment protocols, etc. the whole pathway. This revision allowed identification of critical points, organizational redundancies, wasted resources, shortcomings and the resulting corrective actions.
A set of macro-indicators was identified and standards in compliance with the literature and / or to the local situation have been defined. Several procedures were defined, including: patient identification, surgical site and side, pain assessment and management, management and removal of catheters and drainage, prevention of thromboembolism and nosocomial infections, etc.
The Hip Replacement therapeutic and diagnostic pathway has been implemented since 2008.
Its application is annually monitored through collection, verification and evaluation of a well-known set of indicators (defined in the re-engineering phase).
Data on indicators: from april 2008 to july 2009 (15 months after the implementation of the HRTDP).
The review of this care pathway has supported the reduction of average length of stay, the spread of standardized procedures in other care pathways (eg: patient and site identification , pain assessment and management, trichotomy, catheter removal) agreement and collaboration among professionals.
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