Article: https://www.ajan.com.au/archive/Vol36/Issue3/5Wang.pdf
As a former orthopedic nurse, I have witnessed several complications from surgery in a wide variety of ages. In the article I am sharing nurses trialed the efficacy and outcome of fast-track rehabilitation (FTR) for orthopedic surgery patients. This study was a randomized quantitative trial. The trial was approved by an ethics committee. Patients were informed and all were voluntary to participate and had the right to withdraw. Oral informed and written consents obtained. The study included 220 patients undergoing orthopedic surgery under general anesthesia between November 2015 to March 2017 at Central Hospital of Weihai, Shandong, China. There was no significant difference in gender, age and operation time between the two groups (P > 0.05). The patients were randomly divided into 110 cases in the control and the FTR groups using a random number table. The control group consisted of 46 male and 64 female, aged from 29 to 91 (57.76 ± 13.76) years with 24 cases of upper limb fracture and 86 cases of lower limb fracture. The operation time ranged from 55 to 220 (128.04 ± 69.29) minutes. There were 54 males and 56 females in the FTR group, aged from 25 to 88 (59.22 ± 15.74) years. 28 and 82 patients in the group had upper limb lower extremity fracture, respectively, and the operation time was 65 to 210 (120.26 ± 55.16) minutes. All patients had limb fractures. Patients with pathological fractures and serious cardiovascular or other organ dysfunction were excluded.
The 220 patients were divided, 110 were the controlled group, 110 were the fast-tracking rehabilitation group (FTR). The controlled group received the average post-operative care with no changes. Cares were changed with the FTR group in six different areas: body temperature, infusion control, extubation stimulation, pain care, nausea vomiting prevention and psychological intervention. Body temperature control – patients were heated at 38 degrees Celsius until body temperatures reached 37 degrees Celsius. Infusion control – fluids were titrated according to change in vital signs to avoid excessive heart and lung burden. Reducing extubation stimulation – Propofol was continued in the PACU until spontaneous breathing occurred, tidal volume and ventilation volume had restored to normal ranges. Pain care – 30 minutes prior to extubation patients received analgesics. After extubation if pain levels were < 4 distraction techniques were used for pain management, if pain levels were > 4 analgesics were administered. Nausea vomiting prevention – if the fracture was from a lower extremity nerve blocks were used to prevent pain instead of opioids, antiemetics were administered with opioids. Psychological intervention – patients were immediately reoriented in the PACU and frequently updated on how the surgery went to let the patients have a full understanding. Evaluation methods were to check temperature immediately after surgery and one hour after, Riker sedation-agitation scale (SAS), pain numeric rating (PNR) scale and recordings of incidences of nausea vomiting. Data were analyzed using SPSS21.0 software. Measurement data were compared using the t test and rank sum test. χ2 test was used to compare enumeration data. The significant level was set at 0.05. One-hour postoperative body temperature was higher in FTR group than in the control, and the incidence of restlessness, pain and 24 hour postoperative nausea and vomiting were significantly lower (P < 0.05, P < 0.01). The hospital stays were shorter following the FTR, but the difference was not statistically significant as compared with the control.
I believe this study shown improvement on patient post-operative complications I would like to see another study with the elective joint replacement patients instead of traumas. This past year Medicare decreased the length of stays for total joint replacements making a total knee replacement considered to be an outpatient service. Most of the joint replacement patients are above the age of 65 and have other co-morbidities. By making knee replacements an outpatient service, Medicare removed the option for swingbeds for the elderly post-operative knee replacements. Now the patients have to go home to recover many of them alone. The implementation of nurse navigators help select appropriate patients and have a discharge goal planned prior to surgery. This study did help decrease several post-op complications and shorten length of stay but I would like to see a study with just the elderly and recovery.
Journal Club Critique Form (1)
Thank you for educating me about the Fast-Track Rehab program. My father had total knee replacement on both his knees in the beginning of this year. He was at the hospital for 5 days then was transferred to a rehabilitation center for 20 days. According to Quack, Ippendorf, Betsch, Schenker, Nebelung, Rath, Tingart, & Luring (2015), the goals of fast-track rehabilitation are to reduce the length of hospital stays and achieve early functional improvements by optimizing the perioperative setting. This particular study was done in Germany. Fast-track rehabilitation shortened hospital stays as well as facilitating cost savings and can be used to optimize the condition of the patient before admission to a rehabilitation facility (Quack, Ippendorf, Betsch, Schenker, Nebelung, Rath, Tingart, & Luring, 2015). I think early mobilization is key in reducing complications such as thromboembolism, constipation, pneumonia, and pain. The article you researched was done in China. Has this Fast-Track Rehab program been implemented here in the US? When my father was hospitalized, the doctor informed us that his length of stay is dependent on medical necessity. In general, it seems that hospitals do not want patients to stay longer than they have to.
Quack, V., Ippendorf, A. V., Betsch, M., Schenker, H., Nebelung, S., Rath, B., Tingart, M. & Luring, C. (2015). Multidisciplinary rehabilitation and fast-track rehabilitation after knee replacement: faster, better, cheaper? A survey and systematic review of literature. Rehabilitation, 54(4), 245-251.
After working so many years in the ortho department, I agree that early ambulation is key in reducing complications. I have not found any research from here in the United States but that doesn’t mean fast tracking isn’t happening here. I have seen numerous studies done in Europe as well as China.
I have not worked in orthopedics before, so this information was new and interesting! I agree with you that it would be interesting to see a study conducted with older adults with non-emergent surgeries. My grandmother had both of her knees replaced in her 70’s at the same time. I cannot imagine her having to go home right away after surgery. So many older adults have problems after having anesthesia and it takes them awhile to get alert and oriented and back to their normal mental state. I wonder what research the insurance companies base their decisions on. The fast-track rehab seems like a good option for most surgeries as long as everything was tolerated well and they are relatively healthy.
I wish I knew what insurance companies base their decisions on. According to Medicare age is not a diagnosis. So if a 20 year old breaks their ankle, needs surgery and are able to go home then so can a 95 year old. Its completely ridiculous. I have had numerous patient have to go to a nursing home or swingbed but pay out of pocket because their injuries don’t qualify for ‘inpatient’ status.
I recently had a case where an older adult had back surgery and the insurance didn’t cover his inpatient rehab stay… they would only cover outpatient rehab… on a 80 year old!
Kristen it really is crazy to think the elderly can just go home after a procedure! The anesthesia alone can cause major complications.
I do not have any orthopedic experience, but this study was really interesting to read and learn about. It truly surprises me that there have not been many studies conducted in the United States that prove or reject the efficacy of a fast track program.
The study I came across gathered information from three Swedish hospitals. This particular study concluded that the care provided after discharge was essential in the overall recovery. They also inquired about patient-specific approaches but stated that further research would be needed for this (Berg, Berg, Rolfson, et. al., 2019).
I think that the latter is particularly important. The majority of the population undergoing these procedures are older and have many comorbidities that may hinder their ability to perform ADLs. This could lead to complications post-surgery and even readmission. Another factor to consider is how much help these people will have after discharge.
Berg, U., Berg, M., Rolfson, O. et al. Fast-track program of elective joint replacement in hip and knee—patients’ experiences of the clinical pathway and care process. J Orthop Surg Res 14, 186 (2019). https://doi.org/10.1186/s13018-019-1232-8
At my place of employment there is a nurse navigator assigned to joint replacement patients. Specifically aimed for pre-op and post discharge education. The patients meet with the navigator at least once if not twice before surgery. The navigator informs the patients what they may need in their home for after surgery. The patients also have to have a ‘coach’, which is someone who can stay with the patient at home after the surgery to help around the house and get them to therapies.