SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Efficacy
evaluation
of
a
protocol
for
safe
hip
surgery
(total
hip
arthroplasty)
夽
Antônio
Augusto
Guimarães
Barros
∗,
Carlos
Henrique
Cardoso
Mendes,
Eduardo
Frois
Temponi,
Lincoln
Paiva
Costa,
Carlos
Cesar
Vassalo,
Euler
de
Carvalho
Guedes
HospitalMadreTeresa,BeloHorizonte,MG,Brazil
a
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t
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o
Articlehistory:
Received10November2016 Accepted26January2017 Availableonline18August2017
Keywords: Hiparthroplasty Protocols
Postoperativecomplications Hospitalization
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Objective:Toproposeamultidisciplinaryprotocoltostandardizethecareofpatients under-goingtotalhiparthroplasty(THA)andevaluateiteffectivenessafterimplementation. Methods:Retrospectiveevaluationof95consecutivepatientsundergoingTHAdividedinto twogroups,onegroupof47patientsoperatedbeforetheprotocolimplementationand48 after.
Results:Assessingthere-admissionrate,among47patientsevaluatedpriorto implemen-tationoftheprotocol,seven(14.9%)werere-admitted,andwhenobservingthe48patients evaluatedafterimplementation,one(2.1%)wasre-admitted,showingstatisticalsignificance (p<0.05).Thechanceofre-admissionbeforetheprotocolwaseighttimesthechanceof hospitalizationafterimplementation(95%CI:1.01to377.7).Bycomparingtheclinical com-plicationsamongthegroups,itwasobservedthattherewasalowerrateofcomplications followingimplementationoftheprotocol(p=0.006).
Conclusion: Theintroductionofamultidisciplinaryprotocoltostandardizethemanagement ofpatientsundergoingTHAdecreasedtheratesofrehospitalizationandclinical complica-tionsaftertheprocedure.
©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Avaliac¸ão
da
eficácia
do
protocolo
para
cirurgia
segura
do
quadril
(artroplastia
total)
Palavras-chave: Artroplastiadequadril Protocolos
Complicac¸õespós-operatórias Hospitalizac¸ão
r
e
s
u
m
o
Objetivo:Proporumprotocolomultidisciplinarparapadronizac¸ãodocuidadodospacientes queserãosubmetidosa artroplastiatotaldoquadril(ATQ) eavaliarsuaeficáciaapósa implantac¸ão.
Métodos:Avaliac¸ãoretrospectivadosresultadosde95pacientesconsecutivossubmetidosa ATQdivididosemdoisgrupos,umcom47operadosantesdaimplantac¸ãodoprotocoloe48 após.
夽
StudyconductedatHospitalMadreTeresa,BeloHorizonte,MG,Brazil. ∗ Correspondingauthor.
E-mail:antonioagbarros@gmail.com(A.A.Barros).
http://dx.doi.org/10.1016/j.rboe.2017.08.004
Resultados:Naavaliac¸ãodataxadereinternac¸ão,tem-sequeentreos47pacientesavaliados antesdaimplantac¸ãodoprotocolo,sete(14,9%)foramreinternadosedos48avaliadosdepois daimplantac¸ão,um(2,1%)foireinternado,mostrou-sesignificânciaestatística(p<0,05). Achancedereinternac¸ãoantesdaimplantac¸ãofoioitovezesmaiordoqueachancede internac¸ãoapósaimplantac¸ão(IC95%:1,01a377,7).Aocompararascomplicac¸õesclínicas entreosgruposobservou-sequehouvemenortaxadecomplicac¸õesapósaimplantac¸ãodo protocolo(p=0,006).
Conclusão: Aintroduc¸ãodeumprotocolomultidisciplinarparapadronizac¸ãodomanejodo pacientesubmetidoaATQdiminuiuastaxasdereinternac¸ãoedecomplicac¸õesclínicas apósoprocedimento.
©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Forroughly50years,totalhiparthroplasty(THA)hasbeenone ofthemosteffectiveorthopedicinterventionsfroma func-tionalandeconomicstandpoint.1–4Itisanelectiveprocedure whentreatinghiparthrosis,anditisperformedaftercareful preoperativeevaluationtominimizerisks.Advancesin tribol-ogy,surgical,anesthetic,andrehabilitationtechniqueshave improvedtheendresult.Thisevolutionhasledtoanincrease insurgicalindicationsandinthesafetyoftheprocedure,1with anoverallcomplicationrateoflessthan4%andoverall90-day mortalityoflessthan1%.5–7
Despitetheseadvances,patientsundergoingthistypeof procedure are subject to complications such as infection, implantdislocation,deepvenousthrombosis(DVT),and pul-monaryembolism(PE),amongothers,5resultinginincreased hospitallengthofstayandratesofrehospitalization.8
Identifying the riskfactors for complicationsas well as applyingscientificallyeffectivemethodsfortheirprevention are importantsteps inthe strategy toreducesuch events, reducingriskstothesurgeonandpatient,aswellashospital costs.5,9
Considering the need to cover all these aspects, the creation of a protocol that encompasses pre-, peri-, and post-operative measures is a valid strategy to standard-ize care and increase the safety of the procedure. The present study aimed to propose a multidisciplinary pro-tocol to standardize the care of patients undergoing THA and to evaluate the effectiveness of the protocol after its implantation.
Material
and
methods
Aninstitutionalprotocolwascreatedforthemanagementof patientsundergoingTHA.Thisprotocolisdividedinto pre-, peri-,and post-operativemeasures andincludesmedical, nursing,andphysiotherapyprofessionals.
Itbeginswiththerequestofpreoperativeexamsinorderto identifypossibleriskfactorsandinfectionsites(urinaryand airway), andacardiologist and anesthesiologistevaluation; whennecessary,bloodcomponentsandtheanintensivecare unitbed(ICU)arereserved.Thepatientisadvisedtoshower
preoperativelyusingchlorhexidinedetergent,andtopurchase elasticcompressionstockingsforpostoperativeuse.
After the preoperative procedures are concluded, the patientisadmittedonthedayofsurgery;the recommenda-tionsfromtheWorldHealthOrganization(WHO)manualfor safesurgeryarefollowed.10Intheoperatingroom,upto60 minutesbeforetheincisionismade,antibioticprophylaxisis administered;shavingisperformedonlyifnecessary.After surgery,elasticcompressionstockingsareplaced,followedby thefinalcontrolX-ray.Antibioticprophylaxisismaintainedfor 24h,andthromboprophylaxisisinitiatedwith40mg enoxa-parindailyuntildischarge.
Oncethepatientisintheroom,theinternalmedicinestaff initiatesmonitoring.Gaittrainingisinitiatedonthefirst post-operativeday(POD)bytheattendingphysician,andablood countisrequested.Thedressing ischangedafter48h, and thedischargeisplannedforupto96h.Athospitaldischarge, the patient isadvised on the use ofthe anticoagulantfor fiveweeksaftersurgery,analgesiaaccordingtothepain,gait withawalkerandalwayswithanassistant,home physiother-apy,identificationofrisksignsthatrequirereevaluation,and measurestopreventprosthesisdislocation.Thisprotocolwas implementedinMay2012.
Thecharts ofpatientswho underwent elective THAfor hip arthrosis treatment were retrospectively evaluated. A databasewascreatedinMicrosoftExcel.Initially,information on100patientsoperatedin2011and2012wasenteredinto thedatabase;50patientshadbeenoperatedonbefore proto-colimplantationand50,after.Thissampleincludedpatients with previous hipsurgeries, those withadvanced deformi-ties, and those withhip infection sequelae.Three patients who wereoperatedonbeforeimplantationofthe multidis-ciplinaryprotocolwereexcluded(twoweresubmittedtoTHA duetofemoralneckfractureandthenecessaryinformation wasnotavailableforthethirdpatient),aswellastwowho wereoperatedonafterprotocolimplantation(inbothcases, surgerywasduetofracture). Thus,95patientswere evalu-ated,47ofwhomwereoperatedbeforeand48afterprotocol implantation.
relatedtothe musculoskeletalsystemthatoccurred during thehospitalizationperiod(e.g.,acutemyocardialinfarction, acute pulmonary edema, pneumonia, renal failure, or uri-narytractinfection).Thestudywasapprovedbythehospital’s ResearchEthicsCommittee.
Thevariables evaluatedwerecomparedbeforeand after theprotocolimplantation.Thequalitativevariableswere com-paredusingPearson’schi-squaredtestorFisher’sexacttest (for caseswithan expectedfrequencyofless than 5). The associationswerequantifiedbycalculatingtheoddsratio(OR) and95%confidenceinterval(95%CI).Thequantitative vari-ableswerecomparedusingStudent’st-testwhentheusual assumptions(normalityandhomoscedasticity)weremet,and usingMann-Whitney’stestwhen theywerenot. Normality wasassessedusingtheShapiro-Wilktestand homoscedas-ticity(constantvariance)bytheLevenetest.Rversion3.2.0 andMINITABwereusedforthestatisticalanalyses.
Results
Meanpatientagewas68years(26-97);51(53.7%)werefemale and44(46.3%)weremale.Onaverage,patientspresentedone comorbidity(approximately),withastandarddeviationof1.2. Thestudiedgroupswerehomogeneousregardinggender,age, andpresenceofcomorbidities(Table1).
Regarding the re-hospitalization variable,among the 47 patientsevaluated beforethe implantationofthe protocol, seven(14.9%)werere-admitted;ofthe48evaluatedafterthe implantation,one(2.1%)wasre-admitted,andthisdifference wasstatisticallysignificant (p<0.05).Theriskof rehospital-izationbeforeprotocolimplantationwaseighttimeshigher thanafterimplantation(95%CI:1.01–377.7)Thiswide confi-denceintervalwasduetothefactthatonlyonepatientwas re-admittedafterprotocolimplantation.Whencomparingthe 90-dayclinicalcomplicationsbetweengroups,itwasobserved thattherewasalowerrateofclinicalcomplicationsafter pro-tocolimplantation(p=0.006;Table2).
Regarding hospital stay, before protocol implantation patients were hospitalized for 6.3 days (± 4.7) and after implantation,for5.1days(±2.9).Thestudydidnotassess whether the length of hospitalization was influenced by patientswithcomplexcasessuchasprevioushipsurgeries, large deformities,or hip infection sequela. Thisdifference wasnotstatisticallysignificant,buttherewasatrendtoward
shorterhospitalstayaftertheprotocolwasfollowed.Inthe presentstudy,thedifferenceinERvisits,DVT,infection,and dislocationwasnotstatisticallysignificant,butthegroupafter protocolimplantationpresentedfewerevents.
Discussion
TheabilityofTHAtoimprovepain,function,andqualityof lifeiswidelyrecognized.11 However,asinanysurgery,THA has risks, including death. Although the principles of hip arthroplastyhavenotchangedinrecentyears,patient man-agementhasevolvedinmanyrespectsoverthepastdecade, improving postoperative recovery and patient satisfaction, whiledecreasing morbidityandperiodofhospitalstay.6 In recentyears,protocolsforrapidrecoveryafterTHAhavebeen introduced.Severalstudieshaveshownthattheseprotocols havereducedthelengthofhospitalstay,aswellas complica-tionandre-admissionrates.8
The results of the present study indicate a lower rate of hospital readmission (2.1%) in a multidisciplinary and standardized patient management protocol. Inthe current literature,Mahomedetal.12observeda90-dayhospital read-mission rateof4.6%forpatientsundergoingTHA. Another studybyZhanetal.,13whenassessing230,000primaryTHAs, observedthat8.9%ofpatientswerere-admittedinthatsame post-operativeperiod.Dowseyetal.14alsosucceededin reduc-ing the rate of readmission after adopting a protocol for standardizingthemanagementofpatientsundergoingTHA.
Althoughthesuccessofthistypeofprocedureiswell doc-umented, complicationsoccur;this rateisdifferentamong institutionswithaspecializedorthopediccenterandgeneral hospitals.Crametal.15reporteda90-daycomplications(death, sepsis,hemorrhage,pulmonaryembolism,DVT,andsurgical woundinfection)rate of2.8%inspecializedcenters andof 6.2%innon-specialized hospitals.In astudy thatassessed theclinicalcomplicationsin251,199THAsfrom2008to2010, a general rate of 2.7%was observed.16 In addition to per-formingthesurgeryinaspecializedcenter,thepresentstudy demonstrated thatstandardizationofpre-, peri-,and post-operativeprocedurescanfurtherreducethesecomplications. Byassessingtheriskfactorsassociatedwiththeseconditions inastandardizedway,atendencytowardreductionofthese eventswasobserved,makingtheprocedureevensafer.
Table1–Comparisonofpatients’gender,age,andnumberofcomorbiditiesbeforeandafterprotocolimplementation.
Characteristics Protocolimplementation p-value
Before After
Gender,n(%) 0.467a
Female 27(57.5) 24(50.0)
Male 20(42.5) 24(50.0)
Age(mean±SD[median]) 69.7±16.1(71.0) 66.7±14.2(68.5) 0.329b
No.ofcomorbidities(mean±SD[median]) 0.6±1.1(0.0) 0.9±1.3(0.0) 0.130b
SD,standarddeviation.
Table2–Comparisonofhospitalstayandotherpatients’characteristicsbeforeandafterprotocolimplementation.
Characteristics Protocolimplementation p-value
Before After
Hospitalstayindays(mean±SD[median]) 6.3±4.7(5.0) 5.1±2.9(5.0) 0.152a
ERvisits 0.125b
Yes 9(19.2) 4(8.3)
No 38(80.8) 44(91.7)
Re-admission,n(%) 0.030a
Yes 7(14.9) 1(2.1)
No 40(85.1) 47(97.9)
90-daymortality,n(%) 0.495a
Yes 0(0.0) 2(4.2)
No 47(100.0) 46(95.8)
Thrombosis,n(%) 0.495a
Yes 1(2.1) 0(0.0)
No 46(97.9) 48(100.0)
90-dayclinicalcomplications,n(%) 0.006a
Yes 7(14.9) 0(0.0)
No 40(85.1) 48(100.0)
Infection,n(%) 0.242a
Yes 2(4.3) 0(0.0)
No 45(95.7) 48(100.0)
Dislocation,n(%) 0.242a
Yes 2(4.3) 0(0.0)
No 45(95.7) 48(100.0)
ER,emergencyroom.
a Student’st-test.
b Pearson’schi-squaredtest.
Longer hospitalstaysis directlyassociated withgreater clinical and psychological complications, as well as with highercostsforinstitutions.Glassouetal.,17inacohortstudy thatevaluatedthelengthofhospitalstayofpatients submit-tedtoarthroplastyinanorthopediccenter,demonstratedthat themeanperiodofhospitalstaydecreasedfromfourtothree daysaftertheimplantationofaprotocolforthemanagement ofpatientsundergoingTHA.Afterotherorthopediccentersin Denmarkimplementedsimilarprotocols,thenationalmean lengthofhospitalstayreducedfromsixtothreedaysfrom 2005to2011;79,098arthroplastieswereassessed.
Thepresentstudyhadthelimitationofevaluatingonly95 patients;alargersampleisneededtodemonstratethetrue efficacy ofsuchprotocols.Thepositivepointsofthe study includeahomogeneoussampletreatedinasingleinstitution bythesamegroupofsurgeons.
Conclusion
Theintroductionofamultidisciplinaryprotocolforthe stan-dardizationofthemanagementofpatientssubmittedtoTKA decreasedtheratesofrehospitalizationandclinical complica-tionsaftertheprocedure.Withthecontinuingmedical,social, andorganizationaladvancesinhealthcaresystems,thistrend shouldpersist.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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