New morbidity and readmission

Several patients in the study developed morbidity as an inpatient following a period with no morbidity. Re-starting anticoagulation medication that the patient was taking pre-operatively was not counted as morbidity in this evaluation.

Some patients had a second surgical procedure during their inpatient stay. They developed morbidity after the second surgical procedure following a period without morbidity between the two procedures. This occurred in the following situations:

 1 UKR patient developed a perforated duodenal ulcer 2 days after his knee surgery. This patient developed infectious, cardiovascular and haematological morbidity following his laparotomy.

155  1 RTKR patient had no morbidity on POD 8. He subsequently developed

a deep knee infection and returned to theatre on POD 12 for knee washout and change of liner. On post-operative day 15 he had pulmonary, renal and gastro-intestinal morbidity.

 3 RTHR patients had no morbidity on POD 8. 2 of these patients

developed deep infection and returned to theatre on POD 9 and POD 12 respectively for hip washout and change of liner. They both had

pulmonary morbidity and 1 had gastro-intestinal morbidity on POD 15. The other patient fell and sustained a periprosthetic fracture. He returned to theatre for surgical fixation. On POD 15 he had pulmonary and pain morbidity.

Some patients developed morbidity after a period with no morbidity without a further surgical procedure. This occurred in the following cases:

 4 TKR patients had no morbidity on POD 3 and developed cardiovascular morbidity by POD 5. 3 patients had deep vein thromboses and 1 patient had a myocardial infarction.

 8 TKR patients had no morbidity on POD 3 and developed wound morbidity on POD 5.

 1 RTKR had no morbidity on POD 5 and developed wound morbidity by POD 8. The indication for revision surgery was infection of the primary prosthesis.

 2 HR patients had no morbidity on POD 3 and developed wound morbidity by POD 5.

156  8 THR patients had no morbidity on POD3 and developed wound

morbidity by POD 5.

 1 THR patient had no morbidity on POD 5 and developed neurological morbidity by POD 8 due to a CVA.

 1 THR patient had no morbidity on POD 8 and developed infectious morbidity by POD 15 due to an infected peripheral intra-venous cannula site. This could have been avoided if the cannula had been removed and the patient discharged on POD 8.

 2 RTHR patients had no morbidity and then developed cardiovascular morbidity (on POD 5 and 8 respectively) due to the commencement of anticoagulation for pulmonary emboli.

 6 RTHR patients had no morbidity on POD 3 and developed wound morbidity by POD 5. The indication for revision surgery in these patients was infection of the primary prosthesis.

In summary, 33 out of 501 patients who underwent a single surgical procedure developed morbidity as defined by the POMS after a period of time with no morbidity. 25 of these patients developed wound morbidity, 6 developed cardiovascular morbidity, 1 patient developed neurological morbidity and 1 patient developed infectious morbidity.

Of the 25 patients who developed wound morbidity, 24 of them had no morbidity on POD 3 and developed wound morbidity by POD 5. 1 RTKR patient had no morbidity on POD 5 and developed wound morbidity by POD 8.

157 Of the 6 patients that developed cardiovascular morbidity following a period with no morbidity, 5 of them had no morbidity on POD 3 and developed morbidity by POD 5. 3 patients had a DVT, 1 had a PE and 1 had an MI. 1 RTHR patient had no morbidity on POD 5 and developed cardiovascular morbidity on POD 8. This patient had a PE.

1 THR patient had no morbidity on POD 5 and had a CVA by POD 8. This is a rare event (1/529). 1 patient had no morbidity on POD 8 and developed

infectious morbidity (an infected peripheral cannula site) by POD 15.

No patient in this study was readmitted to the same hospital within one year of discharge for any reason relating to his or her surgery.

3.4 Discussion

3.4.1 Summary

This study identifies that many patients remain in hospital with no identifiable morbidity following hip and knee arthroplasty in a UK teaching hospital. The rate of inappropriate bed occupancy varies with the type of arthroplasty and time after surgery. Two general trends are seen. Firstly, the more ‘invasive’ the surgery, the longer a patient remains in hospital with no identifiable morbidity. Thus revision arthroplasty patients remain in hospital with no morbidity longer

158 than primary total knee/hip replacement patients who remain longer than

unicondylar knee/hip resurfacing patients. Secondly, the proportion of patients remaining in hospital with no morbidity decreases with time following surgery. This trend is seen in the UKR, TKR, HR and THR groups. In the revision arthroplasty groups there is a rise in patients with no morbidity between POD 3 and 5. The proportion then decreases.

The most common reason for patients remaining in hospital with no identifiable morbidity was on-going physiotherapy and occupational therapy. This suggests that improving both pre- and post-operative therapy planning could reduce inappropriate bed occupancy. Prior to surgery, patients could be taught their post-operative physiotherapy exercises in group classes. Occupational therapists could assess each patient’s home environment and ensure

necessary modifications are made prior to surgery. In the post-operative period ‘fast-track’ pathways could be used to ensure maximum therapy input at the earliest possible opportunity. Some physiotherapy and occupational therapy could be provided post-operatively at the patient’s home rather than as an

inpatient. This would require safety and cost evaluation prior to implementation.

3 of the top 5 reasons for patients remaining in hospital with no identifiable morbidity relate to ‘social’ issues (awaiting home equipment, awaiting a rehabilitation bed, awaiting a package of care from social services). Pre-

operative clinics could identify and address these problems prior to admission. Such clinics could also be used to manage patient expectation so that each

159 patient is made aware of the difficulties they may encounter in the post-

operative period and the expected timing of discharge.

This is the first time the POMS has been used as a bed utilisation tool. It has not been validated for this purpose but has previously been used to identify patients in hospital without morbidity20,21_{. In the US over 98% of inpatients had} morbidity defined by the POMS20 _{suggesting that those with a POMS score of} zero were rapidly discharged. In a previous UK study, 63% of orthopaedic patients remained in hospital with no morbidity on POD 3 and 42% on POD 5 suggesting that discharge efficiency was lower in the UK institution.

Use of the POMS as a bed utilisation tool relies on the assumption that it

captures all reasons for remaining in hospital. In this study, the main reason for remaining in hospital with no identifiable morbidity was ‘on-going physiotherapy and occupational therapy input’. A specific concern in this patient group is that these patients may not be sufficiently mobile to be discharged safely. Including a specific domain for mobility may improve the sensitivity of the POMS for morbidity requiring hospitalisation following orthopaedic surgery. Criteria for a positive result could include an inability to mobilise 10 metres or climb a single flight of stairs. Whilst this domain could be especially relevant for orthopaedic patients, this requires further investigation.

Use of the POMS as a “fitness for discharge” tool in hospital rests on the assumption that patients do not develop new morbidity after they have

160 become free from morbidity, either in hospital or following discharge. 33 of 442 (7%) patients remaining in hospital with no morbidity subsequently developed ‘new’ morbidity without undergoing any further surgery. Following discharge, no patients were readmitted to the study hospital in the first post-operative year for complications linked to surgery.

Of the 33 patients who developed ‘new’ morbidity, 25 developed wound morbidity. A proportion of wound infections may have been due to hospital acquired infection. If these patients had been discharged when first free of morbidity, they may not have developed infection. However, this cannot be assumed. Of the 25 patients who developed wound morbidity, 24 of them had no morbidity on POD 3 and developed wound morbidity by POD 5. Thus, if an arthroplasty patient is discharged before POD 5, regular wound review should be performed by a medical practitioner up until this day. 1 RTKR patient had no morbidity on POD 5 and developed wound morbidity by POD 8. Thus, if a revision arthroplasty patient is discharged before POD 8, regular wound review should be performed by a medical practitioner up until this day. A doctor or nurse, in either a primary or secondary care setting, could perform the review. If this protocol is followed, there should be prompt diagnosis and treatment of surgical site infection, thus minimising its impact.

1 patient developed infectious morbidity (an infected peripheral cannula site) after a period with no morbidity. If the patient had been discharged when first

161 free of morbidity, the cannula would have been removed and this infection would have been prevented.

Of the 6 patients who developed cardiovascular morbidity following a period with no morbidity, 3 had a DVT, 2 had a PE and 1 had an MI. 1 THR patient had a CVA after a period with no morbidity. These results stress the importance of patient education regarding the symptoms of DVT, PE, MI and CVA prior to discharge. Patients should be made aware that these morbidities could occur following a period of feeling ‘well’ with no apparent morbidity. Patients should be given clear written instructions about what to do if they suspect one of these complications is occurring. As long as these precautionary measures are put in place, POMS has potential as a bed utilisation tool.