Reduced length of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty

Background: In 1991 the orthopedics department at St. Paul's Hospital, Vancouver, British Columbia, Canada, identified the clinical path as a way to shorten length of stay, improve efficiency of resource use, and minimize variation in care processes without compromising clinical outcomes for patients admitted for elective knee or hip arthroplasty. Methods: A team of direct care providers collected baseline data for 77 patients to identify variables influencing length of day (LOS) and variability in care processes. The team proposed an improved sequence of coordinated clinical decisions and treatments on a daily basis. The clinical path was disseminated by educating nursing and medical staff and by developing pre-printed orders and modifying the nursing care plan. Results: Nine months after implementation of the clinical path, there was a statistically significant reduction in median LOS (12 to 9 days; p < 0.001), which was sustained for at least 18 additional months. Decreased use of inappropriate perioperative antibiotics and laboratory tests and no change in postoperative complications or readmissions rate were also found. Discussion: A new team is now developing a clinical path for hip fracture patients. In addition, other programs are using the template employed by the arthroplasty team to develop clinical paths for acute myocardial infarction, coronary artery bypass grafting stroke, and drug overdose in the intensive care unit. Summary: The team is now working toward a seven-day LOS for these patients. This experience has served as a model for development and implementation of other clinical paths for other groups of patients at the hospital.