Sorensen Lyle, Idemoto Lori, Streifel Janet, Williams Barbara, Mecklenburg Robert, Blackmore Craig
Department of Orthopedic Surgery, Seattle, Washington, USA.
Center for Health Care Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA.
BMJ Open Qual. 2019 Jul 10;8(3):e000664. doi: 10.1136/bmjoq-2019-000664. eCollection 2019.
Knee and hip arthroplasties vary in cost, quality and outcomes. We developed a Lean quality improvement intervention for knee and hip arthroplasty patients encompassing the recognition, readiness, restoration and recovery phases of care. The intervention included standardised, evidence-based pathways, shared decision making, patient and family member engagement, and transdisciplinary rounding, implemented successively through a series of rapid process improvement workshops. We evaluated the intervention through run charts and time series analysis for 2005-2014. Outcomes included length of stay (LOS), 30-day readmission, discharge disposition, postsurgical complications and patient satisfaction. Included were 4253 total joint arthroplasty procedures, 1659 hip and 2594 knee. LOS decreased from 3.2 to 2.4 days postintervention for both hip and knee patients (p<0.001). The 30-day hospital readmission rate for hip patients decreased from 3.1% (18/576) to 1.1% (5/446, p=0.032) with knee patients unchanged. Discharge to home (vs rehabilitation facility or skilled nursing facility) increased from 72% (415/576) to 91% (405/446) (p<0.001) for hip patients, and from 70% (599/860) to 87% (578/663) for knee patients (p<0.001). Our standardised multifaceted Lean quality improvement programme was associated with reduced LOS, decreased readmission rates and improved discharge disposition in total knee and hip arthroplasty patients.
膝关节和髋关节置换术在成本、质量和疗效方面存在差异。我们针对膝关节和髋关节置换术患者开发了一种精益质量改进干预措施，涵盖护理的识别、准备、恢复和康复阶段。该干预措施包括标准化的循证路径、共同决策、患者及家属参与以及跨学科查房，通过一系列快速流程改进研讨会相继实施。我们通过2005 - 2014年的运行图和时间序列分析对该干预措施进行了评估。结果包括住院时间（LOS）、30天再入院率、出院处置情况、术后并发症和患者满意度。共纳入4253例全关节置换手术，其中髋关节置换1659例，膝关节置换2594例。干预后，髋关节和膝关节置换患者的住院时间均从3.2天降至2.4天（p<0.001）。髋关节患者的30天医院再入院率从3.1%（18/576）降至1.1%（5/446, p = 0.032），膝关节患者的再入院率未变。髋关节患者出院回家（相对于康复机构或专业护理机构）的比例从72%（415/576）增至91%（405/446）（p<0.001），膝关节患者从70%（599/860）增至87%（578/663）（p<0.001）。我们标准化的多方面精益质量改进计划与全膝关节和髋关节置换患者住院时间缩短、再入院率降低及出院处置改善相关。
