Introduction There exists a paucity of research regarding the role of OT with elective total joint replacement (TJR) patients. Determining this role will.

Introduction

• There exists a paucity of research regarding the role of OT with elective total joint replacement (TJR) patients.

• Determining this role will help support further OT research on efficacy and best practice within this population.

• There appears to exist a significant variation in the clinical practice of OT’s within the elective TJR population. (Munin et al, 2011)

• In the current environment of limited third-party reimbursement, and the need for justification of all services provided to patients, it is necessary to determine best practice for OT’s.

Literature Review: Impact of TJR

• 2010:– 719,000 total knee replacements (TKR)– 332,000 total hip replacements (THR)(Centers for Disease Control and Prevention, 2010).

• 2009: – 75% of TJR patients received some form of post-acute rehab:

• home-based therapy• skilled nursing facility,• acute/intensive inpatient rehabilitation program(Dejong et al, 2009).

• Average hospital LOS for THR in the USA:– 1980’s: 3 weeks (Epstein et al, 1987)

– 2005: 4 days (Herbold et al, 2011)

Literature Review• Meta-analysis of data determined only weak evidence supports the

benefits of OT intervention for elective THR patients (College of Occupational Therapists:

Specialist Section, Trauma and Orthopaedics, 2012). • Evidence supports the involvement of OT’s during the pre-op

educational process (Couteyre et al, 2007).• Research suggests criteria for d/c from the hospital include that

patients: – Are able to perform self-care, including med-management– Are able to understand the signs and symptoms indicating return to the

hospital– Are able to perform ADL’s with minimal assistance

• Research does not report who determines whether or not these goals are met.

(Raphael et al, 2011)

Literature Review

• Study of elective TJR patients in Norway revealed that rehab there typically included PT and medical interventions by a doctor, but not always OT or social services interventions

• It was found that patients reported un-addressed difficulties with activities of daily living and home-related activities

(Grotle et al, 2010).

Literature review

• Assessment of psycho-emotional factors in an elective TJR program revealed that an emphasis on positive feedback was correlated with positive outcomes.

(Stavrev & Ilieva, 2003)

• OT’s are poised to provide holistic, functional, patient-centered, and occupation-based interventions that are presumed to have a positive impact on overall success following elective TJR.

• Given that the greatest declines in strength/functional performance occur in the immediate post-op period, it can be deduced that OT’s should have evidence to guide their practice during this essential time.

(Bade & Stevens-Lapley, 2012)

Problem Statement/Purpose

• The OT field lacks participation in tracking outcomes of ADL and IADL performance in the TJR population; when in fact, OT’s would be the most qualified healthcare professionals to determine success in these goals.

• Lack of research in this area may put OT in danger of being phased out of elective TJR programs.

• This preliminary study seeks to determine the most recent trends in OT assessment, intervention, and pt education, prior to efficacy research being performed.

Objectives• Demographically describe OT’s treating TJR patients.• Calculate the frequency of use of standardized

programs/protocol/clinical pathways.• Determine OT’s current role in the pre-operative education

process.• Ascertain time spent on various treatment activities from

therapists’ perspectives.• Clarify AE commonly recommended or issued.• Determine use of standardized assessments and outcome

measurements.• Summarize common discharge setting recommendations among

OT’s.

Methodology

• Subjects: – OT’s/COTA’s working in acute care (including full-time, part-

time, prn).• Instrumentation: – Survey was created by the researcher and reviewed by

several other OT’s, then revised.• Data Collection: – Online via email, social media (twitter, fb, etc), anonymous

via web-link.• Data analysis: – Descriptive statistics was used to determine trends.

Preliminary Results: Demographics

• Collection of results is ongoing.• Survey has been posted online for 1 week.• N=10• 9 OT’s, 1 COTA’• 4 Full-time, 4 Part-time, 2 PRN• Of these, 8 had worked at some point in

another treatment setting (SNF, outpatient, home health, peds, mental health, or inpatient rehab).

Preliminary Results: Demographics

2

2

3

1

2

Years in OT2 to 5

6 to 10

11 to 15

16 to 20

20+

6

3

1

Years in Acute Care

2 to 5

6 to 10

11 to 15

Preliminary Results: TJR Program Characteristics

• 6 therapists worked at hospitals that have a standardized TJR program/protocol/pathway.

• All had pre-op education classes.– The pre-op education class was mandatory for 4.– No pre-op education classes had OT involvement.

• No therapists reported the use of standardized assessments.

• 2 worked in settings that tracked outcomes to measure the success of the TJR program.

Preliminary Results: Eval & Treatment Activities

• All respondents reported they receive OT orders for all TKR, anterior THR, and posterior THR patients.

• Treatment Activities: See Tables.

Equipment Recommendations• Percent of OT depts that issued/recommended certain

AE/DME as standard to ALL patients:– TKR: 30%

• 100%: elevated toilet seat, shower chair/tub bench, reacher, sock aid, long sponge, long shoehorn

• 60%: 3-1 commode, dressing stick

– Anterior THR: 50%• 100%: elevated toilet seat, shower chair/tub bench• 25%: 3-1 commode, reacher, sock aid, long sponge, long shoehorn,

dressing stick

– Posterior THR: 100%• 100%: Reacher, Sock aid• 80%: 3-1 Commode, Shower chair/tub bench, long sponge• 60%: elevated toilet seat, long shoehorn• 30%: dressing stick• 20%: leg lifter, elastic laces

Equipment Recommendations• Percent of respondents that personally issued/recommend

certain AE/DME as standard to ALL patients:– TKR: 30%

• 100%: Shower chair/tub bench, reacher• 66%: elevated toilet seat, sock aid, long sponge, long shoehorn

– Anterior THR: 70%• 71%: elevated toilet seat, shower chair/tub bench, reacher, sock aid• 57%: 3-1 commode, long sponge, long shoehorn• 28%: dressing stick

– Posterior THR: 80%• 100%: Reacher, sock aid• 75%: 3-1 commode, elevated toilet seat, shower chair/tub bench, long

handle sponge• 62%: long shoehorn• 38%: leg lifter, dressing stick• 25%: elastic laces

Discharge Recommendations: TKR

None 1 to 25% 26 to 50% 51 to 75% 76 to 100%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Home without OT f/u

Home with HHOT

SNF/Sub-acute rehab

Acute/Inpatient rehab

Discharge Recommendations: Ant THR

None 1 to 25% 26 to 50% 51 to 75% 76 to 100%0

10

20

30

40

50

60

70

Home without OT f/u

Home with HHOT

SNF/Sub-acute rehab

Acute/Inpatient rehab

Discharge Recommendations: Post THR

None 1 to 25% 26 to 50% 51 to 75% 76 to 100%0

20

40

60

80

100

120

Home without OT f/uHome with HHOTSNF/Sub-acute rehabAcute/Inpatient rehab

Discussion

• A Majority of respondents were OT’s, and either full- or part-time employees. There was a diversity of experience levels.

• A majority of respondents has worked in practice settings other than acute care.

• Slightly more than half had standardized protocols/pathways for elective TJR patients.

• All provided pre-op education, but none involved OT.• None used standardized assessments, and few tracked

outcomes to determine the success of their program.

Discussion

• Respondents spent more time on ADL’s and transfers, than on ambulation. No time was spent on exercise for any populations.

• OT depts issued or recommended certain equipment as standard to all posterior THR patients, but only some anterior THR and TKR patients.

• OT’s personally recommended more equipment to THR patients than TKR patients.

Discussion

• OT’s more commonly recommended home health OT or rehab in a skilled nursing facility for THR patients (anterior and posterior) than for TKR patients.

• Patients frequently discharged home without a recommendation for follow-up from OT afterward.

Conclusion

• These results are preliminary, from a very small sample size. Data collection and analysis is ongoing. Interpretation of these results is guarded.

• OT’s commonly focus on ADL’s and transfers in the immediate post-op period.

• A diversity of clinical judgment exists in determining the need for adapted equipment.

• A large amount of patients discharge home without further follow-up from OT.

• Further research is required to determine efficacy and best practice for OT in the immediate post-op period following elective TJR.

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