NEW YORK—February 19, 2008
Infection control and length of stay are concerns for any hospital, so when the United Kingdom decided to create a new state-of-the-art orthopedic hospital concentrating on joint replacement surgery they reached out to the largest orthopedic hospital in the world, Hospital for Special Surgery. With the goal of reducing the rate of infection and length of stay after surgery in the new facility, they entered into a collaboration with staff at Hospital for Special Surgery (HSS), involving them at every stage of planning and execution.
As reported in the first issue of The Journal of Arthroplasty this year, data collected during the first 10 months in operation of the South West London Elective Orthopaedic Centre in 2004 showed that the hospital had decreased their infection rates from one percent to 0.16 percent and length of stay by an average of five days, from 11 to 6 days.
This decrease was benchmarked against a 2000 national survey by the Royal College of Surgeons of England and the British Orthopaedic Association that showed for total hip replacement surgery, the average patient stay was between eight to 12 days and that the deep wound infection rate was one percent.
“The waiting time for patients undergoing hip replacement surgery in the United Kingdom was almost a year. The government issued a report in 2003 stating that the time should be decreased to reduce unnecessary pain and suffering," said Thomas P. Sculco, M.D., surgeon-in-chief of HSS. "The construction of a new hospital for orthopedic procedures was one of the outcomes of the report, and they contacted HSS to incorporate our best practices in their new hospital." Representatives from Hospital for Special Surgery went to London right at the beginning, as the construction plans were being drawn up. With infection control a huge issue in the UK and in Europe because of antibiotic resistant bacteria, the HSS representatives wanted to make sure the hospital was designed to combat the spread of infection right from the start.
"We had the opportunity to go in before the facility was even built, to help them design infection control at every level," said Eileen Finerty, R.N., director of Nursing for Infection Control and Occupational Health, at Hospital for Special Surgery. "We were creating a state-of-the-art facility that was focused on infection control and length of stay."
At Hospital for Special Surgery, infection control is considered everyone’s responsibility and it should be maintained at every level – from washing hands and having clean equipment to patient placement and traffic patterns for patients, equipment and supplies. "The separation of clean and dirty is one of the basic principles of infection control,” said Ms. Finerty. “But hospitals are busy places and busy people take shortcuts. You need to remind them to stop and do the basics."
Controlling infection is one way to shorten length of stay, but HSS also helped the London hospital staff understand its method of patient-focused care. At Special Surgery, the staff has built a patient flow grid, with every department working together in a multidisciplinary approach to maximize patient progress.
"HSS is all about patient-focused care; the entire staff is trained to help with the patient's recovery," said JeMe Cioppa-Mosca, P.T., MBA, assistant vice president, Department of Rehabilitation, at Hospital for Special Surgery.
A large part of patient coordination starts before the patients are admitted. At a pre-operative class, patients are given a seminar and manual to lead them through every step, from the day before surgery through recovery. "The patients and the staff all know beforehand what the expectations are and how the clinical course should progress," continued Ms. Cioppa-Mosca. "We helped the London hospital write their pre-operative education manual and their patients have responded positively to it."
The paper, Effectiveness of Best Practice Implementation in Reducing Hip Arthroplasty Length of Stay, shows that the transfer of knowledge was successful after only a few months as was evidenced by reduction in infection rates and length of stay. Since that time, their average length of stay for hip and knee replacement has continued to be one of the best performances in the United Kingdom.
"This model demonstrates that best practice transfers are possible and effective," said Dr. Sculco. "They reduced length of stay to six days, infection rate to 0.16 percent and lowered waiting times for patients. Transfers like this, of ideas and methods that work, have a profound effect on patients' lives."