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UAB Care Program Helps Orthopaedics Achieve More Positive Results For Patients

Pam FlournoyPam Flournoy remembers the moment she decided she could no longer live with excruciating knee pain. While attending a Christmas Eve church service, her pain was so bad that she was afraid she wouldn’t be able to walk to the altar or stand after kneeling for communion.

“I probably spent two hours a day crying because the pain was so bad,” she recalls of that difficult period in her life.

As a licensed captain in the United States Coast Guard, Flournoy had always been active and led chartered yacht excursions on inland waters and in the Caribbean. She previously had two shoulder replacement surgeries at UAB Medicine, so she turned to Elie Ghanem, MD, for knee replacement surgery on both knees. It couldn’t have happened at a better time.

 

The Case for Change

For more than a year, UAB Medicine frontline nursing staff had been working to find ways to better help patients following orthopaedic surgery. Many patients had difficulty with the patient-controlled analgesia (PCA) pumps, and their pain was not well controlled. The nursing staff sought assistance from UAB Care, a division of the UAB Medicine Quality and Patient Safety Department.

UAB Care’s Laura Leal, MSN, RN, spearheaded a project to find better ways to care for patients specifically following elective knee and hip replacement surgeries. She assembled a multidisciplinary team that included Dr. Ghanem as the physician lead; Will Potter, MD, as the anesthesia lead; inpatient and ambulatory nurses; physical therapists; and pharmacists. The team studied current literature and best practices for post-operative pain management, including orthopaedic-specific policies and anesthesia guidelines.

“Our research helped us determine that a multimodal approach to pain management is the favorable pathway for these patients,” Leal says.

Some of the standards of care introduced by the group include:

  • Using spinal rather than general anesthesia to reduce complications and help with pain.
  • Changing the location for nerve block placement.
  • Replacing PCA usage with multiple medications that attack pain differently.
  • Working with patients to get them standing and moving on the same day as the surgery.
  • Revamping pain education so that patients fully understand their treatment plan
Pam Flournoy

“Patients are reporting improved pain control using the multimodal pain protocol and anesthesia blocks that preemptively alleviate pain,” Dr. Ghanem says. “They are consuming fewer narcotics with fewer side effects from those medications, which also helps minimize narcotic dispensing postoperatively. Patients are able to get moving much faster and do physical therapy the same day, which gets the muscles recovering faster. In general, it's faster recovery with less pain and need for narcotics.”

Flournoy says the patient education component helped her better understand the care plan and work through the pain. “Knowing when my next pain medication was coming was helpful,” she says. “You knew that every two hours something different wore off. They had staged it so that every two hours there was a different pain medicine, so we were always on top of the pain. We never really let it get bad. My care team made me comfortable at every turn.”

Positive Results

Reducing variations in care and following new evidence-based care standards are making a positive difference for UAB Medicine patients. In the eight months since implementation:

  • Less than 1% of patients have needed a PCA pump to control pain, compared to 93% prior to implementation, thus reducing the amount of opioid pain medication patients need.
  • 84% of patients are being mobilized on the same day as surgery.
  • A patient who has undergone a knee or hip replacement surgery can go home an average of one day sooner.

“Both clinic and inpatient staff say that their patients don’t hurt as much, that they are much more active, and that this new plan just works,” Leal says.

River Ride

Patients are recognizing the positive changes, too. “I believe that the procedures Dr. Ghanem used were a part of my fast recovery,” Flournoy says. “It’s the difference in going to a boutique and going to a box store. You would think you are going to a box store when you go to a hospital the size of UAB, but my experience was like a boutique. The whole care team listened to me, from my nurse, Amy, who felt like part of my family, to the person setting up my therapy and the physical therapists. They didn’t just treat me like a person with knee replacement surgery. They treated me like me. It was all extremely personalized, and I can’t say enough about that.”

 

Getting Back to Normal

Tubing

Flournoy is resuming her active lifestyle by biking and swimming several times per week. She says she can’t imagine what life would be like without the surgery, and she recounts the moment when she knew things were back to normal.

“I went tubing behind a boat. I haven’t tubed since I was 30 years old, and I’m 62,” she says. “They slung me from one end of the lake to the other behind that boat. I actually texted Amy, my nurse, and said, ‘You’re not going to believe it, I actually tubed today.’ She texted back and said, ‘Boom! You’ve got your life back.’”