There exists a paucityofresearchregarding the role ofOT withelective totaljoint replacement (TJR) patients.Determiningthis rolewill helpsupport furtherOT research onefficacyand bestpractice within this population.There appears to exist a significant variation in the clinical practice of OT’s within the elective TJR population.(Muninet 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)(Centersfor Disease Control and Prevention, 2010).2009:75% of TJR patients receivedsome form of post-acuterehab:home-based therapyskillednursingfacility,acute/intensive inpatientrehabilitationprogram(Dejonget 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)
Meta-analysisofdata determined onlyweak evidencesupportsthe benefits ofOT intervention for elective THR patients(College of Occupational Therapists: Specialist Section, Trauma andOrthopaedics, 2012).Evidencesupportsthe involvement ofOT’sduring thepre-opeducational process(Couteyreet al, 2007).Research suggests criteriaford/cfrom the hospitalinclude that patients:Are able to perform self-care, including med-managementAre able to understand the signs and symptoms indicating return to the hospitalAre able to perform ADL’s with minimal assistanceResearch does not report who determines whether or not these goals are met.(Raphael et al, 2011)
Studyof elective TJR patients inNorwayrevealed thatrehabthere typically includedPT andmedical interventions by a doctor, but not alwaysOT orsocial services interventionsIt was found that patients reported un-addressed difficulties with activities of daily living and home-related activities(Grotleet al, 2010).
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)
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.
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.
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=109 OT’s, 1 COTA’4 Full-time, 4 Part-time, 2 PRNOf these, 8 had worked at some point in another treatment setting (SNF, outpatient, home health,peds, mental health, or inpatient rehab).
Preliminary Results: Demographics
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.
Percent ofOTdeptsthat 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 shoehorn60%: 3-1 commode, dressing stickAnterior THR: 50%100%: elevated toilet seat, shower chair/tub bench25%: 3-1 commode,reacher, sock aid, long sponge, long shoehorn, dressing stickPosterior THR: 100%100%:Reacher, Sock aid80%: 3-1 Commode, Shower chair/tub bench, long sponge60%: elevated toilet seat, long shoehorn30%: dressing stick20%: leg lifter, elastic laces
Percent of respondents thatpersonallyissued/recommend certain AE/DME as standard to ALL patients:TKR: 30%100%: Shower chair/tub bench,reacher66%: elevated toilet seat, sock aid, long sponge, long shoehornAnterior THR: 70%71%: elevated toilet seat, shower chair/tub bench,reacher, sock aid57%: 3-1 commode, long sponge, long shoehorn28%: dressing stickPosterior THR: 80%100%:Reacher, sock aid75%: 3-1 commode, elevated toilet seat, shower chair/tub bench, long handle sponge62%: long shoehorn38%: leg lifter, dressing stick25%: elastic laces
Discharge Recommendations: TKR
Discharge Recommendations: Ant THR
Discharge Recommendations: Post THR
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.
Respondents spent more time on ADL’s and transfers, than on ambulation. No time was spent on exercise for any populations.OTdeptsissued 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.
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.
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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