Running head: PRE-OPERATIVE EDUCATION IN TOTAL KNEE 1

Pre-operative Education in Total Knee Arthroplasty and Length of Hospital Stay

Miranda L. Csontos

State University of New York Polytechnic Institute

PRE-OPERATIVE EDUCATION IN TOTAL KNEE 2

Abstract

Total knee replacements are becoming one of the most common elective surgery in the

United States. It is thought by many that the sooner patients can return to their own home the

better the outcomes. While a prevalent surgery research on the effects of postoperative education

and patients' outcomes is scarce. The author compares the length of stay between participants

who chose to have preoperative education and those who chose not to participate at an Upstate

New York Hospital. The study was conducted over a one year period, with the hospital's

previous year's average length of stay also calculated. Once data was collected, a t-Test was used

to analyze the data. Results will be displayed in table form, comparing the two independent

groups with each other and the prior year's length of stay.
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 3

Pre-operative Education in Total Knee Arthroplasty and Length of Hospital Stay

Background and Significance

Osteoarthritis is a disease that can be treated conservatively at first, but over time requires

surgical intervention for relief of pain and return of mobility. Total hip and knee arthroplasty are

common elective treatments for those who suffer from osteoarthritis. An arthroplasty is a

surgical procedure used to restore joint function, most commonly by the insertion of an artificial

joint or prosthesis (Arthroplasty, retrieved 2017).

According to Wengler, Nimptsch & Mansky (2014) there was a total of 702,415 knee

arthroplasties completed in the United States in 2011. When this number is compared to the

465,034 total hip arthroplasties completed in 2011, the prevalence of the total knee arthroplasty

is obvious which is why this proposal will focus on total knee arthroplasty. Like any surgical

procedure, complications can ensue; many of these complications can lead to an increased length

of hospital stay (LOS). Length of hospital stay is the number of days from admission to

discharge that a patient spends in the hospital. With the rising demand for total joint

replacements, there is an increased financial burden which means there is risk for increase in

complications and length of stay (Tait, Dredge, Barnes, 2015).

Preparing a patient for knee arthroplasty during the pre-operative phase does not just

begin once they walk through the door. Many patients attend a "joint academy" or "joint school"

about a week before their scheduled surgery. Hoping to maintain efficiency while providing the

highest quality of care, such programs were started on the principle that pre-operative

preparation may reduce stress and anxiety which will thus transfer to faster recovery and

decrease length of hospital stay (LOS) (Yoon et al.,2010).

PRE-OPERATIVE EDUCATION IN TOTAL KNEE 4

Furthermore, the use a set education plan will help prevent results from different facilities

being biased. Lastly, the majority of the current research regarding knee arthroplasty is United

Kingdom based so this proposal will be an American based proposal.

Problem Statement

In order for patients to receive high quality care, healthcare professionals must remain

committed to evidenced based practice. After reviewing the literature using key phrases such as

"pre-operative education" "length of hospital stay" and "hip and knee arthroplasty" it became

obvious that much of the literature was ten or more years old. Even literature reviews published

within the last two years reviewed literature from the late 1990's to early 2000's. This literature

does have a strong lean towards there being no effect on pre-operative education and LOS.

However, when evidenced based practice is no longer current, it is an indication that new

research is needed.

Throughout the literature search, a great deal of literature was devoted to the correlation

between pain management and complications or overall outcomes. While there is current

literature on LOS in the total knee arthroplasty population, the current research does not use pre-

operative education as a factor effecting LOS. This is why new literature that looks at

standardized education and LOS in total knee arthroplasty is needed.

Purpose of the Research

Given the above problems, the purpose of this research proposal is to determine if there is

a current correlation between pre-operative education and length of stay, specifically in total

knee arthroplasty. With pre-operative education being a standard of care; up to date evidence is

essential.
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Review of Literature

Literature that Gave the Option of Attending Joint Academy

While many consider pre-operative education the standard of care, the role of pre-

operative education remains slightly controversial. A literature review reveals very limited

studies on the effect pre-operative education has on postoperative outcomes in the total joint

arthroplasty population. Both Moulton, Evans, Starks & Smith (2015) and Tait, Carter & Barnes

(2015) use the method of comparing two groups: those who attended a Joint Academy (JA) and

those who did not before a total knee arthroplasty. The selection of both groups was made the

same, participants were given the choice to attend JA or not. Tait, Carter & Barnes (2015) had

an overwhelming number of participants attend JA (802) as opposed to those who did not attend

(102). Similarly, Moulton, Evans, Starks & Smith (2015) also saw a greater number of attendees,

but the gap between those who chose to attend and those who did not was a smaller margin (85

and 233).

Moulton, Evans, Starks & Smith do not give the specific details of the pre-operative

education used, except that participants sit in on presentations and dialogues with the anesthetist,

physical therapist and occupational therapist. LOS among other variables was analyzed via the

Mann-Whitney and chi-squared tests. Their results concluded that there was a reduced LOS for

the patients that attended what they term Joint School compared to those who did not attend

(3.53 vs 4.27 days, p=0.046).

Tait, Dredge, & Barnes Joint Academy is a daylong activity 7-10 days before the patients

scheduled surgery. Only ten participants are allowed per session. These sessions are run by

salaried hospital employees (care navigators, physical therapists, specialized nurses) who focuses

on teaching about the risks of surgery, pain management, what to expect once in their room, and
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 6

discharge expectations. Patients were highly encouraged to have a family member or friend who

was appointed by their coach to attend the JA with them. Tait Dredge & Barnes found that

participants of the JA had a LOS average of 2.17 in comparison to the 4.28 LOS for those who

did not attend (p< .01).

In conclusion, while both studies offered similarities in their sample method, they

differed in their application of pre-operative education. Even through their differences both

studies found that pre-operative education can shorten LOS for patients.

Literature that Looks at Enhanced Recovery Programs

A relatively new term found in literature is Enhanced Recovery after Orthopedic Surgery

Programs (ERAS), these programs general include education sessions such as JA, specific pain

regimes and additionally they look at any social, medical and nutritional barriers that may need

to be addressed (Moulton, Evans, Starks & Smith,2017). However there is no standard ERAS

protocol as they can vary from institution to institution.

Moulton, Evans, Starks & Smith (2017) published a follow up article to the 2015 copy

discussed above. Utilizing the term ERAS as they assess the impact of Joint School on patient

outcomes for those undergoing a total knee arthroplasty, LOS was the chosen outcome. The

Joint School consists of a 2 hour class of a maximum of ten people as well as a chance to talk

with various members of their care team (physical therapy, nursing). Inclusion criteria were

patients with a planned total knee arthroplasty again it appears attendance at Joint School was

optional. Results found that those 503 that attended Joint School has an average LOS of 4.3

days compared to 4.57 days for the 60 patients who did not attend (p=0.118).

Auyong et al. (2015) looked to update their institutions previous ERAS to an evidence

based ERAS where LOS was the primary outcome measurement. Inclusion criteria was all total
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 7

knee arthroplasty completed at their institution from January 2012 to July 2013. An equal

number (126) represented those underwent the surgery with the existing ERAS and those who

used the updated ERAS. Several changes were made to the existing ERAS including required

pre-operative education class versus optional education class. Results showed that the average

LOS for those is the existent ERAS was 76.6 hours compared to 56.1 hours in the updated ERAS

(p<0.001).

Much like an ERAS Mertes, Raut & Khanduja (2013) implemented what they phrased as

an Integrated Care Pathway (ICP). Much like an ERAS, the ICP encompassed a patient

education program. The education program consisted of an optional two hour education session

taught by a nurse specialist, physical therapist and occupational therapist. All patients at their

institution that had total knee arthroplasty and total knee arthroplasty that was not a revision or a

bilateral extremity surgery were included in the study. Pre ICP patients' data was collected from

September 2007 to January 2008 while post ICP data was collected from September 2008 to

January 2009. Time in between was spent developing and refining the ICP and thus data from

that time was excluded to avoid contamination. The Mann-Whitney U test was used to analyze

the results. Pre ICP LOS was found to be 6.4 days while Post ICP was found to be 5.6 days.

Literature Over Five Years Old

Kearney, Jennrich, Lyons, Robinson & Berger studied 150 patients who underwent either

a total hip arthroplasty or total knee arthroplasty at Advocate Good Samaritan Hospital (2011).

Participants were excluded from the study if they could not read or write in English, had a joint

surgery in the past five years, or if they were transferred to another floor of the hospital

postoperatively for medical reasons. Participants were separated into two groups those: who

attended a structured hospital staff facilitated education class (77) and those who did not (73).
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 8

Again the Mann-Whitney U test was utilized in which a deviation of .848 was found (0.5 was

considered statistically significant) concluding that there was no statistical significance between

taking the educational class and LOS.

Yoon et al. (2010) found that preoperative education significantly reduced length of stay

by one day for both total hip arthroplasty and total knee arthroplasty. Patients who had previous

hip or knee arthroplasty were excluded which left a sample size of 261 participants. Of those

participants, 168 participated in the offered education program while 93 did not. Yoon et al.

education program consisted of a preoperative patient educator reaching out via telephone to

offer a one on one education which could be completed either in person or on the telephone

(2010). If patients agreed to the education they were given a book 60 to 70 pages long titled

"What to Expect" in it preoperative checklist, progress guidelines, discharge instructions and

more were included. Those who accepted preoperative education had an average LOS of 3.1

days compared to 4.1 days when education was declined (p<.0001).

In 2015 Aydin, Kilt, Jacobsen,Troelsen & Husted conducted a literature review of twelve

articles that discussed the effects of preoperative education on hip and knee arthroplasty. While

published within the last two years the articles analyzed were published between the years 1996-

2013, of which one discussed strictly knee replacements, five discussed both hip and knee

arthroplasty and six discussed strictly hip arthroplasty. According to Aydin et al. two studies

showed significant reduction in LOS, seven showed no significance, and three did not evaluate

LOS (2015). Aydin et al. (2015) states that information itself (education) may not fulfill the

functional discharge criteria. However more recent data does show a positive correlation with

preoperative education and decreased LOS. One of the issues being that each organization

modifies the education for their preference so any sense of standardization is lost.
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 9

Research Question

Given the above information, I developed the following research question: with

standardized pre-operative education, would the length of a hospital stay decrease in total knee

arthroplasty? In this setting standardized education means a consistently similar education

program called a joint academy.

Methods

Research Design and Setting

Unlike a true experiment where randomization is a factor, quasi experiments lack

randomization; more specifically use of the nonequivalent control group pretest-posttest design

(Polit & Tatano Beck, 2012). In this type of design, data is collected before and after an

implementation from two groups of participants. Two different groups of patients from one

hospital would be analyzed; one group that does not receive pre-operative education, the other

does; standardized pre-operative education will be the implementation. Therefore the

implementation group will be the group that attends and participates in this specific pre-operative

course. The control group will be the group that does not participate in any pre-operative

education.

An Upstate New York Hospital with full orthopedic services, specifically one that

already uses a form of JA will provide the setting of the study. Full orthopedic services include

orthopedic surgeons, mid-level practitioners, and an inpatient unit equipped with a staff (nurses,

physical therapists, occupational therapists) trained in post-operative care of total joint

replacements. The hospital's average length of stay over the past year for a total knee arthroplasty

will be collected and used as a baseline. Comparing the length of stay between these two groups

will start to prove or disprove the research question.

PRE-OPERATIVE EDUCATION IN TOTAL KNEE 10

Joint Academy Outline

One week before their scheduled surgery date no more than ten patients during a session

will attend the JA. The JA will be taught by nurses, physical therapist and occupational

therapists. After a presentation which is outlined below, patients will have a chance to ask

questions and discuss concerns to the teaching staff and one of the orthopedic surgeons.

JA Outline

I. Welcome
II. Elective Surgery- you are not sick therefore we do not want to keep you in the hospital
long.
III. Recovery- if you live alone, making arrangements to have someone stay with you or
staying with someone. Short term rehab if deemed necessary by physical therapy.
IV. Risks of Surgery
V. Infection
VI. Blood Clots
VII. Pneumonia
VIII. Constipation
IX. Pain Management
X. Expectations:
i. Night before surgery
ii. Morning of Surgery
iii. Day of Surgery
XI. Pre-Op
XII. Intra-Op
XIII. Post-Op
XIV. Open Forum

Adapted from Tait, Dredge & Barnes, 2015

Procedures

Upon approval of the Institutional Review Board and the hospital's own ethics committee

all patients who undergo a total knee arthroplasty will be identified. Patients will be asked after

deciding to undergo a total hip arthroplasty if they wish to be a part of the study. If they agree to

take part in the study, they will not receive compensation and they will have to sign a consent

form. Patients will then have the choice to receive pre-operative education or not. As a result

they will be separated into their respective groups. Due to the fact that this study is aiming to
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 11

discover if pre-operative has an effect on LOS, patients who do not participate may have a

greater risk of increased LOS, but that has yet to be proven. Exclusion criteria will consist of if

patients have had prior joint surgery, have diabetes, COPD or heart disease. The study will run

for one full year, with the first 100 that meet the criteria being included.

Hospital staff (nurses, physical therapists, and occupational therapists) that participates in

pre-operative education will have to complete an education session that discusses the concepts

and outline of the course so that they can effectively teach. While staff that care for patients in

the post-operative setting will be aware of the study their care during the post operative period

will not change.

Measurement Instruments

When patients attend the JA they will have to sign an attendance sheet to track that they

did actually attend. Two individuals will be assigned to track a patient's LOS, one individual

will follow those who attended JA and the other will follow those who did not. Patients will be

followed by their medical record number and all other identifying information will be removed.

While numbers are a valid instrument, the reliability of those numbers depends a great deal on

the individuals collecting the data. Therefore random individuals should not be selected but more

volunteers who have no stakes in the outcomes. However validity may be affected given the

small sample size of this study. One individual will obtain the hospital's previous year's average

LOS. All data will be processed in Microsoft Excel.

Analysis

Because t-Tests are parametric, with a sample size of 100 it should be a large enough

sample to assume normal distribution. Specifically a t-Test of independent groups would be

used to determine if the mean of two independent groups are significant different from each
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 12

other (Poilt & Beck, 2012). The two independent groups would be those who attend the

educational class and those who do not with the dependent variable being length of stay.

Limitations

With technology being a major part of day to day activities, patient's now have access to

different resources via the internet. One limitation of this study is that even if a patient declines

the JA they may still research information on their own. These patients also may ask others who

have gone through a similar surgery about what to expect. Due to this limitation, the second

group will not represent a true control group. The second group could potentially go into the

surgery with uncontrollable biases. The second limitation is that patients an overwhelming

amount of patients could chose to attend JA instead of not. Patients are trending more towards

giving themselves all of the education available especially with an elective surgery.

Dissemination of Findings

Any findings from this study would be presented at the study's housing hospital via an

open form surgical and nursing grand rounds. Here one of the staff members who are

participating in the study would present the research design, procedures and results. There will

also be an allotted time at the end of the presentation for discussion and questions. If the findings

were favorable that pre-operative education decreased LOS the findings should also be shared

with patients coming into clinic for a total knee arthroplasty.

If applicable the steps towards publication would also be taken with a peer review. As

this was a nursing driven study any nursing research conferences would also be appropriate for

presentations.
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 13

Conclusion

Based on the previous research it is suspected that the results of the proposed study

would show a positive effect on LOS when pre-operative is provided. For nursing this means

short hospital stays which allows for more beds for patients who are truly sick. For patients this

could mean better outcomes and a decrease in post operative complications.

PRE-OPERATIVE EDUCATION IN TOTAL KNEE 14

References

Arthroplasty. (n.d.). Retrieved March 06, 2017, from

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=92&contentid

=P07677

Auyong, D. B., Allen, C. J., Pahang, J. A., Clabeaux, J. J., MacDonald, K. M., & Hanson, N. A.

(2015). Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients

Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. The

Journal Of Arthroplasty, 301705-1709. doi:10.1016/j.arth.2015.05.007

Aydin, D., Kilt, J., Jacobsen, S., Troelsen, A., & Husted, H. (2015). No major effects of

preoperative education in patients undergoing hip or knee replacement- a systemic

review. Danish Medical Journal, 62(1), 1-5.

El Bitar, Y. F., Illingworth, K. D., Scaife, S. L., Horberg, J. V., & Saleh, K. J. (2015). Hospital

Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide

Inpatient Sample Database. The Journal Of Arthroplasty, 301710-1715.

doi:10.1016/j.arth.2015.05.003

Fawcett, J., & Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of

nursing models and theories. Philadelphia: F.A. Davis.

Kearney, M., Jennrich, M. K., Lyons, S., Robinson, R., & Berger, B. (2011). Effects of

preoperative education on patient outcomes after joint replacement surgery. Orthopaedic

Nursing, 30(6), 391-396. doi:10.1097/NOR.0b013e31823710ea

Mertes, S., Raut, S., & Khanduja, V. (2013). Integrated are pathways in lower-limb arthroplasty:

are they effective in reducing length of stay? International Orthopaedics , 37(6), 1157-

1163. doi:10.1007/s00264-013-1829-1
PRE-OPERATIVE EDUCATION IN TOTAL KNEE 15

Moulton, L., Evans, P., Starks, I., & Smith, T. (2015). Pre-operative education prior to elective

hip arthoplasty surgery improves postoperative outcome. International Orthopaedics , 39,

1483-1486. doi:10.1007/s00264-015-2754-2

Moulton, L., Evans, P., Starks, I., & Smith, T. (2017). Preoperative education prior to elective

knee athroplasty surgery does not change patient outcomes. Musculoskeletal Care, 1-4.

doi:10.1003/msc.1177

O’Shaughnessy, M. (2014). Application of Dorothea Orem’s Theory of Self-Care to the Elderly

Patient on Peritoneal Dialysis. Nephrology Nursing Journal, 41(5), 495-498.

Polit, D. & Beck, C. (2012). Nursing Research: Generating and Assessing Evidence for

Nursing Practice (9th ed.). New York: Lippincott Williams & Wilkins.

Tait, M. A., Dredge, C., & Barnes, C. L. (2015). Preoperative Patient Education for Hip and

Knee Arthroplasty: Financial Benefit?. Journal Of Surgical Orthopaedic Advances, 24(4),

246-251.

Wengler, A., Nimptsch, U., & Mansky, T. (2014). Hip and Knee Replacement in Germany and

the USA. Deutsches Aerzteblatt International, 111(23/24), 407-VI.

doi:10.3238/arztebl.2014.0407

Williams SN, Wolford ML, Bercovitz A. Hospitalization for total knee replacement among

inpatients aged 45 and over: United States, 2000–2010. NCHS data brief, no 210.

Hyattsville, MD: National Center for Health Statistics. 2015.

Wolford ML, Palso K, Bercovitz A. Hospitalization for total hip replacement among inpatients

aged 45 and over: United States, 2000–2010. NCHS data brief, no 186. Hyattsville, MD:

National Center for Health Statistics. 2015.

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Yoon, R. S., Nellans, K. W., Geller, J. A., Kim, A. D., Jacobs, M. R., & Macaulay, W. (2010).

Patient Education Before Hip or Knee Arthroplasty Lowers Length of Stay. The Journal

Of Arthroplasty, 25547-551. doi:10.1016/j.arth.2009.03.012