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Innovative end-to-end total arthroplasty care

By: Rowena Chona O. Sano, MSN, BSChE, RN, CNL, CPHQ, CQA(ASQ), CLSSBB, and Caroline Kihunah, MSN, RN-BC

An improvement project reduces surgical site infections.


  • Establishing an end-to-end care process involves collaboration with the patient, clinical coach (family/support system), the multidisciplinary team, and all the facilities involved.
  • Reducing surgical site infections starts with recognizing pre-surgical risks and home environment conditions to ensure patients are optimized before surgery and establishing a conducive post-acute discharge environment.

JOINT INFECTION after arthroplasty can be devastating, requiring long-term antibiotics, additional surgery, and pain management, and it can lead to disability. Infection also can result in out-of-pocket expenses, time away from work, and reliance on caregivers.

Hip and knee arthroplasty are high-cost, high-volume surgeries, and the Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention, and the Institute of Healthcare Improvement have targeted them for surgical site infection (SSI) prevention. Studies estimate that one infection after hip arthroplasty can cost a hospital $100,000; $60,000 after knee arthroplasty. Standardized infection ratios (SIRs) reflect the rate of actual observed SSI to expected SSI and are publicly reported by the National Healthcare Safety Network (NHSN).

In 2016, leadership at Memorial Hermann Greater Heights Hospital in Houston saw an opportunity to improve SIRs for total hip arthroplasty (THA) and total knee arthroplasty (TKA) and formed a project team to review and improve processes.


A project charter was developed to create an end-to-end patient care process to prevent SSI after THA and TKA. Outcome objectives were defined as:

• prevent any new infections for the next 6 months (short term)
• reduce SIRs for THA and TKA to the 25th percentile by May 2017 (hip)/July 2017 (knee) via patient-centered care.

The project followed the Plan-Do-Check-Act/Adjust quality improvement process.


Plans and timelines were developed for the Knee Arthroplasty/Hip Arthroplasty Care Continuum Project. The chief operations officer served as executive sponsor, and the Memorial Hermann Orthopedic and Spine Hospital Joint Center (Joint Center) medical director and nurse navigator served as process owners.

In September 2016, a project team was formed and included the chief nursing officer, chief medical officer, joint surgeons, surgical services director, pre-admission testing charge nurse, Joint Center nurse navigator, infection preventionist, rehabilitation director, and representatives from the quality department, case management, home healthcare, and other post-acute care departments. The senior patient safety specialist (who has a Lean Six Sigma Black Belt) served as the project facilitator.

The project scope was limited to elective THA and TKA patients, for all payer types. Nonelective/trauma patients, nonorthopedic surgeries, and surgeries on joints other than the knee and hip were excluded.

A first step involved redefining the process flow, beginning when a patient first meets a surgeon to discuss a THA or TKA and ending approximately 90 days after surgery. (See End-to-end patient care algorithm.) The new process was defined in six timeframes.

Timeframe 1
The pre-visit stage, an existing process, was integrated into the continuum of care and begins when a patient calls the number posted on the Joint Center website or contacts a provider’s office based on a referral.

Timeframe 2 (more than 30 days preop)
The surgeon and his or her office collaborate with the patient’s provider and the Joint Center. Two new screening forms were developed and introduced at this stage:

A total joint risk assessment (TJRA) completed by the surgeon or clinician to identify SSI risk factors and help optimize the patient before surgery (ensure he or she is in the best condition possible before the operation), and a home assessment completed by the patient. The nurse navigator reviews and evaluates both forms to identify concerns that might affect the patient’s recovery. Also, at this stage, referrals are made to home health for a physical therapy or social work visit as needed.

Quarterly coordination meetings with provider offices are conducted to provide opportunities for buy-in and feedback, and coordination was established with the hospital’s business office to ensure clearly defined requirements to prevent unnecessary treatment delays.

Timeframe 3 (15 to 30 days preop)
Referrals are generated to home health, case management, and social work for high-risk patients identified through the home assessment. High-risk factors include limited social support from family and friends, frequent fall history within the last year, cognitive impairment, living alone, severe mobility impairment, and presence of young children or pets.

Timeframe 4 (14 days preop)
Patients attend Joint Camp and surgery clearance is confirmed. Joint Camp is an in-person class that coincides with patient registration and preoperative diagnostic testing. Virtual attendance with a remote conferencing app is provided for patients who aren’t physically able to attend. As part of the new process, Joint Camp was moved from 1 week to 2 weeks before surgery to allow adequate time for patient education and optimization. Other Joint Camp changes include mandatory attendance for first-time surgery patients and for those who had joint replacement more than 2 years before or who are having a different joint surgery.

In addition to standardized education for joint surgeries, patients receive individualized teaching based on needs identified during screening. Patients also meet with the multidisciplinary team, which answers questions about rehabilitation and home health services. Patients report that this interaction helps reduce their anxiety on the day of surgery. Discharge care (home with outpatient therapy, home with home health therapy, or skilled nursing facility [SNF] placement) is arranged. SNF is recommended for patients living in home environments that aren’t conducive to postop care based on the home health preop assessment visit. Post-acute care service and case managers collaborated to develop a criteria-based list of preferred home health and SNF agencies.

Timeframe 5 (surgery day)
The preop nurse performs presurgery cleansing with preop “nose-to-toes” disinfection (including povidone-iodine nasal swab application and a third cycle of chlorhexidine cleansing bath). During Joint Camp, patients learn about the “nose-to-toes” process and why it’s important.

Timeframe 6 (1 to 90 days postop)
Patients are admitted to the Joint Center for postop care, and the multidisciplinary team evaluates and recommends patients for discharge. Patients and their families make decisions as to the location of post-acute care, based on recommendations from the team. The nurse navigator calls patients at least five times after discharge: 24/48 hours after discharge; 8 to 15 days after, depending on the first follow-up visit with the surgeon; and 30, 60, and 90 days after discharge. At each call, the nurse navigator asks a series of specific questions about the surgical site and dressing, pain management, mobility, deep vein thrombosis prophylaxis treatment, and physical therapy and provider visits. Follow-up also is based on any identified risk factors; concerns are reported to the surgeon or provider.


With patients’ consent, the nurse navigator enrolls patients in My Health Advocate, a free app that monitors patients 7 days before and 30 days after surgery, to support preop and postdischarge follow-up processes. The app provides patients with consistent and personalized communication with their clinicians about their condition and how to manage it. Patients have 1 year of access to the app, with follow-up calls from the nurse navigator at 90, 180, and 365 days after surgery.

In addition, an enhanced nurse navigator role was established with responsibility for managing the program to ensure that new processes are implemented. The nurse navigator manages the end-to-end care process for THA and TKA and is key to preop assessment and postop follow-up. The role includes coordinating and maintaining Joint Commission certification for the Joint Center.


Monitoring of process compliance included completion of TJRA and home assessment forms; home assessment visits; Joint Camp participation 2 weeks before surgery; “nose-to-toes” disinfection documentation; patient discharge disposition with outpatient/ home health physical therapy; and post-discharge follow-up calls.

Significant improvements in both SIR and SSIs were made. For example, the SIR rate decreased to 0.00 for TKA and 0.75 for THA as of April 2018. (See Project results.)


Orthopedic surgeons adopted hard stops (surgery cancellation) and soft stops (surgeons evaluate individual patients for postsurgery infection risk) as recommended by the project team based on issues identified during project implementation. Indications for hard stops include body mass index (BMI) > 45 or < 20 (BMI > 40 is a soft stop), albumin < 3 g/dL, hemoglobin A1c > 7.5% (patients with diabetes), and preop (day of surgery) glucose level > 350 mg/dL. Smoking cessation is required 30 days before surgery (nicotine tests are performed to validate) and recommended for 90 days after. Throughout the project, compliance with the new process improved, even after handing it off to new process owners in August 2017.


Challenges encountered during implementation of the new process included time working with providers and office staff to conduct the screening process and ensure home assessment forms were completed by all patients; collaborating with provider office staff to ensure adequate lead time for patient screening, optimization, and preparation; and coordinating and following up with post-acute providers (SNF, home health) to ensure implementation of individual agreed-upon plans of care.

The nurse navigator addressed potential issues and process deviations with all of the stakeholders to assess and evaluate the effectiveness of any changes.

Practice implications

The end-to-end care process was developed in response to recent CMS mandates for elective TKAs. As many of these surgeries transition to same-day procedures, this process will be critical to ensuring adequate presurgical patient preparation and optimization while still maintaining positive outcome measures such as reduced SSIs, length of stay, and readmissions.

Project outcomes at this hospital demonstrated how a multidisciplinary approach can support an end-to-end care process for total arthroplasty patients. Factors contributing to its success included leadership involvement and interprofessional participation. Overall management and coordination by a nurse navigator and project facilitator supported hardwiring the process into the organization. Preoperative screening, optimization, and postop evaluation of patient progress can be adopted for any elective surgery procedure.


At the time this article was written, Rowena Chona O. Sano was manager of clinical projects at Memorial Hermann Greater Heights Hospital (MHGH) in Houston. Caroline Kihunah is an orthopedic nurse navigator in the MHGH Joint Center.

Selected references

Berbari EF, Osmond DR, Lahr B, et al. The Mayo prosthetic joint infection risk score: Implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol. 2012;33(8):774-81.

Johnson R, Jameson SS, Sanders RD, et al. Reducing surgical site infection in arthroplasty of the lower limb: A multi-disciplinary approach. Bone Joint Res. 2013;2(3):58-65.

Premier, Institute for Healthcare Improvement. Integrated care Pathway for Total Joint Arthroplasty. 2013.

Ward KT, Reuben DB. Comprehensive geriatric assessment. UpToDate. July 2019.


  • Would the authors of the article be willing to share their pre-surgical forms- the TJRA and home assessment questionnaire?

  • Cynthia Saver
    November 5, 2019 4:41 pm

    Thank you for your comment, Betty. There was a typo in the algorithm, which has now been corrected.
    Cynthia Saver, MS, RN, Editorial Director, American Nurse Today

  • Hello, thanks for the article. I am on the Nevada HAI prevention committee and one type of infections that we are working to prevent are Hip replacement infections.

    I have forwarded your article to: Kimisha Causey, MPH Health Program Specialist II who can be contacted at:
    Nevada Department of Health and Human Services
    Division of Public and Behavioral Health | Office of Public Health Informatics and Epidemiology
    3811 W. Charleston Blvd, Suite 205 |Las Vegas, NV 89102
    T: (702) 486-3568 |F: (702) 486-0490|E: | OPHIE online

    Thank you for the article that we will use to reduce infections in Nevada.

    Norman Wright, RN, BSN, MS

  • I am confused by the algorithm.
    CThe algorithm says Patient discharge to home then No then Patient needs home health and then a yes leads to SNF. It seems that if the answer is yes it should be refer to home health and if no then one line to home with outpatient services or no services and one line with refer to SNF.

  • Elaine Stecker-Kochanski
    October 15, 2019 9:00 pm

    I oppose pushing for these joint replacement surgeries to become same day surgeries, or discharge within 24 hour surgeries. I think some of the tasks requiring coordination between surgeon and surgical office staff, hospital staff, home care staff and families could be reduced if the patient just stayed in the hospital with professional nursing and medical observation and care for several days. I think infection prevention and pain management would be better, and with family caregivers observing the care needed they would be more confident in taking the patient home. I state this as someone who has had knee replacements and who worked for many years in home care after some years in hospital care.

Comments are closed.

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