Prevent rapid responses after total joint replacement.

Elective total joint replacement surgery has revolutionized the treatment of arthritis as one of the most successful orthopedic interventions, with fast-track joint replacement programs (replacing extended periods of bed rest) becoming the gold standard. These programs, which initiate physical therapy on postoperative Day 0, have yielded positive outcomes related to patient experience and decreased morbidity. Key objectives include early mobilization as a critical component of the interprofessional postoperative care plan. Evidence suggests a link between early mobility and decreased morbidity, lower incidence of postoperative pneumonia, and reduced risk for deep vein thrombosis as well as other postsurgical complications.

Significant challenges to early mobilization after joint replacement include postoperative orthostatic hypotension (OH), a sustained reduction in the systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg within 3 minutes of standing after being supine for 5 minutes. OH can adversely affect patient experience, participation in physical therapy, patient safety, and length of stay. Anastasio and colleagues note that this increase in length of stay is a key driver of increased cost. Among patients who’ve received a total joint replacement, orthostatic intolerance can hinder postoperative mobilization, which negatively impacts other outcomes and quality indicators. Contributors to OH include anesthesia, medications, decreased oral intake, reduced mobility, I.V. fluid administration, and sedation.

Smits and colleagues estimate the prevalence of OH after total hip replacement at between 40% to 50%. A 2013 study by Bundgarrd-Nielsen and colleagues noted that many incidents of OH occurred within 6 hours after surgery. Recent reviews highlighted an increased number of rapid response calls attributable to OH. Effective prevention and management of OH supports early mobilization and improves patient outcomes.

A multidisciplinary team (including the nurse manager, assistant nurse manager, clinical nurses, and the patient safety nurse) implemented a quality improvement (QI) project at a 293-bed, tertiary-level, acute care, non-academic hospital located in Westchester County, New York. The project aimed to identify and prevent OH in patients after total joint replacement to ultimately reduce acute rapid response events and enhance overall patient care.

The situation

The QI team conducted this project on a specialized, 28-bed orthopedic nursing unit. In 2021, the hospital performed 267 total arthroplasties (117 hip and 150 knee). The average length of stay for total joint replacement patients in 2021 was 2.75 days for knees and 1.98 days for hips.

A comprehensive review of patient charts, combined with interdisciplinary clinical feedback, identified 11 rapid response activations related to OH in the total joint replacement patient cohort. All events occurred within 24 hours after surgery, prompting a detailed review into the underlying contributing factors.

The literature review

The team conducted a comprehensive literature review to identify evidence-based practices aimed at decreasing postoperative OH in patients undergoing joint replacement surgery. The review included studies of adult patients (18 years and older) who underwent elective total hip or knee replacement. Several articles highlighted similar trends and potential areas for performance-improvement initiatives.

The literature consistently demonstrated the well-documented occurrence of OH in this patient population. Notably, according to Skarin and colleagues, OH frequently occurs within 24 hours after surgery. According to Kurkis and colleagues, prevention strategies typically center on evidence-based practices related to fluid volume management.

Bundgaard-Nielsen and colleagues and Skarin and colleagues describe pharmacologic agents known to contribute to OH, including vasodilators, antihypertensives, diuretics, antidepressants, and opioid medications. Swope and Adams noted that postoperative medication combinations also may increase the risk for OH.

Bundgaard-Nielson and colleagues highlighted the opportunity for adopting a more proactive approach to managing fluid volume status in patients after total joint replacement. Although the incidence of OH is well-documented, Skarin and colleagues noted the limited research exploring the associated risk factors.

The project

This QI project aimed to decrease the incidence of rapid response activations in this patient population by transitioning from a reactive model of care to a proactive, preventive model. The team followed the Plan-Do-Study-Act cycle to guide their evidence-based QI efforts.

The team initiated a baseline, pre-intervention, and retrospective chart review process of all total hip and knee replacement patients in which a rapid response occurred postoperatively. This review, with the goal of identifying factors potentially contributing to these activations, included a comprehensive analysis of patients’ past medical histories, lab results, vital signs, intake and output, and medication administration records in the postoperative period. The QI team developed a data-tracking spreadsheet to document and evaluate trends.

Chart audit reviews revealed no relationship between episodes of postoperative OH and hemoglobin levels, co-morbidities, or postoperative pain-management interventions. Key clinical findings leading to activation of a rapid response included dizziness, nausea, pallor, fainting, heat, and changes in vital signs or mentation. The team also noted that all rapid response events occurred within 24 hours after surgery.

According to hospital policy, criteria for initiating a rapid response intervention include an acute change in mental status, level of consciousness, systolic blood pressure less than 90 mmHg, heart rate below 40 beats per minute or above 150, respiratory rate less than 8 breaths per minute or above 28, chest pain, oxygen saturation less than 90% despite oxygen therapy, urinary output less than 50 mL in 4 hours, or clinical staff concern. A review of the documentation identified an opportunity to implement more precise assessment and management of fluid volume status in this patient population.

The interventions

The QI project team designed interventions focused on prevention and patient monitoring and assessment by tracking data trends such as decreases in blood pressure, pattern of oral intake, and adequate urinary output. Before implementation, the team developed and presented an action plan to the orthopedic committee (which includes nursing leaders, orthopedic surgeons, clinical educators, data analysts, advanced practice providers, infection control nurses, an outpatient orthopedic practice administrator, a holistic nurse, physical therapists, the medical director of the hospitalist program, the medical director of anesthesia, and care managers) for discussion and approval by key stakeholders.

Discussion centered on metrics related to postoperative rapid responses, case reviews, evidence-based intervention evaluation, and the proposed implementation plan. The QI team aimed to ensure a comprehensive understanding of the factors contributing to rapid response activations and to establish a consensus regarding effective preventive strategies.

Patients participate in both preoperative and postoperative Enhanced Recovery After Surgery protocols; however, the QI team observed variability in postoperative fluid volumes and oral intake. To address this issue, the team recommended a fixed oral and I.V. fluid volume along with proactive assessment of orthostatic vital signs early in postoperative Day 1 with a repeat at 12:00 pm. Additionally, as described by Swope and Adams, the team initiated close monitoring of the patient’s intake and output to evaluate hydration status.

The QI project team created a modified version of an evidence-based clinical protocol, which begins when the patient arrives on the inpatient orthopedic nursing unit. Nurses performed a clinical assessment on arrival and at every shift to evaluate the patient’s level of consciousness and sedation, assess for nausea or emesis, and test swallowing ability. Patients who met the criteria—awake, able to swallow, and no nausea or emesis—continued with the protocol.

The protocol elements included continuous I.V. fluid therapy overnight until at least 9:00 am on postoperative Day 1; 500 mL of oral intake on the evening of surgery and on postoperative Day 1starting at 6:00 am; and measurement, documentation, and monitoring of oral intake and urinary output. These measures aimed to facilitate early detection of potential fluid volume deficits. Nurses implemented orthostatic vital signs at 8:00 am and 12:00 pm on post-operative Day 1 only. They then proactively communicated their assessments to the responsible provider for timely adjustments in fluid orders and administration of fluid boluses as clinically indicated.

The QI team created a protocol worksheet detailing nurses’ responsibilities to verify completion of all protocol elements, assess patient goals, and review protocol progress during daily interdisciplinary discharge rounds. For easy access, the team made the worksheet available at the nurse’s station, attached it to the patient’s Situation-Background-Assessment-Recommendation report sheet, and included it in the nursing shift-to-shift handoff. (See Protocol worksheet.)

Upon discharge, the RN placed the completed form in a designated area for clinical review, tracking, and trending of hypotension and rapid response interventions. Critical to the success of this initiative included the designation of day and night shift nurses as Orthostatic Hypotension Prevention Champions. These champions facilitated ongoing team education and peer support. In addition, they ensured that all patients with total joint replacements participated in the protocol unless excluded. Exclusions included patients admitted to critical care postoperatively, those unable to tolerate oral intake, and those who couldn’t be mobilized as well as at the providers discretion.

The education plan

The interdisciplinary orthopedic committee developed a comprehensive education plan to address OH and its management. Education began with detailed reviews of orthopedic cases involving patients who experienced OH and required rapid response interventions. The team then introduced the protocol to the units and reviewed it in detail.

Ensuring that learners understood the connection between the protocol and the prevention of rapid responses resulting from OH proved critical to the success of the education plan. Competency reviews conducted for unlicensed assistive personnel focused on the assessment of orthostatic vital signs. Established criteria for discontinuation of the orthostatic vital sign assessment included symptoms such as dizziness, blurred vision, nausea, or change in vital signs. Unlicensed assistive personnel also learned how to recognize these symptoms and immediately notify the primary nurse, which would prompt a nursing assessment and subsequent provider notification.

Members of the QI team conducted education sessions during departmental staff meetings, unit-based huddles, other training events, and orthopedic committee meetings. In addition, nurses attended physical therapy huddles to provide education and gather ongoing feedback regarding the project. Weekly unit leadership updates, communication during departmental staff meetings, and unit-based huddles proved pivotal to maintaining staff engagement and ensuring protocol adherence.

The results

As a result of this QI initiative, the hospital saw a substantial reduction in the activation of rapid response for patients who underwent total joint replacement surgery. After providing targeted education and implementing the new OH protocol, the QI team conducted a series of chart audits to ensure adherence to the revised protocol.

In addition, the team systematically tracked and analyzed comprehensive data metrics concerning rapid response occurrences within this patient cohort. Initially, the data indicated 11 rapid response events. However, postintervention analysis showed no rapid responses attributable to OH during the first year. Continued monitoring and chart reviews of rapid response incidents confirm ongoing success.

The nursing implications

The meticulous monitoring of hydration status in patients undergoing total joint replacement aids in mitigating the risks associated with postoperative OH and optimizing patient outcomes. By implementing a proactive management strategy, this OH-focused QI project ensured that all patients received high-quality, standardized care grounded in current best practices. In addition, improved communication among team members facilitated a seamless exchange of information and collaboration. The model emphasized rigorous monitoring during postoperative recovery, which enabled healthcare providers to promptly address potential complications.

Given its success, this QI project presents a model that other organizations managing patients with total joint replacements can replicate. As orthopedic surgical programs continue to focus on quality and efficiency metrics, clinical teams must implement proactive care models to facilitate early recovery and achieve optimal patient outcomes

The authors work at White Plains Hospital in White Plains, New York. Judy Badia is a clinical nurse scientist. Merin Aby is a nurse manager

American Nurse Journal. 2025; 20(7). Doi: 10.51256/ANJ072519

References

American Academy of Orthopaedic Surgeons. American Joint Replacement Registry Annual Report. 2023. aaos.org/registries/publications/ajrr-annual-report

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