Innovative Approaches to Orthopaedic Care
Applying innovation and understanding of the patient's needs and lifestyle produce better clinical outcomes and more lasting results for the patient.

Compare Akron General with National Standards in Orthopaedic Care:

Total Knee Replacement
Annual Hospital Volume
Annual Surgeon Volume
Physician Board Certification
Length of Stay
Antibiotic Prophylaxis
Blood Clot Prevention
Orthopaedic Services
Corrrect-Patient, Correct-Procedure, Correct-Site

1. Annual Hospital Volume
The number of surgeries performed at a hospital is easily measured and has been used as a marker for clinical expertise. Procedure volume (number of cases per hospital or surgeon) has therefore become a widely-used quality indicator for surgery. However, some hospitals may have fewer procedures performed per year and still have excellent outcomes.

A study of 80,904 Medicare patients demonstrated that patients receiving primary (first time) total knee replacement in higher-volume hospitals (hospitals with an annual volume exceeding 200 primary and revision total knee replacement procedures) generally have lower rates of mortality, pneumonia, and deep knee infection than do patients managed in lower-volume hospitals (hospitals with an annual volume of 25 primary and revision total knee replacement procedures or fewer) (The Journal of Bone and Joint Surgery, 2004: 86; 1909-1916).

Other important factors associated with higher complication rates following total knee replacement are advanced patient age and additional patient health problems (The Journal of Bone and Joint Surgery, 2006; 88: 480-485).

Akron General Medical Center performed 424 total knee replacements (primary and revision) procedures in 2006.

2. Annual Surgeon Volume
Studies have demonstrated an association between higher surgeon volumes and better patient outcomes for total knee replacements. Surgeon volumes of at least 15 total knee replacements per year were associated with lower mortality rates (The Journal of Bone and Joint Surgery, September 2003: 85; 1775-1783).

Another study of 80,904 Medicare patients noted that patients who had a first time total knee replacement, done by surgeons who performed more than 50 procedures annually, had fewer complications than patients who had surgeons with an annual volume of 12 procedures or less (The Journal of Bone and Joint Surgery, 2004: 86; 1909-1916).

Other important factors associated with higher complication rates following total knee replacement are advanced patient age and additional patient health problems (The Journal of Bone and Joint Surgery, 2006; 88: 480-485).

Seventy-six percent (76%) of Akron General Medical Center's orthopaedic surgeons performed at least 12-15 total knee replacements in 2006.

3. Physician Board Certification
A board-certified physician has completed an approved educational training program and an evaluation process including an examination designed to assess the knowledge, skills, and experience necessary to provide quality patient care in that specialty. A specialty certificate is issued by a medical specialty certifying board, which is valid nationwide. Although certification is not required for an individual physician to practice medicine, most hospitals and managed care organizations require that at least a certain percentage of their staff be " board certified." (American Board of Medical Specialties)

All of Akron General Medical Center's orthopaedic surgeons are board certified in Orthopaedic Surgery by the American Board of Orthopaedic Surgery.

4. Length of Stay
According to the most recent national data available from the Healthcare Cost and Utilization Project’s (HCUP) Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality, the average length of stay (ALOS) for total knee replacement was 4.0 days.

In 2006, Akron General Medical Center's average length of stay (ALOS) for total knee replacement was 3.6 days, which was better than the ALOS for total knee replacement in the most recent HCUP data.

5. Antibiotic Prophylaxis
According to Joint Commission Surgical Infection Prevention Core Performance Measures, patients undergoing knee replacement (also called knee arthroplasty) should receive a prophylactic antibiotic within one hour prior to the surgical incision being made.

Surgical site infections affect approximately 500,000 persons per year according to a Centers for Disease Control and Prevention report. Numerous factors such as age and general health status of persons undergoing surgery can affect rates of infection at any given hospital. One of the National Patient Safety Goals from Joint Commission is prevention of health care associated infection.

The Medicare Quality Improvement Community (MedQIC), a national knowledge forum for healthcare and quality improvement professionals, encourages careful selection and use of antibiotics for surgical procedures. The benefits of selective peri-operative antibiotic use have been repeatedly demonstrated since the 1960's (Archives of Surgery. February 2005;140(2): 174-182). Also, prophylactic antibiotics should be discontinued within 24 hours after the surgery end time.

Ninety-seven percent (97%) of Akron General Medical Center's knee replacement patients received prophylactic antibiotics within one hour prior to the surgical incision in 2006.

6. Blood Clot Prevention
Because of the body's normal response to surgery and the reduction in activity that usually follows surgery, blood clot, or thrombus, formation can be a common complication. A thrombus is a blood clot that blocks a blood vessel and reduces blood flow. A thrombus can also dislodge and travel to other parts of the body, such as the heart, lungs, or brain.

Preventive or prophylactic steps can be taken to decrease the chance of developing a blood clot (thrombosis). The Joint Commission recommends that a venous thromboembolism (VTE) risk assessment be performed within 24 hours of admission to the hospital or intensive care unit. Treatment options should be evaluated for patients who are at high risk for a thrombus or VTE.

Surgery complications such as the formation of a blood clot within a vein have been significantly reduced by using blood thinning medications and other treatments, such as early mobilization and physical therapy, range-of-motion exercises, elastic stockings, and intermittent pneumatic compression devices (The Journal of Bone and Joint Surgery, September, 2005: 87-A; 2097-2112).

At Akron General Medical Center, one or more types of treatments, such as blood thinning medications, early mobilization and physical therapy, range-of-motion exercises, elastic stockings, and intermittent pneumatic compression devices are available to help prevent blood clots, for patients having total knee replacement.

7. Orthopaedic Services
Several hospital programs, processes, and services can have an effect on the length of stay, prevent complications, and can contribute to improved outcomes for persons undergoing total knee replacements. (NIH Consensus Development Conference on Total Knee Replacement, December 8-10, 2003, Final Statement ; Arthritis & Rheumatism, September 2002: 46(9); 2436-2444; Journal of Nursing Administration, November, 2001: 31(11); 544-549)

Akron General Medical Center offers a comprehensive program of services for patients undergoing total knee replacements, including:

• a dedicated operating room and inpatient unit for orthopaedic surgery,
• a prehospital assessment and patient education program,
• clinical guidelines for total knee replacement,
• an extensive physical therapy program for patients while in the hospital, at an accredited rehabilitation facility and after they go home,
• extensive discharge planning coordinated with home health programs, and
• convenient outpatient physical therapy locations

8. Correct-Patient, Correct-Procedure, Correct-Site
Wrong-patient, wrong-procedure, or wrong-site surgeries are uncommon, but they can be avoided altogether by following careful procedures prior to surgery. The following procedures cover broad areas of concern in preventing surgical mishaps; however, there are additional safeguards used by surgical teams that are not listed here.

Secondly, according to the Joint Commission's Universal Protocol for Prevention of Wrong Site, Wrong Procedure, Wrong Person Surgery, it is recommended that the operating surgeon mark the operative site using a signature or other approved mark.

Extra care should be taken with moist areas that can smear onto another site such as the inside of the thigh, according to a report in Anesthesia and Analgesia (January, 2005; 100 (1): 300). Smearing can occur where marked skin touches unmarked skin and the unintended marks may cause confusion about the correct site for surgery.

Lastly, just prior to surgery a final review is performed to ensure that the right patient is having the right procedure on the right body part, with all necessary patient information available. The armband may be checked several times during this process to verify that the team has the correct patient.

An opportunity for speaking up is provided during this final review; it is a built-in pause (time-out) to provide an opportunity for anyone on the surgical team to speak up about anything related to the procedure or patient that is questionable.

At Akron General Medical Ceneter, the following steps are taken to ensure correct-patient, correct-procedure and correct-site for knee surgery: