Journal of Rehabilitation Medicine 51-10 | Page 69

Preoperative education for hip and knee replacement
health behaviours prior to admission to hospital. Alt-
hough reported to have no effect on postoperative pain
(17), there is evidence that preoperative education can
attenuate anxiety (18, 19), encourage compliance with
physiotherapy (20) and increase self-esteem (19), and
may be most beneficial to high-risk patients, presenting
with co-morbidities or impaired mental health as part
of a targeted prehabilitation programme. The primary
aim of the current study was to compare length of stay
between patients who attended an education class prior
to elective total hip or knee replacement surgery, and
those who did not attend. The secondary aim was to
establish which patients would benefit the most from a
preoperative education class, using the Risk Assessment
and Predictor Tool (RAPT) (21).
METHODS
This is a single-site, retrospective cohort study, reported in
accordance with the Reporting of Studies using Observational
Routinely-collected Data (RECORD) statement (22). Patients
were retrospectively, consecutively recruited between 27 July
2010 and 4 November 2011 from the Royal Bournemouth Hos-
pital, Bournemouth, UK. Patients were considered eligible for
inclusion if they had undergone elective total hip replacement
or total knee replacement surgery. All patients were enrolled
onto a standardised and previously published ERAS pathway
(23), which included: a comprehensive preoperative assessment
process, patient education, discharge planning, admission to
hospital on the day of surgery, a default anaesthetic technique,
effective pain management, and twice-daily physiotherapy until
discharge (23). All hip replacements were performed using the
posterior approach, whilst all knee replacements were carried
out using the medial parapatellar approach. Revision cases and
re-admitted patients were excluded from the study.
Outcome measures and data collection
The primary outcome measures were: (i) length of hospital stay;
and (ii) attendance at the preoperative education class, collected
retrospectively. Attendance at the preoperative education class
was recorded routinely on an attendance register prior to admis-
sion. Length of hospital stay was recorded routinely on the day
of discharge as the number of days between hospital admission
and discharge home. The 2 outcome measures were compared in
order to establish if there was a relationship between attending
a preoperative education class and the time spent in hospital
following surgery. The discharge criteria following total hip
replacement at the Royal Bournemouth Hospital includes:
(i) being able to safely walk independently around the ward
either with crutches or with walking sticks; (ii) being able to
stair climb; being able to get on and off a bed, chair and toilet
independently; (iii) dry wound (with no significant discharge),
showing signs of healing; (iv) satisfactory blood results and
X-ray; (v) controlled pain; and (vi) being medically fit.
The RAPT questionnaire was originally designed to identify
a patient’s risk of needing extended inpatient rehabilitation fol-
lowing total hip or knee replacement (21) and was included within
the current study to compare outcomes between different groups
of patients. At the education session, all patients were asked to
complete a RAPT questionnaire (Appendix I) to aid the therapists’
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discharge planning (21). If patients did not attend their education
session, the RAPT was completed on the day of surgery. Scores
were categorized into red (high-risk of needing extended inpatient
rehabilitation services, score <6), amber (medium-risk of needing
extended inpatient rehabilitation, score 6–9) and green (low-risk
of needing extended inpatient rehabilitation, score >9) (21), and
then compared with length of stay and class attendance data.
Data access
Data were accessed through the hospital’s online administrative
system. The researchers were granted access as they all held
professional positions at the Royal Bournemouth Hospital at
the time of data collection.
Preoperative education
Following a phone call to arrange their operation date, all
patients received a letter with specific instructions to attend a
preoperative education class. The session was delivered within
2 weeks of the date of surgery, by a physiotherapist, occupa-
tional therapist and nurse, who all worked on the ward where
the ERAS programme was delivered. The personnel delivering
the class were regularly rotated and all new staff were trained
to deliver the content. The aims of the 1-h session were: (i) to
reduce anxiety; and (ii) to provide a detailed explanation of the
pathway. Patients were encouraged to ask questions and bring
carers so that their expectations could also be managed. Educa-
tion topics included: what to bring and how to prepare preope-
ratively, exercises to start before the operation, post-operative
pain control and anaesthetic protocols. The patients were also
given the opportunity to practice walking with crutches, and to
discuss any equipment they required for their return home (23).
All patients were given a series of knee range of movement
and quadriceps-strengthening exercises (Appendix II) preope-
ratively and were instructed to complete these 3 times a day.
Non-attendance at preoperative education
Regardless of whether the patient attended the preoperative
education class, all patients received an education booklet at
pre-assessment when they were listed for surgery and there
were no other differences in treatment pathways. The booklet
included advice on protection, rest, ice, compression and
elevation (PRICE) principles to help manage postoperative
pain and swelling. All patients had standardized inpatient phy-
siotherapy and occupational therapy postoperatively until they
met the joint-specific discharge criteria and were discharged
from hospital.
Sample size
No formal power analysis was performed. The initial 15-month
period of the implementation of a modified ERAS pathway (23)
was chosen as study interval, between July 2010 and November
2011 to allow for a minimum of 1,200 consecutive cases.
Statistical analysis
The data were analysed using IBM SPSS Statistics 19. The
normality of the data was tested using the Shapiro–Wilk test,
and a 2-sample t-test was used to detect if there was a statisti-
cally significant relationship between attending a preoperative
education class and length of hospital stay following total hip
and knee replacement surgery. Patients who did or did not at-
J Rehabil Med 51, 2019