Hip and Knee Joint Replacement Center of Excellence

The Hip and Knee Joint Replacement Program at Washington University Orthopedics and Barnes-Jewish Hospital is nationally recognized for its exceptional quality and innovative patient care initiatives that have led to better long-term outcomes and reduced post-surgical complications.

Thousands of patients have come to St. Louis from around the country to undergo knee replacement or hip replacement procedures, as the program ranks in the Top 10 among academic medical centers in the United States by the large number of total joint replacement procedures performed annually.

Outstanding Care Recognition

  • The Hip and Joint Replacement Program is a designated Center of Excellence and has held The Joint Commission’s prestigious Gold Seal of Approval ™ since 2011 for demonstrated care quality and safety of its hip and knee joint replacement procedures.
  • The program is ranked as a “High Performing” program, the highest designation possible, in U.S. News & World Report’s “Best Hospitals for Common Care” rankings for hip and knee replacement. Only 11% of hospitals that perform hip replacements and 10% of hospitals that perform knee replacements are ranked as “High-Performing”.
    Sources: Hip / Knee
  • Barnes-Jewish Hospital is one of only two hospitals in the St. Louis Metro area that has received a Joint Commission certification for hip and knee replacement care. It is also the only academic medical center in both Missouri and Illinois to be Joint Commission certified in hip and knee replacement care.
  • Has the lowest length of stay time (1.5 days on average) for joint replacement patients in the 117-member University HealthSystem Consortium, a group of academic medical centers that collects and publishes clinical, safety, operational and financial data on a wide variety of medical procedures. It also is ranked among the leading programs in the country for low 30-day readmission rates (2.54%).
  • Identified by Medicare in 2015 as the only St. Louis-area hospital among 97 in the nation that scored better than average for the least number of complications reported following joint replacement. The listing is the first time Medicare has tracked outcomes of hip and knee replacement surgeries.

The national designations are the result of a comprehensive, years-long effort by joint replacement specialists at Washington University to identify and track key aspects of care that lower the risk of complications and improve long-standing outcomes and quality of life for hip and knee replacement patients.

The Path Toward Excellence in Joint Replacement Recovery

The focus on high quality patient care doesn’t begin in the hospital when a patient undergoes a joint replacement procedure. It begins weeks, sometimes even months, before.

“Traditional programs in hip and knee replacement have been effective in relieving pain and in improving overall function and quality of life by focusing on the immediate surgical procedure and in-hospital recovery,” says John C. Clohisy, MD, the Daniel C. and Betty B. Viehmann Distinguished Professor of Orthopaedic Surgery at Washington University. “We have found that by actively engaging patients prior to surgery and then for months after their discharge to home, we have improved the likelihood of long-term success for their joint replacement and reduced the risk of readmission or complications.”

Clohisy is the Chief of Washington University Orthopedics’ Adult Reconstruction Service and serves as Director of the Adolescent and Young Adult Hip Service. He has spent much of his career not only advancing innovations in joint reconstruction but also in driving key care practices that improve the quality and safety of such procedures. As a result, highly targeted steps are taken to:

  •  Identify risk factors prior to surgery
  • Educate a “Joint Coach” caregiver to assist patients prior to and after surgery
  • Implement Rapid Recovery protocols while in the hospital to reduce risk of complications and get patients back on their feet
  • Assign an Outpatient Case Manager who proactively maintains contact with a patient following discharge from the hospital

Step 1. Risk-Identification

At Washington University Orthopedics, every patient considering joint replacement undergoes a rigorous exam and pre-screening to identify risk factors that could negatively impact the outcome of a joint replacement procedure. Among the specific risk factors:

  • Smoking – Tobacco use increases the risk of infection and impairs healing and recovery. All patients who smoke are provided with smoking cessation resources and instructed to stop any tobacco use at least one month prior to and following surgery.
  • Obesity — A patient who is morbidly obese is at risk for serious complications both during and after surgery. Doctors will encourage overweight patients to enroll in nutrition counseling and will consider postponing a joint replacement procedure if a patient’s BMI is > 40.
  • Cardiovascular disease — Any history of cardiovascular requires medical clearance and extensive follow-up after a joint replacement procedure.
  • Diabetes — Because diabetes is linked to an increased risk of morbidity and mortality following surgery, patients with previously undiagnosed or uncontrolled diabetes will be referred to a diabetes management clinic before undergoing joint replacement.
  • Venous thromboembolic disease (VTE) — VTE, which includes pulmonary embolism and deep vein thrombosis, occur frequently and can result in long-term complications. Identified patients are placed on a high-risk anti-coagulation protocol to avoid complications.
  • Other co-morbidities — Issues such as inability to walk or cognitive deficits identified prior to surgery are addressed to optimize outcomes.

Step 2. “Joint Coach” Identification

All patients undergoing hip or knee replacement are required to attend a Joint Replacement Education class prior to their surgery date. In addition to themselves, patients are asked to bring along a family member, friend or other individual who is willing to play an active role in their recovery. Why? Because they will serve as “joint coaches” who can keep an eye out for potential problems and also facilitate and encourage home exercises and return to daily living activities. In addition to the education and materials that joint coaches will receive in the class, they also will have access to several online videos that can help them during the recovery process.

Step 3. Inpatient Rapid Recovery Protocols

Evidenced-based research has shown that the sooner a patient is mobile after joint replacement surgery, the better the outcome. Rapid recovery protocols start with optimal pain management and early mobilization. Physical therapy begins before a patient leaves the hospital, with the patient first moving to a chair and then walking. Post-surgery complication risks are rigorously monitored. The result is that orthopedic surgeons with Washington University Orthopedics have complication and infection rates lower than the national average and their patients leave the hospital faster, often within one to one-and-a-half days of surgery.

Step 4. Outpatient Case Manager

A registered nurse is assigned to each patient undergoing joint replacement surgery. These nurses, called outpatient case managers, serve as a patient’s guide from pre-surgery to home recovery. Their responsibilities include:

  • Contacting patients prior to the joint education class to go over any questions or concerns
  • Meeting face-to-face with patients during the joint education class
  • Checking on patients while they are in the hospital to go over any instructions after discharge
  • Contacting patients regularly after they return home for up to 3 months post-surgery to check on progress and monitor them for potential problems that need to be addressed by a physician.

 “The whole idea of our step-by-step care practices is to be highly proactive with the patient,” explains Clohisy. “We can immediately advance their therapy if they are progressing rapidly or identify problems early so that we can avoid post-operative complications. To do that along the full continuum of care — from before surgery to home — we also coordinate services with a multidisciplinary team that includes social workers, home health agencies and skilled nursing, if needed, although the majority of our patients are discharged directly to a home setting.”

The Results

After implementing the comprehensive, evidenced-based care practices, the results have been excellent:

Average Joint Class Attendance — 98 %

Average Hospital Length of Stay (LOS)  — 1.5 days*
National average LOS is 4 days for patients > age 75; 3 days for ages 45-54
Source: CDC/NCHS, National Hospital Discharge Survey

“We have done a tremendous amount of work to make our program one of the best in the country,” stresses Clohisy. “We have high quality, efficient patient care practices that have resulted in excellent outcomes and quality of life for our patients.”

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