Hip Replacement Quality Indicators
Average Length of Stay
The average length of stay (measured in days) provides general information about the efficiency of care delivery, and is therefore
an important quality indicator. However, patients with a greater severity of illness may have a longer average length of stay.
According to the most recent national data from the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality (AHRQ), the average length of stay (ALOS) for hip replacement (partial and total) was 4.9 days.
In 2008, Jefferson University Hospital's average length of stay (ALOS) for hip replacement was 3.4 days, which was better
than the ALOS for hip replacement in the most recent HCUP data.
Antibiotic Prophylaxis
According to the Joint Commission Surgical Infection Prevention Core Performance Measures, patients undergoing hip 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 the Joint Commission is prevention of healthcare 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.
98.12% of Jefferson University Hospital's hip replacement patients received prophylactic (preventive) antibiotics within one
hour prior to the surgical incision in 2008.
98.65% of Jefferson University Hospital's hip replacement patients had their antibiotics discontinued within 24 hours after
the surgery end time in 2008.
Orthopedic Services
Hospitals programs, processes, and services can have an effect on the length of stay, can prevent complications, and can contribute
to improved outcomes for persons undergoing total hip replacements (Arthritis & Rheumatism, September 2002: 46(9); 2436-2444; Journal of Nursing Care Quality, December 1998: 13(2); 67-76).
Dedicated orthopedic units in hospitals are those that have staff members who are specifically trained to work with people
who have orthopedic diseases or conditions. Having highly skilled staff, specialized equipment and areas designed for orthopedic
recovery, reduces the risk for developing avoidable problems while in the hospital.
Jefferson University Hospital has a dedicated orthopedic unit and other dedicated orthopedic services such as
- Dedicated operating room for orthopaedic surgery
- Dedicated orthopaedic unit
- Clinical pathways of care/ guidelines for hip replacement
- Physical therapy available more than once a day
- Prehospital assessment and patient education programs
- Discharge planning and coordination with home health programs
- Pain Management Service
Inpatient Mortality Rate
The mortality rate (measured as a percentage) provides general information about the quality of care delivery, and can be
an important quality indicator. However, some hospitals care for patients with a greater severity of illness and therefore
may have a higher mortality rate.
Hip replacement, an elective surgery, has a relatively low mortality rate. The known predictors of in-patient mortality include
age, presence or type of hip fracture, and the presence of any significant coexisting conditions.
According to the most recent data available from the Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality (AHRQ), the inpatient mortality rate for hip replacement (partial and total) was 0.90 percent.
The inpatient mortality rate for hip replacement at Jefferson University Hospital was 0.09% in 2008, which is better than
the rate for hip replacement in HCUP's Nationwide Inpatient Sample.
Correct-Patient, Correct-Procedure, Correct-Site
Wrong-patient, wrong-procedure, or wrong-site hip 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.
The first procedure involves review of relevant medical records prior to surgery. These records may contain information that
will prevent the need for additional tests, saving time and money. They may also provide vital facts about your health history
that your surgical team needs to know. 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 Jefferson University Hospital, the following steps are taken to ensure correct-patient, correct-procedure and correct-site
for hip surgery:
- Review of relevant medical records prior to surgery
- Marking operative site with non-smearing signature or other approved mark
- Armband check
Surgical Options for Hip Surgery
Various materials are used to manufacture hip prosthetics, so patients and surgeons have a wide array of hip implant choices.
Likewise, there are options for the surgical approach.
Hip prosthesis (implant) wear and hip socket damage (osteolysis) are common causes for hip replacement revision, so choosing
the best artificial hip implant can potentially reduce the need for additional hip surgery and complications. Studies indicate
that implants made of "highly cross-linked polyethylene" (a type of plastic) have superior wear rates when compared to ceramic
and metal types of implants (The Journal of Bone and Joint Surgery, September 2005: 87-A (9); 2133-2146).
Each type of implant material may have a specific advantage in particular circumstances. Age and activity level may influence
implant selection along with other factors that you and your surgeon can discuss.
Minimally invasive (smaller incision) and computer assisted techniques are also being used by some surgeons. Estimated blood
loss has been shown to be significantly lower with the minimally invasive technique. Pain, functional status, and length of
hospital stay were not significantly different when minimally invasive surgery was compared in a clinical trial of 219 patients
(The Journal of Bone and Joint Surgery, April 2005: 87; 701-710).
At Jefferson University Hospital, the following options are available for hip surgery:
- A variety of types of implantable prosthetic hips
- Minimally invasive surgery
- Hip Resurfacing
