Orthopedic Services

Video Transcript:
Newberry Hospital’s Back on Track Program

INTRODUCTION

KAREN (Nurse): Hello and welcome to our Back on Track class. This is the program that we here at Newberry have developed to help patients understand what's going to happen for them — and with them — between now and the time of surgery.

My name is Karen Dial. I'm one of the nurses. This is Kim Krohn, physical therapist. And you'll see our faces often — especially Kim.

KIM (Physical Therapist): That's right.

KAREN: Thank you, first and foremost, for choosing Newberry Hospital. We're very proud of our program. We've been doing this for quite a few years. The purpose is to help you realize that you're a member of our team. You're the most important member of our team. You've got a whole team taking care of you. But as a member of the team, you're going to be doing some work, and we're going to help you understand exactly what to expect between now and your surgery.

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SECTION 1: PRE-SURGERY PREPARATION

KAREN: We're first going to talk about a few things you can do between now and surgery.

Medical Clearances

One of them will be to get all your clearances. You've got your packet of information — we hope you've been able to look through that. If you have any questions, of course you can call us. But we need to get your medical clearances first and foremost. That's one thing I would put at the top of your list.

Medical clearances will include your internal medicine doctor, any specialists you have — maybe a cardiologist, hematologist, endocrinologist, or any other specialist. We need to get everybody on board and have those clearances in your record before your surgery.

Managing Existing Conditions

We realize there are some diagnoses that some of you might have that would bring questions to mind. If you're diabetic — keep your blood sugars under control, just as you always do. That's very important for healing afterwards and avoiding complications.

Diet

Diet is something to keep in mind for everyone. I know you do your best to keep a well-balanced diet, but it's very important now to work some lean proteins into your diet — if you like fish, that's great. Chicken, pork, any lean protein would be good. Probiotic yogurts are also a good source. Beans are a great source of protein if meats aren't your thing. Fiber, fruits, and vegetables — a good balanced diet overall.

Keep yourself well hydrated. When you come in for surgery, you'll be told to go without food and drink for a little while beforehand, so hydrate yourself really well leading up to that. Especially living down here in the South in the summer, keep that in mind.

Smoking

If you are a smoker, we'd like for you to stop. But even if you could stop just a little bit before surgery, that has benefits. There are smoking aids you can talk to your doctor about to help you with that.

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SECTION 2: PREPARING YOUR HOME

KAREN: Now — things to do around the house.

Home Safety Walk

Take a walk around your home — real or imaginary — with your walker in mind. Make sure the areas you'll be most frequently using are free of roll-up rugs and large furniture pieces that might block you. The walker is a little bit wider than you are. It's a folding rolling walker, and you'll be on it for a while. If you've never used one, they don't take up a lot of space, but they take up a little more than you do. Especially the path to your sleeping quarters and your bathroom needs to be clear of anything that would block you.

When you get home, a home health physical therapist will come visit and help you assess everything as well. They'll take an extra look at your bathroom, making sure you've got a toilet situation and shower situation that's comfortable. They'll ask what you have and what you might need.

Bathroom Equipment

If you have grab bars, that's great. If you have an elevated toilet seat already, that's great. If not, you can use what we used to call bedside commodes — we don't use them for that anymore, but they're nice and elevated. They're perfect for new knees because they don't let you go down too far. They give you secure handles and they fit right over your existing toilet. We'll be finding out what you might need as we go along — it's all about safety.

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SECTION 3: WHAT TO BRING TO THE HOSPITAL

KAREN: The first day after surgery, you'll likely be in a hospital gown. But bring something more comfortable — maybe elastic waist pants with nice wide legs. With knee surgeries, we have to be able to roll pants up to look at the knee, so Kim's going to be very interested in that.

KIM: That's right.

KAREN: Shorts are perfect this time of year. Just some kind of comfortable shirt — something you wouldn't mind being seen in the halls in, because that's where you'll be spending time — in the halls and down at the gym. Make sure it's comfortable.

I'm going to let Kim tell you a little bit about footwear.

Footwear

KIM: Footwear is really important because our goal is to get you back in a normal walking pattern. I know when we come to the hospital we want to bring our bedroom shoes, but those don't give you the support your feet need. We try to steer away from those.

You need a shoe that encompasses your whole foot — including your heel — to make sure it's secure. Sometimes patients have had to get shoes a half size larger to accommodate swelling. We can't tell you how much swelling you'll have — that's an individual thing — but you're probably going to have some. If you have shoes at home that are pretty stretchable, that's fine, because the swelling won't stay forever. Our goal is to get you back in that normal walking pattern, and that's why good shoes matter.

KAREN: Any questions about what to bring? One more thing — if you use a CPAP machine at night, bring that as well.

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SECTION 4: THE PRE-OP APPOINTMENT

KAREN: Now we're going to talk about the pre-op appointment, because that's coming up for you both. It's an important appointment. You'll be receiving information from this class, from Dr. Loggins' office, from Dr. Milner's office — but this pre-op appointment is sort of a mini physical.

The nurse will take an extensive health history — making sure we have everything, including your surgical history. That's when you bring your medications. We go over them with a fine-tooth comb — any allergies, any previous surgeries and problems. It's very important that we have everything, so set aside a good while for that appointment.

You'll have your blood pressure checked, weight taken, and labs drawn if you haven't had recent bloodwork. You'll have your pulse oxygenation checked with the little finger clip to give us a baseline. You will also meet at that time with your anesthesiologist — a great time to ask any questions you have. They will explain how they're going to help you through surgery so you won't feel anything. Some people are very interested in the medications used, and that's the perfect time to ask.

You'll also meet with the case manager. They will ask what equipment you might need — a great time to get that sorted out. If you don't have a folding rolling walker, they can help arrange one.

Insurance and Equipment

Insurance — including Medicare — will pay for one folding rolling walker. We use the standard rolling walker with two wheels on the front and standard legs on the back. They fold, and you adjust the height to the person's height. Typically you won't need the walker for very long — sometimes four weeks, just depending on how well you progress.

KIM: We use the standard rolling walker because it gives you a more fluid walking pattern. There are folks who prefer the Rollator — the four-wheel walker with the seat. The issue is it has swivel wheels, and if you've just had a joint replaced and don't have good balance yet, that walker is very lax and you risk a fall. That's why we recommend the standard rolling walker. Once you're past the acute healing phase, you could transition to a rollator, but we don't advocate it for safety purposes early on.

Discharge Planning

KAREN: The case manager will also talk to you about discharge planning. Typically you would go home with home health. They'll set up whatever your discharge plans are and take care of everything pre-op and post-op.

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SECTION 5: MEDICATIONS & PRE-OP CONSIDERATIONS

KAREN: At the pre-op appointment, it's very important to disclose all your medications — and that doesn't just mean prescriptions. We're a very nosy bunch. We need to know everything, including anything over the counter. They'll take that list and when you leave, you'll have a list of everything you need to stop, when to stop it, and what you should take the day of surgery.

Iron

In your booklet, you'll see the suggestion of starting an iron pill, especially if you have a history of low hemoglobin. Many women do. You'll be prescribed a regular over-the-counter iron pill. Your hemoglobin will go down a little after surgery, and the iron keeps you energized. We don't need you dragging.

Stool Softeners

Most people take narcotic medication — at least for a brief time after surgery. One of the most common side effects of narcotics is constipation. If you start a stool softener before coming in, especially if you're prone to constipation, it helps prevent that problem. As long as you're taking narcotic medication, we suggest taking a stool softener. That's not a laxative — just a softener — and that's also something to add to your medication list so we know.

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SECTION 6: THE DAY OF SURGERY

KAREN: You'll know the date of your surgery, but not the time — you'll be given a number to call for that. When you come in for your pre-op appointment, you'll be entering through the front of the hospital — first door on the left, it'll say "Outpatient." That's also where you go the day of surgery.

The day of surgery, you'll be admitted, get your bracelet, and be introduced to your nursing team. Your family member — your cheerleader — can go back with you. The doctor will come speak with you before surgery. The anesthesiologist will come out and explain how they'll help you relax. Most patients say that's about the last thing they remember before they wake up.

You'll be interested to know that we no longer use urinary catheters.

Waking Up in Recovery

You'll wake up with a few more things attached than when you went in. You'll have IV fluids running, three doses of antibiotics total, an oxygen cannula, and your legs will be wrapped in little velcro compression wraps that most people say feel wonderful — they pump air and massage the legs to help with swelling and pain. You'll have ice applied to your knee, because that's what we do — ice and elevation.

You'll be asked a few orientation questions, and your blood pressure will be checked frequently. Once everyone is happy with your status, you'll be moved up to your room on our Back on Track unit on the third floor. Your family will be updated by the doctor after surgery, and once that's done, they can come upstairs to your room.

Arriving on the Floor

When you get to your room, you'll be encouraged to eat. We suggest starting gently, but you'll be offered food and you'll be thirsty — go ahead and drink. Then we'll let you get a little rest before you start work.

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SECTION 7: BLOOD THINNERS

KAREN: You will be placed on a blood thinner after surgery, until the doctor tells you to stop. It may be Coumadin or it may be aspirin — it's done on a completely individual basis. If you've been on a blood thinner already, you'll be right back on one. If it's Coumadin, a home health nurse will come check your levels. If it's aspirin, no blood level monitoring is needed. You won't stop any of it until the doctor tells you to.

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SECTION 8: PHYSICAL THERAPY IN THE HOSPITAL

KIM: As part of the Back on Track program, it is a requirement that you are up on your feet the day of surgery. We do clarify with nursing to make sure you're doing well and there are no ill effects. What we do the day of surgery is some exercises to get that joint moving, and then we get you up at the bedside — usually to the recliner, which is about five to ten feet away from the bed. Getting you sitting upright is one of the best things for healing and for starting to feel better. You've been down for the surgery, and getting upright helps everything start to normalize.

We have a therapist who works late into the evening, but if your surgery is late and you don't get to the floor until after we've gone, nursing will get you up as well — to the recliner or at least sitting on the side of the bed.

Day After Surgery

The next day, we are on the floor by 9:00 AM. When we come to your room, we'll do exercises again to get that joint limbered up, and then we'll do our walking.

Physical Therapy Goals for Discharge

There are three goals you need to meet for physical therapy to clear you to go home:

1. Walking 250 feet with the rolling walker
2. Going up and down steps
3. Getting in and out of a car (we have a model car for practice)

Most of these are short stays, so by noon on the day after surgery — if you've met all your goals — you may be discharged. But it's an individual situation, and we'll work with that.

We also need to know how many steps you have at your home — we'll practice that exact number so that when you're discharged, we know you can do it safely. Do you have handrails? One or two? Even if you have a ramp, we still like to practice steps in case you encounter them somewhere.

Knee Flexion Goal

If you're having a knee replacement, we'll be working on getting your knee to 90 degrees of bend. Most people reach that fairly easily after surgery.

Exercises in Your Booklet

KIM: The exercises I'm referring to are in your booklet. They're the basic exercises we'll be doing. You can start some of them now — but if they cause any discomfort, don't do them. As you progress, home health or outpatient therapy will advance you with more exercises.

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SECTION 9: PAIN MANAGEMENT

KIM: For ice — we put ice in bags and apply it to the knee, the hip, or wherever you're having the pain. What patients typically report is that the pain they had before surgery is gone — it's more of a muscular pain after. The joint isn't hurting, but the muscles have had quite a workout from the stretching during surgery. So that's where you'll want to keep the ice — to keep that muscle calm and help with healing.

My suggestion: stay on top of your pain. Don't let the pain stay on top of you. You may be lying there with no pain, but when we come in and start moving you and you tell me it's a 10 — then you've got to get your pain medicine, which pushes your therapy back 30 to 45 minutes.

Nursing will work closely with you on how much and what kind of pain medication is best — it's individual. Most people need something narcotic for the first week or so. We use the 0–10 pain scale. Try to rate your pain when you're moving the knee, not just at rest — be honest with yourself. When you go home, you'll be in charge of judging your own pain.

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SECTION 10: WOUND CARE & OCCUPATIONAL THERAPY

KAREN: Under those compression wraps, you'll have a dressing. It's a high-tech bandage, applied in the sterile surgical environment. It will stay on until you're instructed to remove it. Under that dressing is your incision line, closed with small skin clips. Those will come out in about a week to ten days — either at your follow-up appointment or by home health.

KIM: Occupational therapy will also be seeing you. They assess your activities of daily living — dressing, bathing, toileting. They may only see you once a day or even just for an evaluation while you're in the hospital. They may also look at your bathroom setup — do you need a tub bench? They can advise you on types and where to find equipment.

Physical therapy will see you twice a day as long as you're in the hospital. Once we've determined you're safe to move with a staff member, you can call nursing to help you get to the bathroom — but you don't want to try to get up on your own.

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SECTION 11: HOME HEALTH SERVICES

KIM: Home health will come within 24 hours of you going home. From a therapy standpoint, they'll come two or three times a week. You'll also have homework exercises they'll leave you with. They will advance your exercises and mobility as you progress. They'll also tell you when it's safe to come off the walker — I don't advise trying that on your own. It's too much of a risk of falling, and you don't want to fall with a new joint.

If you're on Coumadin, a nurse will also come out on Mondays and Thursdays and do a simple finger-prick blood draw to monitor your levels.

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SECTION 12: CPM MACHINE (Continuous Passive Motion)

KIM: Most of our physicians recommend a CPM machine after knee replacement. It stands for Continuous Passive Range of Motion. When therapy does your exercises, that's active range of motion — you're working. This machine does range of motion while you're resting. It's the length of your leg; you put it in your bed while resting and it slowly bends and straightens your knee for you.

The referral typically comes from the orthopedic office. Someone may contact you about it. It is a rental — 21 days — and most insurances cover it. I'll also tell you as a patient advocate: this machine is recommended by our physicians, but it's not required. If your insurance doesn't cover the rental cost, know that it's recommended, not required. They typically try to deliver it before your surgery so you have it, but it's not for use until after surgery.

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SECTION 13: DISCHARGE — HOME VS. REHAB FACILITY

(Q&A with patient)

PATIENT: Are most people really able to manage at home after just a day or two in the hospital?

KIM: For the most part, yes. We're not going to send you home if we don't feel you're safe. That's why physical therapy and occupational therapy work with you — to make sure you're safe to go home.

PATIENT: Dr. Loggins mentioned possibly going to a rehab facility like Encompass, given my home situation. Is that an option?

KIM: Yes, that is an option. Our typical goal is to get you home, but if you live alone or don't have a good support system, or if therapy has concerns, we can talk about rehab. There are different types: acute rehab, like Encompass, does up to three hours of therapy per day — their goal is a short stay and then home. Skilled nursing is done more in a nursing home facility, but includes rehab as well.

KAREN: The other consideration is insurance — whether your plan will authorize a rehab facility stay. We do have to submit clinical documentation to some insurers, and if you're meeting all your therapy goals, they may not authorize it. We meet every day while you're in the hospital — a huddle with therapists, nursing, and your physicians — to discuss your progress and the best plan for you.

PATIENT: I would prefer not to go to a rehab facility if I don't have to. I thought I would have to.

KIM: In rehab, you'd be getting five to seven days of fairly intensive therapy — which does get the leg moving. Versus at home, it's three times a week with a therapist. But you'll also have your daily exercises to do on your own.

PATIENT: Actually, I could do this.

KIM: I'm sure you can. What a relief that would be — to do well enough to go home and practice there. That is typically what happens, and most people are encouraged by that.

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SECTION 14: LIFT CHAIRS & SLEEPING

(Q&A with patient)

PATIENT: What about a lift chair? A friend said I should absolutely get one.

KIM: You do not need one. Actually, they make you weaker. The chair is electric, so you're not using your arms — you're not building up those muscles. For someone with a specific need, we might not say no, but for orthopedic surgery, you shouldn't need one.

PATIENT: Someone told me they were better off sleeping in a recliner for the first few weeks.

KIM: Most people do take a couple of weeks before they can sleep flat in a bed. A lot of people are not able to sleep in a flat bed at first, just because they can't get comfortable. If you have an adjustable bed, that's great — it works like a recliner but with a mattress.

PATIENT: What about sleeping on my side?

KIM: That's fine — just keep those knees apart with a couple of pillows between them.

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CLOSING

KAREN: Well, once again we'd like to thank you for choosing our hospital. That is the end of our program, but we want you to know that you can ask questions at any time. You've been provided with phone numbers in your booklet, and you have Rebecca's card. I will see you at your outpatient preoperative assessment as well — so make a note of your questions and we'll make sure they're all answered. We want you to feel good about the decision you've made.

PATIENT: This was just outstanding — so informative. I felt like the weight of the world was just lifted off me. All the anxiety I've been carrying around for months...

KAREN: Thank you all again for coming, and thank you for watching our Back on Track class.