Post-operative pathway

Recovery Diary Pathway:    

Using an extension of our POA digital tool, patient recovery is remotely monitored in the first six weeks after surgery.   

Following discharge from the centre, patients complete a weekly diary entry based on their pain, wound and function. Patients without access to the digital equipment required are contacted by telephone. The diary is monitored by a specialist team of advanced nurses and physiotherapists, able to act instantly based on the content of the diary entries. Pictures of the wound and videos of patients walking are reviewed. The clinical team contact the patient at 6 weeks post-surgery to complete a final assessment. Patients without access to the digital equipment required will be reviewed face to face. This together with the recovery trend over 6 weeks enables patients to be stratified into:  

• Patient Initiated Follow Up (PIFU) and self-management pathways;  

• review by an advanced nurse or physiotherapist; or  

• face to face surgeon-led follow-up.  

This is a safe and robust way of monitoring patients, with oversight of patient recovery. Problems are identified early and patients not progressing well with recovery are reviewed by the consultant within 1-2 weeks.  

The diary entries flag red/amber and green depending on patient answers and pre-set algorithm. 

The SWLEOC Therapy team aim to ensure that the patient recovery journey is tailored specifically to their needs. This is based on their pre-surgery level of function, the type of surgery that they have had, and how they manage while they are with us in hospital. Through a shared decision-making conversation, the four possible post-operative patient rehabilitation journeys include: 

Patient Initiated Follow Up (PIFU):  

If patients have achieved the goals that we have set for them whilst an inpatient, are coping well with the home exercise program, and team is confident that they will be able to complete their home exercise program without supervision, they are discharged to self-manage, on a PIFU pathway, and contact the SWLEOC therapy team should they have any concerns or questions following discharge. They are provided with the mid-stage and late-stage exercises and can progress to these as directed. (This pathway applies mainly to Primary Total Hip Replacements).  

Patients contact the SWLEOC Physiotherapy with any concerns or complications following discharge home. Based on the clinician’s assessment, patients are offered advice, referred to community MSK, or a face-to-face appointment will be booked for them to be reviewed by the most appropriate clinician. 

SWLEOC Post-Operative Physiotherapy:  

The patient is booked into a ring-fenced face-to-face clinic with one of the SWLEOC Physiotherapists after their surgery, at an individualised time point. (This pathway applies to all Primary and Revision Total Knee and Unicompartmental Knee Replacement patients).  

Community MSK:  

The Therapy team refer patients to their local community for ongoing physiotherapy and rehabilitation, at the point of discharge, to help them achieve their goals beyond the acute phase of recovery. (This pathway applies to patients having had Knee Arthroscopy based only on need, all Hip Arthroscopy, all Shoulder and Elbow surgery).  

Combination of SWLEOC Physiotherapy and Community Physiotherapy:  

The Therapy team refer patients to their local area for ongoing physiotherapy and rehabilitation at the point of discharge. In addition, the SWLEOC Physiotherapy team review the patient virtually (ACLR, PCLR, MPFLR) or face to face (Total Shoulder Replacement, Rotator Cuff Repair and Capsular Release) to check on their recovery and assess that they have met the milestones that have been set for them.   

Patients having had Primary Total Hip Replacement surgery do not follow hip precautions, and Knee Replacement patients discharged on day zero or day one are not required to achieve 90 degrees knee bend for discharge and are only required to have functional range of movement.  

The SWLEOC Team ensure that they complete a robust and comprehensive discharge with the patient, that includes relevant patient information, post-operative exercise progression, information about their recovery journey so that the patient knows what to expect, and important contact numbers for the patient to contact the SWLEOC team with any concerns or complications following discharge.  

SWLEOC Post-Operative face-to-face clinic:   

This clinic is for all Primary and Revision Total and Unicompartmental knee replacement patients.   

Patients discharge on day zero or day one is reviewed five days post-surgery and for patients discharged day two+, two weeks following surgery.   

The aim of this appointment is to assess milestones of gait, range of movement, strength and pain levels, manual treatment if required and their exercise program and mobility is progressed.   

Based on this assessment, the patient is either; discharged to self-manage, reviewed in a SWLEOC Physiotherapy follow up clinic or referred onto community MSK.   

Patients having had Shoulder Replacement, Rotator Cuff Repair or Capsular Release surgery are reviewed to ensure they have met the milestones that we have set for them, as a safety net, while waiting for their community rehabilitation to start and their post-operative exercise is progressed to the next stage.  

SWLEOC Post-Operative Virtual Clinic:  

This clinic is for patients following ACLR, PCLR, MPFLR ensure they have met the milestones that we have set for them, as a safety net, while waiting for their community rehabilitation to start.  

Six-week Follow-Up Clinic: 

Patients undergoing hip or knee replacements will be remotely monitored for the first 6 weeks using the Recovery Diary digital tool. ESTH and SWLEOC patients will receive a final assessment at 6 weeks by telephone call, patients without access to a telephone will be reviewed face to face).  

The final assessment, together with the recovery trend over 6 weeks enables patients to be stratified into:  

• PIFU and self-management pathways;  

• review by an advanced nurse or physiotherapist;or, 

• face to face follow-up with the surgeon.  

This is a safe and robust way monitoring patients, with oversight of patient recovery. Problems are identified early and patients that are not progressing well are reviewed by the consultant within 1-2 weeks. Thus only patients requiring a consultant review will be booked a consultant OPA, significantly improving outpatient capacity. 

Work is underway to implement a SWLEOC-nurse-led follow up clinic for all partners to reduce the number of patients needing to see a consultant at the other trust partners.  

Patients having other non-hip/knee replacement procedures will have a follow-up with their consultant at the specified time. 

Metal on Metal Surveillance Clinic:

The band 7 Physiotherapists work as part of the Consultant team to review patients, according to the MHRA guidelines, who have had metal on metal hip replacements. They are able to compare and interpret blood results (cobalt and chromium levels), imaging, Oxford hip score, and determine whether the patient presentation requires escalation for Consultant review.

Post-operative physiotherapy and review clinics offer a robust safety net and oversight of the acute part of recovery, and follow-up is delivered by the familiar SWLEOC team. This provides consistency, ring-fenced review and prompt escalation to the most appropriate clinician, improving patient confidence and reducing anxiety. In addition, it reduces GP and A&E visits and improves community MSK capacity. 

The above applies to surgical post-operative concerns and complications and excludes medical emergency.