Background

Early mobilization after total joint arthroplasty decreases postoperative complications, decreases length of stay, and optimizes future functional outcomes. Safety during ambulation in the immediate postoperative period is critical, and numerous interventions are employed to prevent patient falls during postoperative ambulation. The purpose of this study was to evaluate the effectiveness of a supervised patient ambulation program during the inpatient stay following total joint arthroplasty.

Methods

In 2014, our institution initiated a mandatory supervised patient ambulation program termed “No One Walks Alone” (NOWA). This program is a comprehensive initiative for all post-surgical patients to limit the number of falls during the inpatient setting. The NOWA program requires that all patients who mobilize are accompanied by a nurse or physical therapist. Gait belts are worn whenever a patient ambulates. Bed and chair alarms are utilized to alert nursing staff if a patient tries to ambulate alone. If a patient experiences a fall, he or she is immediately evaluated by the nursing staff, and details regarding the fall and any injury sustained are documented. A retrospective review of patients undergoing total knee or hip arthroplasty between 2011-2017 was conducted. Patients who had surgery between 2011-2013, before the NOWA program started, were included in the pre-implementation group (N=3,069). Patients who had surgery between 2016-2017, after the NOWA program started, were included in the post-implementation group (N=3,947). Patients undergoing surgery in 2014 were excluded to account for staggered staff training and transition into the program. The incidence of patient falls, fall-related complications, and length of stay were compared between groups.

Results

The number of patient falls was 23 in the pre-implementation group (0.7%) and 9 in the post-implementation group (0.2%). When calculated as a ratio using the number of patient days in hospital, there were 2.5 falls per 1,000 inpatient days in the pre-implementation group and 1 fall per 1,000 inpatient days in the post-implementation group (p=0.002). Fall-related complications occurred in 14 of 23 falls in the pre-implementation group (0.5% overall) and 2 of 9 falls in the post-implementation group (0.05% overall) (p<0.001). Length of stay was 3.0 days and 2.2 days in the pre- and post-implementation groups respectively (p<0.001). Among patients who experienced a fall, the median day of fall was 1.5 in the pre-implementation group and 2 in the post-implementation group (p=0.529). Patients who experienced a fall were more likely to have undergone total knee arthroplasty (81.3%) compared to those who did not fall (58%) (p=0.008). Patients who fell were older (73.6 years) than patients who did not fall (68.6 years) (p=0.006). The average length of stay for patients who fell was 3.3 days compared to 2.5 days for those who did not fall (p<0.001).

Conclusion

A supervised patient ambulation program can be successful at reducing the incidence of patient falls and complications related to falls in the immediate postoperative setting. Hospital length of stay and resources used to treat complications of falls can also be reduced. Although this study was conducted in an inpatient setting, these results also provide important data for mitigating fall risk in the outpatient setting.