This document summarizes the implementation and results of a Total Knee Replacement clinical pathway at Apollo Health City facility in India. The pathway was adapted from a Canadian hospital and implemented in 2011. Key results included an increase in patient satisfaction from 56% to 77% and a reduction in average length of stay from 7.94 to 5.78 days over 45 months. Compliance with best practices like surgical site marking and DVT prophylaxis also improved. The pathway was evaluated using a standardized framework and found to improve clinical, service, team, process and financial outcomes for total knee replacement patients.

1. A review of the total knee replacement pathway:
Integrated care is quality care

2. Quality in Health
A review of the total knee replacement pathway:
Integrated care is quality care
Shipra Gupta a
, Gaurav Loria b,*
, Nipun Choudhry c
a
Manager, Quality Systems, Apollo Health City, India
b
Group Coordinator, Quality Systems, Apollo Hospitals, India
c
Dy. Chief Medical Administrator, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
a r t i c l e i n f o
Article history:
Received 18 November 2014
Accepted 19 November 2014
Available online xxx
Keywords:
TKR
Quality care
Prophylaxis
a b s t r a c t
A Total Knee Replacement (TKR) Pathway (adapted from the Credit Valley Hospital, Can-
ada) is in place at the Apollo Health city facility since 2011. We re-visited the pathway
design and the priority grid that led to its adaptation. We analyzed the data with the aim to
analyze repetitive and unique trends and evaluate the performance of the pathway. Even
with the increased volume the patient satisfaction rose from 56% at the time of pathway
implementation to 77% at the end of the evaluation period of 45 months. The Average
Length of Stay reduced by 27% from 7.94 to 5.78 days (the difference between the initial and
final recorded values), in the same evaluation time period. The methodology of evaluation
of the pathway was adapted from the Leuven Clinical Pathway Compass 5 way approach.9
Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
The health care industry is at an inflection point. The amal-
gamation of Clinical best practices (e.g. Goal based patient
care approach) with management techniques of improving
efficiency, will lead to higher standards of care. It is estimated
that every year the United States sees 44,000 and 98,000 people
negatively affected from medical errors.1
The Integrated Care Pathways (ICP's) are good examples of
standard guidelines which match the needs of the local pop-
ulation, based on the best practices and learning from the
experience of individual patients. Additionally, ICP's records
the deviation in care from the planned care in the form of
variances.2
Health care systems are prone to variation. Trends in the
industry are often evidence based, each patient being
different, medical evidence is not widely documented or
standardized and the most important fact that treatment
process is riddled with uncertainties.3e8
61% of patient hospitals admit in the Low and Middle In-
come countries which include India covered their hospitali-
zation cost out of their own pocket (WHO Database, Global
Health Expenditure Database, 2012). This puts immense cost
burdens on patients who undergo treatments especially sur-
geries. The best alternative which addresses the concerns of
costs and quality are again, Integrated Care Pathways.
This article aims to highlight a case of the Total Knee
Replacement Pathway implementation at a super-specialty
setup. The article covers why the pathway was
* Corresponding author.
E-mail address: gaurav_l@apollohospitals.com (G. Loria).
Available online at www.sciencedirect.com
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Please cite this article in press as: Gupta S, et al., A review of the total knee replacement pathway: Integrated care is quality care,
Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.007

3. implemented, what were the steps taken to ensure it was
accepted by the clinical care providers and an analysis of what
were the results of it.
1.1. Objectives of a surgical clinical pathway8
1. Selecting a treatment plan which the majority of Care-plan
implementers follow and abide by.
2. Clear responsibility segregation at each level of care thus
defining measurable parameters for example Average
Length of Stay.
3. Defining goals at each care level which helps in role-
awareness and keeping the patient and the family atten-
dants on the same page.
4. Collection and analysis of data and trend, which help in
continuous improvement with updated patient condition
logs.
5. Consolidating information in a standard format helps the
staff understand the goal-based approach of treatment and
their role.
We analyzed the Total Knee Replacement pathway at
Apollo Health City, which was implemented in the year 2011.
Our objective was to analyze whether the pathway was ful-
filling the above objects in sufficient measure.
1.2. Clinical pathway development
The care process organization triangle (based on Donabedian
and including the terminology used by Pawson & Tilley,
Mitchell, Batalden, Heskett et al, and Teboul).
According to the above paradigm, the solution which re-
sults is based on which situations are most conducive for the
working of a particular organization.19,20,21,22
Based on the above methodology the answers to the
following were to be determined:
1. To assess the differences in perceptions of the Health Care
providers on the care protocols.
2. To access whether the care process supported by the
pathway will yield to a better implementation and docu-
mentation compliance.
3. To assess the specific parameters which would rate the
efficacy of the pathway be compliant.
A survey was conducted among the Doctors and Nurses
(Total N ¼ 35) of the Orthopedics department, where the
following were determined. Based on the survey conducted
among the healthcare providers the following were the results:
1. A clinical pathway being interdisciplinary the involvement
of all care providers was essential.
2. The Structure of the pathway would require the most delib-
eration,onceinplaceitneedsatrialruntotestforitsworking.
3. The Context and the design of the program would require
situations specific to the health care setup for example:
Patients suffering from chronic knee pain pre-operation
suddenly may feel the urge to quickly ambulate, where
early mobilization is aided.
4. The process needs to be a structured one, with due
weightage for complications example Surgical Site In-
fections (SSI's) and Deep Vein Thrombosis (DVT) prophy-
laxis were to be assessed at all care levels with an impetus
on Infection Control.
The Total Knee Replacement Pathway was adapted from
the Credit Valley Hospital, Canada. The implementation of the
pathway was done following the steps:
1. Followed an Evidence-based Method was used to examine
the gaps in our care process analyzing health care data.
2. Involving a multidisciplinary team to cater to the different
aspects of care (Surgeon, Anesthetists, Nurses, Dietitians,
Physiotherapist, Social Worker and as need be others).
3. Defining the patients who would fulfill the criteria.
4. Review practices and modify the base document based on
our practices and patient mix.
5. Development and Pilot run of the Pathway.
6. Ongoing evaluation.
1.3. Selection of indicators10,17,18
The scoring on a priority grid helped us identify the impor-
tance of implementing a pathway using the following
parameters:
1. Patient population affected e This was done by identifying
the patient volumes which would benefit from a pathway
implementation.
2. Relevancetoidentifiedpatientpopulation,diagnosis, disease
e Since a surgery involves high involvement in the patient
care plan and the hospital stay is affected by the process.
3. Resources available to provide care e Being a tertiary care
setup and skilled surgical teams place us on the favorable
end of patient choice spectrum.
4. PatientRiske Basedonthepatientin-flowhowmanypatients
will benefit immensely from the pathway being in place.
5. Patient Outcome e As a direct reflection of patients being at
the epicenter of the care process.
6. Cost to implement e Any factors which directly improve
patient care, without escalating costs of implementation
beyond the cost-benefit grid.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e52
Please cite this article in press as: Gupta S, et al., A review of the total knee replacement pathway: Integrated care is quality care,
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4. 7. Patient needs/expectations: Being at the centre of the care
process. the patient feedback scores reflect the efficacy of
the care process.
8. Impact on Quality Care e Being interdisciplinary and
multidisciplinary in nature, the quality care process was to
be directly proportional to improved care plans.
9. Impact on Safety e Being a safe hospital, and following the
International Patient Safety Goals without fail was to be
achieved 100% of the times.
Based on the scoring the adaptation of the clinical care
pathway ranked on the top priority of implementation.
2. Managing change
As a change management exercise the following were taken
care of:
1. A pre-training session for all involved in the patient care
plan.
2. A core-group which has been a part of JCI Trainings to
further the training in their respective departments.
3. A score-card devised to monitor regular progress and
address the cause of deviation.
4. Data from the pilot was used to identify the process vari-
ations and close any gaps.
5. A TKR Committee was established which met every
quarter to discuss the progress of the pathway and address
any issues faced.
3. Results & discussion
The pathway has been in place for over 45 months at the time
of publication. To analyze the pathway the standard tool of
The Leuven Clinical Pathway Compass was used.9e16
The tool is designed to evaluate the impact of a clinical
pathway.
The compass operates with 5 major indicators9
:
1. Clinical Domain e The compliance data aimed at
addressing the clinical and the functional parameters for
the patient.
2. Service Domain e Measuring patient satisfaction has been
an important goal in signifying the success rate of the
pathway implementation.
3. Team Domain e The co-ordination between teams, a
difficult parameter to monitor, was seen as a result of
completion of each part of the pathway.
4. Process Domain e The data was analyzed in the pre and
the post training, any variations were addressed in the
dedicated quarterly pathway meeting with all the
stakeholders.
5. Financial Domain e the Volume of the satisfied patients
(with exclusion of natural growth in numbers) and the
Average length of the patient, which helped us further our
bed-turns specific to orthopedic patients, were measured.
The trend analysis was done on the pre and the post
implementation phase of the pathway implementation. The
initial 3 months have been not included to exclude the change
management process. (See Graphs 1.1 and 1.2) (Tables 1.1 and
1.2)
As the results show, the tangible increase in the satisfac-
tion of patients is a result of improved coordinated services
between departments.
1. Patient Satisfaction improved significantly, where 56% of
the patients at the time of implementation gave Excellent
and Very Good scores to the services of the TKR Team. At
the end of the evaluation period of 45 months, the per-
centage had risen to 77%, with a parallel rise in the number
of average discharges per week.
2. Patient Length of Stay in the Hospital showed considerable
improvement as well. A decrease in 27% with the initial
7.94 days (at the time of implementation) stay now reduced
to 5.78 days, per discharge.
3. Percentage compliance to surgical Site marking improved
over the duration from not being captured to 99.4% of the
Graph 1.1 e Comparative of the average length of patient
stay over the 45 months of implementation.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e5 3
Please cite this article in press as: Gupta S, et al., A review of the total knee replacement pathway: Integrated care is quality care,
Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.007

5. Graph 1.2 e Patient volumes vs the patient feedback trends.
Table 1.1 e Comparative of the Clinical Pathway Indicators e Pre-pathway Implementation and Post-Pathway
Implementation Compliance Percentage (first three months i.e. January to March 2013 were not included to smoothen
adaptation).
Clinical pathway indicators Pre-pathway
implementation
compliance
percentage
Post-pathway
implementation
compliance
percentage
Percentage of patients on whom site marking has been done Not measured 99.4
Percentage of patients who received DVT prophylaxis post surgery 90 99
Average length of stay 7.94 6.12
Number of patients who developed surgical site infection 3 0
Number of patients who developed complications (other than surgical site infection) 1 0
Percentage of patients who were discharged alive after TKR 95 100
Table 1.2 e Comparative data since the inception of the pathway, parameters are measured with open and closed medical
records compliance.
Parameters January 2013e
March 2013
April 2013e
June 2013
July 2013e
August 2013
Sept 2013e
November 2013
December 2013e
February 2014
March 2014e
May 2014
June 2014e
August 2014
Patients discharged 78 99 106 68 90 95 76
ALOS 7.94 6.20 6.22 5.76 6.92 5.82 5.78
Percentage compliance to
surgical site marking
82 85 98 98 100 100 100
Percentage of patients who
received DVT prophylaxis
post surgery
84 96 100 100 100 100 100
Number of patients who
developed surgical site
infection
1 2 0 0 0 0 0
Number of patients who
developed complications
(other than surgical site
infection)
0 1 0 0 0 0 0
Percentage of patients who
were discharged alive
after TKR
100 100 100 100 100 100 100
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e54
Please cite this article in press as: Gupta S, et al., A review of the total knee replacement pathway: Integrated care is quality care,
Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.007

6. times accurate marking before the patient was shifted to
the Pre-Anesthesia Check.
4. DVT prophylaxis improved from 90 to 99%, it also helped
track at all care levels, even in the wards if a complication
developed due to a missed dose of prophylaxis or not.
5. The percentage of patients who were discharged alive
remained the standard at 100%.
4. Conclusion
An integrated care pathway, when implemented in conjunc-
tion with the local needs requires to be completed. Clinical
pathways are indeed quality tools to evaluate the variations of
care if any. The clinical pathway for TKR which has been a
combined effort of the entire care plan, with the priority grid
matrix has enabled the real value of the pathway to be
highlighted.
Conflicts of interest
All authors have none to declare.
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