The human body’s behavior can bend logic. Jab it with dead viruses and it will resist live ones of similar constitution. Work its muscles to the point that tiny fibers tear and it will get stronger. Eat a high-fat, high-protein diet and, as long as you cut the carbs, it drops weight.
UCHealth University of Colorado Hospital (UCH) has been at the forefront of harnessing another corporeal irony: patients long assumed to be best off in bed get better faster if you get them up and moving ASAP. UCH physical therapists and nurses have been doing just that with intensive care unit patients for years. Now a program launched in January takes the same approach with 15 to 20 patients who have total knee and hip replacements done at the hospital each week.
The results have been remarkable. Patients in the program – officially Postoperative Day Zero, nicknamed “Day Zero” – leave the hospital on average a half day earlier, do better in inpatient and outpatient rehabilitation, and generally have smoother recoveries than was the case before Day Zero came into play.
What’s perhaps most striking is how simple Day Zero is. It involves nothing more than getting knee and hip replacement surgery patients out of bed and, if possible, even walking on the day of surgery rather than on day one.
Bone on bone
Randy Joseph, 61, is an ultrarunner, a climber, a mountain biker, and, until he can start running again in a few months, a hiker. He described himself as “extremely active.” He was also in an extreme amount of pain by late 2016. He gutted it out for a while, but on June 19, University of Colorado School of Medicine orthopedic surgeon Craig Hogan, MD replaced his right hip at UCH. Joseph had continued to bike, climb and run to stay in the best shape he could prior to surgery. But bone grated bone in an arthritic hip where cartilage cushions were long gone.
“Biking was painful, as was running and hiking,” Joseph said. “I could really go about three miles, max, with a significant limp.”
The surgery went smoothly. By late morning, Joseph was in an inpatient room. Not long ago, he might have settled into his bed and stayed more or less horizontal until the next day.
With Day Zero, though, an inpatient physical therapist-led team paid him a visit shortly after lunch. They checked his vital signs. They made sure he wasn’t nauseous or dizzy and that there was no numbness in his right hip or leg. They chatted with him about the precautions he should be taking as his leg healed. The physical therapist and accompanying nurse helped him stand up. When it was clear that he was good on two feet, they chaperoned him on a walker-aided slow stroll out of the room, around the corner and down the hallway.
“It was painful, but it felt good to be up and moving and weight-bearing,” Joseph said. “I really saw the boost in my confidence – that this was going to be fine.”
The whole thing took all of 15 minutes. A bit later, the surgeon Hogan came in. He told Joseph that, based what physical therapy was reporting and the understanding that Joseph had family to help him at home for the first couple of days, he could go home the next day. And so, on day one, back to Fort Collins Joseph went.
More than meets the eye
As simple as Day Zero was in concept, making it a reality for a majority of patients took some effort. Before the program was instituted, physical therapists managed to get about a quarter of knee- and hip-replacement patients moving on day zero. They have more than tripled that figure, with about 90 percent of knee and hip replacement patients up and moving the day of surgery. (Most of the rest stay in bed because PT or nursing staff assessments conclude that getting up would present a risk.)
Stephen Miltner, PT, a UCH inpatient physical therapist, said advances in anesthesiology and patient education also contributed to making Day Zero possible. For a couple of years now, UCH surgeons have used a sensory nerve block – which squelches pain but allows commands from brain to leg to get through – as opposed to a motor block, which temporarily cuts the connection. In addition, a preoperative joint replacement class helps patients better understand various aspects of the surgery and recovery, including the value of getting up and moving on day zero.
When patients move on to outpatient physical therapy, there’s a noticeable difference at the start, said Guy Lev, DPT, supervisor of physical therapy in the Anschutz Outpatient Pavilion. On up-front surveys, they report better comfort and function, he says. Once into their eight- to 12-week outpatient rehab stints, they tend to do more on their own, not needing as many interventions such as manual therapy to lessen pain and swelling, for example.
“There’s better function and less visits overall,” Lev said.
The inherent robustness of knee and joint replacements is a help, too, he added.
“It’s such a stable surgery that there are no precautions from the beginning,” he said. “You can’t hurt the patient or the implant by going too fast, so if the patient can tolerate it, we go for it.”
Hogan says Day Zero hinges on the idea that, generally, hip and knee replacement patients aren’t really sick. Getting them moving, he said, “instills confidence in the patient. They know that they’re going to get better.”
“They’re here to have one specific problem addressed, and they want to get back to doing what they want to do,” Hogan said. “We want to make them feel like they’re well.”
Back to nature
Randy Joseph was driving four days after his hip replacement surgery. Six weeks after surgery he hiked pain-free for four miles in Rocky Mountain National Park, and he has hiked and mountain biked on alternating days in the weeks hence. He’s on his mountain bike, too, though still on roads and paths, starting hour-long rides at week six and extending them to three hours by week eight. At his eight-week checkup, Hogan gave him the green light to mountain bike on actual mountains again.
“It’s so much better than it was,” Joseph said. “I have to watch myself because I forget I’ve had this surgery.”
It’s safe to say that Joseph would have done just fine regardless, but Day Zero played its role in his quick recovery, he said. He also appreciates that it saved his insurance company money and frees up beds for other orthopedic patients sooner, he added.
“I think it’s a great protocol on so many levels that they’ve established,” he said.