Successful Implementation of Clinical Pathway for Total Knee Arthroplasty Patients in Clinical Practice

Monday, 30 July 2012

Pensri Lausawatchaikul, RN, MNS
Bungaorn Chatriyanuyok, RN, BSc (Nursing)
Orawan Warapapong, RN, MA
Orthopedic Nursing Service Division, Department of Hospital, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Learning Objective 1: the learner will be able to learn about how to develop and implement pathway for TKA patients.

Learning Objective 2: the learner will be able to study outcome of implementing pathway for TKA patients


The purpose of this study was to develop a clinical pathway for total knee arthroplasty patients and evaluate the effect of the clinical pathway on length of stay (LOS), patient cost, post-operative complications and unplanned readmission.


We formed a multidisciplinary team including orthopedic surgeons, pharmacists and nurses to improve the quality of care provided for total knee arthroplasty patients. Clinical pathway was developed by using evidence-based and standardized protocol by the team. The team set a goal of reducing length of stay and patient costs, yet maintaining or improving quality of care. The team established standardized orders from admission to discharge. Physician & nurse progress note was developed according to the clinical pathway. The clinical pathway was implemented in orthopedic wards at Ramathibodi hospital, Mahidol university, Bangkok, Thailand, during July, 2008 to June, 2010. Clinical indicators and process management indicators were set for evaluation outcome and effectiveness of the clinical pathway implementation. Data were collected and analyzed every 3 months. Continuous quality improvement process were done for target achievement of the clinical pathway.


When comparing before and after implemented clinical pathway, the mean LOS decreased from 7.3 days to 5.6 days and the mean patient cost decreased 14.78 %. Whereas, clinical indicators, such as, infection rate and unplanned readmission rate were also decreased.


  The key factors contribute to pathway success included preoperative patient education, standardized orders derived from evidence-based, collaboration of teamwork, precision of monitoring clinical indicators and continuous quality improvement process. The clinical pathway for total knee arthroplasty patients benefit the hospital, professionals and most importantly, the patients.