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CONTINUING EDUCATION

Gold Seal Certification from Joint Commission for Total Joints Robert Austin, MSN, CRNA, APRN

January 2017

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Obtaining Gold Seal Certification for Total Hip and Total Knee Replacement from the Joint Commission Robert Austin, MSN, CRNA, APRN

Disclosure/Conflict of Interest Statement: Nonewww

Introduction

study period and was projected to exceed $1.62 billion by 2020.4 2015 estimates of the cost of a total knee replacement averaged $31,124, ranging from $11,317 in Montgomery, Alabama, to $69,654 in New York, New York. Total hip replacement averaged $30,124, with costs varying from $11,327 in Birmingham, Alabama to $73,987 in Boston, Massachusetts.5 Given the financial burden associated with total joint replacement, these goals are admirable and necessary. A 148-bed community hospital in the Southern United States recently completed the process and is now Gold Seal Certified by TJC for total hip and total knee replacement. This article shares information relevant to and lessons learned in obtaining this certification.

The Joint Commission (TJC) is a well-known entity in modern healthcare. Since 1951, TJC has evaluated and accredited over 21,000 organizations and facilities in an effort to, “continuously improve health care for the public . . .1” In addition to traditional TJC accreditation, certification in a number of categories is now offered. These Disease-Specific Care categories include; Behavioral Health, Cardiovascular, Endocrine, Gastrointestinal, General Medicine (Sepsis), Hematology/Oncology, Neonatal/Perinatal, Neurologic, Orthopedic, Pediatric, Physical Medicine/ Rehabilitation, Pulmonary, Renal, Rheumatology, Transplant, Trauma, Women’s Health, and Wound Care. Many of these categories are further subcategorized with Certification available in each specific area. The most recent certification offered, beginning in December of 2015, is Advanced or Gold Seal Certification for Total Hip and Total Knee Replacement.2 According to Gideon Howell, TJC, the motivations in offering this Advanced Certification are to, “elevate the quality, consistency and safety of these services in hospitals, critical access hospitals and ambulatory surgery centers. The goal is fostering more cost-effective and safe quality care.3” Joint infection rates are estimated at 2.0% to 2.4% of total knee replacements. In 2012, a study showed that the annual cost of infected revisions to US hospitals increased from $320 million to $566 million during the

The first step in this process is determining whether the total joint program at your facility or institution is even eligible for TJC certification. The minimum requirements as set forth by TJC are: • The program is in the United States, or operated by the US government or under a charter of the US Congress. • The program is provided within a Joint Commission accredited organization. • The program must have served a designated minimum number of patients. • The program uses a standardized method of delivering clinical care based on clinical practice guidelines and/or evidence-based practice. • The program uses performance measurement to improve its performance over time.6 At first glance, these requirements would seem to eliminate new facilities, institutions and total joint programs. However, the minimum number of patients is only ten. Depending upon the facility, institution or program and case load, that minimum can usually be met quickly. Also excluded from eligibility for this certification are those programs or facilities without prior TJC accreditation or those that do not have standardized practices or performance improvement measures already in place. Again, these can be quickly implemented. TJC also offers

Learning Objectives Participants will be able to.. 1. Describe the process of obtaining Gold Seal Certification for Total Hip and Knee Replacement from The Joint Commission. 2. Discuss the meaning and importance of multimodal analgesia in the development or refinement of a total joint program for certification by TJC. 3. Identify three benefits associated with utilizing multimodal analgesia.

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Process

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a Gap Analysis, where an Associate Director in the area of desired certification looks at the processes in place and improvements that may be needed prior to applying for certification. This free assessment also includes a risk analysis and identification of ways to improve the program to meet TJC’s requirements and obtain certification.3 Next, an application is submitted through TJC’s website which must include organizational demographic information, specifically, identification of the disease-specific care service(s) requested to be evaluated and preferred month of review. In this case, Total Hip and Total Knee Replacement was specified. The application must also contain a reference to the clinical practice guidelines (CPGs) used for each disease state selected for certification. CPGs must be based in evidence-based care. When applying through the TJC website, one can connect to the national clearinghouse for evidence-based clinical guidelines.3,6 Finally, the application requested, “specifications including rationale, for four performance measures, including at least two clinically-focused measures.” Regarding these measures, TJC states, “At least 2 of the 4 should be clinical measures related to or identified in clinical practice guidelines for that program or service.  Measures selected by the program or service should be evidence-based, relevant, valid and reliable.  The Joint Commission is not prescriptive during Stage I regarding the specific measures that are implemented; the emphasis is on the use of performance measures for improving care.”3,6 The clinical measures selected included decreasing surgical site infections; patients reporting adequate pain control; distance walked prior to discharge, and improved nursing communication with patients prior to discharge.4 These measures are representative to our program, and are neither exclusive or inclusive of the many measures possible for use in obtaining certification for a total hip and/or total knee replacement program through TJC. (Corinne Hunter, RN, MSN, email communication, June 2016) January 2017

As is true of all processes TJC-related, a site visit is mandatory. The site visit for Advanced Certification in Total Hip and Total Knee Replacement involves a focused assessment of the transitions of care between various stages of the patient’s entire process from initial visit in the Surgeon’s office to pre- and intraoperative stages through inpatient and/or outpatient recovery, rehabilitation and finally return to the surgeon’s office after the procedure.6 (Corinne Hunter, RN, MSN, email communication, June 2016) Certification is granted almost immediately. The Total Joint Program was deemed to have met requirements and “Gold Seal Certified” was awarded by the end of the in-hospital visit. Key Concept Emphasized A key concept that was addressed and questioned repeatedly in this process is Multi-modal analgesia. This approach simultaneously administers two or more analgesic agents with different mechanisms of action. For example, multimodal analgesia for a total knee replacement may consist of the use of opioid and nonopioid pharmacologic agents, as well as regional anesthesia. The multimodal approach has been endorsed by many professional organizations, including the American Society of Anesthesiologists (ASA), the American Pain Society (APS) and the American Society for Pain Management Nursing (ASPMN) The ASA acute pain management practice guidelines state that clinicians should use multimodal analgesia whenever possible in the perioperative setting. Additionally, the ASA guidelines assert that unless contraindicated, patients should receive an around- the-clock regimen of nonsteroidal antiinflamatory drugs (NSAIDs), cyclooxygenase I blockers (COXIBs), or acetaminophen.7,8 Also, regional blockade with local anesthetics should be considered. The choice of medication, dose, route, and duration of therapy should be individualized to optimize efficacy while minimizing the risk of adverse events. Multimodal analgesia has been shown to 5

improve postoperative pain relief, increase patient satisfaction, expedite mobilization and rehabilitation, and reduce healthcare costs.7 The approach used at this facility to meet this goal of multimodal analgesia at the time of certification depended on the surgery, the patient, and the provider. 6

For a total hip arthroplasty (THA), a combination of spinal analgesia (0.75% bupivacaine with or without epinephrine 1:1000, +/- intrathecal dilaudid 100 mcg or duramorph 100 mcg, +/- intrathecal fentanyl. Sedation with propofol 10 mg/ml titrated to effect was utilized during the surgery. If the patient had a CRNA Today

contraindication to central neuraxial anesthesia such as recent lovenox or other blood thinner therapy then General Anesthesia was administered. Additional medications included the NSAID ketorolac, N-Methyl D-Aspartase (NMDA) inhibitor ketamine, and the steroid dexamethasone. Postoperatively, Patient Controlled Analgesia (PCA) morphine was utilized and transitioned to oral opioids on postop day two or three. For a total knee arthroplasty, an Ultrasound guided femoral nerve block and a distal popliteal nerve block of 0.5% ropivicaine 20 ml with decadron 4-10 mg was administered at each site. Sedation with propofol 10 mg/ml titrated to effect or general anesthesia was provided in addition to the nerve blocks and additional medications were similar to those utilized in the THA technique. Postoperatively, PCA morphine was used on post-op day one with transition to oral opioids on postoperative day two or three. One of the first questions asked by the TJC observer in the preoperative area was whether our program was utilizing adductor canal blocks. Whether this was the observer’s personal preference or an indication of the future expectation was not clarified. Included is an example taken from New York Society of Regional Anesthesia (NYSORA) showing the multimodal approach utilized in 2009 at Thomas Jefferson University Hospital and Rothman Institute for Orthopedics.10 Another facility recently surveyed utilizes oral oxycodone XR 10 mg and Celebrex (celecoxib) 200 mg oral the morning of surgery. Patients receive adductor canal and popliteal nerve block with ropivicaine or bupivacaine +/- decadron +/epinephrine for total knee arthroplasty. Pts receive intravenous acetaminophen 1 gram intraoperatively. Postoperative pain control medication varies among the surgeons. (Major Shannon Eldridge, CRNA, MSN, DNP, email communication, June 2016) As indicated, various institutions and programs have found multiple ways to approach the goal of multimodal analgesia. With the ongoing emphasis of reducing opioid consumption, the role of multimodal analgesia will only continue to grow in total joint arthroplasty. Coupled with TJC’s expectations as demonstrated in this facility’s recent process resulting in Gold Seal Certification in Total Hip and Total Knee Arthroplasty, understanding and implementing the lessons learned regarding multimodal analgesia will not only result in obtaining Gold Seal January 2017

Certification for a Total Joint Program from TJC, but also improve postoperative pain relief, increase patient satisfaction, expedite mobilization and rehabilitation and reduce healthcare costs.6 Lessons Learned and Benefits Obtaining Gold Seal Certification in a Total Joint Program can be a relatively painless and rapid process. Utilizing the TJC website, following the steps as outlined and implementing the changes recommended during the Gap Analysis can position a program for almost immediate success in obtaining this advanced certification. This process improves the quality of patient care by reducing variation in clinical processes, reducing the risk of error. It provides a framework for program structure and management, helping to maintain a consistently high level of quality, using 7

effective data-driven performance improvements. The process provides an objective assessment of clinical excellence through reviewer’s provision of expert advice and education on good practices during the on-site review. The certification process provides an opportunity for staff to develop their skills and knowledge and provides the clinical team with common goals and a concrete validation of their combined efforts. Gold Seal Certification may provide an advantage in a competitive healthcare marketplace

and improve the ability to secure new business, affecting marketing, contracting, and reimbursement. In some markets, certification is becoming a prerequisite to eligibility for insurance reimbursement, or participation for managed care plans and contract bidding. Finally, obtaining certification can fulfill regulatory requirements in select states, reducing duplication of time and effort on the part of certified organizations.6

References

1. The Joint Commission. The Joint Commission website. https://www.jointcommission.org/facts_about_the_ joint_commission. Accessed June 18, 2016 2. The Joint Commission. The Joint Commission website. https://www.jointcommission.org/certification/ dsc_home.aspx. Accessed June 18, 2016 3. Podcast. Take 5 with The Joint Commission. The Joint Commission. http://hwcdn. libsyn.com/p/f/8/9/f897e486254c201a/Take_5_THTK_Certification.mp3?c_ id=11744812&expiration=1466692183&hwt=552b18a8277fcb1f4af0be4daae851a4. Accessed June 17, 2016 4. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. Journal of Arthroplasty, 2012 Sep: 27(8 Suppl):61-5.e1 doi:10.1016/j.arth.2012.02.022. 5. BlueCross BlueShield. A Study of Cost Variations for Knee and Hip Replacement Surgeries in the U.S.. http://www.bcbs.com/healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf. January 21, 2015. Accessed June 17, 2016 6. The Joint Commission. The Joint Commission website. https://www.jointcommission.org/advanced_ certification_for_total_hip_and_total_knee_replacement_eligibility. 7. American Society of Anesthesiologists Task Force on Acute Pain Management (2012). Practice guidelines for Acute Pain Management in the Perioperative Setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. 2012. Anesthesiology. 2012; 116(2), 248-273 8. Pasero C, Stannard D. The Role of Intravenous Acetaminophen in Acute Pain Management: A caseillustrated review. 2012. Pain Management Nursing. 2012;13(2):107-124.  9. Manworren RCB. Multimodal Pain Management and the Future of a Personalized Medicine Approach to Pain. AORN Journal. 2015;101:308-314. doi:10.1016/j.aorn.2014.12.009 10. Gandhi K, Viscusi E. Multimodal Pain Management Techniques in Hip and Knee Arthroplasty. 2009. The Journal of NYSORA. 2012;13: 1-10 8

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Questions:

POST TEST

1. The Joint Commission evaluates and accredits over what number of facilities and organizations? A. 12,000 B. 19,000 C. 20,000 D. 21,000 E. 47,000 2. Which of the following are not an area in which Advanced Certification is offered by TJC? A. Reproduction B. Trauma C. Sepsis D. Wound Care 3. The most recent certification offered by TJC is in what specialty? A. Urosepsis B. Spine Surgery C. Total Hip and Total Knee Replacement D. Total Shoulder Arthroplasty 4. T/F One of the stated goals of TJC in offering this advanced certification is, “Fostering more cost-effective and safe quality care.

5. Which of the following is not a minimum requirement for TJC certification in Total Hip and Total Knee Arthroplasty? A. The program is in the United States, or operated by the US government or under a charter of the US Congress. B. The program is not within a Joint Commission accredited organization. C. The program must have served a designated minimum number of patients. D. The program uses a standardized method of delivering clinical care based on clinical practice guidelines and/or evidence-based practice. E. The program uses performance measurement to improve its performance over time 6. When completing an application for TJC Certification in Total Hip and Knee Arthroplasty, what number of Performance Measure(s) must be included? A. 1 B. 2 C. 3 D. 4

A. True B. False

January 2017

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7. Which of the following specifications relate to the Performance Measure(s)?

13. What key concept was emphasized during the process of obtaining Certification?

A. Evidence-based

A. Throughput

B. Relevant

B. Holistic Medicine

C. Valid

C. Multimodal Analgesia

D. Reliable

D. Decreasing Infection Rates

E. All of the above 8. For Certification in Total Hip and Knee Arthroplasty, a site visit ______ mandatory? A. Is B. Is not 9. Which of the following stages in the patient process is not evaluated by TJC? A. Initial visit in the Surgeon’s office B. Pre-operative C. Inpatient and/or outpatient recovery D. Rehabilitation E. None of the above 10. Which of the following is considered a pharmacological intervention? A. Touch therapy B. Continuous Passive Motion (CPM)

14. What additive medications did the author indicate were used in SAB for Total Hip Arthroplasty at the time of obtaining Certification at the facility? A. Dilaudid B. Duramorph C. Fentanyl D. All of the above E. None of the above 15. In the New York Society of Regional Anesthesia Flowchart, Epidural with LA was not used for postoperative pain control in which Total Joint Procedure? A. Total Hip Replacement B. Total Knee Replacement 16. What medication was listed as a possible contraindication to central neuraxial anesthesia for total hip arthroplasty?

C. Capsaicin

A. Acetaminophen

D. Cryotherapy

B. Ketorolac

11. According to the graphic, which of the following medications do not work at the dorsal horn? A. Anticonvulsants B. Antidepressants C. Acetaminophen D. Alpha-2-adrenergic Agonists 12. Multimodal analgesia has been shown to improve all of the following except?

C. Lovenox D. Heparin 17. What oral medication were mentioned in the article as being utilized in addition to regional anesthesia at another facility surveyed? A. Oxycodone B. Celecoxib C. Gabapentin

A. Preoperative pain relief

D. A and B

B. Patient satisfaction

E. All of the above

C. Mobilization and rehabilitation D. Reduced health care costs.

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18. T/F According to the Article, there is one correct protocol required by TJC to meet the goal of multimodal analgesia. A. True B. False 19. Which of the following is a benefit of obtaining TJC Certification in Total Hip and Total Knee Replacement? A. Increasing variation in clinical process B. Increasing staff skills and knowledge C. Decreasing ability to secure new business D. Decreasing level of quality of care 20. In some markets, certification ____ becoming a prerequisite to eligibility for insurance reimbursement, or participation for managed care plans and contract bidding. A. Is B. Is not

Test questions must be completed online, visit CRNAToday.com January 2017

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“THE JOINT COMMISSION CERTIFICATION FOR TOTAL JOINTS”

Across 2. T/F One of the stated goals of TJC in offering this advanced certification is, “Fostering more costeffective and safe quality care. 5. is considered a pharmacological intervention 6. Number of Performance Measures to be included in an application for TJC Certification in Total Hip and Knee Arthroplasty 7. T/F According to the Article, there is one correct protocol required by TJC to meet the goal of multimodal analgesia. 8. Multimodal analgesia has been shown to improve patient(blank) 9. (Blank) is an advanced Certification offered by TJC 10. medication that is listed as a possible contraindication to central neuraxial anesthesia for total hip arthroplasty? Down 1. A stage in the patient process that is evaluated by TJC 3. Multimodal (blank) was emphasized during the process of obtaining certification 4. A site visit is (blank) for Certification in Total Hip and Knee Arthroplasty 5. in some markets (blank) is becoming a prerequisite for eligibility in insurance reimbursement, or participation for managed care plans and contract bidding.

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