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Table 2 Blue distinction criteria, points awarded, accommodations made to meet the criteria, and barriers to criteria’s implementation for process and outcomes and volume criteria

From: Enhancing the quality of international orthopedic medical mission trips using the blue distinction criteria for knee and hip replacement centers

Criteria Points earned out of total Explanation Accommodation Barrier
Process     
Structured functional assessments that are routinely performed and tracked for all knee and hip replacement patients include: 3/3 Criterion met. N/A N/A
--Pre-operative functional assessments
--Functional assessments four or more weeks post-operatively
Program identifies routine pre- and post-op assessment of functional status that are used for standardized indexes (e.g., Knee Society Score or Harris Hip Score, Western Ontario and McMaster Osteoarthritis Index, SF-36, EuroQol 5-D) Informational Criterion met. N/A N/A
Program has written patient selection criteria that are applied to all adult patients referred for knee or hip replacement 1/1 Criterion met. N/A N/A
Patient selection criteria are developed by a multi-disciplinary team of physicians and staff 1/1 Criterion met. N/A N/A
Program screens knee and hip patients pre-operatively for the presence of anxiety or depression 1/1 Criterion met. N/A N/A
Program uses formal measures to screen pre-operatively for anxiety or depression: 1/1 Criterion met. N/A N/A
--Beck Depression Inventory (BDI) Op-Walk Boston uses the mental health subscale of the SF-36.
--The Hospital Anxiety and Depression Scale (HADS)
--The nine-item depression scale of the Patient Health Questionnaire (PHQ-9)
--The mental health subscale of the Health status Questionnaire Short Form-36 (SF-36)
--Euro Qol 5-D
Program employs or is willing to implement SDM processes with patients considering knee or hip replacement surgery Informational Criterion not met. N/A Dominican patients are accustomed to agreeing with Doctors’ recommendations.
Program provides standardized pre-operative patient education 1/1 Criterion met. N/A N/A
Pre-operative patient education activities include: 2/2 Criterion met. Educational sessions, classes, and print material provided. Hospital’s staff offers reading help for all print material. N/A
Educational group session or class
Interactive electronic media program
Materials provided to the patient (print, video)
Written questionnaire completed by the patient
Percentage of patients participating in pre-operative patient education process greater than or equal to 90% 1/1 Criterion met. N/A N/A
Protocol informing patients with relevant comorbidities (e.g., BMI > 40 kg/m2, diabetes mellitus) of the increased risks associated with knee and hip replacement surgery 1/1 Criterion met. N/A N/A
Program utilizes established practice standards/recommendations for the peri-operative care of knee and hip replacement patients: 2/2 Criteria met. ASA, ACC, and ADA requirements met. N/A Following AHA guidelines requires prolonged and repeated contact with patients.
--American Society of Anesthesiologists (ASA) Practice Advisory for Pre-anesthesia Evaluation
--American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Perioperative Cardiovascular Evaluation for Non-cardiac Surgery
--American Diabetes Association (ADA) Standards of Diabetes Care in the Hospital
--AHA recommendations for Smoking Cessation - Making Hospital-Wide System Level Changes That Succeed
Program has a thromboprophylaxis protocol in place that is specific for knee and hip replacement patients and incorporates the American Academy of Orthopedic Surgeons (AAOS) Clinical Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Total Knee Arthroplasty [THA or TKA] 1/1 Criterion met. N/A N/A
Program implements the following anesthesia practices: 1/1 Criterion met. N/A N/A
--Knee and hip replacement patients are routinely evaluated for the use of regional anesthesia
--The program has a protocol in place for monitoring and maintaining intraoperative normothermia for appropriate knee and hip replacement patients
Program has protocols for the assessment and treatment of physical therapy needs in the post-operative knee and hip replacement surgery patients 1/1 Criterion met. N/A N/A
Program identifies aspects of PT/OT care that are provided routinely (e.g., pre-operative and post-operative education, home assessment, functional Informational Criterion met. N/A N/A
assessment, readiness-for-discharge assessment)
Standard practices for case management and discharge planning for knee and hip replacement patients include: 0/1 Criteria not met. Does not evaluate discharge needs before admission and lacks protocols for emergency evaluations and treatment post discharge. N/A N/A
--Evaluation for discharge needs occurs prior to the hospital admission
--Written criteria for hospital discharge and readmission
--Coordination of post-discharge needs (e.g., physical therapy, home care services)
--Written protocol for emergency evaluation and treatment post discharge
Percentage of patients admitted from home who return to home Informational 100% return home. N/A N/A
Program monitors transitions of care for patients discharged to another setting (e.g., home, rehab facility) using a formal method 0/1 Criterion not met. Patient stored in hospital’s EHR, so patient information could be tracked. Formal tracking protocol not followed.
Program has an established protocol ensuring the operation note and discharge summary of each patient are made available to the primary care physician upon discharge 0/1 Criterion not met. Op-Walk Boston’s colleagues follow-up with their patients for any needed post-op care. Most patients lack PCPs and there is no care coordination infrastructure.
Program tracks receipt of the operation note and discharge summary by primary care physician Informational Criterion not met. N/A Most patients lack PCPs and there is no care coordination infrastructure.
Program utilizes services of the local Blue Cross Blue Shield case management care team to coordinate transitions of care Informational Criterion not met. N/A Blue Cross/ Shield does not operate in the DR.
OUTCOMES AND VOLUME     
Average and median surgeon volumes (across all surgeons actively performing TKA or THA) are at least 50 primary or revision TKA or THA procedures during reported 12 month period. Surgeons may include cases done at any facility. Required Criteria met. N/A N/A
Facility performs at least 100 total knee and total hip replacement surgeries (primary and revisions) during reported 12 month period, with at least 25 each of total knee and total hip replacements Required Requirement met. N/A N/A
Facility volume > = 250 surgeries during reported 12 month period 0/3 Criterion not met. N/A N/A
Facility volume > = 500 surgeries during reported 12 month period 0/2 Criterion not met. N/A N/A
Facility performs 50 net revisions for Total Knee and Total Hip Arthroplasty 0/2 Criterion not applicable. N/A N/A
(Net Volume = total reported TKA/THA revisions minus revisions performed
< 6 months following a primary procedure where both procedures were done at the facility)
Average LOS for primary Total Knee Arthroplasty (TKA) less than or equal to 3.5 days 3/3 Criterion met. N/A N/A
Average LOS for primary Total Hip Arthroplasty (THA) less than or equal to 4.0 days 3/3 Criterion met. N/A N/A
Average LOS for Revision Hip Replacement, Hip Resurfacing and Revision Knee Replacement Informational Revisions rare. Inadequate data to access criterion. N/A N/A
Average 30-day readmission rate for primary Total Knee Arthroplasty (TKA) less than or equal to 10% 2/2 Criterion met. N/A N/A
Average 30-day readmission rate for primary Total Hip Arthroplasty (THA) less than or equal to 10% 2/2 Criterion met. N/A N/A
Program tracks the selection, administration and discontinuation of prophylactic antibiotics for total knee replacement patients: SCIP INF 1e, INF 2e, and INF 3e Informational Criterion not met. Each surgeon tracks their patients, but no programmatic level tracking. N/A