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Orthopedic Quality Measures

Orthopedic Quality Measures

(all data collected in 2010)

Our Orthopedic Quality Care Measures:

Patient Length of Stay at St. Mary Medical Center: 

  • Total Hip Replacement:  St. Mary =  2.9 days; National Benchmark = 4.9 days (AHRQ/HCUPnet).
  • Total Knee Replacement:  St. Mary = 2.6 days; National Benchmark = 3.8 days (AHRZ/HCUPnet).

What a shorter length of stay means for our patients and why it's important: Our Joint Replacement program was developed in collaboration with input from our patients as well as the therapists, physicians and nursing staff. Our Patient Centered Team includes a dedicated OR team, dedicated Physical and Occupational Therapists, Pharmacists and Certified Orthopedic Nurses. Our patients are leading the way in their ability to recover quicker and optimize their outcomes. We offer a fully comprehensive plan of care that begins with exercising and strengthening your muscles prior to surgery. After surgery, patients are out of bed and walking on the evening of surgery.  Physical Therapy and Occupational Therapy will begin the morning after surgery and continue twice daily while in the hospital. We have a fully equipped gym on our unit for patients to receive more aggressive therapy and simulate their home environment. Patients get dressed the day after surgery in their own clothes and most patients will walk 150 feet to the gym the day after surgery and go up and down steps. Patients use a rolling walker initially after surgery, but most will progress to the use of a cane within two weeks.

Discharge Disposition to Home: (Percentage of patients who go directly home from the hospital without needed to go to an in-patient rehab center).

  • Total Hip Replacement: 80%; No National Benchmark Available.
  • Total Knee Replacement: 92%; No National Benchmark Available.


Why our patient are able to avoid going to a rehab center a higher percentage of the time: As part of our overall Joint Replacement program, this allows our patients to recover rapidly and safely go home in 2-3 days, thereby avoiding the need to go to a rehab center. By allowing patients the ability to return to their normal activities of daily living in a quicker manner, we are able to get their muscles strengthened in a quicker time frame which yields a quicker recovery and optimal outcomes. By offering such a collaborative patient-focused approach, we have achieved very high patient satisfaction rates with very low complication rates.


Surgical Site Infection Rate: (rate is based on following patients for one year following their surgery, not just their hospitalization period)  


  • Total Hip Replacement: St. Mary = 0%    National Benchmark = 1.26% (US National Library of Medicine National Institutes of Health).
  • Total Knee Replacement: St. Mary = 0.8%   National Benchmark = 1.4% (US National Library of Medicine National Institutes of Health).


Mortality Rate:

  • Total Hip Replacement: St. Mary = 0%  National Benchmark = 0.9% (AHRQ/HCUPnet).
  • Total Knee Replacement: St. Mary = 0% National Benchmark = 0.12% (AHRQ/HCUPnet).

 **Patient Satisfaction Rate: Top 1% of the nation in Hip/Knee Replacement Surgery (NRC Picker HCAHPS).

Orthopedic Initiatives:

  • Participatant in Surgical Care Improvement Project (SCIP)
  • Member of Quality Insights Regional Committee 
  • NAON (National Association of Orthopedic Nurses) Poster Presenter at 2011 National Conference
  • Presenter at Marshall Steele & Associates National Conference in 2010
  • Orthopedic Strategic Planning Committee Participants for SG2
  • Pharmacy Managed Coumadin Protocol
  • Pre-Op MRSA Screening
  • Host Community Joint Pain Seminars
  • Host Community Seminars on Injury Prevention for Athletes
  • Host Reunion Lunches for Joint Replacement Patients
  • Host Annual Jog for Joints event

Orthopedic Awards:

(all data collected in 2010)

First Hospital in the State of Pennsylvania and 14th in the Nation to be awarded the Joint Commission Disease Specific Certification in Hip and Knee Replacement Surgery.  

  • What this distinction means: to earn and maintain this distinction of honor, St. Mary's program undergoes an extensive, unannounced, on-site evaluation by a Joint Commission reviewer every two years, in addition to an annual performance improvement review. The on-site evaluation includes a rigorous review of the program's processes, the program's ability to evaluate and improve care within its own organization, and interviews with patients and colleagues. Through this evaluation process, St. Mary demonstrated that its hip and knee replacement program meets or exceeds national standards and guidelines that can significantly improve outcomes for joint-replacement patients.


Blues Distinction Center of Excellence in Hip and Knee Replacement Surgery. To be designated as a Blue Distinction Center for Knee and Hip Replacement, the following selection criteria were developed with input from a panel of expert physicians:


  • How we earned this distinction: established acute care inpatient facility, including intensive care, emergency care, and a full range of patient support services with full accreditation by a national accreditation organization; experience and training of program surgeons; tracking and evaluation of clinical outcomes and process of care; multidisciplinary teams to coordinate and streamline care; including shared decision making and preoperative patient education.

Other Noteable Information:

  • The Pennsylvania Society of Health System Pharmacists Innovative and Collaborative Practice Award in 2010.
  • 100% of eligible Nurses hold Orthopedic Certification.
  • All orthopedic surgeons on staff at St. Mary are Board Certified and many hold additional qualifications of Fellowship Training in specialty areas such as Total Joint, Sports Medicine, Spine and Hand. Some surgeons have obtained Certificate of Added Qualifications in areas available such as Sports Medicine and Hand. 


Our Current Research Projects:

  • Out of Bed Day of Surgery
  • CPM (Continuous Positive Motion) usage
  • Prophylactic Pain and Nausea Study