Specifications Manual for Joint Commission National Quality Measures (v2020B1)
Posted: 3/30/2020

Release Notes:
Measure Information Form
Version 2020B1

Measure Information Form

Measure Set: Total Hip and Total Knee Replacement Inpatient (THKR-IP)

Set Measure ID: THKR-IP-2

Set Measure ID Performance Measure Name
THKR-IP-2a viewtopic Postoperative Ambulation on Day of Surgery - Hip & Knee Overall
THKR-IP-2b viewtopic Postoperative Ambulation on Day of Surgery - Hip
THKR-IP-2c viewtopic Postoperative Ambulation on Day of Surgery - Knee

Performance Measure Name: Postoperative Ambulation on Day of Surgery

Description: Patients undergoing total hip or total knee replacement who ambulated postoperatively the day of surgery or ambulated in the PACU or within 4 hours of discharge from the PACU.

Rationale: Early ambulation as close to the time of surgery as possible can reduce the risk of complications associated with bed rest such as deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia and urinary retention. Additionally, early ambulation results in a decreased length of stay, lowering the patient’s risk for hospital acquired infections and other complications. Early ambulation leads to improvement in outcomes (range of motion, gait, balance, muscle strength and pain) without an increase in adverse events.1 Studies demonstrating positive results showed that rapid ambulation can be achieved as early as in the PACU.2

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients undergoing total hip or total knee replacement who ambulated postoperatively the day of surgery or ambulated in the PACU or within 4 hours of discharge from the PACU.
Included Populations:
  • Postoperative ambulation (walking) on the day of surgery
  • Postoperative ambulation (walking) in the PACU or within 4 hours of discharge from the PACU

Excluded Populations: None

Data Elements:

Denominator Statement: Patients undergoing a total hip or total knee replacement.
Included Populations:
  • Patients with an ICD-10-PCS Principal Procedure Code as defined in Appendix A: Table 14.01a Total Hip Replacement or Table 14.02a Total Knee Replacement

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a Length of Stay greater than 120 days
  • Patients with an ICD-10-PCS Other Procedure Code as defined in Appendix A: Table 14.05a (partial hip and partial knee replacements), or Table 14.06a (revision and resurfacing procedures, or Table 14.07a (removal of implanted devices/prostheses)
  • Patients with an ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Code as defined in Appendix A: Table 14.08 (complication of Internal Fixation Device/Prosthesis) or Table 14.09 (malignant neoplasm of the pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow or a disseminated malignant neoplasm), or Table 14.10 (femur, hip, pelvic fracture)
  • Postoperative patients who are admitted to ICU on Principal Procedure Date or PACU Discharge Date
  • Patient expired on Principal Procedure Date
  • Patient expired on PACU Discharge Date
  • Patient left AMA on PACU Discharge Date
  • Documented contraindication by physician/APN/PA/nurse/physical therapist/occupational therapist for not ambulating on day of surgery (e.g. nerve block has not worn off, hypotensive upon standing, patient is vomiting)

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion. Proportion for hip replacements, proportion for knee replacements and aggregated proportion for hip & knee replacements.

Selected References:
  • 1Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clin Rehabil. 2014 Dec 1.
  • 2Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco J. Rapid Mobilization Decreases Length of Stay in Joint Replacement Patients. Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6.
  • AAOS Guidelines on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty”, AAOS.
  • Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
  • Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing THR/TKR. BMJ Qual Saf 2011;20:153-157
  • Larsen K, Sorensen, O, Hansen T, Thomsen P, Soballe K. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: A randomized clinical trial involving 87 patients with 3 months of followup. Acta Orthopaedica 79:2, 149-159.
  • den Hertog A, Gliesche K, Timm J, Mühlbauer B, Zebrowski. Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg. 2012 Aug; 132(8):1153-63.
  • Smith TO, McCabe C, Lister Set al Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty. Orthop Traumatol Surg Res 2012; 98: 499–505.
  • Raut S, Mertes SC, Muniz-Terrera G, Khanduja V. Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop 2012; 36: 1,601–1,608.
  • Raphael M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth 2011; 58: 902–910
  • Pua YH, Ong PH. Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. Am J Phys Med Rehabil 2014; 93:962-970.
  • Chen AF, Stewart MK, Heyl AE, Klatt BA. Effect of Immediate Postoperative Physical Therapy on Length of Stay for Total Joint Arthroplasty Patients. The Journal of Arthroplasty 2012;Vol.27 No. 6
  • Wellman SS, Murphy AC, Gulcynski D, Murphy SB. Implementation of an accelerated mobilization protocol following primary total hip arthroplasty: impact on length of stay and disposition. Current Reviews in Musculoskeletal Medicine Volume 4(3); 2011 Sep
  • Renkawitz T, Rieder T, Handel M. Comparison of two accelerated clinical pathways – after total knee replacement how fast can we really go? Clinical Rehabilitation 2010; 24:230-239
  • Labraca,NS, Castro-Sanchez,AM, Mataran-Penarrocha,G, Arroyo-Morales,M, Sanchez-Joya,M, Moreno-Lorenzo C. Benefits of starting rehabilitation within 24 hours of primary total knee arthroplasty: randomized clinical trial. Clin Rehabil. 2011/25(6):557-566
  • Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.

Measure Algorithm:

Measure Information Form THKR-IP-2
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Specifications Manual for Joint Commission National Quality Measures (v2020B1)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)


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