title: Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients.
abstract: Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable ("wiki") database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care.
  
  
  
  We conducted a retrospective review of patients who underwent primary lower extremity arthroplasty at our institution during three 6-month time periods including immediately before, 6 months after, and 2 years following introduction of the wiki. Adherence to defined perioperative care pathways (laboratory studies, post-operative imaging, perioperative antibiotics, and inpatient pain medications) was compared between the groups.
  
  
  
  After wiki implementation, adherence to protocols improved significantly for laboratory orders (P < .0001), imaging (P < .001), pain control regimen (P = .03), and overall protocol adherence (P < .001). Improvements were seen in some areas almost immediately, while others did not show improvements until 2 years after implementation. Costs associated with unnecessary testing were reduced by 82%.
  
  
  
  Development of an online wiki for tracking post-operative protocols improves care pathway adherence and reduces variability in care while lowering costs associated with unnecessary testing, although some benefits may not be immediately realized. Several practical barriers to implementing the wiki are also discussed, along with proposed solutions.
authors.affiliation: Department of Orthopaedics and Rehabilitation, University of Massachusetts - Worcester, Worcester, Massachusetts.
authors.forename: Eric F
authors.initials: EF
authors.lastname: Swart
authors.affiliation: Department of Orthopaedics, Columbia University Medical Center, New York, New York.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Miller
authors.affiliation: Department of Orthopaedics, Columbia University Medical Center, New York, New York.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Hickernell
authors.affiliation: Department of Orthopaedic Surgery, University of Texas at Austin Dell Medical School, Austin, Texas; Department of Surgery and Perioperative Care, Dell Medical School at UT Austin, Austin, Texas.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Bozic
authors.affiliation: Department of Orthopaedics, Columbia University Medical Center, New York, New York.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Geller
authors.affiliation: Department of Orthopaedics, Columbia University Medical Center, New York, New York; Department of Orthopaedics, New York University, Langone Medical Center, New York, New York.
authors.forename: William B
authors.initials: WB
authors.lastname: Macaulay
mesh_terms: D000818:Animals; D000900:Anti-Bacterial Agents; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D002985:Clinical Protocols; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006614:Hindlimb; D006801:Humans; D008297:Male; D019990:Perioperative Care / Q000191:economics / Q000592:standards*; D011184:Postoperative Period; D012189:Retrospective Studies; D019564:Unnecessary Procedures / Q000191:economics / Q000706:statistics & numerical data
chemical_list: D000900:Anti-Bacterial Agents
keywords: arthroplasty; clinical pathways; critical pathways; perioperative care; replacement