1. Occupational therapy for adults undergoing total hip replacement
Practice guideline   
Royal College of Occupational Therapists
Specialist Section - Trauma and Orthopaedics
CPD Session: PowerPoint, notes and group activities
The slides and information in this CPD session can be used as a template, but can be adapted to reflect local need and priorities.
The overall aim of this resource is to support a continuing professional development session to explore the practice guideline Occupational therapy for adults undergoing total hip replacement (COT 2012).
The resource comprises this PowerPoint presentation and notes which can be used for a one-hour facilitated workshop, or for individual self-directed learning.
There are some interactive activities which are intended to be used to encourage reflection on current practice and to explore some areas in more detail.
Pre-requisite materials:
Guideline document: Occupational therapy for adults undergoing total hip replacement (COT 2012)
Implementation tools i.e.
Audit Form.
Quick Reference Guide.
It is essential that workshop facilitators familiarise themselves with the full guideline document and implementation tools in advance.

2. Learning outcomes
To explore aspects of the practice guideline recommendations in relation to current practice.
To develop an understanding of the importance of using practice guidelines to inform practice.
To explore and develop an understanding of how to use the RCOT Audit Form for use with the evidence-based recommendations.
Slide 3 Practice question
Slide 4 Guideline objective
Slide 5-6 Methodology and recommendation grading
Slide 7 Recommendation areas:
Maximised functional independence
Reduced anxiety (Activity 1 and 2)
Resumption of roles
Low readmission rates
Decrease length of hospital stay
Reduced demand on support services
Reintegration into the community
Slides Evidence overview and list of the recommendations
Slides Impact of the guideline (Activity 3)
Slide 23 Practice guideline resources
Information used in the session is taken from the full practice guideline document and the other implementation tools, particularly the audit tool.
Activities 1 and 2 can potentially be applied to any of the recommendation areas. Choose the one that you think would yield as much discussion as possible by the group in order that they may take plenty of ideas away to think about.

3. Practice question:
What evidence is there to support occupational therapy intervention with adults over the age of 18 undergoing total hip replacement?

4. Key objective of guideline
To describe the most appropriate care or action to be taken by occupational therapists working with adults undergoing total hip replacement. It addresses occupational therapy intervention during the service user’s journey along the care pathway and is applicable to any setting.
Emphasise that the guideline focuses on total hip replacement, but that some of the recommendations will be directly applicable to elective surgery only, rather than trauma surgery. However, the majority of the recommendations will be appropriate to service users over the age of 18 years, undergoing a total hip replacement, whatever the predisposing circumstances.

5. Methodology 2. Guideline scope defined involving stakeholders
1. Guideline development group established
5. Critically appraise articles
4. Screen findings
3. Literature search
6. Development of practice guideline recommendations
7. Peer review, stakeholder and service user consultation
The College of Occupational Therapists’ guideline development process is rigorous and is Accredited by the National Institute for Health and Care Excellence.
Selection of a topic
1. Establish the Guideline Development Group
Submit a proposal
2. Define the scope and practice question(s)
3. Literature search
4. Screen findings
5. Appraisal and grading of the evidence
6. Formulate the recommendations
Write the guideline
7. Peer review and consultation involving stakeholders (includes
occupational therapists as end users) and service users
8. Ratification by the COT Practice Publications Group
Publication and Implementation
Review – within 5 years.
Stakeholder, service user and carer engagement and involvement was fundamental to the development of the guideline.
9. Published by
COT 2012
8. Final draft approved by COT Practice Publications Group

6. Evidence-based recommendations
Recommendations are based on the evidence available within 54 critically appraised papers.
Each recommendation is assigned:
A strength scoring 1 or 2 (Strong or Conditional);
A quality grading A, B, C or D
(High, Moderate, Low or Very Low).
Each relevant article of evidence identified from the search (2001 – 2011) was critically appraised by two members of the guideline development group, and a quality of evidence grading subsequently determined based on that assessment.
The quality of evidence grading reflects the typical hierarchy given to study design. For example the highest level (A) reflects consistent results from randomized controlled trials, whilst the lowest (D) includes studies such as case studies or expert opinion. Higher level studies are perceived as being less susceptible to bias.
The strength of the recommendation is scored as either strong (1) or conditional (2). This is based on the benefits and risks of the evidence. A strong recommendation indicates that benefits appear to outweigh the risks for the majority of the target group, where as a conditional or suggested recommendation, means that the risks and benefits are more closely balanced or there is more uncertainty.
The majority of the 54 items of evidence was assessed as low grade and was made up of predominantly cohort and qualitative studies. 3.73% of the evidence was graded as high (A), 18.5% as moderate (B), 63.0% as low, and 14.8% as very low (D). Sixteen of the 25 recommendations are graded as strong.
Each recommendation is specific and is based on the appraised evidence. Details about the studies referenced can be found in the evidence tables section (Appendix 5) of the full guideline.

7. Recommendation areas Maximised functional independence;
Reduced anxiety;
Resumption of roles;
Low readmission rates;
Decreased length of hospital stay;
Reduced demand on support services;
Reintegration into the community.
The recommendations are based on the synthesis of the best available evidence. It should, therefore, be noted that the guideline is not able to be fully reflective of the role of occupational therapy with adults who are undergoing total hip replacement.
Recommendations, based on the evidence, were developed in seven key areas:
Maximised functional independence
Reduced anxiety
Resumption of roles
Low readmission rates
Decrease length of hospital stay
Reduced demand on support services
Reintegration into the community

8. Maximised functional independence
It is recommended that the occupational therapy assessment is comprehensive and considers factors which may affect individual needs, goals, recovery and rehabilitation, including co-morbidities, trauma history, personal circumstances, obesity and pre-operative function.
(Johansson et al 2010, C; Lin and Kaplan 2004, C; Marks 2008, C; Naylor et al 2008, C; Ostendorf et al 2004, C; Vincent et al 2007, C; Wang et al 2010, C)
1 C
2. It is recommended that goal setting is individualised, enhances realistic expectations of functional independence, and commences at pre-operative assessment.
(Judge et al 2011, C; Mancuso et al 2003, C)

9. Maximised functional independence
contd.
Maximised functional independence
3. It is recommended that occupational therapists ensure that they provide
clear communication and advice that is consistent with that of other
members of the multidisciplinary team.
(Fielden et al 2003, C)
1 C
4. It is recommended that depression and anxiety status are taken into
account during pre-operative and post-operative intervention due to their
potential for impact on recovery.
(Caracciolo and Giaqunito 2005, C; Nickinson et al 2009, C)
5. It is recommended that cognitive status is taken into account during pre-
operative and post-operative intervention due to its potential for impact
on recovery.
(Wang and Emery 2002, C; Wong et al 2002, C)

10. Maximised functional independence
contd.
Maximised functional independence
6. It is recommended that service users are fully involved in decisions
about the equipment required to enable them to carry out daily living
activities and to comply with any hip precautions in their home
environment post-surgery.
(Thomas et al 2010, D)
1 D
7. It is recommended that service users are given advice on effective pain
management strategies, to decrease pre-operative pain experience and
sleep disturbance, and enhance post-operative physical function.
(Berge et al 2004, B; Montin et al 2007, C; Parsons et al 2009, C)
1 B
8. It is suggested that standardised assessment and outcome
measures are used, where appropriate, to determine functional
outcomes and occupational performance in rehabilitation settings, either
inpatient or community based.
(Gillen et al 2007, C; Kiefer and Emery 2004, C; Oberg et al 2005, D)
2 C
Activity 1
Prior to showing the next slide 12, ‘Reducing anxiety’ Activity 1 can be carried out.
Tell the group that the next section deals with reducing anxiety.
Split the group into pairs and ask them to discuss what they think would be covered/recommended in this section. Prompt them to think about their own practice in this area, highlighting examples of their own best practice.
Following discussion, ask the pairs to share 1-2 examples with the group; you might want to record on a flipchart the groups’ suggestions to refer back to these ideas when you show the recommendations.
On completion of the activity present the recommendations for reducing anxiety which are on slides 11 and 12.

11. Reduced anxiety Reduced anxiety
9. It is recommended that the pre-operative assessment undertaken by
the occupational therapist allows adequate time for individualised
questions and discussion of expectations and anxieties.
(Fielden et al 2003, C; McDonald et al 2004, A; Montin et al 2007, C)
1 A
10. It is suggested that occupational therapists offer support and advice to
service users who may be anxious about an accelerated discharge
home.
(Heine et al 2004, D; Hunt et al 2009, D; Montin et al 2007, C)
2 C
11. It is recommended that pre-operative assessment and education is
carried out in the most appropriate environment for the service user.
For the majority of service users a clinic environment is appropriate,
but where needs are complex, a home assessment should be an
available option.
(Crowe and Henderson 2003, B; Drummond et al 2012, C; Orpen and
Harris 2010, C; Rivard et al 2003, B)
1 B

12. Reduced anxiety contd. Reduced anxiety
12. It is suggested that provision of equipment pre-operatively may
facilitate familiarity and confidence in use.
(Fielden et al 2003, C; Orpen and Harris 2010, C)
2 C
13. It is suggested that service users may value being treated by the same
occupational therapist throughout the process, from pre-operative
assessment/education to post-operative rehabilitation wherever
possible.
(Spalding 2003, C)
14. It is suggested that occupational therapists should contribute to
standardised pre-operative education interventions, providing
information, advice and demonstrations where relevant (e.g. of joint
protection principles, equipment, etc.).
(Coudeyre et al 2007, B; Johansson et al 2007, B; Spalding 2003, C;
Spalding 2004, C; Soever et al 2010, C)
2 B
Activity 2
Once the recommendations have been presented, the questions below can be used to encourage the group to talk about the recommendations in relation to their own suggestions:
Do they cover the best practice examples they identified?
Why might these not be the same?
You may want to refer back to the methodology of creating evidence-based guidelines and how it is based on the published literature - evidence-based practice guidelines support practice, but can only reflect current evidence.
It may be important to emphasise that just because their own examples are not covered, this does not necessarily mean they are not best practice. Occupational therapists also need to adhere to other service standards, consider the service user’s perspectives and apply their clinical judgement and reasoning when providing interventions for adults who are undergoing total hip replacement.
The Audit Form can now be used to further consider the reducing anxiety recommendations.
Ask the pairs/small groups to discuss each of the recommendations (give each group a different recommendation), sharing their current practice in relation to the recommendation and how they would evidence this. If the recommendation is not current practice then they should look at what an action plan might consist of to implement that recommendation.

13. Resumption of roles Resumption of roles
15. It is recommended that work roles are discussed at the earliest
opportunity as part of a comprehensive assessment.
(Bohm 2010, C; Mobasheri et al 2006, D; Nunley et al 2011, C)
1 C
16. It is suggested that for service users who are working, advice is
provided relating to maintaining their work role pre-operatively, post-
operative expectations and relevant information for employers.
(Bohm 2010, C; Mobasheri et al 2006, D; Nunley et al 2011, C;
Parsons et al 2009, D)
2 C
17. It is recommended that occupational therapists provide advice to
facilitate service users to establish previous and new roles and
relationships, and shift their focus from disability to ability.
(Grant et al 2009, C)

14. Low readmission rates Low readmission rates
18. It is recommended that occupational therapists consult with the surgical
team regarding any specific precautions to be followed post-operatively.
(Hol et al 2010, B; Peak et al 2005, B; Restrepo et al 2011, B; Stewart
and McMillan 2011, C; Ververeli et al 2009, B)
1 B
19. It is recommended that occupational therapists advise service users,
where protocol includes precautions, on appropriate position behaviours
for those daily activities applicable to the individual's needs, ranging from
getting in/out of a car to answering the telephone.
(Drummond et al 2012, C; Malik et al 2002, D; Peak et al 2005, B;
Stewart and McMillan 2011, C; Ververeli et al 2009, B)
20. It is suggested that due to the uncertainty surrounding the need for hip
precautions, and the potential for an increase in satisfaction and early
functional independence when hip precautions are relaxed or discontinued,
occupational therapists engage in local discussion/review of the emerging
evidence with their surgical and multidisciplinary teams.
(Drummond et al 2012, C; O’Donnell et al 2006, D; Peak et al 2005, B;
Restrepo et al 2011, B; Ververeli et al 2009, B)
2 B

15. Decreased length of hospital stay
21. It is recommended that occupational therapists optimise length of stay,
with due reference to care pathways and enhanced recovery
programme guidance.
(Berend et al 2004, C; Bottros et al 2010, C; Brunenberg et al 2005, C;
Husted et al 2008, C; Kim et al 2003, B)
1 B
22. It is recommended that the occupational therapist is involved in early
multidisciplinary post-operative intervention for service users following
hip replacement, providing either inpatient or home-based rehabilitation.
(Iyengar et al 2007, C; Khan et al 2008, A; Siggeirsdottir et al 2005, C)
1 A

16. Reduce demand on support services
23. It is suggested that there are potential benefits in including informal
carers in pre-operative assessment/education, and post-operative
intervention, to maximise service user independence and reduce carer
stress.
(Chow 2001, C)
2 C

17. Reintegration into the community
24. It is recommended that occupational therapists encourage early
discussion and goal setting for community reintegration, including social
and physical activities.
(de Groot et al 2008, D; Gillen et al 2007, C)
1 C
25. It is suggested that where specific needs are identified, the occupational
therapist refers the service user on to community rehabilitation,
reablement or intermediate care services to enhance community
reintegration.
2 C
Activity 3 – can be carried out before moving onto the next slides
Divide into groups again and ask them to consider what they think the impact of these guidelines will be for themselves, their service managers, the users of their service, and the commissioners of services.
Obtain feedback from the groups before going through the suggested impacts on slides 18–22.

18. Impact of practice guideline for you: the practitioner
Challenges / affirms your current practice.
Provides evidence-based recommendations to inform and support your practice.
Raises awareness of benefits and risks and organisational and financial barriers.
Provides a vehicle for you to audit and justify your practice.

19. Impact of practice guideline for managers
Provides evidence of the need for occupational therapy input into services for adults undergoing total hip replacement.
Provides a structure to audit the work of occupational therapists within the service to improve service quality.
Provides a vehicle for justifying service provision.

20. Impact of practice guideline for commissioners
Articulates the need for occupational therapy interventions within services for adults undergoing total hip replacement.
Provides recommendations developed by a NICE Accredited process.
Can help educate commissioners to identify learning needs for the workforce.
Audit form provides a mechanism to review service delivery in accordance with the evidence.
NB: Highlight the significance of the guideline having been developed by the COT Guideline Development process which is NICE Accredited, e.g.
COT practice guidelines developed using the NICE Accredited guideline process are clearly visible in search results on NICE Evidence.
Guidelines developed via a NICE Accredited process are eligible for consideration as evidence in the development of NICE Quality Standards.
Provides robust evidence-based recommendations that can demonstrate to commissioners the benefits of occupational therapy for the community on whose behalf they are commissioning services.
Further information at:

21. Impact of practice guideline for service users
The recommendations reinforce the fundamental importance of the service user perspective.
In being adopted by services and occupational therapists, the guideline should improve the consistency and quality of intervention for users of services.
Gives assurance that practitioners use the available evidence to support interventions.

22. Service user perspectives
“The home visit by my local OT was extremely helpful. He explained very clearly what I might expect and ways of helping my recovery and improving my post-op mobility.”
“This is a common and routine operation so sometimes you feel all the pre-operative assessment is a ‘tick box’ - but to you it is a major event and very worrying.”
“It is vitally important that your relatives and carers are involved in pre-operative education.”
“It is really important that you are given consistent advice from everyone in the team - you can be told different things by different people and this increases your fears and worries both before and after the operation.”
Conclude the session by summarising some of the key areas of discussion and messages from the guideline recommendations.
Ask each participant to share a thought about the recommendations and to identify something they are going to do following the session.
If applicable, you may also want to identify how as a service you are going to complete and monitor the Audit Form.
Finish by reiterating the importance of a practice guideline in informing work with service users, focusing on empowering the service user to fully engage and take responsibility of achieving individual goals.

23. Practice guideline resources
College of Occupational Therapists (2012) Occupational therapy for adults undergoing total hip replacement: practice guideline. London: COT.
Audit tool.
Quick Reference Guide.
Feedback form.
Resources are available from the Royal College’s website at: