alasdair sutherland - south west healthcare - south west healthcare’s hip fracture patient...
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Alasdair Sutherland, Orthopaedic Surgeon, Director of Orthopaedic Services, South West Healthcare delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting. Find out more at http://www.healthcareconferences.com.au/hipfracture2013TRANSCRIPT
A/Prof Alasdair Sutherland MD (Hons) FRCSEd(Tr&Orth), FRACS (Orth)
Director of Orthopædic Services, South West Healthcare
Regional Hip Fracture Service Redesign
Aberdeen Royal Infirmary
The Aberdeen Experience } Large population, single hospital
} C600 000 population } 1000 bed hospital, all specialties on-site } Hospital NEVER on by-pass
} 900 hip fractures per year } Daily trauma lists, consultant anaesthetist + surgeon } Orthogeriatric Service } Head of Department leader in development of Scottish
Hip Fracture Audit, STAR trial } Hip fractures recognised as clinical priority
The Warrnambool Experience } Smaller population
} Regional population c 100 000 } Several regional referral options } No guarantee of bed availability, no specific orthopaedic ward
} 50-60 Hip Fractures per year } Weekly trauma list, on sufferance
} On call anaesthetist each day has full operating list } Limited day-time emergency theatre available
} No orthogeriatric service, fragmented rehab system } Hip fractures not recognised as clinical priority
The Challenge of Hip Fractures
A problem of perception
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“I had never considered NoFs to be Emergencies”
“I’m busy. I don’t need to come and see that NoF”
Are they surgical patients with medical problems or medical patients with a surgical problem?
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“We don’t do NoFs at the weekend”
“I have a policy not to do NoFs at the weekend, in case something urgent comes in”
“I’m not sitting around waiting for the occasional call”
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On Monday: “I’ll be available to do that NoF on Friday morning”
When is a NoF not a NoF?
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They are elderly patients with hip fractures
Often among the sickest patients in the hospital
The Warrnambool Process
} Key part of wider re-desingn of Surgical Services } “The operating department is the engine–room of the
hospital” SWHC CEO } Denis O’Leary
} Initial Review of Processes
Our Hip Fracture Pathway -‐ South West Healthcare
Ambulance/ED Radiology Acute Ward -‐ Pre-‐operaAve OperaAng Theatre Acute Ward -‐ Post-‐operaAve Sub Acute Care Discharge Measures
Does Amb. inform ED that a pat. with a hip # is arriving?
How is the request for imaging services received?
Is a Hip # clinical pathway used?
Is there a dedicated orthopaedic trauma list 24/7
Is the pain score recorded? Do the pain management team visit the paAent?
Are there daily MulA dispilinary meeAngs?
Is discharge event driven? Are the no. of Hip #s pa known?
SomeAmes In / out of hours process Yes No Yes No G1 H1 Yes
Emergency Department When is pat. trans. to/from X-‐ray and is it Amely?
Is there a designated ward for the fractured hip paAent?
When is the paAent placed on the Op. Th. List?
Is there a protocol in place if Pat. Surg. cancelled?
Are there daily MulA disp team meeAngs? Does the paAent have a
Discharge date?
Is there a home assessment in advance of DD?
Is the Ame from ED triage to surgery reviewed?
When the pat. arr. in ED who is involved in the triage?
No No Uncleas No Physio only G2 H2 yes
Nurse Is there a std. protocol for imaging Hip # pat.?
Are variaAons from clinical pathways analysed?
Is the Ame paAent is booked for surgery recorded?
If the op. is delayed >24 hrs is the reason recorded?
Is mobilisaAon Ame post surgery recorded?
Is there A/H services available at the W/E?
When are prescripAons sent to pharmacy?
Is the mobilisaAon Ame known?
Is there a Hip # Clin. Pathway and is it used? not always ordered by
medical staff Unclear Yes No No G3 H3 No
Most of the Ame Does stanadard imaging include chest xray?
Is the paAent nursed in a same sex room?
With whom does the registrar call to book theatre case?
If the op. is delayed >48 hrs is the reason recorded?
Does the paAent have a EsAmated Discharge date?
Is discharge event driven? Is bone resorpAve therapy part of the prescripAon?
Is the LOS of stay for acute/sub-‐acute reviewed?
In ED are std. procedures followed 24/7 ? not always ordered by
medical staff Yes Several processes No Mostly G4 H4 SomeAmes
No
Who reports on the images?
Is the Expected Discharge Dateagreed when the decision to operate is made?
Does the Ortho consultant speak with AnaestheAst to confrim case ?
Have risk assessment been completed?
Does the paAent have a nutriAonal assessment?
Is the pat. referred to a Fracture Liaison Service?
Is the number of Ames surgery cancelled recorded?
Is there a std. pain management protocol? Radiologist No SomeAmes
Yes G5 H5 Yes
No What is the turn around Ame for reporAng hip fractures?
Does the medical team pre-‐op assess 24/7 ?
Are std. anaesthesia prot. for Hip # used?
Have referrals to SW, OT been made?
Is there a waiAng list for paAents into sub-‐acute beds?
Is there an a^ercare contact number provided?
What % paAents are transferred home?
When is the ortho Reg contacted? unclear someAmes SomeAmes
Not social work G6 H6 Unclear
Once # confirmed on XRAY What is the criteria for ordering head CT's
Are Allied Health available at the Weekend?
Are std. Prostheses used?
Do W/E transfers occur? Does the paAent have a nutriAonal assessment?
Is there community involvement through local council?
Are paAents/carers surveyed?
Whan do you book a ward bed? Clear process Physio only Yes
SomeAmes G7 H7 Unclear
Once # confirmed on XRAY Does the radiology process alter a^er hours?
Is there food available if surgery is cancelled?
Are OperaAng Theater Team briefings held?
Is discharge event driven? Are pressure ulcers recorded ?
% of paAents who are discharged on or before their EDD
When is the Clinical Coordinator contacted? 2 processes yes No
No G8
Unclear
In / out of hours processes
Are there std. handover protocols?
Is there a record of when A/Bs administered?
How o^en does the medical team do ward rounds?
Is the in-‐hospital mortality a^er hip # known?
When is the TLN noAfied? No Yes Daily Yes
3 processes Are daily MulA Disp Team meeAngs held?
Are there agreed post operaAve guidelines?
Are there constraints in transferring pts to sub-‐acute care?
Is the 30 day mortality known?
Is there a designated ward for our fractured hip paAents?
No Yes
Beds
Yes
No Who declares the paAent is fit for surgery ?
Are there wrieen protocols for PONV?
Does the paAent receive nutriAonal supplements?
Is a demenAa assesment undertaken? AnaestheAc Team No
Unclear
Not in ED Radiology Acute Ward -‐ Pre-‐operaAve OperaAng Theatre Acute Ward -‐ Post-‐operaAve Sub Acute Care Discharge Measures
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“I had never considered NoFs to be Emergencies”
Getting the X-Ray
} Limited recall options } Staff start at 0830 } No consideration of hip fracture timing
} Significant shift changes, available up to midnight } Avoid loss to service next day
} Start at 0700, any possible “NoFs” prioritised
“I’m busy. I don’t need to come and see that NoF”
Getting the Patient Reviewed
} Positive diagnosis=admission } No need for ortho review in ED
} OrthoReg called } MedReg called
} 2 hour timescale, times noted } Delays result in calls
} Allied Health referrals activated } Physio, OT, rehab etc
} Mental State, Nutritional State Assessment
In the ED } Analgesia pathways clarified
} Avoidance of cervical collar } Clinical assessment for head-strike
} Standardised investigations
} Bladder management pathway
Are they surgical patients with medical problems or medical patients with a surgical problem?
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Getting Physician Review
} Engaged the Physician group } All hip fractures to be seen as routine for pre-op workup
} Intially registrar } Then consultant
} Post Op care by ortho team and geriatrician
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“We don’t do NoFs at the weekend”
Getting to Theatre } Institutional redesign project
} Create 1600-2000 Emergency Session } New streamlined booking system, early booking of cases } Clarify weekend working, including start times
} Not Perfect, but better
“I have a policy not to do NoFs at the weekend, in case something urgent comes in”
Getting the Anaesthetists onboard
} Discussions within redesign project
} Acceptance of high priority of hip fracture patients } Emergency lists avoid late night high risk anaesthetics } Clarification of anticoagulation, assessment of murmurs
etc
} Recruitment of new staff } Attitude shifts
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On Monday: “I’ll be available to do that NoF on Friday morning”
Nutrition } High calorie, high protein drinks
} MedPass
} Given on medications rounds, 60ml doses } Avoid lengthy fasting periods
} Next step “Immunonutrition”?
Discharge Planning
} Begin in ED } Use of predictive
model for discharge destination
} Transitional Care Pathway to be absorbed into subacute care
} Patient/Family info booklet
Are we getting there?
Time to Theatre July – Sept 2013
Theatre access n
Within 24 hours 8
Within 48 hours 6
After 48 hours 2
When patients present to outlying hospitals
} Portland Hospital } 1 hour by road to Warrnambool
} 12 months to Oct 2013 } 11 patients
} Presentation to surgery = 28 hours } Presentation to surgery <48hours = 10/11
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