Keefai Yeong

Hazel Watters

Radcliffe Lisk

Best Practice Tariff –

How we achieved our results

Outline of talk

Introduction to Ashford and St Peter’s

Orthogeriatric team

Best Practice Tariff

Achieving the goals

Financial implications

Top tips

Location

Ashford Hospital

St Peter’s Hospital

Ashford and St Peter’s Hospitals

Ashford Hospital, Middlesex St Peter’s Hospital, Chertsey

Number of # NOFs in 2009 and 2010

2009 - 102010 - 11

372

442

320

340

360

380

400

420

440

460

Orthogeriatric Team at ASPH

2 Orthogeratricians

11 orthopaedic surgeons

16 junior doctors

Trauma coordinator

Hip Fracture Nurse

Dedicated physios

OTs

Targets:

Improve care in the Orthopaedic Wards

Achieve the Best Practice tariff

Best Practice Tariff

Aim

To reduce unexplained variation in quality and

universalise practice

Key Characteristics :

Surgery within

36 hours +

Involvement

of Ortho-

geriatricians

Best Practice Tariff

Our half of the deal…

1. Admitted under joint care

2. Admitted using an assessment protocol that is

jointly agreed

Joint clerking proforma

INCLUSION CRITERIA:

Mechanical fall with obvious hip pain

Shortening / external rotation

Observations stable

EXCLUSION CRITERIA:

MEWS Score above 3

Major trauma

CVS unstable

Section 1

Medical history and assessment undertaken and documented by A/E Dr

Section 2

Admission observations MEWS score Waterlow Score

ECG ECG Checked

Section 3

Cannula inserted Bloods taken FBC/FRAC/COAG/Group & Save

Section 4

Intravenous fluids - 1000ml Sodium Chloride + 20mmols potassium chloride over 10hours

Section 5 All patients to be prescribed IV Morphine and Paracetamol. If pain score 0-1

administer IV paracetamol, if score 2-3 administer IV morphine and Paracetamol

Pain Score documented Analgesia – IV Morphine titrated as per protocol

Fascia Iliaca Block if appropriate Complete Pink NOF drug chart

Section 6

X rays AP & Lateral hip Chest

Section 7

Complete analgesia on pre printed pink prescription # NOF charts, if patient is suitable to be fast

tracked to Rowley Bristow Ward

Section 8

positive hip fracture – patient can be fast tracked

If negative hip fracture or unclear – patient should not be fast tracked until X-ray has been

reviewed by a Senior grade (orthopaedic)

Pre transfer observations completed

FAST BLEEP NOF CALL 2222 (STATE MALE/FEMALE)

Out of hours 19:30hrs – 07:30hrs contact CNSP bleep 5001/5380

Section 9

IF ALL CRITERIA HAVE BEEN MET AND THERE ARE NO EXCLUSION CRITERIA - THE

PATIENT HAS REMAINED STABLE – THEY THEN CAN BE TRANSFERRED TO A HIP

FRACTURE ASSESMENT BAY (JUNIPER WARD):

IF THE PATIENT UNSTABLE THEY MUST BE MEDICALLY STABILISED BY A&E PRIOR TO

BEING TRANSFERRED TO THE WARD.

Please document why patient could not be fast tracked…………………………………………..

………………………………………………………………………………………………………………..

Orthopaedic clerking

History of Presenting Complaint

What Happened Where/Why/How? E.g. Tripped, L.O.C., Fell inside/outside

Previous Fractures/Falls

Previous Falls in the last 12 months

Injuries sustained/Areas of pain

Does the cause of the fall need investigating Yes/No

If so how?

Parameter What to do CHECKED

1 Dehydrated? Ensure safe rapid rehydration. Set up IVI- Via an

IVAC

2 K+ < 3.4 See A to Z. Supplement K+.

3 Na+< 129 See A to Z. (We may accept if <129, especially if

evidence that it is chronic.)

4 Cr > 200 See A to Z. Ensure hydration and not in retention.

Start fluid balance chart.

5 G&S Please document result of antibody screen. If

screen is positive please request 2 unit Xmatch

6 Hb < 10g/dl See A to Z

If transfused we must have a check Hb.

7 Platelets <120 See A to Z.

8 INR > 1.5 See A to Z.

A to Z Troubleshooting guide

Courtesy of the Royal Berkshire and Portsmouth Hospitals

9 Temp >37.9C Take cultures, start antibiotics if clinically indicated.

Patients with significant untreated sepsis may be

turned down.

10 ECG Must be sinus rhythm or AF with rate < 100.

See A to Z.

11 Pacemaker? Arrange a pacemaker check before theatre if

indicated.

12 Systolic

murmur?

See A to Z. In general patients do not need an

ECHO before urgent trauma surgery.

13 MI or

arrhythmia?

Seek review from cardiology. See A to Z.

14 > 6 hours on

the floor?

Test urine for myoglobin. Renal function must be

available. Ensure hydration.

15 Chest

infection?

Do not cancel surgery. Start antibiotics. See A to Z.

16 Notes? If patient has old notes – PLEASE GET THEM! If

notes are not available, please obtain patient

summary from GP.

A to Z Troubleshooting guide

Courtesy of the Royal Berkshire and Portsmouth Hospitals

Osteoporosis Assessment

BMI<19 □ Steroids □

Xs EToH □ Previous Fragility # □

Smoking □ Premature Menopause □

Sedentary □ Rheumatoid Arthritis □

Parental history □

Considered for

Bisphosponate/Strontium

Yes No If no why not? Reason for prescribing strontium:

Prescribed Ca & Vit D? Yes No If no why not?

Referred for Dexa? Yes No If no why not?

Osteoporosis assessment

Medical Falls Assessment

Medication Review? □ Postural BP’s? □

Visual Assessment? □ History of Syncope? □

ECG reviewed? □ AMT (day 7) □

Likely cause of falls

Referral for Specialist Investigation

24 hour tape H.U.T Echo

Medical falls assessment

Our half of the deal…

1. Admitted under joint care

2. Admitted using an assessment protocol that is

jointly agreed

3. Perioperative assessment by a geriatrician

(within 72 hours)

4. Post operative geriatrician directed

MDT rehabilitation

Fracture prevention assessments (falls and bone

health)

Geriatric achievements (%)

0

36

80

89100 100 100100

0

10

20

30

40

50

60

70

80

90

100

Joint Protocol Orthogeriatric

Review

Falls

Assessment

Bone Health

2009/10

2010/11

Getting the patient to theatre within 36

hours Getting the patient to

theatre within 36

hours

EQuIP Programme Sept 2010

Efficiency Quality Innovation and Productivity

Based on Lean Principles, high level support

Key Objectives

Achieve standards of care set out in the Blue Book,

including achieving the 36 theatre target.

Set up a facilitated agreed pathway for patients with

fractured neck of femur

Improve patient experience and outcome

Improve length of stay

Achieve the best practice tariff

Value Stream Analysis (VSA)

Involves all stakeholders across the pathway

“Unpicking” current pathway

Future state

Action plan

Just Do it events

Rapid Improvement Events

Initial State Go No Go

A Delivery

B Quality

C Cost D Human Dimension

Reflections: 1) Superspell

1%

6%

-4%

-6%

-4%

-2%

0%

2%

4%

6%

8%

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep-

08

Oct

-08

Nov

-08

De

c-08

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep-

09

Oct

-09

Nov

-09

De

c-09

Jan-

10

Feb-

10

Mar

-10

Apr

-10

May

-10

Jun-

10

Jul-1

0

Aug

-10

Sep-

10

28 day readmission rates for #NOF patients to all specialties April 2008 to September 2010

UCL Mean LCL

1%

6%

-4%

-6%

-4%

-2%

0%

2%

4%

6%

8%

Apr

-08

May

-08

Jun-

08

Jul-0

8

Aug

-08

Sep-

08

Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Jul-0

9

Aug

-09

Sep-

09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

Apr

-10

May

-10

Jun-

10

Jul-1

0

Aug

-10

14 day readmission rates for #NOF patients to all specialties April 2008 to August 2010

UCL Mean LCL

7%

31%

0%

0%

5%

10%

15%

20%

25%

30%

35%

Ap

r-0

9

Ap

r-0

9

May

-09

May

-09

May

-09

Jun

-09

Jun

-09

Jul-

09

Jul-

09

Au

g-0

9

Au

g-0

9

Sep

-09

Sep

-09

Oct

-09

Oct

-09

No

v-0

9

No

v-0

9

No

v-0

9

De

c-0

9

De

c-0

9

Jan

-10

Jan

-10

Feb

-10

Feb

-10

Mar

-10

Mar

-10

Ap

r-1

0

Ap

r-1

0

May

-10

May

-10

May

-10

Jun

-10

Jun

-10

Jul-

10

Jul-

10

Au

g-1

0

Au

g-1

0

Weekly crude mortality rates for # NOF patients April 2009 to August 2010

UCL Mean LCL

4%

24%

0%

0%

5%

10%

15%

20%

25%

30%

35%

Apr

-09

Apr

-09

May

-09

May

-09

May

-09

Jun-

09

Jun-

09

Jul-

09

Jul-

09

Au

g-0

9

Aug

-09

Sep

-09

Sep

-09

Oct

-09

Oct

-09

No

v-0

9

Nov

-09

Nov

-09

De

c-0

9

De

c-0

9

Jan

-10

Jan

-10

Feb

-10

Feb

-10

Mar

-10

Mar

-10

Apr

-10

Apr

-10

May

-10

May

-10

May

-10

Jun-

10

Jun-

10

Jul-

10

Jul-

10

Au

g-1

0

Aug

-10

Weekly pressure ulcer rates for # NOF patients April 2009 to August 2010

UCL Mean LCL

47%

96%

0%

0%

20%

40%

60%

80%

100%

120%

Apr

-09

Apr

-09

May

-09

May

-09

May

-09

Jun-

09

Jun-

09

Jul-0

9

Jul-0

9

Aug

-09

Aug

-09

Sep-

09

Sep-

09

Oct

-09

Oct

-09

Nov

-09

Nov

-09

Nov

-09

Dec

-09

Dec

-09

Jan-

10

Jan-

10

Feb-

10

Feb-

10

Mar

-10

Mar

-10

Apr

-10

Apr

-10

May

-10

May

-10

May

-10

Jun-

10

Jun-

10

Jul-1

0

Jul-1

0

Aug

-10

Aug

-10

Weekly rates for # NOF patients returning to own home/sheltered housing April 2009 to August 2010

UCL Mean LCL

24.49

46.52

2.46

0

10

20

30

40

50

60

Ap

r-0

9A

pr-0

9A

pr-0

9A

pr-0

9M

ay

-09

Ma

y-0

9M

ay

-09

Ma

y-0

9M

ay

-09

Jun

-09

Jun

-09

Jun

-09

Jun

-09

Jul-

09

Jul-

09

Jul-

09

Jul-

09

Au

g-0

9A

ug

-09

Au

g-0

9A

ug

-09

Au

g-0

9S

ep

-09

Se

p-0

9S

ep

-09

Se

p-0

9O

ct-

09

Oc

t-0

9O

ct-

09

Oc

t-0

9O

ct-

09

No

v-0

9N

ov

-09

No

v-0

9N

ov

-09

De

c-0

9D

ec

-09

De

c-0

9D

ec

-09

Jan

-10

Jan

-10

Jan

-10

Jan

-10

Jan

-10

Fe

b-1

0F

eb

-10

Fe

b-1

0F

eb

-10

Ma

r-1

0M

ar-

10

Ma

r-1

0M

ar-1

0A

pr-1

0A

pr-1

0A

pr-1

0A

pr-1

0M

ay

-10

Ma

y-1

0M

ay

-10

Ma

y-1

0M

ay

-10

Jun

-10

Jun

-10

Jun

-10

Jun

-10

Jul-

10

Jul-

10

Jul-

10

Jul-

10

Jul-

10

Au

g-1

0A

ug

-10

Au

g-1

0

Weekly average length of stay for #NOF patients April 2009 to August 2010

UCL Mean LCL

Currently only 5 day/week rehabilitation

SPC Surgery within 24 hours Apr 09 - Aug 10

0:00

48:00

96:00

144:00

192:00

240:00

288:00

336:00

384:00

432:00

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10

UCL Mean LCL

43% of patient operated within 24

hours (Apr10 – Aug10)

SPC Superspell Length of Stay (June09 - Apr10 *complete data only, 37

patients, 2 outliers excluded)

48.79

116.75

0

0

20

40

60

80

100

120

140

Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10

UCL Mean LCL

Target State

Reflections:

Go No Go

A Delivery B Quality

C Cost D Human Dimension To reduce average length of hospital stay (spell) &

therefore superspell

To increase the number of patients operated

on within 24 hours

% of patients returning to own

home/sheltered accommodation

Mortality, Re-admissions & Pressure

Ulcers

43%

85%

25

Days 8

Days

ASPH Simple

Case

ASPH

Complex

Case

35

Days

Superspell

(incl. Community)

%

Days

7% 5%

4%

%

Mortality

2%

Pressure Ulcers

47% 55%

%

Act Tgt Act Act

Act

Tgt Tgt

Act Tgt Act Tgt Tgt Act Tgt

17

Days

63

Days

Residential

Home

Patient

25

Days

30.5

Days

Act Tgt

Re-admissions

1.8% 1.8%

Act Tgt

16 days

average

target overall

Priority List Orthopaedic Trauma

1 Life or Limb Trauma

2 NOF Fracture

3 Acute Paediatric

4 In Patients

5 Ambulant

6 Chronic

Time to theatre within 36 hrs (%)

EQuIP Sept

36 Hours 24 Hours

Financial implications

Best practice tariff (BPT)

Before EQUIP After EQUIP

Q1 Q2 total Q3 Q4 total

No of pts

achieving BPT

44 62 106 88 83 171

Actual no of

patients

90 85 175 110 96 206

Percentage 48.8% 72.9% 60.5% 80% 86% 83%

Extra income generated after EQuIP = £20470

% achieving BPT at ASPH 2010

48

73

8085

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Total generated 2010/11 = £123710 @ £445 extra per patient

% achieving BPT at ASPH 2011

85

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Total generated 2011 = £67640 @ £890 per patient

Cost of running an EQuIP programme

Cost of attendees £18009

Venue hire & refreshments £5956

Total £23965

The benefits of a geriatrician

You can’t get BPT without one (or two)!

Reduction in length of stay (hence cost saving)

Reduction in mortality

Funnel plot for mortality

SPH

The benefits of a geriatrician

You can’t get BPT without one (or two)!

Reduction in length of stay (hence cost saving)

Reduction in mortality

Reduction in complaints

No of complaints Elm and Juniper Wards

14

10

0

2

4

6

8

10

12

14

2009-2010 2010-2011

Top Tips on how to achieve BPT

1. Employ a geriatrician (or two)

2. Clerking proforma

- Audit

- Optimise patients from presentation

3. Prioritise NOFs

Acknowledgements

Anaesthetic Department – Martin Raymond

Orthopaedic Department

Kevin Newman (Lead Trauma Surgeon)

David Elliott (Divisional Director)

Hazel Watters (Trauma Coordinator)

Helen Grimsey (Hip fracture Nurse)

Thank you.