MSK & Orthopaedic Quality Drive Programme

Philip LuntsHead of Service Improvement

Executive Lead for Programme

Ali MehdiHead of Orthopaedic

ServiceClinical Lead for

Programme

The two work-strands from the MSK Project that have had the greatest impact for Borders Patients:

• Work-strand 4: Hip fracture care pathway

• Work-strand 5: Demand & Capacity Modelling (DCAQ)

Work-strand 4: Hip #Clinical Leads: Drs Antrobus & Bennison

1.Frail Elderly Care bundle within acute care

• Plan: to trial use of daily “single question in delirium” (SQID)

• Aim: the earlier identification of patients who have developed delirium during their hospital admission.

• This allows for earlier investigation and treatment of delirium, leading to improved patient experience, reduced symptoms and complications and shorter hospital length of stay

• Method: Nursing staff place “SQID” sticker in notes daily and answer question “Is this person more confused than yesterday”. All patients over the age of 65 should be included.

• If answer is “Yes” – nursing staff inform the ward medical staff. Medical staff then carry out AMT / 4AT / start delirium bundle as appropriate

1. Care bundle: Frail Elderly

Comprehensive Geriatric Assessment

Medication review / analgesia

Avoid / treat delirium

Refer all patients for geriatric assessment on admission

Refer to “blue sheet” / UPR for geriatrician management plan

All patients mobilized day of surgery to chair

All patients reviewed by physiotherapist by day 1 post opo Mobility / balance / gait / falls risk

OT assessment starts day 1 post admission.

Social work input as required Complete nutritional / pressure area

assessment on admission

Analgesia as per preop. bundle.oGive regularlyoReview regularly

Review all medications as per polypharmacy protocol:

oValid indication?oSymptomatic relief?oVital hormone replacement?oHigh risk combination?oPoorly tolerated?oNNT for benefit vs risks

Document reasons for changes in UPREnsure appropriate VTE prophylaxis prescribed

Complete AMT and 4AT on admissionDaily SQiD

o“Is this patient more confused than yesterday”?

Start delirium bundle when identified (sticker)Identify and treat causesReorientate patient regularlyEncourage mobilityCheck hearing aids / spectaclesAvoid constipationMaintain sleep pattern / fluid intakeProvide carers with delirium leaflet / explanationDo not

oCatheterizeoSedate routinely / restrainoArgue with the patient

Reduce falls risk Assess bone health Plan dischargeOn admission

oTake accurate falls history including risk factorsoComplete nursing admission falls assessment

Take action to reduce identified risksComplete active standTreat postural hypotension if present

oIncrease oral fluidsoTEDSoReview medication

Document visual acuityDocument AMT / 4ATIf urinary incontinence present:

oMSUoPost void bladder scanoBladder chart

Prescribe and give vitamin D stat dose – colecalciferol 100,000 units orally

o**check if peanut allergy**If patient is over 80 years old start bone protection:

oCalcium and vitamin D / alendronateoRefer osteoporosis service if contraindications (eg renal impairment)

If under 80 years old request DEXA scanComplete bone health risk factor checklist (on “blue sheet”)

oIf high risk start bone protection whilst results awaitedoIf low risk await DEXA result before starting treatment

Set EDD on admissionInform patient and carers of date and any changes to this during admissionRefer to PT / OT on admissionRefer to social work as soon as need identifiedAfter first DME review

oUpdate EDD and anticipated place of dischargeoPlace patient on community waiting list if appropriate

All patients discussed at daily MDT board round (update plan / EDD)Day before

oEnsure IDL completedoBook transportoEnsure equipment / care ready

‘SQiD’ sticker: Single Question in Delirium

Is this patient more confused than yesterday?

Date Time Name Signature

2. Care bundle: anaesthetic

Anaesthetic ‘sticker’

YES

IS PATIENT FIT FOR

SURGERY?

HIP FRACTURE: Anaesthetic Review Date: Time:

Anticipated date and time of surgery:

Give all medicines as prescribed on kardex (unless crossed off) Adequate analgesia. Pain score ………./10YES / NO - Follow trauma fasting policy

Reason for delaying surgery:

Will benefits of optimisation

outweigh risks of delaying surgery?

Outcome required for surgery to proceed:

Adequate analgesia prescribedPain score: ………… /10 * Consider repeat nerve block if pain NRS >3 Nerve block repeat

If extra investigations

required will they change patient management?

YES / NO

Expected time to fitness for surgery:

* Please review every 24h

Signed: Print name:

NO

YES

Is this Patient fit for Surgery?

Using Demand and Capacity• Established predicted demand and capacity

required• Developed ongoing DCAQ modelling tool – updated

weekly• Weekly ‘huddle’ – all ortho consultants plus

booking managers - review– last week actual against predicted (and reasons)– Last week theatre start times– This week planned against required– Outpatient clinic actual against predicted (NEW!)

Impact• Excellent engagement with clinicians• Shared ownership and solution of

problems • competition – gold star of the week!

Next Steps•Establish similar process for OPD•Model demand from OPD vs capacity in real-time

Virtual Fracture Clinic

•Virtual Trauma Meeting set up – avoids need for additional staffing for service•Direct Discharge recently commenced. Direct discharge of: Paediatric Clavicle

5th Metacarpal5th MetatarsalMallet fingerRadial headTorus/buckle Ankle injury

ERAS Workstream