Post on 25-May-2015
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Care of the Patient with a Fractured
Neck of Femur Injury
Fiona Nielsen – Quality Coordinator Surgical CSU
Our health service
75,000 in-patients
900 beds
70,000 emergency attendances
12,500 surgical operations
6,200 staff
#NOF Presentations
2010-2011- 262
2011-2012- 246
165,000 out-patients
Objectives- A Walk Through
• Diagnostics
– Metrics
• Improvements
• Lessons Learnt
– What worked and what didn’t
• Project Outcomes
Information we were given
• Health Round Table Information
• DRG 108- Neck of Femur Fracture
• Austin Health had an average LOS >14 days
• The four exemplar hospitals average LOS around 8 days
• Aim – Reduce Length of Stay to that of exemplar hospitals
Background
Visit to another facility and a literature search revealed we
needed:
1.Full time Head Of Unit – implemented Sept 2009
2.More theatre sessions and better access for trauma –
implemented over 2009
3.Institute ortho-geriatric service – commenced February
2010
OGS
Orthogeriatric Service
–New full-time Orthogeriatric registrar
–Over seen by a senior geriatrician
• Involved in every patient >65yo with low-impact trauma #
• Ortho in Rehab hospital
• Geriatric in Acute hospital
Diagnostics
• Walk Thorough
– Follow the patient journey from the front door to discharge.
– Chance for two way communication and to understand work flows
» What works
» What doesn’t
• File audit- 30 patient files
• Interview with patients and their families
Walk Through-Fact finding
Where the patient goes
Steering Committee
• Attendance List List
• Executive- CEO, CMO, Executive Directors
• CSU/ Medical Directors
• Senior Clinical Staff- ED, Anaesthetists , Orthopedics
Geriatricians
• Austin By Design
• Physiotherapy
• Access, Care & Patient Flow coordinators
• NUM
• Ward nurses
• Theatre staff…and more
Ambulance/ED Ambulance/EDAcute Ward - Pre-
operative
Acute Ward - Post-
operative Sub Acute Care Discharge Measures
Does Amb. inform ED that a
pat. with a hip # is arriving?
Is a dementia/delirium
assessment undertaken?
Is a Hip # clinical pathway
used?
Is there a dedicated
orthopaedic trauma list 7/24
Is the pain score recorded? Do the pain management
team visit the patient?
Are there daily MDT
meetings?
Is discharge event driven? Are the no. of Hip #s pa
known?
No No No No Yes Not Routinely No No Yes
Emergency
DepartmentRadiology
Are there diff. in the std.
b/w ortho and non ortho
ward?
When is the patient placed
on the Op. Th. List?
Is there a protocol in place if
Pat. Surg. cancelled?
Are there daily MDT team
meetings?
Does the patient have a DD? Is there a home assessment
in advance of DD?
Is the time from ED triage to
surgery reviewed?
When the pat. arr. in ED
who is involved in the
triage?
How is the request for
imaging services received? YesOn orthopaedic
assessmentNo Yes Yes No
Nurse ElectronicallyAre variations from clinical
pathways analysed?
Is the time patient is
booked for surgery
recorded?
If the op. is delayed >24 hrs
is the reason recorded?
Is mobilisation time post
surgery recorded?
Is there A/H services
available at the W/E?
When are prescriptions sent
to pharmacy?
Is the mobilisation time
known?
Is there a Hip # Clin.
Pathway and is it used?
How is pat. trans. to/from X-
ray and is it timely? No Yes No Yes No Yes
NoWithin 60 mins
of request
Is the patient kept in a same
sex bay?
Are std. anaesthesia prot.
for Hip # used?
If the op. is delayed >48 hrs
is the reason recorded?
Does the patient have a D/D Is discharge event driven? Is bone resorptive therapy
part of the prescription?
Is the LOS of stay for
acute/sub-acute reviewed?
?
In ED are std. procedures
followed 24/7?
Is there a std. protocol for
imaging Hip # pat.? When possible No No No No Yes No
No NoIs the D/D agreed when the
decision to operate is
made?
Are std. Prostheses used? Have risk assessment been
completed?
Does the patient have a
nutritional assessment?
Is the pat. referred to a
Fracture Liaison Service?
Is the number of times
surgery cancelled recorded?
?
Is there a std. pain
management protocol?
Who reports on the images?
No Yes Yes Yes No No
No Senior ED DrDoes the geriatrician pre-op
assess 7/24?
Who provides anaesthesia? Have referrals to SW, OT
been made?
Is there a waiting list for
patients into sub-acute
beds?
Is there an aftercare contact
number provided?
What % patients are
transferred home?
Is there a falls risk
assessment done?
When are the images
reported on? NoOther
consultant/registYes- social work and OT Yes For the ward Not known
No Within 60 minsAre allied health available
at the W/E?
Who performs the surgical
procedure?
Do W/E transfers occur? Are pressure ulcers
recorded ?
Is there community
involvement through local
council?
Are patients/carers
surveyed?
?
When is the Ortho. Dept.
Contacted ?No Registrar Sometimes Yes No
After Xray
confirms #
Is there food available if
surgery is cancelled?
Are Op. Th. Team briefings
held?
Is discharge event driven? % of patients who are
discharged on or before
their EDD
A3?
When is the Orthogeriatric
registrar contacted?No No No
Maybe delayedAre there std. handover
protocols?
Is there a record of when
A/Bs administered?
How often does the OG do
ward rounds?
Is the in-hospital mortality
after hip # known?
Is the Emerg Surgery Nurse
Coord informed?No Yes Mon-Fri Yes
A3
No - positionAre daily MDT meetings
held?
Are there agreed post
operative guidelines?
Are there constraints in
transferring pts to sub-acute
care?
Is the 30 day mortality
known?
Is the patient transferred to
a known Ortho. Ward?Yes Yes Yes No
YesWho declares the patient is
fit for surgery ?
Are there written protocols
for Post Op N/V?
Does the patient receive
nutritional supplements?
No No
Ambulance/ED RadiologyAcute Ward - Pre-
operative
Acute Ward - Post-
operative Sub Acute Care Discharge Measures
Our Hip Fracture Pathway - Austin Health
Operating Theatre
Operating Theatre
Where we focused
• Three main areas
– ED
– Pre operatively
– Post operatively
• Three main care elements
– Fasting
– Pain management
– Delirium
The Case for Change• Why not be exemplar?
• The care delivered to this patient group should be best
practice.
• Senior Clinical Staff became the leaders for this vision
• Confronting to clinicians
• Challenges to beliefs
Finding the problems is simple, understanding and
developing solutions is complex and solutions can be
simple
0%
10%
20%
30%
40%
50%
60%
70%
65-79 80+ 65-79 80+ 65-79 80+ 65-79 80+ 65-79 80+
% o
f To
tal p
resen
tati
on
s% of Presentations by
Age
Red = Austin Health
Myth busting
ED
Before
• No Standard Pain-relief
• Mostly narcotic-based
• Minimal use of blocks (<10%)
• No review of analgesia efficacy
• Multiple trips to Radiology
• Gap from ED until drug chart written up (on ward)
Emergency / Radiology Sets
Standarised
Analgesia
• Regular Paracetamol
• Incremental boluses of Fentanyl to effect (or Morphine)
• Regular pain scores on function
• Fascia Iliaca Blocks –Blind and in >80% of presentations
0
10
20
30
40
50
60
70
80
90
100
Mar-May2010
Jan-11 Feb-11 Mar-85 Apr-85 May-11 Oct-12
% o
f P
ati
en
ts h
av
ing
FI b
olo
cks i
n E
D
FI Blocks In ED
On the ward
• Admitted to the ward at various
times of the day.
• Orthopaedic staff in theatre.
• Variable pain relief
• Fasted for varying lengths of time
• Time to theatre varied
• Information for patients and
families
Fasting
• Big source of patient and family dissatisfaction
• Highly variable times
– Not documented
– Not monitored
– Frequent cancellations
• Patients often deconditioned on admission
Hunger clock
Set to monitor fasting
By the patients bedside
Counts down the agreed 12 hours
Initially reduced fast to 9 hours
Recent measurement
September 2012-
back to 13 hours
Pain• No Standard Pain-relief
• Delay until patient admitted and drug chart written
• Mostly narcotic-based
• Usually inadequate doses / Intermittent or infrequent
doses
• No review of analgesia efficacy
• Usually ceased if patient became confused
Pain Plan
• Designed by Orthogeriatrician/ Orthopaedic Surgeon/ Acute
Pain Services
• Nursing Pain Champions
– Nursing Staff Familiar with PCAs
– System for PCAs and functional pain scores/ Campbells
– CEASE protocols
• Months in designing the algorithm
• Plan to roll it out and re-measured a week
• Failed in the first two days
WHY?
Answer-
Residents and Interns- didn’t know how to write up PCAS
And they needed permission- for narcotics in the elderly
Model from the IHI
March 2011-March 2012
0
2
4
6
8
10
12
14
Ma
y-0
9
Jun-0
9
Jul-0
9
Aug-0
9
Sep-0
9
Oct-
09
No
v-0
9
De
c-0
9
Jan-1
0
Feb
-10
Ma
r-1
0
Apr-
10
Ma
y-1
0
Jun-1
0
Jul-1
0
Aug-1
0
Sep-1
0
Oct-
10
No
v-1
0
De
c-1
0
Jan-1
1
Feb
-11
Ma
r-1
1
Apr-
11
Ma
y-1
1
Jun-1
1
Jul-1
1
Aug-1
1
Sep-1
1
Oct-
11
No
v-1
1
De
c-1
1
Jan-1
2
Feb
-12
Ma
r-1
2
Days
Average Length of Stay (HRT Data)
Exemplars
A H
Project starts
Pain Plan Starts
Standardised Care
• Patient receives the same care no matter what time they
are admitted.
• Patients receive analgesia via a pain plan designed by
senior clinicians
• Nursing staff make this a priority
Management of Clinical Knowledge
Delirium
Baseline measurement
-Sept 12 – 90% of patients
had CAM score done on
admission.
-Clocks in rooms
-Family aware of risks
-Day time/night time
-Plan to spread to other
wards
-All new nursing staff
trained in assessment
Nursing Management
The Patient Experience
Happy
Supported
Safe
Good
Comfortable
In Pain
Worried
Lonely Sad
PatientsArriving/ED Information Waiting Going to theatre Post Op Phase Ward 8N Ward 11 Leaving
3 3 1 1 3 2
3 3 1 1 3 2
3 3 2
3 3 3 2
1 1
1 1
1 1 1 1 1 1
1 3 3 3 2 2
1 1 1 1
3 3 3 3 1 1 1 1
2 2 1 1 1 1
2 2 1 1 1 1
3 1 1 1 1 1 1 3
3 3 1 1 3 3 3 3
3
3
3
1
2
3
4
5
6
7
8
9
10
11
12
PatientsArriving/ED Information Waiting Going to theatre Post Op Phase Ward 8N
13 3 1 1 3 2
3 3 1 1 3 2
23 3 1 2
3 3 3 2 2
31 1
1 1
41 1 1 1 1
1 3 3 3 2
5 1 1 1
3 3 3 3 1 1 1
62 2 1 1 1 1
2 2 1 1 1 1
73 1 1 1 1 1 3
3 3 1 1 3 3 3
8
3
9
Patient Stories
• Very powerful
• Can cause distress to staff
• Use quotes: “ I was in that much pain I was going no where”
“They starved her and staved her”
• Manage up – encourage staff to talk about improvments
Executive Leadership
Executive Interview with patients
Visibility of projects importance
Accountability for Care
People remember what they have
seen
Becomes personal
Sustainability questionnaire
Process
1.Benefits beyond helping patients
2.Credibiltiy ( to affected staff) of benefits from improved processes
3.Adaptability of improved process
Staff
1.Staff involved and training to sustain process
2.Staff attitudes toward sustaining the improved process
3. Senior leaders responsibility taking and staff action toward the leader
4. Clinical leaders responsibility taking and staff action toward the leader
Organisation
1. Effectiveness of the system to monitor progress of the improvement
2. Fit with the organisation strategic aims and culture
3. Staff attitudes toward sustaining the improved process
Sustainability Summary
1.0 3.0 5.0 7.0 9.0 11.0 13.0 15.0
Benefits beyond helping patients
Credibility of the evidence
Adaptability of improved process
Staff involvement and training to sustain theprocess
Staff behaviours toward sustaining the change
Senior leadership engagement
Clinical leadership engagement
Effectiveness of the system to monitor progress
Fit with the organisation's strategic aims andculture
Infrastructure for sustainability
Potential
May
February
October
July
Measures
Measures- to September 2012
Pain
Plan
Started
Fasting
Times
Controlled
Theatre times
Ambulance/ED Ambulance/EDAcute Ward - Pre-
operative
Acute Ward - Post-
operative Sub Acute Care Discharge Measures
Does Amb. inform ED that a
pat. with a hip # is arriving?
Is a dementia/delirium
assessment undertaken?
Is a Hip # clinical pathway
used?
Is there a dedicated
orthopaedic trauma list 7/24
Is the pain score recorded? Do the pain management
team visit the patient?
Are there daily MDT
meetings?
Is discharge event driven? Are the no. of Hip #s pa
known?
No Yes- CAM YesDedicated
trauma listYes Yes No Yes
Emergency
DepartmentRadiology
Are there diff. in the std.
b/w ortho and non ortho
ward?
When is the patient placed
on the Op. Th. List?
Is there a protocol in place if
Pat. Surg. cancelled?
Are there daily MDT team
meetings?
Does the patient have a DD? Is there a home assessment
in advance of DD?
Is the time from ED triage to
surgery reviewed?
When the pat. arr. in ED
who is involved in the
triage?
How is the request for
imaging services received? YesOn orthopaedic
assessmentYes Yes Yes Yes
Nurse ElectronicallyAre variations from clinical
pathways analysed?
Is the time patient is
booked for surgery
recorded?
If the op. is delayed >24 hrs
is the reason recorded?
Is mobilisation time post
surgery recorded?
Is there A/H services
available at the W/E?
When are prescriptions sent
to pharmacy?
Is the mobilisation time
known?
Is there a Hip # Clin.
Pathway and is it used?
How is pat. trans. to/from X-
ray and is it timely? Yes Yes Yes Trialled Yes
YesWithin 60 mins
of request
Is the patient kept in a same
sex bay?
Are std. anaesthesia prot.
for Hip # used?
If the op. is delayed >48 hrs
is the reason recorded?
Does the patient have a D/D Is discharge event driven? Is bone resorptive therapy
part of the prescription?
Is the LOS of stay for
acute/sub-acute reviewed?
?
In ED are std. procedures
followed 24/7?
Is there a std. protocol for
imaging Hip # pat.? When possible No Yes Not always No Yes Yes
Yes YesIs the D/D agreed when the
decision to operate is
made?
Are std. Prostheses used? Have risk assessment been
completed?
Does the patient have a
nutritional assessment?
Is the pat. referred to a
Fracture Liaison Service?
Is the number of times
surgery cancelled recorded?
?
Is there a std. pain
management protocol?
Who reports on the images?
No Yes Yes Yes No Yes
Yes Senior ED DrDoes the geriatrician pre-op
assess 7/24?
Who provides anaesthesia? Have referrals to SW, OT
been made?
Is there a waiting list for
patients into sub-acute
beds?
Is there an aftercare contact
number provided?
What % patients are
transferred home?
Is there a falls risk
assessment done?
When are the images
reported on? NoOther
consultant/registYes- social work and OT Yes For the ward Known
No Within 60 minsAre allied health available
at the W/E?
Who performs the surgical
procedure?
Do W/E transfers occur? Are pressure ulcers
recorded ?
Is there community
involvement through local
council?
Are patients/carers
surveyed?
?
When is the Ortho. Dept.
Contacted ?Registrar Sometimes Yes Interviews
After Xray
confirms #
Is there food available if
surgery is cancelled?
Are Op. Th. Team briefings
held?
Is discharge event driven? % of patients who are
discharged on or before
their EDD
A3?
When is the Orthogeriatric
registrar contacted?Yes No No
Maybe delayedAre there std. handover
protocols?
Is there a record of when
A/Bs administered?
How often does the OG do
ward rounds?
Is the in-hospital mortality
after hip # known?
Is the Emerg Surgery Nurse
Coord informed?Yes Mon-Fri Yes
A3
No - positionAre daily MDT meetings
held?
Are there agreed post
operative guidelines?
Are there constraints in
transferring pts to sub-acute
care?
Is the 30 day mortality
known?
Is the patient transferred to
a known Ortho. Ward?Yes Yes Yes No
YesWho declares the patient is
fit for surgery ?
Are there written protocols
for Post Op N/V?
Does the patient receive
nutritional supplements?
No
Ambulance/ED RadiologyAcute Ward - Pre-
operative
Acute Ward - Post-
operative Sub Acute Care Discharge Measures
Our Hip Fracture Pathway - Austin Health
Operating Theatre
Operating Theatre
Hospitals are Frogs – Not bicycles -Mant
Lessons learnt
• Complex Systems
• Understand systems and work
• Go beyond the simple-
– Problems are complex
– Solutions can be simple
• Align to common goals
• Don’t listen to No
Leading Change Humbly
• Seek out and listen to the wisdom of stakeholders.
• Communicate Communicate Communicate
• Ask people to agree - to a trial.
• Seek to understand rather than judge
– Value the dissenter
• Respect the workplace