NHS FIFE ORTHOPAEDIC UPDATE

Mr Edward DunstanOrthopaedic Clinical Lead

May 2015

Enhanced Recovery

31/1

2/20

11

01/0

2/20

12

04/0

3/20

12

05/0

4/20

12

07/0

5/20

12

08/0

6/20

12

10/0

7/20

12

11/0

8/20

12

12/0

9/20

12

14/1

0/20

12

15/1

1/20

12

17/1

2/20

12

18/0

1/20

13

19/0

2/20

13

23/0

3/20

13

24/0

4/20

13

26/0

5/20

13

27/0

6/20

13

29/0

7/20

13

30/0

8/20

13

01/1

0/20

13

02/1

1/20

13

04/1

2/20

13

05/0

1/20

14

06/0

2/20

14

10/0

3/20

14

11/0

4/20

14

13/0

5/20

14

14/0

6/20

14

16/0

7/20

14

17/0

8/20

14

18/0

9/20

14

20/1

0/20

14

21/1

1/20

140

10

20

30

40

50

60

70

Inpatients Phase II

Hip Revision Hip KneeRevision Knee

Num

ber

of

join

ts

Results – Cumulitive Discharge Rates

0102030405060708090

100

Traditional RehabiliatationERP

Postoperative Day

Cu

mu

liti

ve D

isch

arg

e R

ate

(%

)

Ayr

Cross

hous

eBGH

DGRIFife

Forth

Val

ley

Aberd

een

Elgin

GRIW

IG

Victor

iaSGH

RAH

Inve

rclyd

e

Raigm

ore

Hairm

yres

Mon

kland

s

Wish

aw RIE

Ninew

ells

Perth

Wes

tern

Isle

s

All Site

s0%

20%

40%

60%

80%

100%Was pre-medication given? - Data from last three audit cycles

Premed given No premed Data unavailable

Pe

rce

nta

ge

of

Pa

tie

nts

Ayr

Cross

hous

eBGH

DGRIFife

Forth

Val

ley

Aberd

een

Elgin

GRIW

IG

Victor

iaSGH

RAH

Inve

rclyd

e

Raigm

ore

Hairm

yres

Mon

kland

s

Wish

aw RIE

Ninew

ells

Perth

Wes

tern

Isle

s

All Site

s0%

20%

40%

60%

80%

100%

Type of anaesthesia given - data from last three audit cycles

General Spinal Spinal and regional/Nerve block Spinal and LIA * General and Regional/Nerve block Other

Pe

rce

nta

ge

of

Pa

tie

nts

Factors affecting LoSPredictors in Model

B Value 95% CI p-value

ERP -1.81 -2.1 to -1.6

<0.001

Catheter -1.62 -2.0 to -1.3

<0.001

Age 0.05 0.04 to 0.07

<0.001

ASA 1 Reference

   

  2 0.52 0.30 to 0.75

<0.001

  3 1.04 0.60 to 1.50

<0.001

  4 1.56 0.90 to 2.25

<0.001

Approach Anterolateral

Reference

   

  Posterior -0.27 -0.36 to -0.19

<0.001

Preoperative HHS

-0.028 -0.04 to -0.02

<0.001

RAPT (Risk Assessment and Predication Tool)AgeGenderMobilityWalking AidsCommunity SupportLives alone

Identify those who require extended rehabilitation at time of listing

RAPT42 consecutive patients20 with a score >/= 918 home within 4 days16 of the 18 with a score 6-8 home > 4 days

What to do with those with a score <9? Rehabilitation facility? Community based rehabilitation team

Fracture Neck of Femur

Ayr

Cross

hous

eBGH

DGRIFife

Forth

Val

ley

Aberd

een

Elgin

GRIW

IG

Victor

iaSGH

RAH

Inve

rclyd

e

Raigm

ore

Hairm

yres

Mon

kland

s

Wish

aw RIE

Ninew

ells

Perth

Wes

tern

Isle

s

All Site

s0%

20%

40%

60%

80%

100% Place of residence at 120 days post-admission - all 2014 data

Home/sheltered Care home NHS Continuing Care/Other Rehabilitation Acute hospital Still in acute orthopaedic care DeadUnknown

Pe

rce

nta

ge

of

Pa

tie

nts

Ayr

Cross

hous

eBGH

DGRIFife

Forth

Val

ley

Aberd

een

Elgin

GRIW

IG

Victor

iaSGH

RAH

Inve

rclyd

e

Raigm

ore

Hairm

yres

Mon

kland

s

Wish

aw RIE

Ninew

ells

Perth

Wes

tern

Isle

s

All Site

s0

10

20

30

40

50

60

70

80 Median length of total hospital stay - all 2014 data

Series4

Pe

rce

nta

ge

of

Pa

tie

nts

AyrBGH

Perth

Wes

tern

Isle

s

Cross

hous

e

Ninew

ells

Inve

rclyd

eRAH

GRI

DGRI

Forth

Val

ley

Aberd

een

WIG

Wish

aw

Raigm

ore

Mon

kland

s

Hairm

yres Fife RIE

Elgin

SGH

Victor

ia0

10

20

30

40

50Total hospital length of stay by type of ward/hospital - all 2014 data

Initial acute orthopaedic stay Rehab Further acute ward NHS Continuing Care

Me

an

nu

mb

er

of

da

ys

pe

r p

a-

tie

nt

Theatre Optimization

SUN 0

1/03/1

5

MON

02/0

3/15

TUE 03/0

3/15

WED 0

4/03/1

5

THU 0

5/03/1

5

FRI 06/0

3/15

SAT 07/0

3/15

SUN 0

8/03/1

5

MON

09/0

3/15

TUE 10/0

3/15

WED 1

1/03/1

5

THU 1

2/03/1

5

FRI 13/0

3/15

SAT 14/0

3/15

SUN 1

5/03/1

5

MON

16/0

3/15

TUE 17/0

3/15

WED 1

8/03/1

5

THU 1

9/03/1

5

FRI 20/0

3/15

SAT 21/0

3/15

SUN 2

2/03/1

5

MON

23/0

3/15

TUE 24/0

3/15

WED 2

5/03/1

5

THU 2

6/03/1

5

FRI 27/0

3/15

SAT 28/0

3/15

SUN 2

9/03/1

5

MON

30/0

3/15

TUE 31/0

3/15

08:30

08:45

09:00

09:15

09:30

09:45

10:00

10:15

10:30

10:45

Analysis of Theatre 6, Phase 3Start Times March 15 PT INTO ANAES ROOM

START OF ANAES

TIME INTO THEATRE

START OF PROCEDURE

tIM

E

TUE 03/03/

15

WED 04/03/

15

THU 05/03/

15

FRI 06/03/

15

MON 09/03/

15

TUE 10/03/

15

WED 11/03/

15

THU 12/03/

15

FRI 13/03/

15

MON 16/03/

15

WED 18/03/

15

THU 19/03/

15

TUE 24/03/

15

WED 25/03/

15

THU 26/03/

15

FRI 27/03/

15

MON 30/03/

15

TUE 31/03/

15

08:30

08:45

09:00

09:15

09:30

09:45

10:00

10:15

Analysis of Theatre 2, Phase 2Start Times March 15

PT INTO ANAES ROOM

START OF ANAES

TIME INTO THEATRE

START OF PROCEDURE

TIM

E

?SCAPHOID !!!!!!!!!!!!!!!!!

NHS Fife Orthopaedic Service Improvements

Enhanced Recovery for Hip and Knee Arthroplasty

Reduced length of stay - 4 Days

RedesignPathway to Support QOF Guidance for Knees

Spinal Clinics

New Clinics at WMB and QMH

Increased Capacity 32 Patients

Defined Fife Pathway

Intranet Advice and Guidance90% Patient Satisfaction with Clinics

RedesignLow Back Pain

Pathway

Orthopaedic Advice and Guidance

NHS Fife Orthopaedic Guidance? Desk Top Help Tool

? Referral Advice Fields

Increased Compliance with SIGN Guidelines

Vetting Times Reduced from 10 to 2 Days Referral Management

EnhancedCommunication

Reduces Patient Anxiety

Reduces Patient Pathway by 8 weeks

GP Direct Access to MRI (Radicular Pain)

Advice via Referral Management SystemE-advice e-mail

Maximisation of Workforce

Management Consistency

Reduced Patient ‘Hand-Offs’

• Increased capacity by 40 patients a month

GPwSI Community Knee Clinic

Transfer of Physiotherapy Staff to Primary Care

GP Orthopaedic Training Delivered

PhysiotherapyServices

Shift in Balanceof Care

Primary Care Diagnostics

Redesign

Reduces Risk of Chronicity

Virtual Advice Clinics

Integrated Service

Physiotherapy Community Spinal Clinic

Multidisciplinary Diagnostic Group Exploring Expansion of Access

Patient Involvement

Patient Support and Input

New Service User Information Leaflets

User Involvement and Patient-Centred Ongoing Research

Neck

Lumbar

Shoulder

Hip

Thoracic

Elbow

WristHand

Knee

AnkleFoot

Cauda Equina Acute trauma/fracture

Refer toA&E

Suspected Malignancy Infection Progressive neurology

Refer to Secondary Care

Acute Soft Tissue Injury Service User InformationHealthy Working Lives Adviceline on 0800 019 2211Fife Sport and Leisure

NHS Fife Musculoskeletal Resource Tool

NHS InformMusculoskeletal National Advice

NHS Fife Summary Orthopaedic Referral

Guidelines

Useful Links

Analgesic Ladder

Musculoskeletal Medication Advice

Physiotherapy Referral Guidance

NHS Fife Orthopaedic

Pathway

Hover over area and ‘click’ for further adviceTerms of Use

Minimum Information Required for Orthopaedic

Referrals

NHS Inform

Info Sheet

Chronic Pain

20