Canberra Hospital:

Stimulating Change and

Driving Quality Improvement

through Critical System Analysis The NOF project

Professor Paul Smith

Sue Duggan RN

Number of Hip Fractures in Australia

2006-07 16,518 cases

175/100,000

Cost $15,000 -$ 19,500

AIH&W. The problem of Osteoporotic fracture in Australia.

Bulletin 76. March 2010.

Overview

• Canberra Hospital

• QI project

• Data collection – clinical expertise essential

• Sharing information leads to research by

others

• Identifying limits

• Organization changes resulting from project

Quality Improvement story

• Problem identified

• Stakeholders

• Baseline data to answer what is practice

• Review data with stakeholder team

• Decide on change/s to achieve desired outcome

• Implement changes with education to inform staff

• Collect data to assess practice

• Review data with stakeholder team

# NOF Project

Aims of project

• Reduce mortality

• Reduce Acute LOS

Protocol designed to address

• IVI fluid management

• Early consultation for unstable and high risk cases

• Reduce Delay to Surgery from arrival

Data identifies need for small changes

• Cancellation of procedure due to clinical

status

• Multiple episodes of fasting for theatres due

to repetitive cancellation of cases from

emergency theatre list

• Low urine hourly measures, cases requiring a

medical review

More strategies

• Criteria for Anaesthetic review of unwell patient (2003)

• Introduction of Non Elective Orthopaedic theatre lists (2003)

• Booking criteria for ONE emergency list

• Implementation of a specific # NOF Emergency Department Medical Admission form

• Hourly urine measure sticker

ED NOF Admission Form

Protocol: IVI Fluids to address ARF

DEFICIT (hrs) EXTRACAPSULAR INTRACAPSULAR

Fluid Restrict

patient

Normal fluid Fluid restrict

patient

Normal fluid

3 hr deficit 230 320 mls/hr 145 235 mls/hr

6 hr deficit 250 370 mls/hr 165 290 mls/hr

12 hr deficit 290 475 mls/hr 205 390 mls/hr

18 hr deficit 333 580 mls/hr 250 495 mls/hr

24 hr deficit 375 683 mls/hr 290 600 mls/hr

Fluid management change

IDC insertion to monitor output

Hourly urine measures

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08

pe

rce

nta

ge

of

ca

se

s

% IDC % hourly urine measure

Hourly urine Stickers introduced into ED NOF packages

Management of low urine output Pre operative

• 15% cases, Low urine measure triggered call for JMO review

• Fluids 30

• Continue 4

• Frusemide 10 (1 oral)

• 29 cases had IVI Frusemide pre op for fluid management

Post operative

• 15% cases, Low urine output triggered calls for JMO review,

First review treatment

• Fluids 30

• Continue 4

• Frusemide 11

• 40 cases received IVI Frusemide post op

• High risk – 3 significant co-morbidities

• Early Anaesthetic Consultation criteria

A patient

fall is believed to have resulted from a cardiac or a cerebral

event,

in congestive cardiac failure

has had a myocardial infarction in the last six months; .

with two or more significant intercurrent systemic illness

i.e. ischaemic heart disease, hypertension, arrhythmias,

diabetes, chronic airway limitation, stroke/TIAs, peripheral

vascular disease, chronic renal failure,

A patient for whom you are seeking a Medical review.

Protocol: Early consultation for

unstable and high risk patients

0

20

40

60

80

100

120

140

pre protocol 01/09/02 -28/03/03 01/03/03 -31/08/03 01/09/03 -30/11/03

nu

mb

er o

f ca

se

s

Identifying Unfit cases Early in Admission Total cases presented

Not Fit for OT in ED

Unfit for OT on Review

Total Unfit pre Surgery

Increase in early identification of

unfit for theatre

Logistics of OT availability

• 2001 just one Emergency Theatre per day

• September 2003 Trial of Orthopaedic trauma

lists Monday to Friday one list per day.

• Criteria developed for Registrars to book

patients to ‘Ortho Non Elective lists

• Review of Orthopaedic trauma load in total

trauma load.

• Needed but few NOF cases

The time it takes to complete

emergency cases

00:00

04:48

09:36

14:24

19:12

00:00

04:48

09:36

14:24

Non Elective Ortho List

Ortho Emergency cases

Non Orthopaedic Emergency cases

Time to theatre

0

10

20

30

40

50

60

70

80

Ho

urs

pre protocol 05/10 2003 05/10 2004 05/10 2005

Percentage of cases to OT by 36 hours ( delayed diagnosis not included)

<=36 hrs

>36 hrs

Number of Non Elective surgery cases per month

July 2003 to April 2006

0

50

100

150

200

250

300

350

400

450

Nu

mb

er o

f ca

se

s

Orthopaedic

Non orthopaedic cases

Linear (Orthopaedic)

Linear (Non orthopaedic cases)

Monthly average hours per day of Non Elective

surgery performed at CH July 2003 to April 2006

0

5

10

15

20

25

ave

rag

e h

ou

rs p

er

da

y

Orthopaedic

Non Orthopaedic

Linear (Orthopaedic )

Linear (Non Orthopaedic)

Orthopaedic trauma load and time to surgery for NOF

cases between May 2004 to April 2006

0

20

40

60

80

100

120

140

160

180

200

Ma

y-0

4

Ju

n-0

4

Ju

l-0

4

Au

g-0

4

Se

p-0

4

Oct-

04

Nov-0

4

Dec-0

4

Ja

n-0

5

Fe

b-0

5

Ma

r-0

5

Ap

r-0

5

Ma

y-0

5

Ju

n-0

5

Ju

l-0

5

Au

g-0

5

Se

p-0

5

Oct-

05

Nov-0

5

Dec-0

5

Ja

n-0

6

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Ho

urs

Nu

mb

er

of

ca

se

s

Number of Orthopaedic Trauma cases

# NOF average Time to OT

Linear (Number of Orthopaedic Trauma cases)

Linear (# NOF average Time to OT )

Achievements and organization changes

• Protocol adopted

• Comprehensive data collection 2001 -2011

• Database 1700+ cases

• ACT Health Quality First Award

• Dedicated Orthopaedic trauma theatre lists 7

days/week

• Increase in Ortho-geriatric involvement in the fine-

tuning fluid management in the frail aged

• Improvement in early discussions on end of life

choices for NFR, respecting patient choices.

Regional changes

• Lead to the establishing rehabilitation services in the

private sector at Calvary John James and National

Capital private hospital

• Information utilized during the establishment of

rehabilitation service on Calvary public site

• Sharing of protocol with regional referral hospitals

resulting in patients arriving ‘worked – up’ IVI fluids in

progress, IDC insitu, baseline bloods taken

13

2

64

4

63

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

pre protocal 11/01-4/02

09/02-02/03 03/03-11/03 04/04-11/04 05/05-10/05 06/07-06-08

Destination of patients presenting from 'home'

Death

Nursing Home

Rehab

Other

Home

other hospital

Project aims - Outcomes

• Reduced Acute length of stay

DRG 108A benchmark 16.64 days. CH 12.11 & 11.53

days

DRG 108B benchmark 8.27 days. CH 7.52 & 7.40 days

• Reduced mortality 9.8 % (8.1 %) to 6.64% , 5.15% in

surgical population

• Time to surgery remains an ongoing issue with fit

fasting patients cancelled each month. 80.3% to

surgery under 48 hours 2010/11

Plans for the future

• NOF SOP (standard operating procedure) on

Intranet for staff access

• Trauma and Orthopaedic research unit

developing a fracture online entry database

• Clinical Governance is establishing a working

group to look at ‘fasting for surgery’

• Geriatric Medicine are proposing to develop

criteria for diagnosis and documentation of

Delirium

Thanks for

listening

Acknowledgements

Prof Paul Smith

Assoc Prof Alex Fisher