Striving to improve hip fracture care

Transcription

1 Striving to improve hip fracture care The UHL experience Mr F. Condon, Consultant Orthopaedic Surgeon Ms Jude Ryan, Consultant Ortho-Geriatrician (Mat Leave) & A. Butler Orthopaedic CNS (Mat Leave!!) 3 RD Irish Hip Fracture Meeting 6 th March 2015 RCSI

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3 Blood Supply External Iliac a. *Children *Adults Ligamentum Teres. Medial Circumflex a. Lateral Circumflex a. Femoral a. Profunda Femoris a.

4 University Limerick Hospitals Clare, North Tipperary & Limerick Population > 400,000 Dept Trauma Orthopaedics, Peri-Operative Directorate 29 bedded Trauma Ward One Trauma Theatre Six Orthopaedic Consultants Orthogeriatrician (mat leave)

5 Hip Fracture Activity

6 2008- start of the seven year journey! Step 1: Appointment of Orthopaedic CNS Responsibility to introduce the 1 st hip fracture database available to Irish hospitals Merck Sharp & Dohme Ireland On-line database managed by Riomed (UK) Review current hip fracture care & services in UHL and highlight areas for improvement

7 Data collection for one year completed Results presented at Atlantic Orthopaedic Club annual meeting in Galway (awarded best clinical paper) Highlighted many areas of service that required improvement 69% surgery < 48hrs 47% of cancellations due to list theatre access 34% awaited medical review/treatment/stabilisation 13% received routine falls assessment / bone protection therapy Majority of patients were discharged to nursing homes 41%, poor focus on rehabilitation and striving to assist patients back to independent living

8 Step 2: Establishment of hip fracture review clinics CNS managed follow up Early identification of complications Audit of post operative progress Opportunity to refer for out-patient Dexa and liaise with GP re: bone protection therapy where necessary New evidence based guidelines for pre & post op care of hip fracture patients

9 HOPE: Hospital Optimisation Programme Exemplar Step 3: A joint initiative by the HSE Mid-West & the University of Limerick October May 2011 To support the introduction of proven methodologies within the Lean Healthcare environment to support sustainable improvements in patient care service delivery areas and other ancillary supporting functions within the Mid West Regional Hospital, Limerick

10 Service Improvement Project Consultant Ortho Surgeon ED Consultant Theatre CNM Anaesthetics Ortho CNS Trauma CNM Hospital Optimisation Programme Exemplar

11 Aim To develop and implement a process and controls using Lean principals to achieve two of the BOA (2007) standards of care No longer than 4hrs in the Emergency Dept Non Complex # NOF Patients Surgery within 48hrs of presentation

12 Observation Period Undertaken by Lean Expert from Limerick University Patient sent for 08:10am Arrived in theatre 08:58am (48mins) Anaesthetist Reg 09:05am Anaesthetist Consultant 09:30am Surgery 09:58am (1hr7mins) Patient removed from theatre 11:30am 2nd surgery 12:28 (1hr)

13 Changes in Practice Post Lean Thinking... Care Process & Pathway ED & Ortho Hospital Pre Alert System U/S Guided Femoral Nerve Block One ring fenced hip fracture bed 8am-22:00hrs Appropriate air mattress Fast track protocol ED-Ward

14 Suspected Neck of femur fracture (#NOF) DEPARTMENTS OF EMERGENCY MEDICINE & ORTHOPAEDICS Joint Protocol FAST TRACK MANAGEMENT OF PROXIMAL FEMORAL FRACTURES SIMPLE ISOLATED MECHANICAL FALL AND STABLE MEDICAL HISTORY / EXAM SUITABLE FOR FAST TRACK PROTOCOL FBC, EUC, BM, COAG, G&H, ECG, CXR, PELVIS X-RAY, LATERAL HIP X- RAY, URINALYSIS, ULTRASOUND GUIDED 3:1 FEMORAL NERVE BLOCK, O 2 AND IV FLUIDS COMMENCED RAPID SENIOR EM RISK ASSESSMENT & EXAMINATION DEDICATED PRESSURE RELIEVING MATTRESS FOCUSED WORK UP AS PER PROTOCOL #NOF PAGE: ORTHOPAEDIC SERVICE, ANAESTHETICS, BED-MANAGER, OT BOOKING CONTACTED, X-RAYS REVIEWED ARRANGE FAST TRACK TRANSFER TO TRAUMA ORTHOPAEDICS WARD ORTHOPAEDIC REVIEW ON WARD PATIENT ON PRESSURE RELIEVING MATTRESS IN TRAUMA ORTHOPAEDICS WARD COMPLICATED PRESENTING COMPLAINT AND / OR UNSTABLE MEDICAL HISTORY / EXAM NOT SUITABLE FOR FAST TRACK PROTOCOL STANDARD WORK UP STANDARD ORTHOPAEDICS REFERRAL ORTHOPAEDIC REVIEW IN ED FURTHER SPECIALIST ASSESSMENT AND OPTIMISATION REQUIRED PRE OT

15 TO-BE-PROCESS TO-BE- PROCESS # Activity Responsible Timing / Deadline Comment-1 Comment-2 1 Identify a 1st patient for morning surgery inform CNM/RGN Trauma Wd Consultant Surgeon/ Ortho SPr 10:00 pm Subject to change - by Registrar on Call Final Confirm at 07:30 2 Theatre List sent to T5 1 ST Patient Clearly Highlighted Ortho SPr 07:30-07:45 3 Theatre CNM Request 1 st Patient T5 08:00 4 Handover Patient Ward Nurse to Theatre 5 Patient Wheeled into Anesthetic Room or Operating-Theatre Theatre 6 Commence Anesthesia Anesthetist 7 Commence Surgery Surgeon before 09:00 8 Identify & send for 2nd patient T5 CNM AT 09:30 depending on first Op.

16 Results: Transfer times ED-Trauma ( 10% in <4hrs) ( 15% within 4/8hrs)

17 Results: Theatre Access Increase in 38 mins theatre start time 7% reduction in theatre cancellations

18 Results: Theatre < 48hrs Increase operated patients <24 Hrs =12% Increase operated patients within <48hrs=8%

19 Cost Savings

20 Did it work?? Lean methodology proved an effective for the duration of the project only Benefits of HOPE project results were never supported by higher hospital management, unsurprisingly. Improvements not sustained at all Initial targets never met for any period of time Ring fencing was no longer available when ED overcrowding led to extra patients on trolleys on corridors on Trauma Ward

21 Orthogeriatrics at UHL Dr. Jude Ryan Step 4 Geriatrician led since July 2011 Peri-operative assessment of all hip fracture patients (70%) Optimisation for theatre Post op monitoring, management of medical complications Early assessment for rehabilitation Secondary prevention clinic Reduction in LOS from 10 to 8 days 412 bed days saved = 412,000

22 OG v Pre-service data

23 Impact on BOA Standard 3 & 4 Falls Assessment & Bone Protection Therapy Pre % With OG Service 70%

24 HIQA Review 2014 Step 5: Weakness highlighted Local validation of data No discussion of data from directorate level Only 23% of patients admitted within 4hr target No formal cognitive assessment documented/recorded Trauma list accommodates complex elective cases Non-adherance with national HSE medical records standards

25 Quality Improvement Plan Re-establishment of hip fracture bed Increased admissions from 23% - 45% Twice yearly audit of medical records of hip fracture patients Shown improvement in standards of documentation Improvements still required in weekend documentation

26 Quality Improvement Plan Monthly reports on BOA standards now submitted to peri-operative directorate team for evaluation & discussion Outstanding QIP S (CLINICAL TEAM UNABLE TO ADDRESS) Full time Orthogeriatrician assessment & input needed for efficient, safe, cost effective care Formal plans to cease high risk medical elective cases on trauma lists

27 Utilising the IHFD (Step 6) has assisted with undertaking a vast amount of Research Papers / Presentations 1. Hip in Your 90 s: An Analysis of Hip Fracture Morbidity and Mortality in a Prospective Cohort of Patients over Age Limerick Hospital Hip Fracture Score (LHFS): Content Validation by the International Classification of Functioning, Disability and Health (ICF) World Health Organisation System. 3. Double hip fractures: Twice the burden and twice the danger? 4. Modern Uncemented versus Cemented Bipolar Hemiarthroplasty. 5. Primary total hip replacement surgery for hip fractures. A prospective cohort study of 901 hip fractures. 6. The 36 hour watershed for hip fractures: Functional outcome benefits of maintaining NICE guidelines. 7. Can the use of Lean Principles improve services for hip fracture patients in the Irish Health Care Setting 8. Comprehensive Orthogeriatric Assessment Services for Trauma (COAST) improves Social and Functional Outcome after Hip Fracture Surgery: a Prospective Cohort Study

28 The effect of time to surgery on functional outcome in hip fracture patients in Mid-West Ireland Butler, A, Hahessy, S, Condon, F. Dept of Trauma Orthopaedics Limerick University Hospitals

29 Introduction/Background Sustaining a hip fracture can result in permanent changes to lifestyle, independence & mobility (Reid et al 2010) Delayed surgery is associated with increased risk of developing complications such as UTI S, pressure ulcers, pneumonia, venous thromboembolism, non union, necrosis of the femoral head and death (Brener, 2013)

30 Aim To establish if a relationship exists between a delay to surgery, functional outcome and time to return to pre-fracture residence, at six weeks post hip fracture utilising the validated Barthel Index Score (BIS).

31 Methods Functional ability with ADL s was evaluated using the BIS in 51 pts, on admission to establish pre-fracture abilities and repeated six weeks post surgery Data analysed using SPSS V.20

32 Variables Time To Surgery: calculated from time of presentation at the ED to the time of surgery Described as: 12hrs: Prompt Time to Surgery >12hrs & 36hrs: Target Time to Surgery >36hrs: Delayed Surgery

33 Variables The BIS measures functional disability by quantifying a patient s performance in ten activities of daily living (ADL S) The results are described in numerical value ranging from : Independent 60-79: Needs minimal help with activities of daily living 40-59: Partially Dependant 20-39: Very Dependant < 20 : Totally Dependant Sinoff & Ore (1997)

34 Inclusion Criteria Hip fracture patients can represent a very heterogeneous group but by using specific sampling criteria it was possible to make the sample exhibit a reasonable degree of homogeneity to limit the effect of confounding extraneous variables

35 Findings Patient demographics Mean age 81.8 yrs 82.4% Female Median LOS 7 days (IQR 4-10) 63% ASA Grade 3 Severe Systemic Disease Mean pre-fracture BIS= (independent) Mean post-op BIS= (needs help with ADL s)

36 Fracture Type/ Surgical procedures

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38 Waiting Times

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40 Main Findings Variables Statistical Analysis Result Relevance Change of 6/52 & time to surgery Whitney U Test P=.000 Z value of Significant Duration of time in ED and the change in BIS Kruskal Wallis Test p=.033 Significant

41 Correlation between duration of time in ED and the change in BIS This Boxplot displays the difference between the three classification groups representing the duration spent in the emergency department and the corresponding median change in BIS at six weeks post surgery.

42 Correlation between change of BIS & time to surgery This Boxplot shows the difference between the two theatre groups and the corresponding median BIS at six weeks following surgery.

43 Other findings... Variables Time to Theatre & ASA Grade Returning six weeks and time classification to theatre Controlling for age & Returning six weeks Statistical Analysis Result Relevance Chi-Square Analysis p=.227 No correlation Chi-Square Analysis p=.000 Significant Mann-Whitney & Wilcoxon Signed Rank test Z (p=.010) Significant A delay to surgery and the ability to return home while controlling for age

44 Conclusion This study has revealed statistical significance between delayed time to surgery and functional ability at six weeks, using the BIS. no correlation found between the patients ASA grade and a delay to surgery, which suggests that the patients pre-existing comorbidities did not contribute to their delay. Pts who encountered a wait of > four hours within the ED functioned less well as a result, which was statistically significant as demonstrated by the change in their BIS at six weeks. Pts who were delayed for surgery were less likely return to early independent living. This finding remained significant when age was controlled for as a confounding contributory factor, within this cohort of patients.

45 Six steps in the right direction

46 Recommendations Mandatory admission pathways & policies for #NOF patients nationally Ring fenced protected orthopaedic trauma beds to ensure admission pathways can work and not just a paper exercise! Ensure adequate NCHD S are available 7/7 to admit and to ensure timely recognition of medical issues prior to surgery Continue to advocated for full time Orthogeriatrician in-put Adequate access to theatre! Advocate for Advanced Nurse Practitioners in Orthopaedics who could assist in the timely admission assessment of these patients and may reduce delays in ED.