What can a redesigned facture pathway look like?

Transcription

1 GRI FRACTURE CLINIC MODERNISATION What can a redesigned facture pathway look like? Lech Rymaszewski Consultant Orthopaedic Surgeon

2 DETROIT BAILOUT

3 TRADITIONAL ORTHOPAEDIC FRACTURE (#) CLINIC All non operated # patients Routinely seen within a few days after A/E visit Many discharged at 1 st visit with no change in treatment

4 CONSEQUENCES Clinics too busy Little time with patients Little time for teaching trainees No data for audit / research /management Attendance often Wrong time Wrong clinic Unnecessary

5 REDESIGN METHODOLOGY Easily understood, patient focused aims Existing practices challenged WORK SMARTER -NOT HARDER

6

7 MODERN TOOLS Electronic information systems PACS, PAS, EDIS, BLUESPIER Telephone, esp mobiles

8 GOOD PRACTICE EVIDENCE BASED PROTOCOLS AGREED BY ALL CLINICIANS > CHECKLIST METHODOLOGY fracture clinic appt only for something to be done ACCURATE ELECTRONIC DATA COLLECTION > TRANSPARENCY / ACCOUNTABILITY > TRACKING > COMMUNICATION (Staff / Patients) > CREDIBILITY > TRUST

9 REAL TIME DATABASE clinically sourced / clinically credible

10 NHS CHANGE MANAGEMENT RESISTORS DATA DRIVERS ELECTRONIC TOOLS CULTURAL CHANGE EVIDENCE-BASED MANAGEMENT

11 NATURAL HISTORY - INJURIES IN MAMMALS

12 The basic message is simple -don't take back pain lying down! - Keep going - Try to remain at work or get back as soon as possible

13 PATIENT INFORMATION LEAFLETS CONSENSUS all local A/E and Ortho Consultants Torus # s Radial head/neck # s (fat pad signs) Neck of 5 th metacarpal # s Mallet fingers 5 th metatarsal # s Child s clavicle # Seen A/E - standardised info provided - no routine ortho follow-up

14 min 2 more visits after A/E Glasgow Royal Infirmary Emergency Department Torus Buckle Fractures Discharge Advice Your child has suffered a Torus or Buckle fracture (Break) of their wrist. This is the most common type of fracture in young children. Young bone is still soft and very flexible. For this reason, instead of breaking all the way through, the bone has a small crack or kink on one side only. This type of injury heals very well in a simple and easy to apply splint rather than a cumbersome plaster. Most of these injuries heal perfectly well if the splint is worn for 3 weeks. It is important to give your child appropriate doses of paracetamol or ibuprofen to help with the pain as it will still be sore for a short period even after the application of the splint. The splint can be removed for bathing/showering without risk to the fracture. If after 3 weeks the wrist is a little sore and stiff after being used, the splint can be reapplied for comfort. Do this for short periods only as it is best to try to start gently using the arm as normally as possible from now on. Use a simple painkiller such as paracetamol or ibuprofen if required. However - if after 3 weeks the wrist still seems very sore, swollen, or the child is not willing to use it contact the Fracture clinic to arrange follow-up. If the child removes the splint before the 3 weeks and appears to be comfortable and can use the arm freely then there is no reason to force them to wear the splint for the full 3 weeks. It is best to avoid sports and rough and tumble play when wearing the splint and for the week or two after its removal. Should you have any worries or concerns following discharge from hospital, please contact either the 1) Fracture Clinic: (8.30am until 4.30pm, Monday to Friday) or 2) Emergency Department: (outwith these times)

15 PRE-LEAFLET distal radial # in children After PACS review 93 buckle 29 no definite fracture seen 30 greenstick (stable, relatively undisplaced)

16 HEALTH ECONOMIST Calculate cost: Direct savings Staffing X ray Consumables Indirect savings Overall cost to society Time of work Days lost from school

17 10.62p

18 Proximal Femur Femoral Shaft A/E DATA - # site essential for managing processes / audit EDIS October '11 - October '12: Discharged Fracture Humeral shaft Distal humerus Olecranon/proximal ulna Radial head Radius Distal Radius Radial Styloid Radial Torus Radius and ulna ULNA Metacarpal(s) Carpal Mallet Finger Finger phalanx Pelvis Spine Patella Fibula Tibia Tibia and Fibula Ankle Os Calcis Talus Midfoot Metatarsal(s) Toe phalanx U/C Fracture Shoulder Scapula Proximal humerus Clavicle % of all Dischaged Fracutres

19 GRI FRACTURES /? FRACTURES Mid Oct 2011 Mid Oct 2012 Virtual Fracture Clinic 62% Direct A&E discharge (information leaflet) 38%

20 CHALLENGES / SOLUTIONS Orthopaedic traditions Orthopaedic pre fracture clinic review of all Xrays prior to patients being seen at clinic Audit? Correct diagnosis clinic timing appointment

21 VIRTUAL CLINIC OCT 2011 Consultant review Mon / Wed / Fri - A/E notes + PACS Xrays projected on large screen c 2 mins / patient Diagnosis / plan recorded Every patient phoned same day Snr Nurse Virtual discharge or OP appt - Letter / copy to GP Agreed plan > database

22 GRI FRACTURES /? FRACTURES Mid Oct 2011 Mid Oct 2012 Virtual Fracture Clinic 62% Consultant-Led Subspeciality Fracture Clinic 29% Nurse-Led Fracture Clinic 8% Discharged via telephone 25% Direct A&E discharge (information leaflet) 38%

23 QUALITY CONTROL x 3 / 4 INDEPENDENT ASSESSMENTS

24 SCOTTISH GOVT SUPPORT Health economist / data analyst Promotion velcro splints over POP - National procurement

25 TRANSFORMATIONAL CHANGE KEY REDESIGN ELEMENTS Patient centred care most appropriate person / time Open-door if any problems 93 % positive on satisfaction surveys (325 pts) Collaboration / Consensus Agreement of pathways clinicians

26 Here is Edward Bear, coming downstairs now, bump, bump, bump on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop that bumping for a moment and think of it.