Our Experience as Mortality Outliers. Calderdale and Huddersfield NHS Foundation Trust Chris Ramsdale Sudhi Ankarath

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1 Our Experience as Mortality Outliers Calderdale and Huddersfield NHS Foundation Trust Chris Ramsdale Sudhi Ankarath

2 Where were we? 2 orthopaedic wards 61 beds Patients admitted wherever the empty bed was Orthogeriatric input on adhoc basis General concerns about outcomes and the care we provided

3 What did we do? Business case to have a dedicated fractured neck of femur ward Pressure put on Medical Division to provide on-going Orthogeriatric support

4 What happened next? The NHFD wrote to the Trust and advised us we had a problem We sought an external opinion for advice on where we could improve care A visit was arranged for a multidisciplinary group to visit us in May 2013

5 We d already made changes before the visit Discussions had happened at Board level regarding concerns Business case for dedicated Orthogeriatrician Reviewed membership of Fractured Neck of Femur Group

6 Practical changes Documentation changes were on the way after a routine CQC visit Staff education Back to basics with nursing care Daily input from Outreach Daily contact with Orthogeriatricians Checking haemacue in Recovery and early transfusion

7 How did we feel about the impending visit? Upset Concerned as to what was being done wrong Didn t feel our care was bad Integrity challenged

8 Background 2011/2 466 hip fractures 68% to an orthopaedic ward within 4 hours 70% to theatre within 36 hours 5% saw a geriatrician pre-op 2% grade 2 or above pressure sores 0.3% completed falls assessment 4% non-operative management Wide variation in both hemiarthroplasty and trochanteric treatment <5% THR 30 day mortality outlier compared with the national mean % 0% BPT

9 The Reviewers Mr Tim Chesser Dr Iain Moppett Dr Helen Wilson Mrs Karen Hertz Mr Paul Dixon Prof Peter Roberts Consultant Orthopaedic Surgeon, North Bristol NHS Trust Consultant Anaesthetist, Nottingham University Hospital Consultant General and Geriatric Medicine, Royal Surrey County Hospital ANP, University Hospital of North Staffordshire Consultant Orthopaedic Surgeon, City Hospitals Sunderland NHS Trust Non-exec Director, Calderdale and Huddersfield NHS Trust

10 Who did they meet? Bev Walker General Manager David Wise Medical Director Claire Brearley Associate Divisional Director Huw Masson ED Consultant Mark Davies ED Consultant and ED Clinical Director Sudhi Ankarath Clinical Director Orthopaedics Graham Walsh Orthopaedic Consultant and Hip Fracture Lead John Esmond Consultant Anaesthetist Peter Hall Consultant Anaesthetist Gudrun Seebass Consultant Geriatrician and Geriatric Lead Bryony Greenwood Speciality Doctor Geriatrics Chris Ramsdale Trauma Nurse Co-ordinator Lisa Cooper Matron for Trauma Debbie Mallinson Lead Orthopaedic Physiotherapist Anthony Dawson Lead Orthopaedic Occupational Therapist

11 What did they find? No BPT payments were achieved Good basic infrastructure A well managed, dedicated hip fracture ward Hip fracture patients are prioritised for theatre Lack of leadership on the hip fracture programme Significant variation in fracture treatment Lack of Orthogeriatric input pre-op Lack of consistency with therapy Preventing delirium work that should be commended P.S. The trauma co-ordinator provides and excellent service

12 Revitalising the Neck of Femur Group Building on the impetus from the new hip fracture ward More members invited, with a multidisciplinary membership New General Manager with specific hip fracture responsibilities Visitied other centres for new ideas

13 Where are we now? A&E have a protocol for giving vitamin K to patients taking warfarin Femoral nerve blocks are frequently given to patients in A&E Pre-load carbohydrate drink is given to pre-op patients Analgesia protocol is in progress Weekly staff education sessions Staff rota has reverted back to traditional earlies and lates Ward based junior doctors ETS is generally used for intracapsular fractures Slight improvement in THR rate BPT achieved in approx. 25% of patients

14 The future New Orthopaedic consultant with commitment to hip fracture programme Continue pressure to employ an Orthogeriatrician Engagement work with therapy staff and ward teams to improve mobility rehabilitation Continue to achieve more BPT payments Dedicated hip fracture theatre list

15 Staff thoughts now Cohorting # neck of femur patients is the way forward Beds are generally protected for hip fracture patients Delirium work continues to improve patient outcomes