The Experience in Exeter with hip fracture care Data For Change John Charity Associate Specialist in T&O, Lead NHFD Clinician, Royal Devon and Exeter NHS Foundation Trust Respond Deliver & Enable
People are saying, Big Data is the new oil. Gary Wolf
Background Hip fractures in Exeter -types & numbers 550 patients / year 34 Intracapsular (undisplaced) 6% 36 Subtrochanteric 7% 194 Intertrochanteric 35% 52% 288 Intracapsular(displaced)
Aims NICE Guideline on Hip Fractures CG 124 National Hip Fracture Database (NHFD) and the positive impact to our service: 30-day mortality, Time to surgery, LoS Effect of a multidisciplinary approach
NICE CG 124 -Key priorities 1. Timing of surgery On the day of, or the day after, admission 2. Planning Schedule hip procedure on a planned theatre list 3. Surgery Cemented arthroplasty for displaced intracapsular Sliding hip screw for simple intertrochanteric
4. Mobilisation Starting on day aftersurgery, at least once a day 5. Multidisciplinary protocol Orthogeriatric-led team Rapid return to pre-fracture status & place of residence Falls prevention, cognitive & bone health assessments 6. Early supported discharge Once medically stable & mobilising short distances
3. Surgical procedures Displaced intracapsular fractures Cemented arthroplasty hemiarthroplasty (84%) or total hip replacement (16%) Use a proven femoral stem design (Exeter Trauma Stem - ETS)
Proven Stem Design?
Exeter Trauma Stem Based on the Exeter stem: familiarity Proven durable stem fixation Technically straightforward Low cost (1/3 price of Exeter stem) Ease of revision to THR
Exeter Trauma Stem: Results Australia: Cumulative % revision 3.8% @ 5 yrs (Favorable)
3. Surgical procedures Hemi or THR? For displaced intracapsular fractures offer THR if: walking independently out of doors and cognitively intact and medically fit for anaesthesia 2010 in Exeter: ~15% 2013: 30%
The National Hip Fracture Database Web-based audit of hip fracture care England, Wales, N. Ireland, Isle of Man & Channel Islands BOA BGS
184 eligible hospitals 95% of total cases recorded >60,000 cases / year >300,000 recorded since 2007 Largest national hip fracture audit in the world 6 standards: prompt admission early surgery pressure ulcers orthogeriatric input bone health falls assessment All hospitals in rank order
Best Practice Tariff Dept of Health initiative rewarding the achievement of specified standards with 1350 uplift: Age > 60 years Time to theatre < 36 hours Joint care between Orthopaedics and Geriatrics Assessment using agreed protocol Seen peri-operatively by Geriatrician Post op Geriatrician led: Rehabilitation Bone health and falls prevention AMTS pre and post op
Orthogeriatric Service (2010) Joint care with geriatricians Multidisciplinary board round at 09:00 coordinating pathway of every patient Planning for discharge: arrangements start on day of admission assessment of patient needs on an individual basis Trauma nurse practitioner + healthcare assistant providing 7 day cover 2 additional rehabilitation therapists & 1 OT providing 7 day cover Consultant geriatrician patient reviews on Saturdays & Sundays Daily trauma list starting at 08:00 by designated surgeon Hip surgeon availability with 6 day cover for total hip replacements Multidisciplinary monthly meeting to review hip fracture admissions data
Auditing our patients journey Current projects Time of admission to orthopaedic ward Warfarin reversal Hip fracture consent form Start times in trauma theatre Efficiency of trauma evening lists Failure rate of cephalomedullary nails Impact of time to theater on length of stay Accuracy of coding and quality of discharge summaries 30-day readmissions for all causes
April 2012 -March 2013
Mortality RDEFT
Mortality RDEFT 15% 10% 5% 30 Day Mortality 13% 5.7% 0% 2007 2013
Exeter Hip Fracture Service Last quarter 2012 vs.first quarter 2013 30 25 Q4 2012 Q1 2013 20 15 10 5 0 % > 36 hrs % lack of time % unfit for surgery
2010 report RDE = 15.5 days 2013 report RDE = 11.5 days
The Future Summary More ETS hip hemis More Exeter THRs Early Supported Discharge strategies Theatre time Reduced mortality Less delays to theatre Reduced length of stay Benefits of a multidisciplinary approach High quality care can be cost effective