Taking an Innovative Approach to
Managing Surgical Treatment for
Orthopaedic Trauma Patients
Robert Middleton
Consultant O...
www.enhancedrecoveryblog.com
The current challenge
Previously we have….
 Increased capacity and budget
 Increased capaci...
www.enhancedrecoveryblog.com
Why do our solutions fail?
 Treating the symptoms of the problem
 The end result doesn’t ch...
www.enhancedrecoveryblog.com
Deming system of profound knowledge
Understanding variation is the
most important aspect when...
www.enhancedrecoveryblog.com
There is little evidence for why there is variation –
THR case-mix adjusted LOS
-4
-3
-2
-1
0...
www.enhancedrecoveryblog.com
History of Enhanced Recovery
• In the late 1990’s Henrik Kehlet introduced a multimodal appro...
www.enhancedrecoveryblog.com
What is Enhanced Recovery?
“Enhanced Recovery is an evidence-
based approach to care. It is d...
www.enhancedrecoveryblog.com
Enhanced Recovery aims to minimise the effects of
surgery and optimise a quicker recovery pos...
Enhanced Recovery is a team game
• Patients
• Nurse specialists
• Physiotherapy
• Occupational therapy
• Social workers
• ...
www.enhancedrecoveryblog.com
The generic principles of Enhanced Recovery
www.enhancedrecoveryblog.com
Results of Implementing Enhanced Recovery
www.enhancedrecoveryblog.com
Results – Reducing length of stay
Introduction of pathway in 2007 = 50% reduction in LOS
www.enhancedrecoveryblog.com
Results – Benchmarking case mix adjusted
length of stay
-4
-3
-2
-1
0
1
2
3
4
5
6
AVLOS great...
www.enhancedrecoveryblog.com
Results – Benchmarking case mix adjusted
length of stay
-3
-2
-1
0
1
2
3
4
5
AVLOS significan...
www.enhancedrecoveryblog.com
Volume of work - increasing year-on-year
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2000/...
www.enhancedrecoveryblog.com
Waiting time decreasing
www.enhancedrecoveryblog.com
Number of beds has decreased
www.enhancedrecoveryblog.com
78 beds reduced to 63
15 beds saved
www.enhancedrecoveryblog.com
Increasing tariff per bed day
www.enhancedrecoveryblog.com
Spreading the principles of enhanced
recovery
• Applying the principles of enhanced recovery
...
www.enhancedrecoveryblog.com
www.enhancedrecoveryblog.com
Demographics and metrics
Bournemouth Bournemouth ESD Rest of England
Dates October 2005 - Jul...
www.enhancedrecoveryblog.com
Length of stay – hip replacement
Patients >=85 yearsAll patients
Boxplots show the median and...
www.enhancedrecoveryblog.com
Length of stay – knee replacement
Patients >=85 yearsAll patients
Boxplots show the median an...
www.enhancedrecoveryblog.com
Post-operative length of stay – Bournemouth only
Knee replacementHip replacement
Boxplots sho...
www.enhancedrecoveryblog.com
National Hip Fracture Database
National Report 2012
• 59,365 cases
• Illustrates progress…
– ...
www.enhancedrecoveryblog.com
Number of Fractured NOFs per year
Poole Hospital – 1002 episodes and 897 spells
Graph shows n...
www.enhancedrecoveryblog.com
Length of stay
Quarterly trend from 2002/03-Q1 to 2013/14-Q3
www.enhancedrecoveryblog.com
Length of stay vs Case-mix expected
Quarterly trend from 2002/03-Q1 to 2013/14-Q3
www.enhancedrecoveryblog.com
LOS vs Case-mix Expected LOS
Graph shows quarterly trend from 2008/09-Q1 to 2013/14-Q3
www.enhancedrecoveryblog.com
Understanding Relative Risk
• This shows the ratio of the observed number of outcomes to the ...
www.enhancedrecoveryblog.com
Length of stay – Relative Risk
Average LOS last quarter = 12.3
Graph shows quarterly trend fr...
www.enhancedrecoveryblog.com
Total bed days
Graph shows 5-yr annual trend
www.enhancedrecoveryblog.com
Length of stay – Relative Risk
Average LOS last 12 months = 12.3 days
Graph shows annual tren...
www.enhancedrecoveryblog.com
Mortality – Relative Risk
Mortality rate last 12 months = 5.8%
Graph shows annual trend from ...
www.enhancedrecoveryblog.com
Re-admissions – Relative Risk
28 day re-admission rate last 12 months = 10.2%
Graph shows ann...
www.enhancedrecoveryblog.com
Discharge destination
Graph shows annual trend from 2002/03-Q1 to 2013/14-Q3
www.enhancedrecoveryblog.com
Summary
Every system is perfectly designed to get the
results it gets…
Upcoming SlideShare
Loading in...5
×

Taking an innovative approach to managing surgical treatment for orthopaedic trauma patients

2,344

Published on

Rob Middleton presentation at Streamlining Pathways in Orthopaedic Trauma Care Conference, Birmingham, UK.
Wednesday 30 April 2014

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
2,344
On Slideshare
0
From Embeds
0
Number of Embeds
7
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Deming advocated that all managers need to have what he called a System of Profound Knowledge, consisting of four parts:Appreciation of a system: understanding the overall processes involving suppliers, producers, and customers (or recipients) of goods and services (explained below);Knowledge of variation: the range and causes of variation in quality, and use of statistical sampling in measurements;Theory of knowledge: the concepts explaining knowledge and the limits of what can be known (see also: epistemology);Knowledge of psychology: concepts of human nature.Deming explained, "One need not be eminent in any part nor in all four parts in order to understand it and to apply it. The 14 points for management in industry, education, and government follow naturally as application of this outside knowledge, for transformation from the present style of Western management to one of optimization.""The various segments of the system of profound knowledge proposed here cannot be separated. They interact with each other. Thus, knowledge of psychology is incomplete without knowledge of variation."A manager of people needs to understand that all people are different. This is not ranking people. He needs to understand that the performance of anyone is governed largely by the system that he works in, the responsibility of management. A psychologist that possesses even a crude understanding of variation as will be learned in the experiment with the Red Beads (Ch. 7) could no longer participate in refinement of a plan for ranking people."[21]The Appreciation of a system involves understanding how interactions (i.e., feedback) between the elements of a system can result in internal restrictions that force the system to behave as a single organism that automatically seeks a steady state. It is this steady state that determines the output of the system rather than the individual elements. Thus it is the structure of the organization rather than the employees, alone, which holds the key to improving the quality of output.The Knowledge of variation involves understanding that everything measured consists of both "normal" variation due to the flexibility of the system and of "special causes" that create defects. Quality involves recognizing the difference to eliminate "special causes" while controlling normal variation. Deming taught that making changes in response to "normal" variation would only make the system perform worse. Understanding variation includes the mathematical certainty that variation will normally occur within six standard deviations of the mean.The System of Profound Knowledge is the basis for application of Deming's famous 14 Points for Management, described below.
  • History – fit this in with your story about being a House officer and seeing colorectal ptsAlso introduce how you got involved with reducing LOS (BUPA) and also understanding about pathways (your pts going home quickest – but due to your pathway and you operating on a Monday)
  • Kehlet schematic diagram – talk through the slideNot about changing functional ability on discharge – ER is about getting their quicker, by optimising pre-op, minimising intra-op, and promoting recover post-op
  • This is a generic (all surgical specs) from the DOH.Worth running through though
  • Spend some time on this graphic emphasizing the gains for the elderly
  • Basket: Diagnoses - ALL|Outcome group: ActivityFirst / Last: 2012/13-Q4 to 2013/14-Q3|Admission type: All|Chapter: All|Diagnosis: Fracture of neck of femur (hip)Superspells: 63,486|Spells: 71,061|Episodes: 107,352
  • Basket: Diagnoses - RTM|Outcome group: Length of stayFirst / Last: 2002/03-Q1 to 2013/14-Q3|Admission type: Non-elective|Chapter: All|Diagnosis: Fracture of neck of femur (hip)Superspells: 8,974|Spells: 9,587|Episodes: 11,978
  • Basket: Diagnoses - RTM|Outcome group: Length of stayFirst / Last: 2002/03-Q1 to 2013/14-Q3|Admission type: Non-elective|Chapter: All|Diagnosis: Fracture of neck of femur (hip)Superspells: 8,974|Spells: 9,587|Episodes: 11,978
  • Basket: Diagnoses - HSMR|Outcome group: Length of stayFirst / Last: 2002/03-Q1 to 2013/14-Q3|Admission type: Non-elective|Chapter: All|Diagnosis: Fracture of neck of femur (hip)Superspells: 8,974|Spells: 9,587|Episodes: 11,978
  • Basket: Diagnoses - HSMR|Outcome group: MortalityFirst / Last: 2002/03-Q1 to 2013/14-Q3|Admission type: Non-elective|Chapter: All|Diagnosis: Fracture of neck of femur (hip)Superspells: 8,974|Spells: 9,587|Episodes: 11,978
  • Basket: Diagnoses - HSMR|Outcome group: ReadmissionsFirst / Last: 2002/03-Q1 to 2013/14-Q3|Admission type: Non-elective|Chapter: All|Diagnosis: Fracture of neck of femur (hip)Superspells: 8,974|Spells: 9,587|Episodes: 11,978
  • Transcript of "Taking an innovative approach to managing surgical treatment for orthopaedic trauma patients"

    1. 1. Taking an Innovative Approach to Managing Surgical Treatment for Orthopaedic Trauma Patients Robert Middleton Consultant Orthopaedic Surgeon and Director of Trauma, Poole Hospital NHS Foundation Trust Wednesday 30th April
    2. 2. www.enhancedrecoveryblog.com The current challenge Previously we have….  Increased capacity and budget  Increased capacity and efficiency, but with an increased budget But now we must  Increase capacity, efficiency, and quality, but with a decreased budget
    3. 3. www.enhancedrecoveryblog.com Why do our solutions fail?  Treating the symptoms of the problem  The end result doesn’t change because we don’t change the whole system Every system is perfectly designed to get the results it gets (Deming)
    4. 4. www.enhancedrecoveryblog.com Deming system of profound knowledge Understanding variation is the most important aspect when trying to understand a system But…..How do we go about this in healthcare when so many factors vary from patient to patient?
    5. 5. www.enhancedrecoveryblog.com There is little evidence for why there is variation – THR case-mix adjusted LOS -4 -3 -2 -1 0 1 2 3 4 5 6 AVLOS is nearly 3 days less than expected for the case-mix in this hospital AVLOS is nearly 5 days more than expected for the case-mix in this hospital
    6. 6. www.enhancedrecoveryblog.com History of Enhanced Recovery • In the late 1990’s Henrik Kehlet introduced a multimodal approach to improve functional recovery after colonic surgery • Colorectal Clinical Teams from England visited the centre and started to adopt this approach in general surgery • In parallel, orthopaedic models termed “Accelerated Recovery” or “Rapid Recovery” were being developed in some UK and international units • To date, the experience in the UK has seen a piecemeal approach. The approach has not been adopted by all units and so therefore the benefits for patients and the health service have not been maximised.
    7. 7. www.enhancedrecoveryblog.com What is Enhanced Recovery? “Enhanced Recovery is an evidence- based approach to care. It is designed to prepare patients for, and reduce the total impact of, surgery, helping them to recover more quickly. It is a multi-modal approach similar to that of care bundles”
    8. 8. www.enhancedrecoveryblog.com Enhanced Recovery aims to minimise the effects of surgery and optimise a quicker recovery post surgery
    9. 9. Enhanced Recovery is a team game • Patients • Nurse specialists • Physiotherapy • Occupational therapy • Social workers • Surgeons • Anaesthesia • Pain management • Pre-assessment • Nutrition / Dietician • Team assistant • Ward nursing staff • Medical staff • Management • Primary Care • Pharmacist
    10. 10. www.enhancedrecoveryblog.com The generic principles of Enhanced Recovery
    11. 11. www.enhancedrecoveryblog.com Results of Implementing Enhanced Recovery
    12. 12. www.enhancedrecoveryblog.com Results – Reducing length of stay Introduction of pathway in 2007 = 50% reduction in LOS
    13. 13. www.enhancedrecoveryblog.com Results – Benchmarking case mix adjusted length of stay -4 -3 -2 -1 0 1 2 3 4 5 6 AVLOS greater than expected for case mix. Hospital placed in lower half of UK hospitals
    14. 14. www.enhancedrecoveryblog.com Results – Benchmarking case mix adjusted length of stay -3 -2 -1 0 1 2 3 4 5 AVLOS significantly shorter than expected for case mix. Hospital placed top of all UK hospitals
    15. 15. www.enhancedrecoveryblog.com Volume of work - increasing year-on-year 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
    16. 16. www.enhancedrecoveryblog.com Waiting time decreasing
    17. 17. www.enhancedrecoveryblog.com Number of beds has decreased
    18. 18. www.enhancedrecoveryblog.com 78 beds reduced to 63 15 beds saved
    19. 19. www.enhancedrecoveryblog.com Increasing tariff per bed day
    20. 20. www.enhancedrecoveryblog.com Spreading the principles of enhanced recovery • Applying the principles of enhanced recovery to all patients – not just the young and fit • Applying the principles of enhanced recovery to other orthopaedic procedures e.g. Fractured Neck of Femur
    21. 21. www.enhancedrecoveryblog.com
    22. 22. www.enhancedrecoveryblog.com Demographics and metrics Bournemouth Bournemouth ESD Rest of England Dates October 2005 - July 2007 inclusive August 2007 - May 2009 inclusive August 2007 - May 2009 inclusive Patients All >=85years All >=85years All >=85years Total joint replacements 2065 134 2128 116 190506 8604 THR 966 71 883 61 86722 4390 TKR 1099 63 1245 55 103784 4214 Mean age (years) 72 87 71 86 69 87 Minimum age (years) 26 85 28 85 10 85 Maximum age (years) 98 98 93 93 100 100 Male 740 38 752 32 77176 2638 Female 1325 96 1376 84 113294 5965 % Male 36% 28% 35% 28% 41% 31% Discharged home 2028 123 2119 113 183875 7265 % discharged home 95.3% 91.8% 99.6% 97.4% 96.5% 84.4% Long length of stay 412 73 94 16 38297 4572 % Long length of stay 20.0% 54.5% 4.4% 13.8% 20.1% 53.1% (binomial confidence intervals) (18.3% - 21.7%) (46.3% - 62.7%) (3.6% - 5.3%) (7.8% - 20.7%) (19.9% - 20.3%) (52.1% - 54.2%) Emergency readmissions (30-day) 114 8 101 6 11752 808 % readmissions 5.5% 6.0% 4.7% 5.2% 6.2% 9.4% (binomial confidence intervals) (4.6% - 6.5%) (2.2% - 10.4%) (3.9% - 5.7%) (1.7% - 9.5%) (6.1% - 6.3%) (8.8% - 10.0%) 30-day mortality 2 0 0 0 317 72 % readmissions 0.1% 0.0% 0.0% 0.0% 0.2% 0.8% (binomial confidence intervals) (0.0% - 0.2%) (0.0% - 0.0%) (0.0% - 0.0%) (0.0% - 0.0%) (0.1% - 0.2%) (0.7% - 1.0%)
    23. 23. www.enhancedrecoveryblog.com Length of stay – hip replacement Patients >=85 yearsAll patients Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range
    24. 24. www.enhancedrecoveryblog.com Length of stay – knee replacement Patients >=85 yearsAll patients Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range
    25. 25. www.enhancedrecoveryblog.com Post-operative length of stay – Bournemouth only Knee replacementHip replacement Boxplots show the median and interquartile range of the data with whiskers extending to a maximum of 1.5 x interquartile range Age: over 85 years only
    26. 26. www.enhancedrecoveryblog.com National Hip Fracture Database National Report 2012 • 59,365 cases • Illustrates progress… – Mean total LOS reduced from 21.2 days to 20.2 days – Decreased in hospital mortality (9.5% to 9.1%) – Pre-op assessment by an orthogeriatrician – (increased from 37% to 43%) • and challenges… – 52% of pts admitted to an orthopaedic ward within 4hrs (Down from 56% in 2011) and 83% receive surgery within 48hrs (down from 87%)
    27. 27. www.enhancedrecoveryblog.com Number of Fractured NOFs per year Poole Hospital – 1002 episodes and 897 spells Graph shows number of fractured NOFs spells in all English hospitals per year 2012/13- Q4 to 2013/14-Q3
    28. 28. www.enhancedrecoveryblog.com Length of stay Quarterly trend from 2002/03-Q1 to 2013/14-Q3
    29. 29. www.enhancedrecoveryblog.com Length of stay vs Case-mix expected Quarterly trend from 2002/03-Q1 to 2013/14-Q3
    30. 30. www.enhancedrecoveryblog.com LOS vs Case-mix Expected LOS Graph shows quarterly trend from 2008/09-Q1 to 2013/14-Q3
    31. 31. www.enhancedrecoveryblog.com Understanding Relative Risk • This shows the ratio of the observed number of outcomes to the expected number of outcomes. • RR = [n(observed) / n(expected)] x 100. • The benchmark figure (the NHS England average) is 100 – Values greater than 100 represent performance higher than the benchmark – Values less than 100 represent performance lower than the benchmark • 95% confidence intervals are then applied to determine statistical difference to the same England case-mix. • The risk is calculated from the national dataset and casemix adjusted for sex, age, deprivation, diagnosis group/procedure group, method of admission into hospital, co-morbidity index and for certain conditions (respiratory) the seasonal variation
    32. 32. www.enhancedrecoveryblog.com Length of stay – Relative Risk Average LOS last quarter = 12.3 Graph shows quarterly trend from 2002/03-Q1 to 2013/14-Q3
    33. 33. www.enhancedrecoveryblog.com Total bed days Graph shows 5-yr annual trend
    34. 34. www.enhancedrecoveryblog.com Length of stay – Relative Risk Average LOS last 12 months = 12.3 days Graph shows annual trend from 2002/03-Q1 to 2013/14-Q3
    35. 35. www.enhancedrecoveryblog.com Mortality – Relative Risk Mortality rate last 12 months = 5.8% Graph shows annual trend from 2002/03-Q1 to 2013/14-Q3
    36. 36. www.enhancedrecoveryblog.com Re-admissions – Relative Risk 28 day re-admission rate last 12 months = 10.2% Graph shows annual trend from 2002/03-Q1 to 2013/14-Q3
    37. 37. www.enhancedrecoveryblog.com Discharge destination Graph shows annual trend from 2002/03-Q1 to 2013/14-Q3
    38. 38. www.enhancedrecoveryblog.com Summary Every system is perfectly designed to get the results it gets…

    ×