Hip Fracture Management And Patient Safety: A Clinical Excellence Report


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Bronwyn Shumack, Manager of Patient Safety, Clinical Excellence Commission delivered this presentation at the 2012 Hip Fracture Management conference in Australia. The only regional event to discuss practical innovations and improvement processes for the management of hip fractures in the hospital setting. For more information on the annual conference, please visit the website: http://bit.ly/14lcuVY

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Hip Fracture Management And Patient Safety: A Clinical Excellence Report

  1. 1. Fractured Hip Surgery in the Elderly Bronwyn Shumack Manager Patient Safety December 2012
  2. 2. The Clinical Excellence Commission and its role in Patient Safety in NSW • 2001 – Institute for Clinical Excellence established by a small committed group with focus on ‘better systems, better training, better research’ • 2004 (NSW) – Camden/Campbelltown CEC ‘should be responsible for investigating and making recommendations with respect to systems issues that have the potential to have an area or Statewide significance’ • 2011 – CEC ‘...will take responsibility for quality and safety and providing leadership in clinical governance with LHDs’
  3. 3. INCIDENTS UNREPORTED ERRORS Loukopoulos/Dismukes, 2002, NASA ACCIDENTS Our drivers 1,500,000 patient admissions for around 6,000,000 bed days each year. A further 2,000,000 non-admitted ED presentations and many more people treated in the community. In most cases, care goes well. Around 140,000 clinical incidents reported annually (representing 8.0 percent of all admissions). 600 of these rated as serious. 400 were associated with patient deaths. The Patient Safety Team oversees and analyses the clinical incidents reported in “IIMS” and to the Ministry
  4. 4. So what do we do with all this “bad news”? • Aggregated analysis in collaboration with clinicians • Use IIMS, RCA and clinician input to determine how and where to drive change • Provide system and public feedback • Provide education in patient safety, RCA/incident investigation and basic “human factors” We rely heavily on cake, jelly snakes, coffee and black humour
  5. 5. • “In health care we are learning slowly and painfully that safety is a tough intractable problem that will take much more than reporting to resolve” Charles Vincent 2008
  6. 6. Serious incident reported RCA conducted Report reviewed & endorsed by CE NSW Ministry of Health (MoH) Relevant health service managers allocated responsibility for implementing recommendations. Implementation overseen by senior managers and Director Clinical GovernanceOther MoH directorates/state bodies for action as appropriate CECRCA review committees CEC undertakes aggregated analysis of issues identified in RCA and IIMS reports; develops and distributes reports to Minister, public, LHDs – including Clinical Focus Reports and Patient Safety Reports Ongoing monitoring and improvement cycles Open disclosure & support processes commence Report provided to patient, family & relevant staff
  7. 7. In 2011 that included …. http://www.cec.health.nsw.gov.au/__documents/programs/patient- safety/patient-safety-report-hip-fractures-1.pdf Developed in conjunction with SCIDUA, CHASM and in consultation with ACI
  8. 8. A long time ago in this fair city...
  9. 9. a request was made … From Wikipedia, the free encyclopedia Securiger 23 Feb 2005
  10. 10. http://www.innomed.net/hip_tools_other.htm A lot has changed since 1972
  11. 11. Improved technology, but still a major intervention for the patient • The length of stay in acute wards for patients admitted to hospital with a hip fracture has fallen by an average of one day—to just over 20 days—over the past year, concludes the latest report from the national hip fracture database for England, Wales, Northern Ireland, and the Channel Islands. BMJ 2012;345:e5940 • Compared with expected stay of 8 days for elective THR http://healthtopics.hcf.com.au/TotalHipReplacement.aspx This is a highly complex patient group. There is strong evidence that early, comprehensive treatment greatly increases the likelihood of a good outcome
  12. 12. Case 1 • Patient brought to ED with #hip, reviewed by ED & orthopaedic registrars • Anaemic, left-sided consolidation and effusion on CXR, no evidence that this was followed up. • Senior clinician on call was contacted and patient transferred to a ward to await surgery the next day. • ED registrar documented that a review by the medical registrar was required. Again – not followed up - did not occur. • Next day patient had decreased UO - reviewed by intern, managed with oral fluids. • Surgery postponed due to OT load
  13. 13. Case 1 (cont’d) • Later review by orthopaedic registrar - no evidence that poor renal function was recognised by team or communicated to the orthopaedic surgeon. • Pre-anaesthetic review occurred the same evening. • Documentation did not reflect patient assessment or any discussion with the anaesthetist about anaesthetic risks. • The next day a different anaesthetic registrar was allocated to administer the patient’s anaesthetic. This registrar did not review the patient on the morning of surgery as the patient had been assessed the night before.
  14. 14. Case 1 (cont’d) • The patient underwent surgical fixation of the fractured hip under spinal anaesthesia and sedation. • Uneventful but hypotension both intra-operatively and in recovery, managed by a senior anaesthetist. • Once stable, the patient was transferred to an orthopaedic ward. A few hours later it was noted that the patient had no urinary output despite IV fluids. Fluid boluses were given. • Continued hypotension, transiently unresponsive and reviewed by the anaesthetist and intern. ?cardiac event. • No evidence of escalation to a senior clinician. The patient died.
  15. 15. Case 2 An elderly patient requiring surgery for a fractured femur (category 4 requiring surgery within 24 hour) had the surgery postponed twice. On the first occasion other emergencies took precedence and on the second, the elective lists took precedence as no surgeon was available. When the patient was finally booked for surgery, it was cancelled by the anaesthetist as the patient was assessed as no longer fit. A cardiology review was required prior to the surgery proceeding.
  16. 16. A recent RCA Described a very similar story • A patient arrived in ED after falling a breaking her hip at the hostel where she lived • Her comorbidities included AMI, for which she was taking Clopidogrel, COPD and chronic renal failure. • Accepted by ortho team and listed for surgery • Anaesthetist reviewed her and said “leave for a week”.
  17. 17. A recent RCA (cont) • During the week - several calls for review due to low BP, O2, ↑RR, HR, but only seen by ortho team. Later given transfusion (Hb 85) • ORIF under spinal completed 9 days after admission. She died six days after surgery • The RCA team found: the patient had comorbidities which may have been managed earlier if the specialist medical team were consulted at the time of admission and the expectations for treatment and follow-on care made clear to the consulting team.
  18. 18. Back to the report: the scope of the review Report Type Date range Number identified in initial search Number used in analysis IIMS incident reports - SAC1 (RCA reports) - SAC2 - SAC3 - SAC4 January 2010 – December 2010 April 2003 - December 2010 January 2010 - January 2011 April 2010 - January 2011 26 337 1,000 1,000 26 79 CHASM summary reports 2007 - 2010 23 15 SCIDUA summary reports 2005 - 2011 43 20 2,429 140
  19. 19. Age of patients in SAC 2-4 incidents
  20. 20. Clinical management sub-classification for the RCAs reviewed (n=26) indicates a fall during inpatient stay 73% of cases reviewed
  21. 21. Clinical risks identified in the RCAs
  22. 22. “System” factors which may have contributed to the incidents Very human factors
  23. 23. System factors (cont) Inadequate care planning and coordination were the most common system issue identified. • Care plans were: • not developed at all • not documented and/or communicated appropriately • inadequate for the patient’s complex needs
  24. 24. System factors (cont) • Care coordination was: • poor or fragmented between specialties, teams and/or clinicians; • unclear in regard to which clinician had primary responsibility for overseeing the patient’s care; or • there was no evidence of effective teamwork, including lack of involvement of a senior clinician/consultant.
  25. 25. Issues identified during the review • Hip fracture surgery is often undertaken after hours and on emergency lists, reducing the availability of necessary support services. • Optimisation of patients prior to hip surgery is a less than a robust process in some facilities. Co- management (joint responsibility) of high risk patients is not evident. • Time to surgery (including access) is not standardised or monitored. The patient’s state of readiness for surgery is not the deciding factor on when surgery occurs.
  26. 26. Issues identified (cont) • Senior clinician input to post-operative care is less than optimal. Patients deemed ASA 4 or 5 are not always seen by a senior clinician prior to anaesthesia. • The appropriateness of high risk elderly patients undergoing major hip surgery in facilities which have no ICU/HDU must be considered. • Although guidelines promoting an orthogeriatric model of care are available they appear not to be widely known and/or applied.
  27. 27. Recommendation 1.8.1 in the NICE clinical guideline on hip fracture States that people with hip fracture are offered from admission access to a formal, acute orthogeriatric or orthopaedic ward-based Hip Fracture Programme (HFP) that includes all of the following: • orthogeriatric assessment • rapid optimisation of fitness for surgery • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing
  28. 28. NICE clinical guideline (cont) • continued, coordinated, orthogeriatric and multidisciplinary review • liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community
  29. 29. Best Practices for Elderly Hip Fracture Patients (a Canadian review) Consistent evidence of benefit for use of: • spinal anesthesia pressure-relieving mattresses • perioperative antibiotics deep vein thromboses prophylaxes Routine preoperative traction was not associated with any benefits and should be abandoned Types of surgical management, postoperative wound drainage, and even ‘‘multidisciplinary’’ care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition ). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices. Beaupre LA, Jones A et al How important are these elements if patient is unfit for surgery?
  30. 30. UK National Confidential Enquiry Report into Patient Outcomes and Death (2009) Caring to the End? • “half the patients dying within four days of admission in the UK lacked input from senior doctors”. Expert reviewers assessed patient records found that consultants were not involved in making a diagnosis in just over half (53 per cent) of cases. • There was evidence of poor decision-making and lack of senior input, particularly in the evenings and at night. • Other findings indicated a clinically important delay in the first review by a consultant in 25 per cent of cases, poor communication between/within teams in 13.5 per cent of cases and nearly 22 per cent of ‘Do Not Attempt Resuscitation’ (DNAR) orders were signed by very junior staff.
  31. 31. Length of stay and outcome • UK review of costing http://www.nice.org.uk/nicemedia/live/13489/54928/54928.pdf • Estimated that if all strategies introduced LOS would be reduced by two days – saving millions of pounds • NHFD report 2011 http://www.hqip.org.uk/assets/National-Team-Uploads/NHFD-National- Report-2011Final.pdf ..and significant ongoing benefit for the patient – less likely to be “de-conditioned”, confused or suffering complications/exacerbation of comorbidities
  32. 32. Benefits of the UK model Since the audit began more patients are being admitted promptly to orthopaedic wards; delays for operation have been reduced, with the great majority of patients now having surgery within 48 hours. Fewer patients develop pressure ulcers; and more have specialist pre-operative assessment by a care of elderly physician. Prevention of future fractures is being addressed too: 71 per cent of patients will receive both falls and bone health assessments before leaving hospital. The CEC report found far too many patients who did not get to theatre for several days
  33. 33. Recommendations based on evidence and discussions with ACI • All elderly patients with hip fracture must be admitted under a co-admission process with joint responsibility (orthogeriatrician, geriatrician or general physician and surgeon)... • ...access to surgery within 48 hours of admission and high dependency care in the immediate post operative phase if the patient is deemed ASA 4 or 5. • ACI Orthogeriatric Model of Care Clinical Practice Guide 2010...be implemented across NSW.
  34. 34. Recommendations (cont) • Implementation will require the establishment of support structures at state and local health districts level including changes to patient flow and admission processes, access to operating suite, management of elective surgery waiting lists. • In consultation with orthopaedic services state wide key performance indicators be developed related to the care processes of elderly patients, who sustain hip fractures. This should include the establishment of state wide benchmarks for the management of hip fractures in both the metropolitan and rural sector.
  35. 35. Recommendations (cont) • A state wide process for the monitoring of these agreed key performance indicators be established. This should include monitoring of patient outcomes, variation in care and actions taken when none compliance/variation occurs. • A full economic evaluation be conducted to identify the financial impact of the above recommendations.
  36. 36. In summary CEC would like to see: • Orthogeriatric models, such as the ACI model in NSW implemented • Supported by good quality data collection and feedback • Improved outcomes for elderly patients undergoing hip surgery – as in UK report
  37. 37. QUESTIONS??? bronwyn.shumack@cec.health.nsw.gov.au