Delivering Standardised And Quality Care For Fractured Neck Of Femur Patients: Austin Health Project Re-Plan Case Study

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Fiona Nielsen, Quality Coordinator Surgical CSU, Austin Health 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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Delivering Standardised And Quality Care For Fractured Neck Of Femur Patients: Austin Health Project Re-Plan Case Study

  1. 1. Care of the Patient with a Fractured Neck of Femur Injury Fiona Nielsen – Quality Coordinator Surgical CSU
  2. 2. Our health service 75,000 in-patients 900 beds 70,000 emergency attendances 12,500 surgical operations 6,200 staff #NOF Presentations 2010-2011- 262 2011-2012- 246 165,000 out-patients
  3. 3. Objectives- A Walk Through • Diagnostics – Metrics • Improvements • Lessons Learnt – What worked and what didn’t • Project Outcomes
  4. 4. Information we were given • Health Round Table Information • DRG 108- Neck of Femur Fracture • Austin Health had an average LOS >14 days • The four exemplar hospitals average LOS around 8 days • Aim – Reduce Length of Stay to that of exemplar hospitals
  5. 5. Background Visit to another facility and a literature search revealed we needed: 1.Full time Head Of Unit – implemented Sept 2009 2.More theatre sessions and better access for trauma – implemented over 2009 3.Institute ortho-geriatric service – commenced February 2010
  6. 6. OGS Orthogeriatric Service –New full-time Orthogeriatric registrar –Over seen by a senior geriatrician • Involved in every patient >65yo with low-impact trauma # • Ortho in Rehab hospital • Geriatric in Acute hospital
  7. 7. Diagnostics • Walk Thorough – Follow the patient journey from the front door to discharge. – Chance for two way communication and to understand work flows » What works » What doesn’t • File audit- 30 patient files • Interview with patients and their families
  8. 8. Walk Through-Fact finding
  9. 9. Where the patient goes
  10. 10. Steering Committee • Attendance List List • Executive- CEO, CMO, Executive Directors • CSU/ Medical Directors • Senior Clinical Staff- ED, Anaesthetists , Orthopedics Geriatricians • Austin By Design • Physiotherapy • Access, Care & Patient Flow coordinators • NUM • Ward nurses • Theatre staff…and more
  11. 11. Ambulance/ED Ambulance/ED Acute Ward - Pre- operative Acute Ward - Post- operative Sub Acute Care Discharge Measures Does Amb. inform ED that a pat. with a hip # is arriving? Is a dementia/delirium assessment undertaken? Is a Hip # clinical pathway used? Is there a dedicated orthopaedic trauma list 7/24 Is the pain score recorded? Do the pain management team visit the patient? Are there daily MDT meetings? Is discharge event driven? Are the no. of Hip #s pa known? No No No No Yes Not Routinely No No Yes Emergency Department Radiology Are there diff. in the std. b/w ortho and non ortho ward? When is the patient placed on the Op. Th. List? Is there a protocol in place if Pat. Surg. cancelled? Are there daily MDT team meetings? Does the patient have a DD? Is there a home assessment in advance of DD? Is the time from ED triage to surgery reviewed? When the pat. arr. in ED who is involved in the triage? How is the request for imaging services received? Yes On orthopaedic assessment No Yes Yes No Nurse Electronically Are variations from clinical pathways analysed? Is the time patient is booked for surgery recorded? If the op. is delayed >24 hrs is the reason recorded? Is mobilisation time post surgery recorded? Is there A/H services available at the W/E? When are prescriptions sent to pharmacy? Is the mobilisation time known? Is there a Hip # Clin. Pathway and is it used? How is pat. trans. to/from X- ray and is it timely? No Yes No Yes No Yes No Within 60 mins of request Is the patient kept in a same sex bay? Are std. anaesthesia prot. for Hip # used? If the op. is delayed >48 hrs is the reason recorded? Does the patient have a D/D Is discharge event driven? Is bone resorptive therapy part of the prescription? Is the LOS of stay for acute/sub-acute reviewed? ? In ED are std. procedures followed 24/7? Is there a std. protocol for imaging Hip # pat.? When possible No No No No Yes No No No Is the D/D agreed when the decision to operate is made? Are std. Prostheses used? Have risk assessment been completed? Does the patient have a nutritional assessment? Is the pat. referred to a Fracture Liaison Service? Is the number of times surgery cancelled recorded? ? Is there a std. pain management protocol? Who reports on the images? No Yes Yes Yes No No No Senior ED Dr Does the geriatrician pre-op assess 7/24? Who provides anaesthesia? Have referrals to SW, OT been made? Is there a waiting list for patients into sub-acute beds? Is there an aftercare contact number provided? What % patients are transferred home? Is there a falls risk assessment done? When are the images reported on? No Other consultant/regist Yes- social work and OT Yes For the ward Not known No Within 60 mins Are allied health available at the W/E? Who performs the surgical procedure? Do W/E transfers occur? Are pressure ulcers recorded ? Is there community involvement through local council? Are patients/carers surveyed? ? When is the Ortho. Dept. Contacted ? No Registrar Sometimes Yes No After Xray confirms # Is there food available if surgery is cancelled? Are Op. Th. Team briefings held? Is discharge event driven? % of patients who are discharged on or before their EDD A3 ? When is the Orthogeriatric registrar contacted? No No No Maybe delayed Are there std. handover protocols? Is there a record of when A/Bs administered? How often does the OG do ward rounds? Is the in-hospital mortality after hip # known? Is the Emerg Surgery Nurse Coord informed? No Yes Mon-Fri Yes A3 No - position Are daily MDT meetings held? Are there agreed post operative guidelines? Are there constraints in transferring pts to sub-acute care? Is the 30 day mortality known? Is the patient transferred to a known Ortho. Ward? Yes Yes Yes No Yes Who declares the patient is fit for surgery ? Are there written protocols for Post Op N/V? Does the patient receive nutritional supplements? No No Ambulance/ED Radiology Acute Ward - Pre- operative Acute Ward - Post- operative Sub Acute Care Discharge Measures Our Hip Fracture Pathway - Austin Health Operating Theatre Operating Theatre
  12. 12. Where we focused • Three main areas – ED – Pre operatively – Post operatively • Three main care elements – Fasting – Pain management – Delirium
  13. 13. The Case for Change • Why not be exemplar? • The care delivered to this patient group should be best practice. • Senior Clinical Staff became the leaders for this vision • Confronting to clinicians • Challenges to beliefs Finding the problems is simple, understanding and developing solutions is complex and solutions can be simple
  14. 14. 0% 10% 20% 30% 40% 50% 60% 70% 65-79 80+ 65-79 80+ 65-79 80+ 65-79 80+ 65-79 80+ %ofTotalpresentations % of Presentations by Age Red = Austin Health Myth busting
  15. 15. ED Before • No Standard Pain-relief • Mostly narcotic-based • Minimal use of blocks (<10%) • No review of analgesia efficacy • Multiple trips to Radiology • Gap from ED until drug chart written up (on ward)
  16. 16. Emergency / Radiology Sets
  17. 17. Standarised Analgesia • Regular Paracetamol • Incremental boluses of Fentanyl to effect (or Morphine) • Regular pain scores on function • Fascia Iliaca Blocks – Blind and in >80% of presentations 0 10 20 30 40 50 60 70 80 90 100 Mar-May 2010 Jan-11 Feb-11 Mar-85 Apr-85 May-11 Oct-12 %ofPatientshavingFIbolocksinED FI Blocks In ED
  18. 18. On the ward • Admitted to the ward at various times of the day. • Orthopaedic staff in theatre. • Variable pain relief • Fasted for varying lengths of time • Time to theatre varied • Information for patients and families
  19. 19. Fasting • Big source of patient and family dissatisfaction • Highly variable times – Not documented – Not monitored – Frequent cancellations • Patients often deconditioned on admission
  20. 20. Hunger clock Set to monitor fasting By the patients bedside Counts down the agreed 12 hours Initially reduced fast to 9 hours Recent measurement September 2012- back to 13 hours
  21. 21. Pain • No Standard Pain-relief • Delay until patient admitted and drug chart written • Mostly narcotic-based • Usually inadequate doses / Intermittent or infrequent doses • No review of analgesia efficacy • Usually ceased if patient became confused
  22. 22. Pain Plan • Designed by Orthogeriatrician/ Orthopaedic Surgeon/ Acute Pain Services • Nursing Pain Champions – Nursing Staff Familiar with PCAs – System for PCAs and functional pain scores/ Campbells – CEASE protocols • Months in designing the algorithm • Plan to roll it out and re-measured a week • Failed in the first two days
  23. 23. WHY? Answer- Residents and Interns- didn’t know how to write up PCAS And they needed permission- for narcotics in the elderly
  24. 24. Model from the IHI
  25. 25. March 2011-March 2012 0 2 4 6 8 10 12 14 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Days Average Length of Stay (HRT Data) Exemplars A H Project starts Pain Plan Starts
  26. 26. Standardised Care • Patient receives the same care no matter what time they are admitted. • Patients receive analgesia via a pain plan designed by senior clinicians • Nursing staff make this a priority Management of Clinical Knowledge
  27. 27. Delirium Baseline measurement -Sept 12 – 90% of patients had CAM score done on admission. -Clocks in rooms -Family aware of risks -Day time/night time -Plan to spread to other wards -All new nursing staff trained in assessment
  28. 28. Nursing Management
  29. 29. The Patient Experience Happy Supported Safe Good Comfortable In Pain Worried Lonely Sad
  30. 30. PatientsArriving/ED Information Waiting Going to theatre Post Op Phase Ward 8N Ward 11 Leaving 3 3 1 1 3 2 3 3 1 1 3 2 3 3 2 3 3 3 2 1 1 1 1 1 1 1 1 1 1 1 3 3 3 2 2 1 1 1 1 3 3 3 3 1 1 1 1 2 2 1 1 1 1 2 2 1 1 1 1 3 1 1 1 1 1 1 3 3 3 1 1 3 3 3 3 3 3 3 1 2 3 4 5 6 7 8 9 10 11 12
  31. 31. Patients Arriving/ED Information Waiting Going to theatre Post Op Phase Ward 8N 1 3 3 1 1 3 2 3 3 1 1 3 2 2 3 3 1 2 3 3 3 2 2 3 1 1 1 1 4 1 1 1 1 1 1 3 3 3 2 5 1 1 1 3 3 3 3 1 1 1 6 2 2 1 1 1 1 2 2 1 1 1 1 7 3 1 1 1 1 1 3 3 3 1 1 3 3 3 8 3 9
  32. 32. Patient Stories • Very powerful • Can cause distress to staff • Use quotes: “ I was in that much pain I was going no where” “They starved her and staved her” • Manage up – encourage staff to talk about improvments
  33. 33. Executive Leadership Executive Interview with patients Visibility of projects importance Accountability for Care People remember what they have seen Becomes personal
  34. 34. Sustainability questionnaire Process 1.Benefits beyond helping patients 2.Credibiltiy ( to affected staff) of benefits from improved processes 3.Adaptability of improved process Staff 1.Staff involved and training to sustain process 2.Staff attitudes toward sustaining the improved process 3. Senior leaders responsibility taking and staff action toward the leader 4. Clinical leaders responsibility taking and staff action toward the leader Organisation 1. Effectiveness of the system to monitor progress of the improvement 2. Fit with the organisation strategic aims and culture 3. Staff attitudes toward sustaining the improved process
  35. 35. Sustainability Summary 1.0 3.0 5.0 7.0 9.0 11.0 13.0 15.0 Benefits beyond helping patients Credibility of the evidence Adaptability of improved process Staff involvement and training to sustain the process Staff behaviours toward sustaining the change Senior leadership engagement Clinical leadership engagement Effectiveness of the system to monitor progress Fit with the organisation's strategic aims and culture Infrastructure for sustainability Potential May February October July
  36. 36. Measures
  37. 37. Measures- to September 2012 Pain Plan Started Fasting Times Controlled
  38. 38. Theatre times
  39. 39. Ambulance/ED Ambulance/ED Acute Ward - Pre- operative Acute Ward - Post- operative Sub Acute Care Discharge Measures Does Amb. inform ED that a pat. with a hip # is arriving? Is a dementia/delirium assessment undertaken? Is a Hip # clinical pathway used? Is there a dedicated orthopaedic trauma list 7/24 Is the pain score recorded? Do the pain management team visit the patient? Are there daily MDT meetings? Is discharge event driven? Are the no. of Hip #s pa known? No Yes- CAM Yes Dedicated trauma list Yes Yes No Yes Emergency Department Radiology Are there diff. in the std. b/w ortho and non ortho ward? When is the patient placed on the Op. Th. List? Is there a protocol in place if Pat. Surg. cancelled? Are there daily MDT team meetings? Does the patient have a DD? Is there a home assessment in advance of DD? Is the time from ED triage to surgery reviewed? When the pat. arr. in ED who is involved in the triage? How is the request for imaging services received? Yes On orthopaedic assessment Yes Yes Yes Yes Nurse Electronically Are variations from clinical pathways analysed? Is the time patient is booked for surgery recorded? If the op. is delayed >24 hrs is the reason recorded? Is mobilisation time post surgery recorded? Is there A/H services available at the W/E? When are prescriptions sent to pharmacy? Is the mobilisation time known? Is there a Hip # Clin. Pathway and is it used? How is pat. trans. to/from X- ray and is it timely? Yes Yes Yes Trialled Yes Yes Within 60 mins of request Is the patient kept in a same sex bay? Are std. anaesthesia prot. for Hip # used? If the op. is delayed >48 hrs is the reason recorded? Does the patient have a D/D Is discharge event driven? Is bone resorptive therapy part of the prescription? Is the LOS of stay for acute/sub-acute reviewed? ? In ED are std. procedures followed 24/7? Is there a std. protocol for imaging Hip # pat.? When possible No Yes Not always No Yes Yes Yes Yes Is the D/D agreed when the decision to operate is made? Are std. Prostheses used? Have risk assessment been completed? Does the patient have a nutritional assessment? Is the pat. referred to a Fracture Liaison Service? Is the number of times surgery cancelled recorded? ? Is there a std. pain management protocol? Who reports on the images? No Yes Yes Yes No Yes Yes Senior ED Dr Does the geriatrician pre-op assess 7/24? Who provides anaesthesia? Have referrals to SW, OT been made? Is there a waiting list for patients into sub-acute beds? Is there an aftercare contact number provided? What % patients are transferred home? Is there a falls risk assessment done? When are the images reported on? No Other consultant/regist Yes- social work and OT Yes For the ward Known No Within 60 mins Are allied health available at the W/E? Who performs the surgical procedure? Do W/E transfers occur? Are pressure ulcers recorded ? Is there community involvement through local council? Are patients/carers surveyed? ? When is the Ortho. Dept. Contacted ? Registrar Sometimes Yes Interviews After Xray confirms # Is there food available if surgery is cancelled? Are Op. Th. Team briefings held? Is discharge event driven? % of patients who are discharged on or before their EDD A3 ? When is the Orthogeriatric registrar contacted? Yes No No Maybe delayed Are there std. handover protocols? Is there a record of when A/Bs administered? How often does the OG do ward rounds? Is the in-hospital mortality after hip # known? Is the Emerg Surgery Nurse Coord informed? Yes Mon-Fri Yes A3 No - position Are daily MDT meetings held? Are there agreed post operative guidelines? Are there constraints in transferring pts to sub-acute care? Is the 30 day mortality known? Is the patient transferred to a known Ortho. Ward? Yes Yes Yes No Yes Who declares the patient is fit for surgery ? Are there written protocols for Post Op N/V? Does the patient receive nutritional supplements? No Ambulance/ED Radiology Acute Ward - Pre- operative Acute Ward - Post- operative Sub Acute Care Discharge Measures Our Hip Fracture Pathway - Austin Health Operating Theatre Operating Theatre
  40. 40. Hospitals are Frogs – Not bicycles -Mant
  41. 41. Lessons learnt • Complex Systems • Understand systems and work • Go beyond the simple- – Problems are complex – Solutions can be simple • Align to common goals • Don’t listen to No
  42. 42. Leading Change Humbly • Seek out and listen to the wisdom of stakeholders. • Communicate Communicate Communicate • Ask people to agree - to a trial. • Seek to understand rather than judge – Value the dissenter • Respect the workplace

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