Canberra Hospital:
Stimulating Change and
Driving Quality Improvement
through Critical System Analysis
The NOF project
Pro...
Number of Hip Fractures in Australia
2006-07 16,518 cases
175/100,000
Cost $15,000 -$ 19,500
AIH&W. The problem of Osteopo...
Overview
•
•
•
•

Canberra Hospital
QI project
Data collection – clinical expertise essential
Sharing information leads to...
Quality Improvement story
•
•
•
•
•
•
•
•

Problem identified
Stakeholders
Baseline data to answer what is practice
Review...
# NOF Project
Aims of project
• Reduce mortality
• Reduce Acute LOS

Protocol designed to address
• IVI fluid management
•...
Data identifies need for small changes
• Cancellation of procedure due to clinical
status
• Multiple episodes of fasting f...
More strategies
• Criteria for Anaesthetic review of unwell
patient (2003)
• Introduction of Non Elective Orthopaedic
thea...
ED NOF Admission Form
Protocol: IVI Fluids to address ARF
DEFICIT (hrs)

EXTRACAPSULAR

INTRACAPSULAR

Fluid Restrict
patient

Normal fluid

Flu...
Fluid management change
IDC insertion to monitor output
Hourly urine measures
% IDC

% hourly urine measure

Hourly urine Stickers introduced
into ED NOF packages

120.00%

perce...
Management of low urine output
Pre operative
• 15% cases, Low urine measure triggered call for JMO review
• Fluids
30
• Co...
Protocol: Early consultation for
unstable and high risk patients
• High risk – 3 significant co-morbidities
• Early Anaest...
Increase in early identification of
unfit for theatre
Total cases
presented

Identifying Unfit cases Early in Admission
14...
Logistics of OT availability
• 2001 just one Emergency Theatre per day
• September 2003 Trial of Orthopaedic trauma
lists ...
The time it takes to complete
emergency cases
14:24

09:36

Non Elective
Ortho List

04:48
Ortho Emergency
cases

00:00

1...
Time to theatre
Percentage of cases to OT by 36 hours ( delayed diagnosis not included)

80
70
60

Hours

50
<=36 hrs

40
...
Number of Non Elective surgery cases per month
July 2003 to April 2006
Orthopaedic
Non orthopaedic cases
Linear (Orthopaed...
Monthly average hours per day of Non Elective
surgery performed at CH July 2003 to April 2006
Orthopaedic
Non Orthopaedic
...
Orthopaedic trauma load and time to surgery for NOF
cases between May 2004 to April 2006
200

Number of
Orthopaedic
Trauma...
Achievements and organization changes
•
•
•
•
•

Protocol adopted
Comprehensive data collection 2001 -2011
Database 1700+ ...
Regional changes
• Lead to the establishing rehabilitation services in the
private sector at Calvary John James and Nation...
Destination of patients presenting from 'home'
100%
Death
90%
Nursing Home

4
80%

13

6

4

2

63

70%

Rehab

60%

Other...
Project aims - Outcomes
• Reduced Acute length of stay
DRG 108A benchmark 16.64 days. CH 12.11 & 11.53
days
DRG 108B bench...
Plans for the future
• NOF SOP (standard operating procedure) on
Intranet for staff access
• Trauma and Orthopaedic resear...
Thanks for
listening
Acknowledgements
Prof Paul Smith
Assoc Prof Alex Fisher
Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Cri...
Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Cri...
Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Cri...
Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Cri...
Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Cri...
Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Cri...
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Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Critical System Analysis

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Sue Duggan, Orthopaedic Quality Improvement Officer, The Canberra Hospital delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting.

Find out more at http://www.healthcareconferences.com.au/hipfracture2013

Published in: Health & Medicine
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Sue Duggan - The Canberra Hospital - The Canberra Hospital: Stimulating Change And Driving Quality Improvement Through Critical System Analysis

  1. 1. Canberra Hospital: Stimulating Change and Driving Quality Improvement through Critical System Analysis The NOF project Professor Paul Smith Sue Duggan RN
  2. 2. Number of Hip Fractures in Australia 2006-07 16,518 cases 175/100,000 Cost $15,000 -$ 19,500 AIH&W. The problem of Osteoporotic fracture in Australia. Bulletin 76. March 2010.
  3. 3. Overview • • • • Canberra Hospital QI project Data collection – clinical expertise essential Sharing information leads to research by others • Identifying limits • Organization changes resulting from project
  4. 4. Quality Improvement story • • • • • • • • Problem identified Stakeholders Baseline data to answer what is practice Review data with stakeholder team Decide on change/s to achieve desired outcome Implement changes with education to inform staff Collect data to assess practice Review data with stakeholder team
  5. 5. # NOF Project Aims of project • Reduce mortality • Reduce Acute LOS Protocol designed to address • IVI fluid management • Early consultation for unstable and high risk cases • Reduce Delay to Surgery from arrival
  6. 6. Data identifies need for small changes • Cancellation of procedure due to clinical status • Multiple episodes of fasting for theatres due to repetitive cancellation of cases from emergency theatre list • Low urine hourly measures, cases requiring a medical review
  7. 7. More strategies • Criteria for Anaesthetic review of unwell patient (2003) • Introduction of Non Elective Orthopaedic theatre lists (2003) • Booking criteria for ONE emergency list • Implementation of a specific # NOF Emergency Department Medical Admission form • Hourly urine measure sticker
  8. 8. ED NOF Admission Form
  9. 9. Protocol: IVI Fluids to address ARF DEFICIT (hrs) EXTRACAPSULAR INTRACAPSULAR Fluid Restrict patient Normal fluid Fluid restrict patient Normal fluid 3 hr deficit 230 320 mls/hr 145 235 mls/hr 6 hr deficit 250 370 mls/hr 165 290 mls/hr 12 hr deficit 290 475 mls/hr 205 390 mls/hr 18 hr deficit 333 580 mls/hr 250 495 mls/hr 24 hr deficit 375 683 mls/hr 290 600 mls/hr
  10. 10. Fluid management change
  11. 11. IDC insertion to monitor output
  12. 12. Hourly urine measures % IDC % hourly urine measure Hourly urine Stickers introduced into ED NOF packages 120.00% percentage of cases 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08
  13. 13. Management of low urine output Pre operative • 15% cases, Low urine measure triggered call for JMO review • Fluids 30 • Continue 4 • Frusemide 10 (1 oral) • 29 cases had IVI Frusemide pre op for fluid management Post operative • 15% cases, Low urine output triggered calls for JMO review, First review treatment • Fluids 30 • Continue 4 • Frusemide 11 • 40 cases received IVI Frusemide post op
  14. 14. Protocol: Early consultation for unstable and high risk patients • High risk – 3 significant co-morbidities • Early Anaesthetic Consultation criteria A patient  fall is believed to have resulted from a cardiac or a cerebral event,  in congestive cardiac failure  has had a myocardial infarction in the last six months; .  with two or more significant intercurrent systemic illness i.e. ischaemic heart disease, hypertension, arrhythmias, diabetes, chronic airway limitation, stroke/TIAs, peripheral vascular disease, chronic renal failure,  A patient for whom you are seeking a Medical review.
  15. 15. Increase in early identification of unfit for theatre Total cases presented Identifying Unfit cases Early in Admission 140 Not Fit for OT in ED number of cases 120 Unfit for OT on Review 100 Total Unfit pre Surgery 80 60 40 20 0 pre protocol 01/09/02 -28/03/03 01/03/03 -31/08/03 01/09/03 -30/11/03
  16. 16. Logistics of OT availability • 2001 just one Emergency Theatre per day • September 2003 Trial of Orthopaedic trauma lists Monday to Friday one list per day. • Criteria developed for Registrars to book patients to ‘Ortho Non Elective lists • Review of Orthopaedic trauma load in total trauma load. • Needed but few NOF cases
  17. 17. The time it takes to complete emergency cases 14:24 09:36 Non Elective Ortho List 04:48 Ortho Emergency cases 00:00 19:12 14:24 09:36 04:48 00:00 Non Orthopaedic Emergency cases
  18. 18. Time to theatre Percentage of cases to OT by 36 hours ( delayed diagnosis not included) 80 70 60 Hours 50 <=36 hrs 40 >36 hrs 30 20 10 0 pre protocol 05/10 2003 05/10 2004 05/10 2005
  19. 19. Number of Non Elective surgery cases per month July 2003 to April 2006 Orthopaedic Non orthopaedic cases Linear (Orthopaedic) Linear (Non orthopaedic cases) 450 Number of cases 400 350 300 250 200 150 100 50 0
  20. 20. Monthly average hours per day of Non Elective surgery performed at CH July 2003 to April 2006 Orthopaedic Non Orthopaedic Linear (Orthopaedic ) Linear (Non Orthopaedic) average hours per day 25 20 15 10 5 0
  21. 21. Orthopaedic trauma load and time to surgery for NOF cases between May 2004 to April 2006 200 Number of Orthopaedic Trauma cases 180 Number of cases 160 140 # NOF average Time to OT 120 100 80 Linear (Number of Orthopaedic Trauma cases) 40 Linear (# NOF average Time to OT ) 20 Apr-06 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Oct-05 Sep-05 Aug-05 Jul-05 Jun-05 May-05 Apr-05 Mar-05 Feb-05 Jan-05 Dec-04 Nov-04 Oct-04 Sep-04 Aug-04 Jul-04 Jun-04 0 May-04 Hours 60
  22. 22. Achievements and organization changes • • • • • Protocol adopted Comprehensive data collection 2001 -2011 Database 1700+ cases ACT Health Quality First Award Dedicated Orthopaedic trauma theatre lists 7 days/week • Increase in Ortho-geriatric involvement in the finetuning fluid management in the frail aged • Improvement in early discussions on end of life choices for NFR, respecting patient choices.
  23. 23. Regional changes • Lead to the establishing rehabilitation services in the private sector at Calvary John James and National Capital private hospital • Information utilized during the establishment of rehabilitation service on Calvary public site • Sharing of protocol with regional referral hospitals resulting in patients arriving ‘worked – up’ IVI fluids in progress, IDC insitu, baseline bloods taken
  24. 24. Destination of patients presenting from 'home' 100% Death 90% Nursing Home 4 80% 13 6 4 2 63 70% Rehab 60% Other 50% Home 40% other hospital 30% 20% 10% 0% pre protocal 11/014/02 09/02-02/03 03/03-11/03 04/04-11/04 05/05-10/05 06/07-06-08
  25. 25. Project aims - Outcomes • Reduced Acute length of stay DRG 108A benchmark 16.64 days. CH 12.11 & 11.53 days DRG 108B benchmark 8.27 days. CH 7.52 & 7.40 days • Reduced mortality 9.8 % (8.1 %) to 6.64% , 5.15% in surgical population • Time to surgery remains an ongoing issue with fit fasting patients cancelled each month. 80.3% to surgery under 48 hours 2010/11
  26. 26. Plans for the future • NOF SOP (standard operating procedure) on Intranet for staff access • Trauma and Orthopaedic research unit developing a fracture online entry database • Clinical Governance is establishing a working group to look at ‘fasting for surgery’ • Geriatric Medicine are proposing to develop criteria for diagnosis and documentation of Delirium
  27. 27. Thanks for listening Acknowledgements Prof Paul Smith Assoc Prof Alex Fisher

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