International Forum for Quality and Safety in Healthcare

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Enhanced Recovery after Surgery
Orthopaedic Example

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  • Kehlet’s definition
  • DOH definition
  • Team effort – anymore we haven’t added?
  • Link from all surgical spec to orthopaedics Why is ortho so important Not just because you are an ortho surgeon! There are compelling arguments from a society and health system perspective
  • On the first point – use the example of “what care would you want for your mum/grandmother? Every patient is somebody’s close relative” Self explanatory – talk round this Add in any extra I haven’t thought off
  • Volume of ortho procedures – means improvements in this area have big benefits to our health systems We have a responsibility to get it right for society
  • Putting the volume into perspective but looking at it’s effect on resource. Not just high vol, but historically long stay Operations taking up most elective inpatient time have long average lengths of stay or high volumes or both. The procedures listed below took up most inpatient time* in 2008-09 (provisional HES)
  • An example DGH Boston Matrix Graph shows elective tariff by spells. Ortho contribution key
  • This shows all trusts in the UK KNEE REPLACEMENT Tariff earned by bed day Those pts with ER and getting it right – earn 3 times as much as the poorest performing trusts per bed day for TKR pts Massive difference Basket: HRGs (v3.5) - ALL | Outcome group: Tariff First / Last: 2011/12-Q1 to 2011/12-Q1 | Admission type: Elective | Chapter: H Musculoskeletal System | HRG: H04 Primary Knee Replacement Superspells: 17,950 | Spells: 17,955 | Episodes: 18,542 Hopsitals with less than 30 cases removed.
  • So there is a clear need Patient need And ecomonic / resource need Seems a no brainer – is everybody doing it?
  • No – is the short answer. Many say they are, and every surgeon will say their pts stay in hosp for 2 days but this is the reality Recent data – for TKR as an example 6-7 day swing But is it related to case mix? Basket: HRGs (v3.5) - ALL | Outcome group: Length of stay First / Last: 2011/12-Q1 to 2011/12-Q1 | Admission type: Elective | Chapter: H Musculoskeletal System | HRG: H04 Primary Knee Replacement Superspells: 17,950 | Spells: 17,955 | Episodes: 18,542 Less than 30 procedures removed.
  • No Explain case-mix adjusted graph Still 6 day swing Basket: HRGs (v3.5) - ALL | Outcome group: Length of stay First / Last: 2011/12-Q1 to 2011/12-Q1 | Admission type: Elective | Chapter: H Musculoskeletal System | HRG: H04 Primary Knee Replacement Superspells: 17,950 | Spells: 17,955 | Episodes: 18,542 Less than 30 procedures removed
  • Superimpose the two graphs There are a couple trusts where the los is longer – but there is expected los is under the line. Point these out. But the majority of long los trusts – show increased case-mix adjusted figures. They haven’t got the pathway right Basket: HRGs (v3.5) - ALL | Outcome group: Tariff First / Last: 2011/12-Q1 to 2011/12-Q1 | Admission type: Elective | Chapter: H Musculoskeletal System | HRG: H04 Primary Knee Replacement Superspells: 17,950 | Spells: 17,955 | Episodes: 18,542 Hopsitals with less than 30 cases removed.
  • How else do we know this Explain dr foster – give background to report
  • Surveyed every ortho dept in the country Picked out 7 elements of ER Talk through table. Not statistically proven but a clear trend which makes sense
  • 1. Safe: Do No Harm. Compliance with National Patient Safety Goals. Safety for all patients, in all processes, all the time 2. Effective: Produces the desired results. Evidence-based. Emphasis on preventing disease, early detection 3. Patient- Centered: Seamless between levels of care. Care provided with respect &compassion 4. Timely: Without undue delay 5. Efficient: Done without waste (resources, time, people), resourced appropriately, done competently. 6. Equitable: Equity at the population level (across subgroups, locations) and at the individual level
  • 7500 - 8000 procedures per year 10 procedures = 65% of the workload Hip and knee replacement Approx 25% of the workload 7.8 day average length of stay Many pathways
  • While I was away on holiday earlier in the summer I read Richard Moore’s book ‘Heroes, Villains, & Velodromes’ which tells the story of Chris Hoy who went on to win three gold medals in Beijing. While Chris’s achievements are not surprisingly the focus of the book, there’s some intriguing insight into the infrastructure that sits behind Chris, namely British Cycling. Britain failed to win an Olympic cycling medal during the whole on the 1980’s. At Atlanta where Britain only won one gold medal in all events (rowing), cycling contributed two medals. Thereafter, guided initially by Peter Keen and later Dave Brailsford, a steady transformation was initiated that culminated in the team winning seven out of the ten available track cycling gold medals on offer in Beijing, and with only one of the track team – Mark Cavendish who had to console himself with his four Tour De France stage wins earlier in the summer – not winning a medal. While British Cycling has undoubtedly benefited from an influx of lottery funding, so too have many sports which haven’t gone on to create similar results. What stands out with British Cycling is the quality of infrastructure that has been built up and the complete professionalism of the team. There’s a nice quote in Moore’s book from Dave Brailsford that summarises the whole ethos, attributing success to ‘performance by the aggregation of marginal gains. It means taking the 1 per cent from everything you do; finding a 1 per cent margin for improvement in everything you do’.
  • But why aren’t these working long term? It is because we are trying to treat the symptoms and not the problem. This just moves the problem onto the next step in the pathway
  • 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.
  • Admissions example Skipped PDSA – No time for experimentation. We didn’t want preparation – we didn’t have time for it – we wanted momentum and big changes to results. Henry Ford – assembly lines – Today’s standardisation is the necessary foundation on which tomorrows improvement will be based More important to do something the same way than to do it the right way, you can then learn form the results 14 consultant surgeons 24 anaesthetists “ Herding cats” Maginot We went round them In fact – they follow naturally
  • The reason we are here Galvanises Wrong pathway better than no pathway Takes away silos Evidence base for orthopaedics isn’t controversial There is no magic bullet AVOID ALL THE CLICHES AND TIRED QI LINES Pause for effect We have done this – It is achievable Is not theory - it is reality
  • 1818 patients, operated on 303 separate days Over 50 anaesthetists, and over 30 surgeons
  • cemented q1 06/07 to q1 07/08 The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 785 760 760 6,042 7.8 8 0.1 1,415 4 TH LARGEST BY VOLUME – 760 SPELLS AV LOS 8 DAYS EXPECTED LOS 7.8 DAYS
  • cemented q1 06/07 to q1 07/08 The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 785 760 760 6,042 7.8 8 0.1 1,415 4 TH LARGEST BY VOLUME – 760 SPELLS AV LOS 8 DAYS EXPECTED LOS 7.8 DAYS
  • LOS KPI – talk round them Not dividing clinical and operational outcomes – they are one in the same - directly related to each other
  • Freedom and responsibility to work within a framework Manage the system and not the people Jim Collins Pilot quote
  • Basket: HRGs (v3.5) - ALL | Outcome: Length of Stay vs. England | LOS (Pre-op): 0 Days | Activity Mode: All | Tariff Year: Data year | Market Forces Factor: Appropriate to Tariff Year Chapter: H Musculoskeletal System | HRG: H04 Primary Knee Replacement | Subgroup: All | Department: All | Team: All First / Last: May-07 / Jan-09 | Admission Type: All | Sex: All | Deprivation: All | Age Range: All Spells: 1099 | Day Cases: 0 (-%) | Inpatients: 1099 | LoS: 4.3 (6.4) | LoS (superspell): 4.3 (6.8)
  • Basket : HRGs (v3.5) - ALL | Outcome : Waiting time (avg) | Activity Mode : All | Tariff Year : Data year | Market Forces Factor : Appropriate to Tariff Year Chapter : All | HRG : All | Subgroup : All | Department : Trauma & Orthopaedics | Team : All First / Last : Jan-05 / Sep-09 | Admission Type : Elective | Sex : All | Deprivation : All | Age Range : All Spells : 34728 | Day Cases : 18149 (52.3%) | Inpatients : 16579 | LoS : 4.8 (5.1) | LoS (superspell) : 5.3 (5.5)
  • How do we turn data into useful information If you have detail – why loose it? If you had only been looking at averages you would not have appreciated the change – VERY important Whilst average time stayed the same – variability decreased. This makes lists easier to plan and therefore more efficient.
  • Basket : HRGs (v3.5) - ALL | Outcome : Tariff per Bed Day (£) | Activity Mode : All | Tariff Year : Data year | Market Forces Factor : Appropriate to Tariff Year Chapter : All | HRG : All | Subgroup : All | Department : Trauma & Orthopaedics | Team : All First / Last : Jan-05 / Sep-09 | Admission Type : Elective | Sex : All | Deprivation : All | Age Range : All Spells : 34728 | Day Cases : 18149 (52.3%) | Inpatients : 16579 | LoS : 4.8 (5.1) | LoS (superspell) : 5.3 (5.5)
  • 1. Safe: Do No Harm. Compliance with National Patient Safety Goals. Safety for all patients, in all processes, all the time 2. Effective: Produces the desired results. Evidence-based. Emphasis on preventing disease, early detection 3. Patient- Centered: Seamless between levels of care. Care provided with respect &compassion 4. Timely: Without undue delay 5. Efficient: Done without waste (resources, time, people), resourced appropriately, done competently. 6. Equitable: Equity at the population level (across subgroups, locations) and at the individual level
  • International Forum for Quality and Safety in Healthcare

    1. 1. Enhanced Recovery after Surgery Improving quality in every dimension An orthopaedic exampleInternational Forum on Quality and Safety in Healthcare, Paris, 20 April 2012 Robert Middleton and Tom Wainwright @officialERblog enhancedrecoveryblog.com
    2. 2. 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” @officialERblog enhancedrecoveryblog.com
    3. 3. What is Enhanced Recovery?• UK Department of Health “A novel approach to elective surgery, ensuring that patients are in the optimal condition for treatment, have different care during their operation, and experience optimal post-operative rehabilitation” “Patients on enhanced recovery pathways recover more quickly following surgery, and so can leave hospital and get back to normal activities sooner” @officialERblog enhancedrecoveryblog.com
    4. 4. The aim is to minimise the stress response andenable a quick return function @officialERblog enhancedrecoveryblog.com
    5. 5. @officialERblogenhancedrecoveryblog.com
    6. 6. Enhanced Recovery is a team game• Patients • Pre-assessment• Nurse specialists • Nutrition / Dietician• Physiotherapy • Team assistant• Occupational therapy • Ward nursing staff• Social workers • Medical staff• Surgeons • Management• Anaesthesia • Primary Care• Pain management • Pharmacist @officialERblog enhancedrecoveryblog.com
    7. 7. Why is enhanced recovery inorthopaedics important? @officialERblog enhancedrecoveryblog.com
    8. 8. Why are improvements needed inorthopaedics?• The ongoing need and responsibility to improve quality and safety for our patients• Changing expectations of patients• Wider economic pressures• Variations in outcomes coming under scrutiny (LOS, Atlas of variation, PROMS)• Changes to methods of commissioning• Competition (private and state)• Changing demographics of population @officialERblog enhancedrecoveryblog.com
    9. 9. Why is orthopaedic enhanced recoveryimportant to our health systems? Volume of procedure comparison for the eight operations in the four specialty areas (Musculoskeletal, Colorectal, Gynaecology and Urology) that formed part of the UK DOH Enhanced Recovery Program. @officialERblog enhancedrecoveryblog.com
    10. 10. Why is orthopaedic enhanced recoveryimportant to our health systems? In the UK, TKR and THR account for 8% of all elective bed days @officialERblog enhancedrecoveryblog.com
    11. 11. Why is orthopaedic enhanced recoveryimportant to our hospitals? @officialERblog enhancedrecoveryblog.com
    12. 12. Why is orthopaedic enhanced recovery important to ourhospitals?Data - National TKR (HO4) Tariff per bed day 2011/12 (Min 30 procedures) @officialERblog enhancedrecoveryblog.com
    13. 13. If the need for Enhanced Recovery isestablished – is everyone doing it?• What does the data tell us?• What does a recent national survey tell us? @officialERblog enhancedrecoveryblog.com
    14. 14. National TKR (HO4) length of stay data 2011/12-Q3 (Min 30 procedures) @officialERblog enhancedrecoveryblog.com
    15. 15. National TKR (HO4) Difference from expected case-mix adjusted length of stay 2011/12 (Min 30 procedures) @officialERblog enhancedrecoveryblog.com
    16. 16. National TKR (HO4) Difference from expected case-mix adjusted length of stay and actual length of stay data 2011/12-Q1 (Min 30 procedures) @officialERblog enhancedrecoveryblog.com
    17. 17. Enhanced recovery and LOS – The results of anational survey @officialERblog enhancedrecoveryblog.com
    18. 18. Enhanced recovery and LOS – The results of a national survey1. Pre-op education for patients. 14 trusts did not offer pre-op education.2. Admission on day of surgery. Most trusts did admit some patients before the day of surgery for reasons of age and co- morbidities only.3. Standardised anaesthetic protocol (SAP): 54 trusts do not have an SAP.4. Multi-disciplinary recording of patient records: 37 trusts do not use multi- disciplinary recording.5. Orthopaedic physiotherapy service available seven days a week. 30 trusts don’t have a seven-day service, and seven trusts have cover seven days a week but not through specialist teams.6. Criteria-based discharge. 12 trusts said they do not have a criteria-based checklist.7. Phoning patients in the 48 hours following discharge: Only 47 trusts said they phone within 48 hours. @officialERblog enhancedrecoveryblog.com
    19. 19. We believe that Enhanced Recovery improvesquality in every dimension of qualityThe IOM Specific Aims for Quality in Healthcare (2001): States that healthcare should be:• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable @officialERblog enhancedrecoveryblog.com
    20. 20. Case study example @officialERblog enhancedrecoveryblog.com
    21. 21. Baseline – The context for change Waiting times Balancing demand with capacity Reduce costs Competition Most importantly – To improve patient experience and clinical outcomes @officialERblog enhancedrecoveryblog.com
    22. 22. Baseline – Pareto analysis to identify where to focus our improvement efforts12010080 Local context 12 procedures make up 80% of the60 orthopaedic work load (Pareto analysis)4020 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 @officialERblog 2007 Orthopaedic activity enhancedrecoveryblog.com
    23. 23. Baseline – Performance and activity Specific details Over 6000 procedures per year 12 procedures = approx 80% of the workload Hip and knee replacement Approx 25% of the workload 7.8 day average length of stay Many pathways – Variation at every clinical step of the pathway @officialERblog enhancedrecoveryblog.com
    24. 24. What did we do? We analysed the issues using quality improvement theory Assessed the variability Recognised what we could change and what we couldn’t Provided a framework which accounted for variability Kept it patient centred @officialERblog enhancedrecoveryblog.com
    25. 25. Our approach – The aggregation of marginalgains ‘you can achieve optimal performance by the aggregation of marginal gains. It means finding a 1 per cent margin for improvement in everything you do’ Dave Brailsford @officialERblog enhancedrecoveryblog.com
    26. 26. This is very importantTHR and TKR pathways are multi-step processesNo single magic step @officialERblog enhancedrecoveryblog.com
    27. 27. Prior to this - Why had our solutions beenfailing? Treating the symptoms of the problem The end result didn’t change because we didn’t change the whole system Every system is perfectly designed to get the results it gets (Deming) @officialERblog enhancedrecoveryblog.com
    28. 28. Deming system of profoundknowledge Understanding variation is the most important aspect when trying to understand a systemBut…..How do we go about this in healthcarewhen so many factors vary from patient topatient? @officialERblog enhancedrecoveryblog.com
    29. 29. Focused on what we could change Non-confrontational SDSA (standardise-do-study-act) Single pathway – Reduced variation Introduced daily and weekly outcome measures Ongoing audit/performance management @officialERblog enhancedrecoveryblog.com
    30. 30. We made everything patient-centred The reason we are here Galvanises professional groups Evidence base for orthopaedics isn’t controversial There is no single magic bullet @officialERblog enhancedrecoveryblog.com
    31. 31. We also focused on the clinical and process steps equally “Doing the right things right for every patient” Clinical Decisions Do right things (EBM) Process/System Do right changes things right Do things right (QI) Good Patient CareAdapted from Glasziou et al. BMJ Qual Saf 2011;20(Suppl 1): i13-i17 @officialERblog enhancedrecoveryblog.com
    32. 32. EBM – Getting the clinical steps rightWe reviewed the literature to inform us about every clinical step.Examples that have since been published as reviews include anaesthetictechnique and surgical approach. @officialERblog enhancedrecoveryblog.com
    33. 33. Getting the process and system right – e.g. removingartificial variation in therapy staffing @officialERblog enhancedrecoveryblog.com
    34. 34. Getting the process and system right – Staggered admissiontimes and a predictable theatre list allow for optimal fastinginstructions @officialERblog enhancedrecoveryblog.com
    35. 35. Successful implementation of enhanced recovery involves marginal gains to all managerial and clinical processes, across all departments, locations, and professionsManagerial Clinicalprocesses processes @officialERblog enhancedrecoveryblog.com
    36. 36. Results – Published and peer-reviewed @officialERblog enhancedrecoveryblog.com
    37. 37. Results - Length of stay @officialERblog enhancedrecoveryblog.com
    38. 38. Results – Benchmarking case mix adjusted length of stay 6 5 AVLOS greater than 4 expected for case mix. Hospital placed in lower 3 half of UK hospitals 2 1 0 -1 -2 -3 -4 @officialERblog enhancedrecoveryblog.com
    39. 39. Results – Benchmarking case mix adjusted length of stay 5 AVLOS 4 significantlyshorter than expected for 3case mix. Hospital placed top of all2UK hospitals 1 0 -1 -2 -3 @officialERblog enhancedrecoveryblog.com
    40. 40. Using CUSUM charts to show case-mix adjusted reductions to LOS changeWainwright TW, Middleton RG (2010) An enhanced recovery surgical pathway for hip and knee replacement - How to use DrFoster software to evaluate success. Poster at The International Forum on Quality and Safety in Health Care. @officialERblog enhancedrecoveryblog.com
    41. 41. CUSUM chart used to analyze case-mix adjusted readmissions - No changeWainwright TW, Middleton RG (2010) An enhanced recovery surgical pathway for hip and knee replacement - How to use DrFoster software to evaluate success. Poster at The International Forum on Quality and Safety in Health Care. @officialERblog enhancedrecoveryblog.com
    42. 42. Results• Department wide change• Prospective 2300 pt case series• 40+ Anaesthetists, 20+ Surgeons• Reduced LOS, re-admission rate unchanged• Low complication rate• High patient satisfaction Wainwright and Middleton (2009) Current Anaesthesia and Critical Care 21: 114 Vingerhoeds et al. (2010) J Bone Joint Surg (Br) 92-B: 500 Olyslaegers et al. (2009) J Bone Joint Surg (Br) 91-B: 406 @officialERblog enhancedrecoveryblog.com
    43. 43. Results – First 2391 patients 100% of operation dates are mutually agreed 90% attendance at pre-op education class 100% of patients admitted on day of surgery 99% of patients waited less than 4 hours between admission and operation (Mean = 2hrs 45mins) Early physiotherapy (on average first mobilisation at 7hrs 31 mins)Wainwright T, Middleton R, An orthopaedic enhanced recovery pathway, CurrentAnaesthesia & Critical Care (2010), doi:10.1016/j.cacc.2010.01.003 @officialERblog enhancedrecoveryblog.com
    44. 44. Results – Excellent clinical outcomes Complications rates at or below international accepted norms Decreased % of patients re- admitted Patient satisfaction is extremely high Length of stay dramatically decreasedWainwright T, Middleton R, An orthopaedic enhanced recovery pathway, CurrentAnaesthesia & Critical Care (2010), doi:10.1016/j.cacc.2010.01.003 @officialERblog enhancedrecoveryblog.com
    45. 45. Reduced Mortality rate• The 30 day mortality rate before the introduction of the pathway was 0.47% (6/1274) compared with 0.04% (1/2407) after the introduction of the pathway (P=0.0071).• The 30 day mortality rate after the introduction of the pathway is five times lower than predicted for case mix adjusted national averages @officialERblog enhancedrecoveryblog.com
    46. 46. High patient satisfaction“If this is Orthopaedic RBHstyle; Congratulations.In what is a very difficultclimate of targets and bedemptying...you havesucceeded in remaining totallyfocused on your patients. I forone am truly grateful.” @officialERblog enhancedrecoveryblog.com
    47. 47. High levels of patient satisfaction @officialERblog enhancedrecoveryblog.com
    48. 48. Good PROMS Results RBH EQ5D Index – THRApril 2010 to March 2011 (published 9th February 2012) @officialERblog enhancedrecoveryblog.com
    49. 49. High levels of staff satisfaction Freedom and responsibility to work within a framework 21C - I AM ABLE TO DELIVER THE PATIENT CARE I ASPIRE TO 70 60 50 40 ENG RBH% 30 DER 20 10 0 STRONGLY DISAGREE NEITHER AGREE STRONGLY DISAGREE AGREE NOR AGREE DISAGREE Manage the system and not the people @officialERblog enhancedrecoveryblog.com
    50. 50. Results – Enhanced Recovery benefits the over 85 age group most Age (10-year) Inpatients % of all Day Cases LoS Expected LoS Difference PBDSALL 2160 100% 0 4.3 6.5 -2.3 73725-34 4 0.2% 0 3.3 5.1 -1.9 035-44 8 0.4% 0 3 4.8 -1.8 045-54 82 3.8% 0 3.8 5.2 -1.4 3055-64 396 18.3% 0 3.6 5.2 -1.6 4965-74 845 39.1% 0 3.9 5.9 -2 20575-84 713 33% 0 4.8 7.5 -2.7 36885+ 112 5.2% 0 5.9 10.6 -4.7 86 @officialERblog enhancedrecoveryblog.com
    51. 51. Results – Enhanced Recovery benefits the oer 85 age group most @officialERblog enhancedrecoveryblog.com
    52. 52. But what about productivityWaiting timeIncreased theatre capacityBed capacityNo Waiting list initiative workVolume of patients treated @officialERblog enhancedrecoveryblog.com
    53. 53. Waiting time decreasing @officialERblog enhancedrecoveryblog.com
    54. 54. Theatre productivity improved 04:00 03:31 03:02 02:33 02:04 01:36 01:07 00:38 Practice change 00:09 here @officialERblog enhancedrecoveryblog.com
    55. 55. Orthopaedic Department bed base reduced Before After @officialERblog enhancedrecoveryblog.com
    56. 56. T & O in-patient episodes @officialERblog enhancedrecoveryblog.com
    57. 57. Increasing tariff per bed day @officialERblog enhancedrecoveryblog.com
    58. 58. We believe that Enhanced Recovery improvesquality in every dimension of qualityThe IOM Specific Aims for Quality in Healthcare (2001): States that healthcare should be:• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable @officialERblog enhancedrecoveryblog.com
    59. 59. The approach is not limited to hip and knee joint replacementFigure 1 – Actual Length of Stay (LOS) against case-mix adjusted LOS forfractured neck of femur patients at PGH. The introduction of enhanced recovery principles has resulted in a dramatic reduction to LOS. @officialERblog enhancedrecoveryblog.com
    60. 60. Enhanced Recovery Clinical Decisions Do right things (EBM) Process/System Do right changes things right Do things right (QI) Good Patient CareAdapted from Glasziou et al. BMJ Qual Saf 2011;20(Suppl 1): i13-i17 @officialERblog enhancedrecoveryblog.com
    61. 61. Thank you @officialERblog enhancedrecoveryblog.com

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