Mr. Raphael Hau
MBBS FRACS FAOrthoA
Orthopaedic Surgeon, Box Hill Hospital
Director of Orthopaedic Surgery, The Northern H...
Why?
How?
Requirements?
Delay > 1 day increases in-hospital mortality
Bottle, BJM, 2006
Delay increases 30-days mortality
Holt, J Bone Joint Surg ...
Reduces major medical complications
Hoenig H et al, Arch Int Med. 1997; 157:513-20. Verbeek DOF et al, Int Orthopaedics. 2...
Reduces mortality, pressure ulcers and pneumonia
Simunovic N et al, CMAJ 182(15): 1609-16, 2010.
Code ‘NOF’ in orthopaedic paradise
Emergency physician, Geriatrician,
Orthopaedic surgeon, Anaesthetist,
Cardiologist, Hae...
Delays in patient optimization
Delays in theatre availability
Lack of co-ordination & co-operation: mostly
Lack of resources: often some degree
Lack of knowledge: rarely
Tick boxes
Guidelines
Agreed plans
Fast track clinical care
Audit tool
Geriatrics / Medicine
Orthopaedics
Emergency
Anaesthetics
Haematology
Cardiology
Nephrology
Theatre
Ortho Ward
Rehab Ward
...
A&E
Ambo calls:
○ Alert in charge A&E physician, Ortho,
Geriatricians, Ortho co-ordinator
High energy trauma: trauma call
...
NOF burger:
FBE/U&E/Vit D/Group & Hold +/-
INR/clotting
ECG/CXR/Charnley pelvis XR/ AP lat Hip
Xray Femur if subtrochanter...
A&E senior
Confirms diagnosis
Exclude CVA, AMI, PE, arrhythmia,
pneumonia, other fractures, pathological
fractures
Fascia ...
Orthopaedics
Confirm diagnosis
Organise additional imaging
Organise implant
Book theatre
Anaesthetic referral
Plan: fastin...
Geriatricians / Physicians
Correctable cause for fall
Assess and correct co-morbidities
Poly-pharmacy
Analgesia
Liaise wit...
Nursing care
Oximetry +/- Oxygen
TEDs
Foot pumps
DVT prophylaxis
Air mattress
Book bed
Analgesia / Anti-emetics
Geriatrician? Anaesthetic ?
Pain team involvement?
When? Next round?
As soon as case booked?
Guid...
Passport
Bloods
Imaging
Analgesia VAS
Orthopaedic plan
Anaesthetic R/V
Geriatrician R/V
Anaemia
Anti-coagulation
Volume depletion
Electrolyte imbalance
Uncontrolled diabetes / heart failure
Correctable Arrhythm...
Anaemia / Electrolyte Imbalance
Hb / Na / K / Glucose vs Co-morbidities
Who checks?
Who decides?
Who corrects?
To what lev...
Anaesthetics
Fitness for surgery
Specific end point to achieve
Planned review BD?
Geriatricians / physicians
Fitness for s...
Agreed Indications to defer surgery
AMI or evolving ischaemia
Pulmonary oedema
Fulminant sepsis
Not contra-indications
Hyp...
Warfarin for Atrial fibrillation
Prothrombinex ? How much ? When ?
Vitamin K ? How much ? Route ?
Repeat INR ?
Protocol fr...
Analgesia / Anti-emetics
DVT prophylaxis
Pressure care
Chest physio
Bowel regime
Orientation
Co-ordinate medical reviews
F...
Transfer from regional centres
Investigations, Analgesia
DVT prophylaxis
Bed priority
Mode of transport and urgency
Dialys...
When is it optimal?
Patient ‘ready’
As soon as possible
In-hours
Consultants present
ICU / HDU available if required
As soon as possible
Advantage
○ Decreased mortality & complications
Disadvantage
○ May be late in the day
No increase in mortality
Bosma et al, JBJS 92B: 110-115, 2010
Decreases dexterity and increases error
Taffinder et al, Lan...
Advantages:
○ Staff awake and alert
○ More help available
○ Consultants more likely to be present
Disadvantages:
○ Compete...
Decreases after hours work
Jennings et al, Ann R Coll Surg Eng 81:65-68
Decreases delay and post op morbidity
Elder et al,...
Improves cancellations, supervision &
after hour work
Delays operating and increases length
of stay
Aide et al, JOS 17(3):...
As soon as possible
Dedicated trauma lists
Staffed by consultants
In hours
Frequency?
After hours?
Does not reduce electiv...
Requirements
Will
Co-operation and co-ordination
Monitoring and re-assessment
Resources
○ Extra theatre time
Mr. Raphael Hau
MBBS FRACS FAOrthoA
Orthopaedic Surgeon, Box Hill Hospital
Director of Orthopaedic Surgery, The Northern H...
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?
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Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?

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Raphael Hau, Orthopaedic Surgeon, Box Hill Hospital. Director of Orthopaedics, The Northern Hospital 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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Timing Of Surgery: Moving Towards Standardised And Monitored Clinical Management, What Are The Key Considerations?

  1. 1. Mr. Raphael Hau MBBS FRACS FAOrthoA Orthopaedic Surgeon, Box Hill Hospital Director of Orthopaedic Surgery, The Northern Hospital Moving Towards Standardised & Monitored Clinical Management. What are the key considerations?
  2. 2. Why? How? Requirements?
  3. 3. Delay > 1 day increases in-hospital mortality Bottle, BJM, 2006 Delay increases 30-days mortality Holt, J Bone Joint Surg Br, 2010. Carretta, Int Orthop, 2010 Delay > 48hours increases 120-days & 6-months mortality Clement, J Bone Joint Surg Br, 2011. Maggi, Osteoporos, 2009 Delay > 2 calendar days increases 1 yr mortality Zuckerman, JBJS A, 1995 Delay > 7 days increases 1 yr mortality Maheshwari, J Ortho Surg, 2011
  4. 4. Reduces major medical complications Hoenig H et al, Arch Int Med. 1997; 157:513-20. Verbeek DOF et al, Int Orthopaedics. 2008; 32:13- 18. Reduces length of stay Hommel A et al, Injury. 2008 June 12 Improves rehabilitation at 3 months Villar et al, BMJ 293:1203-1204, 1986 Improves ability to return to independent living Al-Ani AN et al, JBJS (Am) 2008; 90:1436-42
  5. 5. Reduces mortality, pressure ulcers and pneumonia Simunovic N et al, CMAJ 182(15): 1609-16, 2010.
  6. 6. Code ‘NOF’ in orthopaedic paradise Emergency physician, Geriatrician, Orthopaedic surgeon, Anaesthetist, Cardiologist, Haematologist, Radiographer miraculously appear Theatre free! Real world …
  7. 7. Delays in patient optimization Delays in theatre availability
  8. 8. Lack of co-ordination & co-operation: mostly Lack of resources: often some degree Lack of knowledge: rarely
  9. 9. Tick boxes Guidelines Agreed plans Fast track clinical care Audit tool
  10. 10. Geriatrics / Medicine Orthopaedics Emergency Anaesthetics Haematology Cardiology Nephrology Theatre Ortho Ward Rehab Ward Physiotherapy Orthotics Administrators
  11. 11. A&E Ambo calls: ○ Alert in charge A&E physician, Ortho, Geriatricians, Ortho co-ordinator High energy trauma: trauma call Admission: time noted Joint admission Geriatrics / Orthopaedics ○ Age limit ?
  12. 12. NOF burger: FBE/U&E/Vit D/Group & Hold +/- INR/clotting ECG/CXR/Charnley pelvis XR/ AP lat Hip Xray Femur if subtrochanteric fracture identified CT head protocol Triage ? Nurse practitioner ? Doctor ? How are requests made? How are patients transferred?
  13. 13. A&E senior Confirms diagnosis Exclude CVA, AMI, PE, arrhythmia, pneumonia, other fractures, pathological fractures Fascia iliacus block / regional anaesthesia ○ Before or after Xrays IDC +/- CSU – m/c/s
  14. 14. Orthopaedics Confirm diagnosis Organise additional imaging Organise implant Book theatre Anaesthetic referral Plan: fasting, anti-coagulation
  15. 15. Geriatricians / Physicians Correctable cause for fall Assess and correct co-morbidities Poly-pharmacy Analgesia Liaise with Anaesthetics and Orthopaedics Liaise with other medical specialties
  16. 16. Nursing care Oximetry +/- Oxygen TEDs Foot pumps DVT prophylaxis Air mattress Book bed
  17. 17. Analgesia / Anti-emetics Geriatrician? Anaesthetic ? Pain team involvement? When? Next round? As soon as case booked? Guidelines
  18. 18. Passport Bloods Imaging Analgesia VAS Orthopaedic plan Anaesthetic R/V Geriatrician R/V
  19. 19. Anaemia Anti-coagulation Volume depletion Electrolyte imbalance Uncontrolled diabetes / heart failure Correctable Arrhythmia or ischaemia Chest infection / exacerbation COPD
  20. 20. Anaemia / Electrolyte Imbalance Hb / Na / K / Glucose vs Co-morbidities Who checks? Who decides? Who corrects? To what level? Fluid depletion Who checks / decides / corrects?
  21. 21. Anaesthetics Fitness for surgery Specific end point to achieve Planned review BD? Geriatricians / physicians Fitness for surgery Specific end point to achieve Planned review BD?
  22. 22. Agreed Indications to defer surgery AMI or evolving ischaemia Pulmonary oedema Fulminant sepsis Not contra-indications Hyponatraemia Hypokalaemia Aortic sclerosis / Pan systolic murmur
  23. 23. Warfarin for Atrial fibrillation Prothrombinex ? How much ? When ? Vitamin K ? How much ? Route ? Repeat INR ? Protocol from Haematology Aortic valve / recurrent DVT / CVA Haematology referral
  24. 24. Analgesia / Anti-emetics DVT prophylaxis Pressure care Chest physio Bowel regime Orientation Co-ordinate medical reviews Fasting clock
  25. 25. Transfer from regional centres Investigations, Analgesia DVT prophylaxis Bed priority Mode of transport and urgency Dialysis patients Before or after theatre?
  26. 26. When is it optimal? Patient ‘ready’ As soon as possible In-hours Consultants present ICU / HDU available if required
  27. 27. As soon as possible Advantage ○ Decreased mortality & complications Disadvantage ○ May be late in the day
  28. 28. No increase in mortality Bosma et al, JBJS 92B: 110-115, 2010 Decreases dexterity and increases error Taffinder et al, Lancet 352: 1191, 1998
  29. 29. Advantages: ○ Staff awake and alert ○ More help available ○ Consultants more likely to be present Disadvantages: ○ Competes with electives ○ May delay theatre
  30. 30. Decreases after hours work Jennings et al, Ann R Coll Surg Eng 81:65-68 Decreases delay and post op morbidity Elder et al, Injury, Int J Care Injured 36: 1060-1066, 2005 Decreases cancellations and fasting Wixted et al, J Orthop Trauma 22:234–236, 2008
  31. 31. Improves cancellations, supervision & after hour work Delays operating and increases length of stay Aide et al, JOS 17(3): 301-4, 2009
  32. 32. As soon as possible Dedicated trauma lists Staffed by consultants In hours Frequency? After hours? Does not reduce elective Twilight – 1800-2200 Controlled hours
  33. 33. Requirements Will Co-operation and co-ordination Monitoring and re-assessment Resources ○ Extra theatre time
  34. 34. Mr. Raphael Hau MBBS FRACS FAOrthoA Orthopaedic Surgeon, Box Hill Hospital Director of Orthopaedic Surgery, The Northern Hospital Moving Towards Standardised & Monitored Clinical Management. What are the key considerations?

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