Redesigning Hip Fracture

Care

DGH Trauma catchment: 200,000 351 inpatient beds

K & C

Highest UK Life

Expectancy

H & F Wandsworth

Westminster

Trust Performance…

A&E attendances

146,000 per year-

Hospital Admissions

20,075 per year

Hip Fractures…..

Hospital admissions

207 Jan-Dec 2014

225 Jan-Dec 2015

81 yrs.

Where we began in 2010…... a non- collaborative approach

No defined care pathway

No joint assessment protocol

No routine Ortho-Geriatrician input

Hip fractures not being prioritized

Not “ medically fit” ethos

No leader driving hip fracture care

Poor attention to nutritional care needs

Setting the platform for change

Sub-optimal hip fracture care

Improving patients/family/carers satisfaction

Financial incentive

“Grand round table” meeting 18th May 2011

A patient centred re-design

“Making change happen”

Patient experience

Engagement with organisational / managerial influencers of change

Collaborative Partnership with frontline clinicians

MDT communication

Educating staff on “Essential care elements”

Arrival to A&E by

Ambulance from

scene of injury

Admit to AAU Trolleys

under the Medical

Consultant on call

Triage NOF Assessment by

A&ETeam: Hip and Chest X

ray, cannulate, bloods,

analgesia, IV fluids & ECG.

Heel protector affected limb

Medically unfit Medically fit

Direct to theatre if

immediate slot available

New fracture neck of femur pathway from 1st June 2011 (revised)

A&E AAU Within 2 Hours Within 30 minutes

Downstream to AAU bed for

medical optimisation pre-

operatively under the care of Dr.

Kroker within 24 hours

Review by Anaesthetist

X-ray confirms a Hip

Fracture

No hip fracture

Admit to an AAU bed

under Medical on call

team

Admit to Lord Wigram Ward

post-operatively from Main theatres

Recovery

To theatre as soon as deemed

medically fit

Level 1 monitoring not

required

post-operatively

Level 1

monitoring required

post-operatively

Transfer to a Level 1 AAU bed

under the care of Dr Kroker until

medically stabilised

Clarked on admission to AAU by the

Medical SHO using

the AAU Protocol

Bleep 0459 Orthopaedic HO

on call & Ortho Reg. 0908

Within 1 hour ….

Orthopaedic Registrar or SHO will clark /exam

mark limb, consent & liaise

with Anaesthetists/Main Theatres

to place patient on Trauma Board

If a Hip fracture is sustained

during the patient’s in

hospital stay

Bleep Orthopaedic Nurse

Specialist: Emer 9989 8am-4pm.

Out of hours voicemail:Ext.58871

© Emer Bouanem, Orthopaedic CNS. 31/5/2011

Re-assessment by the

Duty Anaesthetic

Team

Trauma care pathway

An agreed Assessment Protocol

Systematic Nursing & medical

Assessments

Falls history

AMTS Day 1

Visual Acuity

Neurological Examination

DNAR

Geriatrician-directed multi-professional

rehabilitation team.

Structured Ortho-Geri Hip fracture ward rounds thrice

weekly

Past Medical History

Fracture type / date of operation

Review ECG, CXR, ECHO.

Medical & Nursing Falls Risk Assessment to ascertain cause of fall and develop a fall prevention action plan

“ Falls and Bone Health Assessment” order set Last word

Post-Operative AMTS (consider MMSE/MOCA)

MDT Rehabilitation and Discharge plan (PDD)

NHFD Hip Fracture data collation and achievement April-December 2015

Best Practice tariff achieved - eligible patients only

Data Category Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Total to

Nov-15

% of

Patients

BPT achieved 11 13 16 11 5 7 7 10 80 60.2%

BPT not achieved 7 7 5 2 5 14 6 7 53 39.8%

Total patient numbers 18 20 21 13 10 21 13 17 133

Monthly achieved percentage 61.1% 65.0% 76.2% 84.6% 50.0% 33.3% 53.8% 58.8% 60.2%

Data Category Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Total to

Nov-15

% of

Patients

BPT achieved 11 13 16 11 5 7 7 10 80 54.1%

BPT not achieved 7 7 5 2 5 14 6 7 53 35.8%

No operation: excluded from data 2 0 1 1 0 0 0 0 4 2.7%

Patient not eligible as overseas

visitor 0 0 0 0 0 0 0 0 0 0.0%

Patient not eligible as <60 years old 0 1 5 1 1 1 1 1 11 7.4%

Total patient numbers 20 21 27 15 11 22 14 18 148

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

Monthly achieved percentage Year-to-Date average

Challenges to non-achievement

Scheduling hip fractures onto a trauma list : not a dedicated hip fracture list and pending expedited cases pre-booked .

HDU monitoring within the 24 hour post-op period

Dedicated hip surgeon to carry out THR: weekend service

Geriatrician review within 72hours :no extended cover at weekends/bank holiday period.

Continuity to ensure the elements of hip fracture care, ward rounds and standards for BPT are continued in my absence.

Delayed discharges secondary to lack of rehab / EMI/ Nursing Home beds. Awaiting Continuing Care Assessments.

Revisiting our Hip Fracture activity

Designated theatre trauma time/week

Mon, Wed, Thurs & Fri 1:30pm- 5:30pm

Tues 08:30- 12:30pm

Saturday 08:30-5:30pm

Sunday additional list

Alternate weeks “all day” trauma list

Daily Trauma MDT Meeting 07:45am: Prioritising NOFF’s

Trauma Whiteboard handover

3 Ortho-Geri ward rounds/week (7 hrs)

Weekly MDT discharge planning meetings

Weekly Osteoporosis Ward round

Engagement with Clinicians and the wider organisation

Clinical Governance Day-Focus on Hip Fracture Care

Process Mapping Exercise

Presentation to Divisional Board

Presence at directorate level strategy meetings

Major fragility fractures

“An MDT Approach”

“Hip fracture management takes a frail patient through a complex clinical pathway involving a widen range of

specialists, clinical teams, departments and agencies”

NHFD annual Report(2015)

Revision of current hip fracture

pathway Major Fragility Fracture Pathway

“Not just a NOFF” ~ A frail, vulnerable group of patients, who have

sustained a major insult to their body resulting in a deterioration of

their pre-morbid functional state.

Standardise guidelines-diagnosis of Dementia / Delirium/ Pain-

assessment: “care bundle approach”

Acquiring collateral history-System One accessibility

Psychiatric Liaison Team involvement

Admit to AAU under the

Medical Consultant on

call

Triage using NOFF Proforma Assessment

by A&E Team: Hip and Chest X ray,

cannulate, bloods, analgesia, IV fluids &

ECG. Heel protector affected limb

Fascia Iliaca Block –

Refer to Analgesic Guideline

Medically unfit

Medically fit

Still awaiting

surgery

Direct to theatre if

immediate slot available

Major Fragility Fracture Pathway (Revised October 2015)

A&E AAU

AAU bed or Level 1 bed for

monitoring & medical optimisation

pre-operatively under the care of

AAU Consultant

Anaesthetist Assessment

1. Complete NOFF Proforma

2. Pre-op investigations

3. Nottingham Hip Fracture Score

4. Consider HDU/post-op level

of monitoring required

X-ray confirms a Hip

Fracture

No hip fracture

Consider further

imaging –MRI/CT

Admit to an AAU bed

under Medical on call

team

Admit to Lord Wigram Ward

post-operatively from Main theatres

Recovery

To theatre as soon as deemed

medically fit

Refer to the Delirium and

Analgesic Guideline

Clerked on admission to AAU by the

Medical SHO using

the AAU Protocol

Bleep 0459 Orthopaedic HO

on call

Within 1 hour ….

Orthopaedic Registrar or SHO will clerk-

mark limb, consent & liaise

with Anaesthetists/Main Theatres

to place patient on Trauma Board

If a Hip fracture is sustained

during the patient’s in

hospital stay

© Emer Bouanem, Orthopaedic CNS. 20/10/2015

Re-assessment by the

Duty Anaesthetic

Team(including above

Elements)

Recovery

Anaesthetic post-op review

Consider Level of monitoring

required post-recovery

CCOT review-NEWS-evidence of

hypotension

What is good about our current pathway?

What are we doing well?

New delirium and analgesia guidance available for resource

Easy to read (revised) pathway on paper-greater focus on importance

of anaesthetic assessment and post-operative recovery episode

Information leaflet for patient / families/carer- place electronically

Robust Consultant led trauma meeting each morning-prioritise trauma

cases; Strong therapy and CNS presence

Therapy morning planning meeting with Orthopaedic CNS

….continued What is good about our current Pathway?

Weekly Osteoporosis ward round with Professor Callan

Falls and Bone Health request set on Last word. Pre and Post

medication set being developed: IVI and Analgesics

Positive dietician input for NOFF’s

FI Block administered in the ED- utilising the NOFF Proforma

What is not so good about the pathway? Why is each time different ; What causes delays?; What

are the barriers/challenges?

Occasional lack of awareness of delirium: misinterpreted for

Dementia/Chronic confusional state

Lack of Ortho-Geriatrician cover over Christmas/New

Year/Weekends/Bank Holiday-non-achievement of BPT 72 hour

review

No time frame by which patient’s maybe taken over by medical team

once medically fit.

“Shared care” pre-operatively being more specific who is ultimately

responsible for the patient pre-op.

Analysis and validation of BPT data monthly: time consuming activity.

….continued

What is not so good about the pathway?

Safari ward rounds-Right Patient, Right Time, Right Place

AAU to facilitate pre-op optimisation- timeframe for Ortho and Geri

reviews not joint (availability of both)

Hospital At Night(HAN) Team via CSM Team to ensure support of

nursing staff and junior doctors: SBAR escalation process. A

reoccurring theme -hypotensive episodes and low urine output

post-operatively

How can we improve?....solutions

Post-operative “care bundle”-including essential care elements

Guideline on ECHO/PPM check pre-operatively

INR check in the ED-admin of Vitamin K earlier

Longer-term: Enhanced Recovery for NOFF’s(next two years).

System 1 accessibility to all community services-DSUM’s from

previous acute spells.

Place new NOFF’s on the AAU medical review locator.

RCA style approach to delay in time to theatre.

Discharge co-ordinator for trauma to focus upon liaison and referrals.

How can we improve?....solutions

More efficient MDT meeting with Medical representation and revise

Board Rounds

Being more prescriptive (with clinical judgement)..setting our LOS at 1-

10 days

Therapy keyworker allocation to each patient

Patient friendly guide to Trauma rehabilitation prescription(DSUM for

rehabilitation)

Capturing patient/relative/carer feedback

….continued How can we improve? “Simple wins”

Education/increase staff awareness and confidence in escalating their

concerns- SBAR in place. How can we mimic 24hour care on the ward

if no HDU bed available- use of Cardiac Monitors?

Nurses-NEWS; Doctors response and action within 30minutes- if no

response then Registrar – Consultant.

How can we improve? ....solutions

Developing the role of nursing staff member(medical/nursing) to act as

a link in ensuring that hip fracture care elements, led ward rounds and

BPT standards are monitored in my absence

Administrative inputting data collected from medical records into the National Hip Fracture Database.

Specialist roles to focus on trauma co-ordinator role, delirium and frailty.

Expedited sub-speciality list to accommodate outstanding trauma

What lies in the year ahead 2016?

Uniformity across both hospital sites in our BPT achievement-sharing

good practice

NHFD new dataset version 9(v9) 2016 additional fields:

• Inpatient falls will be recorded

• Nutritional risk and delirium assessments collected

• 120 day follow up data

Implementing a Fragility Fracture Pathway