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