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NHS FIFE ORTHOPAEDIC UPDATE
Mr Edward DunstanOrthopaedic Clinical Lead
May 2015
Enhanced Recovery
31/1
2/20
11
01/0
2/20
12
04/0
3/20
12
05/0
4/20
12
07/0
5/20
12
08/0
6/20
12
10/0
7/20
12
11/0
8/20
12
12/0
9/20
12
14/1
0/20
12
15/1
1/20
12
17/1
2/20
12
18/0
1/20
13
19/0
2/20
13
23/0
3/20
13
24/0
4/20
13
26/0
5/20
13
27/0
6/20
13
29/0
7/20
13
30/0
8/20
13
01/1
0/20
13
02/1
1/20
13
04/1
2/20
13
05/0
1/20
14
06/0
2/20
14
10/0
3/20
14
11/0
4/20
14
13/0
5/20
14
14/0
6/20
14
16/0
7/20
14
17/0
8/20
14
18/0
9/20
14
20/1
0/20
14
21/1
1/20
140
10
20
30
40
50
60
70
Inpatients Phase II
Hip Revision Hip KneeRevision Knee
Num
ber
of
join
ts
Results – Cumulitive Discharge Rates
0102030405060708090
100
Traditional RehabiliatationERP
Postoperative Day
Cu
mu
liti
ve D
isch
arg
e R
ate
(%
)
Ayr
Cross
hous
eBGH
DGRIFife
Forth
Val
ley
Aberd
een
Elgin
GRIW
IG
Victor
iaSGH
RAH
Inve
rclyd
e
Raigm
ore
Hairm
yres
Mon
kland
s
Wish
aw RIE
Ninew
ells
Perth
Wes
tern
Isle
s
All Site
s0%
20%
40%
60%
80%
100%Was pre-medication given? - Data from last three audit cycles
Premed given No premed Data unavailable
Pe
rce
nta
ge
of
Pa
tie
nts
Ayr
Cross
hous
eBGH
DGRIFife
Forth
Val
ley
Aberd
een
Elgin
GRIW
IG
Victor
iaSGH
RAH
Inve
rclyd
e
Raigm
ore
Hairm
yres
Mon
kland
s
Wish
aw RIE
Ninew
ells
Perth
Wes
tern
Isle
s
All Site
s0%
20%
40%
60%
80%
100%
Type of anaesthesia given - data from last three audit cycles
General Spinal Spinal and regional/Nerve block Spinal and LIA * General and Regional/Nerve block Other
Pe
rce
nta
ge
of
Pa
tie
nts
Factors affecting LoSPredictors in Model
B Value 95% CI p-value
ERP -1.81 -2.1 to -1.6
<0.001
Catheter -1.62 -2.0 to -1.3
<0.001
Age 0.05 0.04 to 0.07
<0.001
ASA 1 Reference
2 0.52 0.30 to 0.75
<0.001
3 1.04 0.60 to 1.50
<0.001
4 1.56 0.90 to 2.25
<0.001
Approach Anterolateral
Reference
Posterior -0.27 -0.36 to -0.19
<0.001
Preoperative HHS
-0.028 -0.04 to -0.02
<0.001
RAPT (Risk Assessment and Predication Tool)AgeGenderMobilityWalking AidsCommunity SupportLives alone
Identify those who require extended rehabilitation at time of listing
RAPT42 consecutive patients20 with a score >/= 918 home within 4 days16 of the 18 with a score 6-8 home > 4 days
What to do with those with a score <9? Rehabilitation facility? Community based rehabilitation team
Fracture Neck of Femur
Ayr
Cross
hous
eBGH
DGRIFife
Forth
Val
ley
Aberd
een
Elgin
GRIW
IG
Victor
iaSGH
RAH
Inve
rclyd
e
Raigm
ore
Hairm
yres
Mon
kland
s
Wish
aw RIE
Ninew
ells
Perth
Wes
tern
Isle
s
All Site
s0%
20%
40%
60%
80%
100% Place of residence at 120 days post-admission - all 2014 data
Home/sheltered Care home NHS Continuing Care/Other Rehabilitation Acute hospital Still in acute orthopaedic care DeadUnknown
Pe
rce
nta
ge
of
Pa
tie
nts
Ayr
Cross
hous
eBGH
DGRIFife
Forth
Val
ley
Aberd
een
Elgin
GRIW
IG
Victor
iaSGH
RAH
Inve
rclyd
e
Raigm
ore
Hairm
yres
Mon
kland
s
Wish
aw RIE
Ninew
ells
Perth
Wes
tern
Isle
s
All Site
s0
10
20
30
40
50
60
70
80 Median length of total hospital stay - all 2014 data
Series4
Pe
rce
nta
ge
of
Pa
tie
nts
AyrBGH
Perth
Wes
tern
Isle
s
Cross
hous
e
Ninew
ells
Inve
rclyd
eRAH
GRI
DGRI
Forth
Val
ley
Aberd
een
WIG
Wish
aw
Raigm
ore
Mon
kland
s
Hairm
yres Fife RIE
Elgin
SGH
Victor
ia0
10
20
30
40
50Total hospital length of stay by type of ward/hospital - all 2014 data
Initial acute orthopaedic stay Rehab Further acute ward NHS Continuing Care
Me
an
nu
mb
er
of
da
ys
pe
r p
a-
tie
nt
Theatre Optimization
SUN 0
1/03/1
5
MON
02/0
3/15
TUE 03/0
3/15
WED 0
4/03/1
5
THU 0
5/03/1
5
FRI 06/0
3/15
SAT 07/0
3/15
SUN 0
8/03/1
5
MON
09/0
3/15
TUE 10/0
3/15
WED 1
1/03/1
5
THU 1
2/03/1
5
FRI 13/0
3/15
SAT 14/0
3/15
SUN 1
5/03/1
5
MON
16/0
3/15
TUE 17/0
3/15
WED 1
8/03/1
5
THU 1
9/03/1
5
FRI 20/0
3/15
SAT 21/0
3/15
SUN 2
2/03/1
5
MON
23/0
3/15
TUE 24/0
3/15
WED 2
5/03/1
5
THU 2
6/03/1
5
FRI 27/0
3/15
SAT 28/0
3/15
SUN 2
9/03/1
5
MON
30/0
3/15
TUE 31/0
3/15
08:30
08:45
09:00
09:15
09:30
09:45
10:00
10:15
10:30
10:45
Analysis of Theatre 6, Phase 3Start Times March 15 PT INTO ANAES ROOM
START OF ANAES
TIME INTO THEATRE
START OF PROCEDURE
tIM
E
TUE 03/03/
15
WED 04/03/
15
THU 05/03/
15
FRI 06/03/
15
MON 09/03/
15
TUE 10/03/
15
WED 11/03/
15
THU 12/03/
15
FRI 13/03/
15
MON 16/03/
15
WED 18/03/
15
THU 19/03/
15
TUE 24/03/
15
WED 25/03/
15
THU 26/03/
15
FRI 27/03/
15
MON 30/03/
15
TUE 31/03/
15
08:30
08:45
09:00
09:15
09:30
09:45
10:00
10:15
Analysis of Theatre 2, Phase 2Start Times March 15
PT INTO ANAES ROOM
START OF ANAES
TIME INTO THEATRE
START OF PROCEDURE
TIM
E
?SCAPHOID !!!!!!!!!!!!!!!!!
NHS Fife Orthopaedic Service Improvements
Enhanced Recovery for Hip and Knee Arthroplasty
Reduced length of stay - 4 Days
RedesignPathway to Support QOF Guidance for Knees
Spinal Clinics
New Clinics at WMB and QMH
Increased Capacity 32 Patients
Defined Fife Pathway
Intranet Advice and Guidance90% Patient Satisfaction with Clinics
RedesignLow Back Pain
Pathway
Orthopaedic Advice and Guidance
NHS Fife Orthopaedic Guidance? Desk Top Help Tool
? Referral Advice Fields
Increased Compliance with SIGN Guidelines
Vetting Times Reduced from 10 to 2 Days Referral Management
EnhancedCommunication
Reduces Patient Anxiety
Reduces Patient Pathway by 8 weeks
GP Direct Access to MRI (Radicular Pain)
Advice via Referral Management SystemE-advice e-mail
Maximisation of Workforce
Management Consistency
Reduced Patient ‘Hand-Offs’
• Increased capacity by 40 patients a month
GPwSI Community Knee Clinic
Transfer of Physiotherapy Staff to Primary Care
GP Orthopaedic Training Delivered
PhysiotherapyServices
Shift in Balanceof Care
Primary Care Diagnostics
Redesign
Reduces Risk of Chronicity
Virtual Advice Clinics
Integrated Service
Physiotherapy Community Spinal Clinic
Multidisciplinary Diagnostic Group Exploring Expansion of Access
Patient Involvement
Patient Support and Input
New Service User Information Leaflets
User Involvement and Patient-Centred Ongoing Research
Neck
Lumbar
Shoulder
Hip
Thoracic
Elbow
WristHand
Knee
AnkleFoot
Cauda Equina Acute trauma/fracture
Refer toA&E
Suspected Malignancy Infection Progressive neurology
Refer to Secondary Care
Acute Soft Tissue Injury Service User InformationHealthy Working Lives Adviceline on 0800 019 2211Fife Sport and Leisure
NHS Fife Musculoskeletal Resource Tool
NHS InformMusculoskeletal National Advice
NHS Fife Summary Orthopaedic Referral
Guidelines
Useful Links
Analgesic Ladder
Musculoskeletal Medication Advice
Physiotherapy Referral Guidance
NHS Fife Orthopaedic
Pathway
Hover over area and ‘click’ for further adviceTerms of Use
Minimum Information Required for Orthopaedic
Referrals
NHS Inform
Info Sheet
Chronic Pain
20