Planning patient care and achieving Best Practice Tariff

Dr John Tsang MB ChB, FRCP

Consultant Orthogeriatrician

Lead clinician Orthogeriatrics Service

National Hip Fracture Database – North West Regional Meeting

13th March 2013

• If you or a loved one suffered a hip fracture, would you recommend your hospital?

• Why hip fractures are so important

• Planning patient care

• Achieving BPT

• Top ten tips

Why hip fractures are so important

• ‘rather be dead than

admitted to a nursing home after a hip fracture’ 80% women over 75 yrs BMJ Feb 2000

2000,000,000

Planning patient care

2008

2009

• LEAN services

• Process mapping

2010-12

Specialty Limb Reconstruction

Mr. B. Narayan

Mr. N. Giotakis

Shoulder & Elbow

Mr. M. Kent Mr. M. Smith

Hand & Wrist Mr. D. Brown Mr. G. Cheung

Pelvis & Acetabulum

Mr. S. Kalra Mr. G. Kumar

Hip & Knee Miss J. Banks Mr. B. Kapoor

Foot & Ankle Mr. A. Roach Mr. C. Walker

OG Dr J Tsang Dr H Cronin

Trauma Co-ordinators

Mrs H Haines Mrs M Nolan

Hip fracture practitioner

Mr M Thompson

Current services

• All hip fractures admitted under joint care

• Enhanced recovery pathway

• Daily consultant orthogeriatrician and orthopaedic surgeon WR’s

• Daily consultant-led MDT -all hip fractures discussed

• Monthly multiprofessional hip fracture meeting

• Monthly trauma directorate meeting

Achieving BPT

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

40

50

60

70

80

90

100

RLUH

National

BPT Surgery within 36 hrs

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

BPT Joint care

0

10

20

30

40

50

60

70

80

90

100

2011 2012

RLU

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

HIP FRACTURE MANDATORY REQUIREMENTS BY ADMITTING SHO or SPR

• 1. All patients must be clerked on the hip fracture pathway only (not A & E or continuation sheets)**

• 2. All patients must have pre-operative 10 point Abbreviated Mental Test Score (AMTS) **

• 3. All patients should be prescribed IV paracetemol & Oramorph PRN as per analgesic algorithm unless contra-indicated

• 4. All patients admitted on Warfarin, give stat dose of IV Vitamin K 2mg and follow trust clinical guideline

• 5. All tests that may delay surgery must be done urgently

• 6. All patients should have VTE assessment and prescribe prophylactic Fragmin unless contra-indicated

• **including subtrochanteric fractures • **including in-hospital hip fractures

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

BPT Perioperative medical assessments

0

10

20

30

40

50

60

70

80

90

100

Apr - Oct

11

Nov - Apr

12

May - Jun

12

Jul - Oct

12

Nov - Jan

13

RLUH

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

BPT Geriatrician-led MDT

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

Blue Book (std 5) Bone health assessment and treatment at discharge

50

55

60

65

70

75

80

85

90

95

100

2010 2011 2012

RLUH

National

Blue Book (std 6) Specialist falls assessment

Best Practice Tariff

• 1. Time to surgery within 36 hrs

• 2. Admitted under joint care Consultant Geriatrician and Consultant Orthopaedic Surgeon

• 3. Admitted using assessment protocol agreed by Geriatric Medicine, Orthopaedics and Anaesthetics

• 4. Assessed by Geriatrician peri-operatively

• 5. Post-operative Geriatrician-led MDT rehab

• 6. Falls and bone health assessment

• 7. Two AMTS pre and post op

AMTS

0

10

20

30

40

50

60

70

80

90

100

Apr-Jun 12 Jul-Sep 12 Oct-Dec 12

Pre-op

Post-op

It’s not all about the tariff

• Dementia care in orthopaedics

• Comprehensive cognitive screening

• Delirium management

• Nutritional support

• Fascia iliaca nerve blocks

• Hip fracture programme – ESD

• Pre-op risk assessment

• Catheter pathway

• Continence assessment

• Bowel care pathway

• Specialist pharmacy education and medication review

• Information provision to primary care

Dementia care in orthopaedics

Hip Fracture Pathway

• Improvement in all areas

0

20

40

60

80

100

Information Malnutrition

Pre

Post

Nutrition in hip fractures

1441.4 1918.2

47.3 71.5

Early removal urinary catheters -HOUDINI B

0

20

40

60

80

100

Pre

Post

Top ten tips 1. LEAN services

2. Dedicated area for all hip fractures

3. Hip fractures 1st on the list

4. Proactive work eg AMTS, mandatory requirements

5. Monthly multidisciplinary hip fracture meetings

6. Information provision –monthly performance review

7. Non-clinical leadership -induction to trust board

8. Clinical leadership – pre-operative to discharge

9. Supportive team/adequate resources –audit department, specialist nurses, junior doctors, consultant colleagues

10.Not all about the tariff! –develop other care aspects

Summary

• Collaborative work achieves high levels of best practice

• If you or a loved one suffered a hip fracture, would you recommend the Royal?

Yes!

Questions?