SIX YEARS OF DATA - rcsi.ie prof O'Byrne.pdf · SIX YEARS OF DATA Professor John M. O’Byrne, President, Irish Institute of Trauma & Orthopaedic Surgery, Joint National Clinical

SIX YEARS OF DATA

Professor John M. O’Byrne, President,

Irish Institute of Trauma & Orthopaedic Surgery,

Joint National Clinical Lead

National Clinical Programme for Trauma &

Orthopaedic Surgery

Trauma and Orthopaedic Charter Day Presentation

Six years of Data

Thursday 9th February 2017

Prof John O Byrne

President Irish Institute of Trauma and Orthopaedic Surgery


National Clinical Programme for Trauma and Orthopaedic Surgery


Six years of Data Thursday 9th February 2017

Prof John O Byrne




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Hospital with Trauma & orthopaedic 24/7 surgery Planned orthopaedic specialty only hospitals

Kerry

Limerick

Galway

Mayo

Sligo

Cork

Waterford

Drogheda

Connolly Beaumont Mater St James’s Tallaght St Vincent’s

Temple st Crumlin

Letterkenny

Tullamore

Hospital with emergency trauma orthopaedic and Planned Orthopaedic services

Cappagh

Navan

Kilkreen

South Infirmary

Croom

Speaking at the launch Minister for Health Leo Varadkar TD said: “This Model of Care is a significant milestone for trauma and orthopaedic surgery. The new document provides the basis for a world-class trauma and orthopaedic service. It gives clinicians, managers and healthcare workers clear guidelines on how to deliver best practice care to trauma and orthopaedic patients. The HSE and the Hospital Groups must now work together on implementing the Model of Care, so that it leads to real improvements.”


Six years of Data

Thursday 9th February 2017

Mr John O Byrne




Activities • Trauma assessment Clinics • Musculo skeletal Physio clinics • Enhanced recovery programs • Joint schools • Pre-admission & DoSA • Capacity planning • Hip Fracture protocol and register • TARN • INOR • Trauma Network • Workforce planning

Activities

• Hip Fracture protocol and register

Why Audit (IHFD)? Hip fracture management takes a frail patient through a

complex clinical pathway involving a wide range of specialties & is an ideal marker condition for the care of frail older patients.

Clearly defined diagnosis

Good evidence base for care and prevention

Care is complex and costly

Care, outcomes and costs vary

Numbers rising

3,591 hip fractures in 2015 at an estimated cost of > € 45 million

Facilities audit (16 hospitals)

Routes of admission

• 13 hospitals receive direct admissions

• 3 hospitals receive direct admissions and admission via another presenting hospital

• Only 2 hospitals have a protected hip fracture bed

Orthopaedic theatre time and resources

• Two hospitals have no dedicated orthopaedic trauma theatre • The average trauma theatre access across the remaining 14

hospitals is 49 hours per week (ranging 20-96 hours) • The number of orthopaedic consultants and registrars/ SHOs vary

dramatically. • Two hospitals have only 3 orthopaedic consultants • There is an average of 6 consultants in the remaining 14 hospitals

(ranging 4-10 per hospitals)

The National Model of Care for Trauma and Orthopaedics recommends seven day trauma theatre access in all sixteen hospitals

Where are all the orthogeriatricians at???

• There is only one full time locum orthogeriatrician in Ireland

• ½ of hospitals caring for hip fracture patients have no routine input from orthogeriatics

• 8 hospitals have some orthogeriatric input ranging from 4 hours a week to 39 hours

The National Model of Care for Trauma and Orthopaedics advocates that hip fracture patients

require specialist medical care, early rehabilitation and discharge planning from a geriatrician with an interest

in fracture care and should be integrated in the orthopaedic department

Fracture Liaison Services

• Only 5 of the 16 trauma units have a fracture liaison service

• 12 hospitals have on-site DXA facilities

• There are a total of 4.5 WTE CNS specialising in fragility fracture care

• 4 hospitals have a falls clinic

The National Model of Care for Trauma and Orthopaedic Surgery recommends there should be a fracture liaison service in each of the sixteen trauma units.

Integrated care pathway

• 5 hospitals have an ICP in place

for hip fracture patients.

• OLOL will pilot the electronic ICP in 2017

Who collects the data?

• 15 nurses and 1 doctor

• Only three data coordinators have protected time

• 9 hospitals have a hip fracture working group

Site Visits

• Local data presented to hospital stakeholders

• Walk through of each service

• Data coordinator support

• Site feedback and summary of visit

Updated reports

DOH KPI

• The HSE is now seeking to use IHFD data to compliment the DOH Hip Fracture KPI

• We will submit

quarterly reports to the HSE

International collaboration

Minimum Dataset

Urgent actions required

• Bypass for hip fracture patients (patients who present indirectly have an increased AvLoS …. 6 days)

• An integrated Orthogeriatric services in all 16 trauma units

• 7 day trauma theatre access in all 16 trauma units

• Protected beds

• Integrated Care Pathway

* Identified using HIPE data for emergency injury presentations who had hemiarthroplasty or internal fixation following trochanteric / sub-capital fracture

Annual Average 2013: 9.7% 2014: 9.1% 2015: 9.0% 1st 8 months 2016: 9.3%

Patients admitted to non-trauma units and then transferred to a trauma hospital for HIP fracture surgery AvLOS shown for hospital where surgery occurred and not the origin hospital

HIPE data extracted from NQAIS.

Hip Fracture Surgery discahrges following emergecny injury admission (Hemiarthroplasty or Internal Fixation following trochanteric / sub-capital fracture)

Arrived in Transfer to for Surgery At # Dchg AvLOS # Dchg AvLOS # Dchg AvLOS # Dchg AvLOS # Dchg AvLOS

Monthly Average 2016 mthly Avg* 2015 mthly Avg 2014 mthly Avg 2013 mthly Avg

Cavan total 5.00 18.5 5.88 12.3 6.33 18.9 3.83 21.8 4.25 20.4

Cavan OLOL Drogheda 4.95 18.6 5.88 12.3 6.25 19.1 3.75 22.2 4.25 20.4

Cavan Beaumont 0.05 7.0 0.08 11.0 0.08 3.0

Wexford total 4.05 20.4 5.75 23.7 3.92 16.6 2.83 20.0 4.25 21.2

Wexford Waterford 4.00 20.4 5.50 24.0 3.92 16.6 2.83 20.0 4.25 21.2

Wexford Mater 0.02 20.0 0.13 20.0

Wexford St Vincent's 0.02 13.0 0.13 13.0

St Luke's Kilkenny total 3.52 18.8 4.25 18.9 3.83 22.5 3.08 16.6 3.17 16.6

St Luke's Kilkenny Waterford 3.52 18.8 4.25 18.9 3.83 22.5 3.08 16.6 3.17 16.6

South Tipperary total 3.07 19.5 3.00 19.3 3.33 25.4 3.08 17.5 2.83 15.0

South Tipperary Waterford 3.07 19.5 3.00 19.3 3.33 25.4 3.08 17.5 2.83 15.0

Naas total 1.25 14.6 0.75 7.3 0.83 20.3 1.50 15.7 1.75 13.0

Naas Tallaght Adult 1.25 14.6 0.75 7.3 0.83 20.3 1.50 15.7 1.75 13.0

Our Lady's Navan total 0.43 13.9 0.38 14.3 0.58 17.1 0.42 10.8 0.33 11.8

Our Lady's Navan OLOL Drogheda 0.43 13.9 0.38 14.3 0.58 17.1 0.42 10.8 0.33 11.8

Bantry total 0.34 15.5 0.13 7.0 0.67 17.0 0.25 21.7 0.25 8.0

Bantry Cork UH 0.34 15.5 0.13 7.0 0.67 17.0 0.25 21.7 0.25 8.0

Louth Co total 0.32 19.0 0.38 11.3 0.33 30.5 0.17 9.5 0.42 18.2

Louth Co OLOL Drogheda 0.32 19.0 0.38 11.3 0.33 30.5 0.17 9.5 0.42 18.2

Mercy Uni Cork total 0.20 9.6 0.13 8.0 0.33 7.0 0.25 13.3 0.08 10.0

Mercy Uni Cork Cork UH 0.20 9.6 0.13 8.0 0.33 7.0 0.25 13.3 0.08 10.0

Portlaoise total 0.20 17.6 0.38 11.3 0.08 40.0 0.08 27.0 0.33 14.3

Portlaoise Tullamore 0.18 16.3 0.38 11.3 0.08 40.0 0.08 27.0 0.25 9.7

Portlaoise Galway UH 0.02 28.0 0.08 28.0

Mullingar total 0.20 11.1 0.25 9.5 0.08 9.0 0.33 12.8 0.17 10.5

Mullingar Tullamore 0.20 11.1 0.25 9.5 0.08 9.0 0.33 12.8 0.17 10.5

Portiuncula total 0.18 7.1 0.25 5.0 0.33 8.3 0.08 9.0

Portiuncula Galway UH 0.18 7.1 0.25 5.0 0.33 8.3 0.08 9.0

Hospt. 1 non-T&O

Hospt. 2 non-T&O Hospt. 3 non-T&O

Hospt. 4 non-T&O

Hospt. 5 non-T&O

Hospt. 6 non-T&O

Hospt. 7 non-T&O

Hospt. 8 non-T&O

Hospt. 9 non-T&O

Hospt. 10 non-T&O Hospt. 11 non-T&O

Hospt. 12 non-T&O

Hospital 1 T&O surgery
















• Bypass pilot SE and Cavan Monaghan?

Activities

• Pre-admission & DoSA

Pre Admission Units

• “Preparing a patient for anaesthesia requires an understanding of the patient’s pre-operative status, the nature of the surgery and the anaesthetic techniques required for surgery, as well as the risks that a particular patient may face during this time”

Association of Anaesthetists Great Britain and Ireland, Safety Guidelines 2010

• Pre-operative assessment is now recognised as part of the elective surgical process

• It ensures that the patient is fully informed about their proposed surgery and post-operative care required

• It identifies patient risk factors thereby ensuring optimum health prior to surgery

• It identifies any necessary tests or investigations

• It ensures the patient has made arrangements for admission, discharge and post-operative care at home

• It provides education to both patient and carer

• It is an efficient and cost effective method of reducing length of stay and cancellations

The National Clinical Programme for Anaesthesia published the Model of Care for Pre Admission units in December 2014 which establishes best practice in the establishment, implementation, delivery and continuous improvement of units both locally and within a hospital group

National Standardised Education/Competency Training Programme has been developed by The National Clinical Programme for Anaesthesia

Planned Admissions

Planned orthopaedic surgery inpatients - Day of Surgery Admittance rate

DoSA % 34.6% 44.7% 65.7% 73.1% 76.3% 82.3%

Planned orthopaedic surgery inpatients – Bed Days Used for DoSA / Non-DoSA admissions

11.4% More Cases with 20.1% Less Bed Days Used 2010 2011 2012 2013 2014 2015

Avg Qtrly # Cases 2,804 2,792 3,003 3,098 2,950 3,123

Avg Qtrly BDU 17,328 15,292 14,813 14,046 13,070 13,707

AvLOS 6.2 5.5 4.9 4.5 4.4 4.4

Overall Increasing

patient volumes

require less beds because

of process improvement.

DoSA is an indicator of

wider process improvement in the care of

planned admissions

Total Hip Replacement – Elective discharge Volumes and AvLOS by quarter 2010 to 2015

AvLOS: 8.6 7.7 6.4 5.7 5.6 5.7

Nationally

Nationally Elective THR as levelled at 5.7 days in hospital per patient However the story is very different at the individual hospital level

Planned orthopaedic surgery inpatients - Day of Surgery Admittance rate (DoSA)

DoSA % 34.6% 44.7% 65.7% 73.1% 76.3% 82.3%

Significant improvement

in Day of Surgery

Admission rates

(DoSA) year on year


AvLOS: 8.6 7.7 6.4 5.7 5.6 5.7

Nationally

Nationally Elective THR as levelled at 5.7 days in hospital per patient However the story is very different at the individual hospital level

Total Hip Replacement – Elective discharge Volumes and AvLOS by quarter 2010 to 2015 – M2S Hospital 1 Hospital 2

Hospital 3 Hospital 4 AvLOS: 7.1 7.0 5.6 5.3 4.5 4.7

AvLOS: 8.5 6.8 5.5 5.2 5.2 4.6 AvLOS: 7.9 7.0 5.6 4.7 4.6 5.4

AvLOS: 7.9 7.6 7.0 6.4 6.2 5.7

Avg. 1 day more

Model 2 S Hospitals


AvLOS: 8.8 7.7 8.7 6.3 5.6 5.5

AvLOS: 8.5 8.4 6.6 6.4 6.0 5.5 AvLOS: 8.7 7.9 5.3 5.1 5.2 5.8

AvLOS: 9.1 8.4 5.1 4.7 4.7 4.6

Avg. 1 day less

Trending upwards

Same Hospital Group

Hospital 1 Hospital 2



AvLOS: 8.7 7.5 4.8 3.8 4.4 5.0 AvLOS: 8.8 7.1 6.9 6.4 5.7 6.4

AvLOS: 11.3 9.7 8.7 8.0 6.6 6.1 AvLOS: 10.6 9.6 7.0 5.5 6.2 6.3

Trending upwards

Trending upwards Above Nat. Avg.

Trending upwards Above Nat. Avg.

4 others Hospitals



• Waiting list data

Outpatient waiting list for Orthopaedics & Paediatric Orthopaedics.

Outpatient waiting list for Orthopaedics – Mar’13 … Jan’17

NCPS uses NTPF waitlist data for reports

Outpatient waiting list (9 mths & Over) for Orthopaedics - Mar’13 … Jan’17


Outpatient

Waits 0-3 Months 3-6 Months 6-9 Months

9-12

Months

12-15

Months

15-18

Months

18-21

Months 21-24 Months

24-36

Months

36-48

Months 48+ Months Grand Total

31/01/2017 14,328 12,003 9,406 7,432 4,590 3,762 2,270 1,424 1,476 150 75 56,916

04/02/2016 14,840 10,686 8,355 6,133 3,538 1,126 214 172 147 23 3 45,237

% 1 Yr change -3% 12% 13% 21% 30% 234% 961% 728% 904% 552% 2400% 26%

Outpatient waiting list for Orthopaedics & Paediatric Orthopaedics – 26% increase in 1 year (31 Jan’17)

31/1/2017 04/02/2016


UH Waterford ( 6,376 )

Croom ( 5,555 )

SIVUH ( 5,265 )

Galway UH ( 4,991 )

Tullamore ( 3,142 )

Tallaght Adult ( 2,960 )

Mater ( 2,476 )

Beaumont ( 2,229 )

Letterkenny ( 2,133 )

Navan ( 2,120 )

St Vincent's ( 2,041 )

Kerry ( 2,024 )

Crumlin ( 1,904 )

Cavan ( 1,864 )

Sligo ( 1,641 )

Naas ( 1,614 )

St James's ( 1,523 )

Temple st ( 1,433 )

SIVUH ( 4,660 )

UH Waterford ( 4,187 )

Galway UH ( 3,969 )

Croom ( 3,752 )

Tullamore ( 3,211 )

Letterkenny ( 2,305 )

Mater ( 1,952 )


St Vincent's ( 1,886 )

Beaumont ( 1,695 )

Cavan ( 1,527 )

Navan ( 1,474 )

St James's ( 1,452 )

Kerry ( 1,452 )

Cappagh ( 1,373 )

Naas ( 1,282 )

Sligo ( 1,255 )

Crumlin ( 1,224 )

Outpatient Chronological scheduling for Orthopaedics & Paediatric Orthopaedics (31 Jan’17)

Long wait’s with NO

appointment date


IP/DC waiting list for Orthopaedics & Paediatric Orthopaedics

IP/DC waiting list for Orthopaedics – Aug’11 … Jan’17


IP/DC wait list 9 months & over for Orthopaedics – Aug’11 … Jan’17


IP/DC wait list: Orthopaedics & Paediatric Orthopaedics: 14% increase in 1 year (as at 31 Jan’17)

31/1/2017 04/02/2016


Day Case &

Inpat Wait 0-3

Months

3-6

Months

6-8

Months

8-12

Months

12-15

Months

15-18

Months

18-24

Months

24-36

Months

36-48

Months

48+

Months

Grand

Total

2017-01-31 4,103 2,727 1,187 1,879 829 458 194 84 6 2 11,469

2016-02-04 3,980 2,667 1,129 1,429 509 167 121 54 9 1 10,066

% 1 Yr change 3% 2% 5% 31% 63% 174% 60% 56% -33% 100% 14%

Cappagh ( 2,009 )


Tullamore ( 1,273 )

Galway UH ( 826 )

Mayo ( 788 )

Crumlin ( 629 )

Letterkenny ( 559 )

Temple st ( 510 )

St James's ( 443 )

SIVUH ( 437 )

Sligo ( 422 )

Navan ( 416 )

Kilcreene ( 382 )

Beaumont ( 212 )

Mater ( 204 )

UH Waterford ( 163 )

Croom ( 126 )

Connolly ( 82 )

Cappagh ( 2,221 )


Tullamore ( 936 )

Galway UH ( 890 )

Crumlin ( 636 )

Mayo ( 589 )

Letterkenny ( 485 )

Sligo ( 432 )

Temple st ( 387 )

St James's ( 360 )

Navan ( 330 )

Kilcreene ( 291 )

SIVUH ( 268 )

Beaumont ( 249 )

Mater ( 225 )

UH Waterford ( 112 )

Croom ( 93 )

St Vincent's ( 63 )

IP/DC wait list: Orthopaedics & Paediatric Orthopaedics split Adult, Child & Endoscope (31 Jan’17)


Work force and number of locums Surgeons and locums ANP …

Irish National Orthopaedic Register (INOR)

• To provide a defined epidemiology of joint replacement surgery in a particular patient population

• Timely generation and sharing of information on the outcomes of joint

replacements and identify risk factors for a poor outcome • Optimise the pre-operative, peri-operative and post operative process to

improve quality of service • Provide orthopaedic surgeons the opportunity to participate and contribute to

measurable clinical audit

Irish National Orthopaedic Joint Register (INOR) Objectives

• Increase patient safety, confidence and overall experience. • Early detection of failing devices, procedures, institutions or surgeons or

any combination thereof) to limit the impact for future patients • Enable better identification and management of individuals in at-risk

groups to improve patient experience and outcomes • Reduce surgical revision rates and improve both costs and patient

outcomes. To monitor implant performance against the group norms for Ireland and within the wider international community

• Monitor patient outcome and to use patient self scoring as part of the

indicator for device failure (not just revision surgery)

Initiation site ----- South Infirmary Victoria University Hospital Development Site -----Midland Regional Hospital Tullamore

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52.9

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567891011

Hospital with Trauma & orthopaedic 24/7 surgery Planned orthopaedic specialty only hospitals

Kerry

Limerick

Galway

Mayo

Sligo

Cork

Waterford

Drogheda

Connolly Beaumont Mater St James’s Tallaght St Vincent’s

Temple st Crumlin

Letterkenny

Tullamore

Hospital with emergency trauma orthopaedic and Planned Orthopaedic services

Cappagh

Navan

Kilkreen

South Infirmary

Croom

Activities • Trauma assessment Clinics • Muscular skeletal Physio clinics • Enhanced recover programms • Joint schools • Pre-admission & DoSA • Capacity planning • Hip Fracture protocol and register • TARN • INOR • Trauma Network • Workforce planning

Thank you

Documents

SIX YEARS OF DATA - rcsi.ie prof O'Byrne.pdf · SIX YEARS OF DATA Professor John M. O’Byrne, President, Irish Institute of Trauma & Orthopaedic Surgery, Joint National Clinical