Care of the Patient with a Fractured

Neck of Femur Injury

Fiona Nielsen – Quality Coordinator Surgical CSU

Our health service

75,000 in-patients

900 beds

70,000 emergency attendances

12,500 surgical operations

6,200 staff

#NOF Presentations

2010-2011- 262

2011-2012- 246

165,000 out-patients

Objectives- A Walk Through

• Diagnostics

– Metrics

• Improvements

• Lessons Learnt

– What worked and what didn’t

• Project Outcomes

Information we were given

• Health Round Table Information

• DRG 108- Neck of Femur Fracture

• Austin Health had an average LOS >14 days

• The four exemplar hospitals average LOS around 8 days

• Aim – Reduce Length of Stay to that of exemplar hospitals

Background

Visit to another facility and a literature search revealed we

needed:

1.Full time Head Of Unit – implemented Sept 2009

2.More theatre sessions and better access for trauma –

implemented over 2009

3.Institute ortho-geriatric service – commenced February

2010

OGS

Orthogeriatric Service

–New full-time Orthogeriatric registrar

–Over seen by a senior geriatrician

• Involved in every patient >65yo with low-impact trauma #

• Ortho in Rehab hospital

• Geriatric in Acute hospital

Diagnostics

• Walk Thorough

– Follow the patient journey from the front door to discharge.

– Chance for two way communication and to understand work flows

» What works

» What doesn’t

• File audit- 30 patient files

• Interview with patients and their families

Walk Through-Fact finding

Where the patient goes

Steering Committee

• Attendance List List

• Executive- CEO, CMO, Executive Directors

• CSU/ Medical Directors

• Senior Clinical Staff- ED, Anaesthetists , Orthopedics

Geriatricians

• Austin By Design

• Physiotherapy

• Access, Care & Patient Flow coordinators

• NUM

• Ward nurses

• Theatre staff…and more

Ambulance/ED Ambulance/EDAcute Ward - Pre-

operative

Acute Ward - Post-

operative Sub Acute Care Discharge Measures

Does Amb. inform ED that a

pat. with a hip # is arriving?

Is a dementia/delirium

assessment undertaken?

Is a Hip # clinical pathway

used?

Is there a dedicated

orthopaedic trauma list 7/24

Is the pain score recorded? Do the pain management

team visit the patient?

Are there daily MDT

meetings?

Is discharge event driven? Are the no. of Hip #s pa

known?

No No No No Yes Not Routinely No No Yes

Emergency

DepartmentRadiology

Are there diff. in the std.

b/w ortho and non ortho

ward?

When is the patient placed

on the Op. Th. List?

Is there a protocol in place if

Pat. Surg. cancelled?

Are there daily MDT team

meetings?

Does the patient have a DD? Is there a home assessment

in advance of DD?

Is the time from ED triage to

surgery reviewed?

When the pat. arr. in ED

who is involved in the

triage?

How is the request for

imaging services received? YesOn orthopaedic

assessmentNo Yes Yes No

Nurse ElectronicallyAre variations from clinical

pathways analysed?

Is the time patient is

booked for surgery

recorded?

If the op. is delayed >24 hrs

is the reason recorded?

Is mobilisation time post

surgery recorded?

Is there A/H services

available at the W/E?

When are prescriptions sent

to pharmacy?

Is the mobilisation time

known?

Is there a Hip # Clin.

Pathway and is it used?

How is pat. trans. to/from X-

ray and is it timely? No Yes No Yes No Yes

NoWithin 60 mins

of request

Is the patient kept in a same

sex bay?

Are std. anaesthesia prot.

for Hip # used?

If the op. is delayed >48 hrs

is the reason recorded?

Does the patient have a D/D Is discharge event driven? Is bone resorptive therapy

part of the prescription?

Is the LOS of stay for

acute/sub-acute reviewed?

?

In ED are std. procedures

followed 24/7?

Is there a std. protocol for

imaging Hip # pat.? When possible No No No No Yes No

No NoIs the D/D agreed when the

decision to operate is

made?

Are std. Prostheses used? Have risk assessment been

completed?

Does the patient have a

nutritional assessment?

Is the pat. referred to a

Fracture Liaison Service?

Is the number of times

surgery cancelled recorded?

?

Is there a std. pain

management protocol?

Who reports on the images?

No Yes Yes Yes No No

No Senior ED DrDoes the geriatrician pre-op

assess 7/24?

Who provides anaesthesia? Have referrals to SW, OT

been made?

Is there a waiting list for

patients into sub-acute

beds?

Is there an aftercare contact

number provided?

What % patients are

transferred home?

Is there a falls risk

assessment done?

When are the images

reported on? NoOther

consultant/registYes- social work and OT Yes For the ward Not known

No Within 60 minsAre allied health available

at the W/E?

Who performs the surgical

procedure?

Do W/E transfers occur? Are pressure ulcers

recorded ?

Is there community

involvement through local

council?

Are patients/carers

surveyed?

?

When is the Ortho. Dept.

Contacted ?No Registrar Sometimes Yes No

After Xray

confirms #

Is there food available if

surgery is cancelled?

Are Op. Th. Team briefings

held?

Is discharge event driven? % of patients who are

discharged on or before

their EDD

A3?

When is the Orthogeriatric

registrar contacted?No No No

Maybe delayedAre there std. handover

protocols?

Is there a record of when

A/Bs administered?

How often does the OG do

ward rounds?

Is the in-hospital mortality

after hip # known?

Is the Emerg Surgery Nurse

Coord informed?No Yes Mon-Fri Yes

A3

No - positionAre daily MDT meetings

held?

Are there agreed post

operative guidelines?

Are there constraints in

transferring pts to sub-acute

care?

Is the 30 day mortality

known?

Is the patient transferred to

a known Ortho. Ward?Yes Yes Yes No

YesWho declares the patient is

fit for surgery ?

Are there written protocols

for Post Op N/V?

Does the patient receive

nutritional supplements?

No No

Ambulance/ED RadiologyAcute Ward - Pre-

operative

Acute Ward - Post-

operative Sub Acute Care Discharge Measures

Our Hip Fracture Pathway - Austin Health

Operating Theatre

Operating Theatre

Where we focused

• Three main areas

– ED

– Pre operatively

– Post operatively

• Three main care elements

– Fasting

– Pain management

– Delirium

The Case for Change• Why not be exemplar?

• The care delivered to this patient group should be best

practice.

• Senior Clinical Staff became the leaders for this vision

• Confronting to clinicians

• Challenges to beliefs

Finding the problems is simple, understanding and

developing solutions is complex and solutions can be

simple

0%

10%

20%

30%

40%

50%

60%

70%

65-79 80+ 65-79 80+ 65-79 80+ 65-79 80+ 65-79 80+

% o

f To

tal p

resen

tati

on

s% of Presentations by

Age

Red = Austin Health

Myth busting

ED

Before

• No Standard Pain-relief

• Mostly narcotic-based

• Minimal use of blocks (<10%)

• No review of analgesia efficacy

• Multiple trips to Radiology

• Gap from ED until drug chart written up (on ward)

Emergency / Radiology Sets

Standarised

Analgesia

• Regular Paracetamol

• Incremental boluses of Fentanyl to effect (or Morphine)

• Regular pain scores on function

• Fascia Iliaca Blocks –Blind and in >80% of presentations

0

10

20

30

40

50

60

70

80

90

100

Mar-May2010

Jan-11 Feb-11 Mar-85 Apr-85 May-11 Oct-12

% o

f P

ati

en

ts h

av

ing

FI b

olo

cks i

n E

D

FI Blocks In ED

On the ward

• Admitted to the ward at various

times of the day.

• Orthopaedic staff in theatre.

• Variable pain relief

• Fasted for varying lengths of time

• Time to theatre varied

• Information for patients and

families

Fasting

• Big source of patient and family dissatisfaction

• Highly variable times

– Not documented

– Not monitored

– Frequent cancellations

• Patients often deconditioned on admission

Hunger clock

Set to monitor fasting

By the patients bedside

Counts down the agreed 12 hours

Initially reduced fast to 9 hours

Recent measurement

September 2012-

back to 13 hours

Pain• No Standard Pain-relief

• Delay until patient admitted and drug chart written

• Mostly narcotic-based

• Usually inadequate doses / Intermittent or infrequent

doses

• No review of analgesia efficacy

• Usually ceased if patient became confused

Pain Plan

• Designed by Orthogeriatrician/ Orthopaedic Surgeon/ Acute

Pain Services

• Nursing Pain Champions

– Nursing Staff Familiar with PCAs

– System for PCAs and functional pain scores/ Campbells

– CEASE protocols

• Months in designing the algorithm

• Plan to roll it out and re-measured a week

• Failed in the first two days

WHY?

Answer-

Residents and Interns- didn’t know how to write up PCAS

And they needed permission- for narcotics in the elderly

Model from the IHI

March 2011-March 2012

0

2

4

6

8

10

12

14

Ma

y-0

9

Jun-0

9

Jul-0

9

Aug-0

9

Sep-0

9

Oct-

09

No

v-0

9

De

c-0

9

Jan-1

0

Feb

-10

Ma

r-1

0

Apr-

10

Ma

y-1

0

Jun-1

0

Jul-1

0

Aug-1

0

Sep-1

0

Oct-

10

No

v-1

0

De

c-1

0

Jan-1

1

Feb

-11

Ma

r-1

1

Apr-

11

Ma

y-1

1

Jun-1

1

Jul-1

1

Aug-1

1

Sep-1

1

Oct-

11

No

v-1

1

De

c-1

1

Jan-1

2

Feb

-12

Ma

r-1

2

Days

Average Length of Stay (HRT Data)

Exemplars

A H

Project starts

Pain Plan Starts

Standardised Care

• Patient receives the same care no matter what time they

are admitted.

• Patients receive analgesia via a pain plan designed by

senior clinicians

• Nursing staff make this a priority

Management of Clinical Knowledge

Delirium

Baseline measurement

-Sept 12 – 90% of patients

had CAM score done on

admission.

-Clocks in rooms

-Family aware of risks

-Day time/night time

-Plan to spread to other

wards

-All new nursing staff

trained in assessment

Nursing Management

The Patient Experience

Happy

Supported

Safe

Good

Comfortable

In Pain

Worried

Lonely Sad

PatientsArriving/ED Information Waiting Going to theatre Post Op Phase Ward 8N Ward 11 Leaving

3 3 1 1 3 2

3 3 1 1 3 2

3 3 2

3 3 3 2

1 1

1 1

1 1 1 1 1 1

1 3 3 3 2 2

1 1 1 1

3 3 3 3 1 1 1 1

2 2 1 1 1 1

2 2 1 1 1 1

3 1 1 1 1 1 1 3

3 3 1 1 3 3 3 3

3

3

3

1

2

3

4

5

6

7

8

9

10

11

12

PatientsArriving/ED Information Waiting Going to theatre Post Op Phase Ward 8N

13 3 1 1 3 2

3 3 1 1 3 2

23 3 1 2

3 3 3 2 2

31 1

1 1

41 1 1 1 1

1 3 3 3 2

5 1 1 1

3 3 3 3 1 1 1

62 2 1 1 1 1

2 2 1 1 1 1

73 1 1 1 1 1 3

3 3 1 1 3 3 3

8

3

9

Patient Stories

• Very powerful

• Can cause distress to staff

• Use quotes: “ I was in that much pain I was going no where”

“They starved her and staved her”

• Manage up – encourage staff to talk about improvments

Executive Leadership

Executive Interview with patients

Visibility of projects importance

Accountability for Care

People remember what they have

seen

Becomes personal

Sustainability questionnaire

Process

1.Benefits beyond helping patients

2.Credibiltiy ( to affected staff) of benefits from improved processes

3.Adaptability of improved process

Staff

1.Staff involved and training to sustain process

2.Staff attitudes toward sustaining the improved process

3. Senior leaders responsibility taking and staff action toward the leader

4. Clinical leaders responsibility taking and staff action toward the leader

Organisation

1. Effectiveness of the system to monitor progress of the improvement

2. Fit with the organisation strategic aims and culture

3. Staff attitudes toward sustaining the improved process

Sustainability Summary

1.0 3.0 5.0 7.0 9.0 11.0 13.0 15.0

Benefits beyond helping patients

Credibility of the evidence

Adaptability of improved process

Staff involvement and training to sustain theprocess

Staff behaviours toward sustaining the change

Senior leadership engagement

Clinical leadership engagement

Effectiveness of the system to monitor progress

Fit with the organisation's strategic aims andculture

Infrastructure for sustainability

Potential

May

February

October

July

Measures

Measures- to September 2012

Pain

Plan

Started

Fasting

Times

Controlled

Theatre times

Ambulance/ED Ambulance/EDAcute Ward - Pre-

operative

Acute Ward - Post-

operative Sub Acute Care Discharge Measures

Does Amb. inform ED that a

pat. with a hip # is arriving?

Is a dementia/delirium

assessment undertaken?

Is a Hip # clinical pathway

used?

Is there a dedicated

orthopaedic trauma list 7/24

Is the pain score recorded? Do the pain management

team visit the patient?

Are there daily MDT

meetings?

Is discharge event driven? Are the no. of Hip #s pa

known?

No Yes- CAM YesDedicated

trauma listYes Yes No Yes

Emergency

DepartmentRadiology

Are there diff. in the std.

b/w ortho and non ortho

ward?

When is the patient placed

on the Op. Th. List?

Is there a protocol in place if

Pat. Surg. cancelled?

Are there daily MDT team

meetings?

Does the patient have a DD? Is there a home assessment

in advance of DD?

Is the time from ED triage to

surgery reviewed?

When the pat. arr. in ED

who is involved in the

triage?

How is the request for

imaging services received? YesOn orthopaedic

assessmentYes Yes Yes Yes

Nurse ElectronicallyAre variations from clinical

pathways analysed?

Is the time patient is

booked for surgery

recorded?

If the op. is delayed >24 hrs

is the reason recorded?

Is mobilisation time post

surgery recorded?

Is there A/H services

available at the W/E?

When are prescriptions sent

to pharmacy?

Is the mobilisation time

known?

Is there a Hip # Clin.

Pathway and is it used?

How is pat. trans. to/from X-

ray and is it timely? Yes Yes Yes Trialled Yes

YesWithin 60 mins

of request

Is the patient kept in a same

sex bay?

Are std. anaesthesia prot.

for Hip # used?

If the op. is delayed >48 hrs

is the reason recorded?

Does the patient have a D/D Is discharge event driven? Is bone resorptive therapy

part of the prescription?

Is the LOS of stay for

acute/sub-acute reviewed?

?

In ED are std. procedures

followed 24/7?

Is there a std. protocol for

imaging Hip # pat.? When possible No Yes Not always No Yes Yes

Yes YesIs the D/D agreed when the

decision to operate is

made?

Are std. Prostheses used? Have risk assessment been

completed?

Does the patient have a

nutritional assessment?

Is the pat. referred to a

Fracture Liaison Service?

Is the number of times

surgery cancelled recorded?

?

Is there a std. pain

management protocol?

Who reports on the images?

No Yes Yes Yes No Yes

Yes Senior ED DrDoes the geriatrician pre-op

assess 7/24?

Who provides anaesthesia? Have referrals to SW, OT

been made?

Is there a waiting list for

patients into sub-acute

beds?

Is there an aftercare contact

number provided?

What % patients are

transferred home?

Is there a falls risk

assessment done?

When are the images

reported on? NoOther

consultant/registYes- social work and OT Yes For the ward Known

No Within 60 minsAre allied health available

at the W/E?

Who performs the surgical

procedure?

Do W/E transfers occur? Are pressure ulcers

recorded ?

Is there community

involvement through local

council?

Are patients/carers

surveyed?

?

When is the Ortho. Dept.

Contacted ?Registrar Sometimes Yes Interviews

After Xray

confirms #

Is there food available if

surgery is cancelled?

Are Op. Th. Team briefings

held?

Is discharge event driven? % of patients who are

discharged on or before

their EDD

A3?

When is the Orthogeriatric

registrar contacted?Yes No No

Maybe delayedAre there std. handover

protocols?

Is there a record of when

A/Bs administered?

How often does the OG do

ward rounds?

Is the in-hospital mortality

after hip # known?

Is the Emerg Surgery Nurse

Coord informed?Yes Mon-Fri Yes

A3

No - positionAre daily MDT meetings

held?

Are there agreed post

operative guidelines?

Are there constraints in

transferring pts to sub-acute

care?

Is the 30 day mortality

known?

Is the patient transferred to

a known Ortho. Ward?Yes Yes Yes No

YesWho declares the patient is

fit for surgery ?

Are there written protocols

for Post Op N/V?

Does the patient receive

nutritional supplements?

No

Ambulance/ED RadiologyAcute Ward - Pre-

operative

Acute Ward - Post-

operative Sub Acute Care Discharge Measures

Our Hip Fracture Pathway - Austin Health

Operating Theatre

Operating Theatre

Hospitals are Frogs – Not bicycles -Mant

Lessons learnt

• Complex Systems

• Understand systems and work

• Go beyond the simple-

– Problems are complex

– Solutions can be simple

• Align to common goals

• Don’t listen to No

Leading Change Humbly

• Seek out and listen to the wisdom of stakeholders.

• Communicate Communicate Communicate

• Ask people to agree - to a trial.

• Seek to understand rather than judge

– Value the dissenter

• Respect the workplace