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Improving Quality of Care for Patients with Fractured Neck of Femur The Royal Surrey County Hospital NHFD Regional Meeting February 2010 The Royal Surrey County Hospital 528 acute Beds 2800 staff District General serving 320,000


  1. Improving Quality of Care for Patients with Fractured Neck of Femur The Royal Surrey County Hospital NHFD Regional Meeting February 2010

  2. The Royal Surrey County Hospital • 528 acute Beds • 2800 staff • District General serving 320,000 population • Cancer Centre serving 1.2 million • Cancer Centre serving 1.2 million • Combined Trauma and Orthopaedic wards • 350-400 patients with # NOF per year

  3. Local Drivers for Change • Recognition by clinicians of need to improve care • RCP and NHFD Audits • High profile complaints • Previous attempts at improving care • Geriatric post-take review of patients with #NOF Geriatric post-take review of patients with #NOF • Ring fenced rehabilitation beds • Weekly referrals ward-round • Buddy ward system Death of an elderly man blamed on hospital system Death of an elderly man blamed on hospital system Surrey Advertiser, Sunday 24th February 2008

  4. National publications and drivers for change • United they Stand 1996 • NSF for older people 2001 • Blue Book 2003 (revised 2007) • RCP National Audits 2006 • RCP National Audits 2006 • NHFD 2007 • Best Practice Tariff

  5. Fractured Neck of Femur – why start here • Have to start somewhere • Most significant fragility fracture • Measurable using NHFD • Often long length of stay • Often long length of stay • Complex pathway • Significant Morbidity and Mortality

  6. Why ortho-geriatrics “The days of entrusting complex medical management to inexperienced medical management to inexperienced and overburdened orthopaedic juniors must be ended”

  7. Supporting the whole pathway……… GP Patient with IMC team Social Services fractured neck Rehab beds of femur Occ. Therapy Complex Discharge Physiotherapists Physiotherapists planning Nurses Theatre Geriatrician Anaesthetics Orthopaedics X-ray End of Life Leadership Planning A&E Make of MDT Decisions ambulance

  8. Business Case for Ortho-Geriatrician • Modelled on Stroke Service • Two established Geriatric Medicine consultants (new post to back fill) • Funding from Orthopaedics • Six funded DCC sessions • Daily ward-rounds and weekly MDT • Virtual #NOF unit • Data on reduction of LoS from another Trust

  9. RSCH Improvement Methodology: DECODER Framework 1 2 3 4 5 6 E E VALUATE D D EFINE E STABLISH E C C REATE O O RGANISE D O D & R R EFINE Focus the Team Confirm “As Is” Cause & Analysis Future State Plan Implement Learn & Share Define the need Establish what Create the best Organise the Do it! Evaluate and Refine for this project in happens in the solution to implementation Aim the context of the process and what achieve the and improvement P1st Goals it could do project goals Team Formed and Process issues are Team is Team is Focused Team has refined Team reflects on its all stakeholders fully understood committed to the and know what and implemented achievement and Effect agree the need for by the Team and chosen solution they need to do the plan and identifies future the project all Stakeholders monitors the opportunities improvement Values : Clinical Quality, Patient Experience, Efficiency, Growth

  10. The Team Wide representation across the Trust - both by function and discipline • Trauma & Orthopaedics • Geriatrics • Nicky Waring (Surgical Associate Director) • Helen Wilson (Consultant) • Anne Stokoe (Speciality Manager) • Hiro Khoshnaw (Consultant) • • Mark Flannery (Consultant) Mark Flannery (Consultant) • • Anaesthetics Anaesthetics • Mike Lemon (Consultant) • Mike Scott (Consultant) • Jo Michie (SBU Matron) • Matt Berry (Consultant) • Andie Blake (Ward Sister) • Gareth Jones (Consultant) • Fran Hole (Trauma Nurse Coordinator) • Gillian Foxall (Consultant) • OT and Physiotherapy • Others • Sam Towers • Wendy Dengate (Radiology Manager) • Vicki MacDonald • Pip Lacey (Site Nurse Practitioner lead) • Kate Iveson • Patients First • Accident & Emergency • Ann Spence (Programme Director) • Mark Pontin (Consultant) • David Tyler (Lean Consultant) Key Lesson : Establish a multi-disciplined team and agree the vision, scope and objectives. 10

  11. Used Data to review Capacity, demand, usage and flow

  12. Benchmarking A detailed literature study and benchmarking against other Trusts’ performances was completed prior to the formal launch of the project. ��

  13. Old Patient Pathway No falls &'������ No end to end Bone ����������+��, risk ownership protection assessment of the patient �������������� ��������� #�������� � ������� ���� ���� ���������� �������������� ��� ������� ��* May re-fall ������� ������������ ��������� Patient owned By FPH &�������'��� 68% ������� �������������� ��$�%��������������� ����������� ���������� ������������ ��� !���������� ($�������������� Not always "������ ���� available Anaesthetic Ambulance Weekday Approval Decision only )�$����*����� )�$����*����� required required “Project 5” ����3���� &'������ SHO Delays �)������������ Geriatric SpR 7% X-ray not One Involvement Review )�$����.��0� Available Per Day Started ($��*���������������3��� �$������������� %��� &/0� #���������� ����1��� "#�� &��-��� #���4� "�'����� *����������� �������� ��������� � ������������ ������� � ������1 �������� � 7���������� � ������������ ����'������ 21*�, �����������4� 5!�6��- *���'��, 3���� ����-�� ��6������$� ������1 ��������3��� ����� ��������� ��������$�� ����� .��0�3��� *�.� �������� ������� �.��0� 3��������� ���� ������� 3������,� � ���� !��������� Intermediate Care Average "������ involvement 2 – 3 days 1 hr #���, �$�����1������������ Average 4.1 hrs Average 36.9 hrs Average 23.6 Days Trauma Nurse Physiotherapy Geriatrics 13

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