The Future Model of Physician Led Elderly Trauma

RoyalSurreyCountyHospital

Proposal for Ortho-Geriatric Service

The future model of physician led elderly trauma

“The days of entrusting complex medical management

to inexperienced and over-burdened orthopaedic SHOs

must be ended”

The Care of Fragility Fracture Patients, British Orthopaedic Association, 2003

background

current service

issues

drivers for change

evidence from other centres

proposed model of care

next steps

Background

A recent orthopaedic work-stream was set up to explore how to accommodate more elective work to meet waiting time targets.

A review of bed occupancy highlighted the length of stay of patients following fracture neck of femur.

Money to fund a middle grade in ortho-geriatric services as a six month pilot was found and discussion between Orthopaedic and Geriatric Medicine departments took place.

It was agreed that an ideal ortho-geriatric service needs to be consultant-led and that running a pilot that was unlikely to be successful was inappropriate.

This report summarises the need for a comprehensive consultant led ortho-geriatric service, using data from pilot projects in other Trusts.

Current Service

There are 56 orthopaedic beds on Bramshott and Ewhurst wards.

A care pathway facilitates fast-track admission of patients with fracture neck of femur to the ward.

Patients are clerked by the ward F1 doctor and reviewed by the Orthopaedic SpR.

X-rays reviewed in trauma meeting and operation planned for next trauma list.

Post-operative day to day care is from the F1 doctors.

Acute medical problems are often out of hours and dealt with by the on-call medical team.

Referral for rehabilitation is made to the Geriatric Medicine Secretaries and allocated in turn to each of the five geriatricians. The patient is reviewed by the SpR/SHO and then by the consultant on their next ward-round.

Operational Issues

No designated orthogeriatric ward/area (recommended by NSF for Older People)
No formal multidisciplinary team/ discharge planning meetings
Lack of liaison with medical and anaesthetic staff pre-operatively
Delays to emergency surgery for non clinical reasons/dubious clinical reasons
Poor continuity of medical input for patients with complications
Delays in referral for rehabilitation
Delays in discharge to residential and nursing homes

Clinical care issues

Fractured neck of femur care pathway not well used with poor documentation
Variable clinical evaluation, often with no holistic thought
Poor social assessment with consequent post operative delays
Poorly documented pre-operative cognitive assessment
Lack of documentation of communication with relatives
Lack of a fracture liaison nurse or similar designated person to perform a falls and osteoporosis assessment on older people with a fragility fracture (NSF for Older People)
No protocol for thromboprophylaxis
Poor medical lead on nutrition
High incidence of post operative infections including aspiration pneumonia, UTI & CDT diarrhoea
Poor recognition and palliation of dying patients

Staff issues

Poor supervision or support for F1 doctors highlighted at recent Deanery review
Difficulties with therapists being consultant based rather than ward-based
Geriatrician input varies with lack of consistency

Drivers for change

Need to meet orthopaedic elective surgery waiting times

Possible withdrawal of Foundation Posts

Standards of care for orthogeriatrics as outlined in NSF for Older People and NICE

Results of National Audit of Organisation of Services for Falls and Bone Health for Older People (Feb.2006) and recommended action plan

Demonstrate ideal model of care – (poor service at local trusts)

Evidence from two other trusts – Northwick Park (NPH) and St Mary’s Hospital (SMH)

Both these Trusts have introduced a Consultant-led Ortho-Geriatric Service in the last two years offering

Daily review of new or sick patients with fracture neck of femur

Twice weekly consultant led ward-rounds of in-patients

Weekly Consultant-led Multidisciplinary meetings

Liaison with early supported discharge team

Out-patient follow-up as appropriate

Overview of Audit project outcomes to date

Length of Stay

Acute inpatient, down from 26 to 23 days (reduction of 12%) – NPH

Total NHS stay, down from 40 to 20 days (reduction of 50%) - SMH

Mortality rate

down from 11% to 4.5% (reduction of 59%) – NPH

still 11% at SMH

Complaint rate

down from 7% to zero – NPH

down to zero - SMH

Happier junior doctors
Changing working practices
Improved Team working and learning
Strengthened liaison with community-based rehabilitation
Improved discharge and follow-up plans

Proposed Model of Care

Two Geriatric Medicine Consultants running service provides daily ward-rounds and cover for annual leave.

Daily ward-round of new / sick patients

Each consultant has twice weekly ward-rounds

Combined consultant led MDT

Patients followed up in falls clinic where relevant

Consultant input into Early Supported Discharge Team / Intermediate Care Team

Monday / Tuesday / Wednesday / Thursday / Friday
Consultant 1 WR and review new patients / Consultant 2 WR and review new patients / Consultant led MDT and review of new patients / Consultant 1 WR and review new patients / Consultant 2 WR and review new patients

Next Steps

Five sessions of Consultant time

4 x 2 hour ward-rounds (2PAs)

MDT and liaison with IMC (0.25 PA)

Out-patient follow-up (1PA)

Administration (0.5PA)

Family meetings / talking to relatives (0.25 PA)

SPA for educational supervision of F1 doctors / development of service / education of MDT (1PA)

Other Staff

One dedicated Ortho-geriatric F1 doctor

? one dedicated Ortho-geriatric F2 doctor

Unit-based Physio / OT / Social Worker

SHA checklist for elderly trauma problems & solutions

A&E attendance / Pre-operative assessment / Surgery / Post-operative rehabilitation and discharge / Falls avoidance
Admission within 1 hour of A&E attendance / Surgery within 24 hours of admission / Reductions in cancellations, readmissions and mortality / Mobilisation within 24 hrs of surgery
Proportion of #NOFs discharged within four days of surgery
Increasing the percentage of #NOFs discharged to their original place of residence
Post-operative relative to pre-#NOF mobility
Common LoS drivers in the #NOF pathway
#NOF information not recorded in a format that can be readily shared or that tracks critical points in the patient pathway where delays occur
Lack fast-track #NOF protocol in A&E and failure to differentiate simple from complex cases
Insufficient non-consultant (especially nurse \and paramedic) autonomy in non-complex cases, e.g. referral for diagnostics and directly admission
Non-urgent diagnostics carried out in A&E, lack of protocols for extended diagnostics
Poor co-ordination, delays and lack of communication across disciplines (A&E, anaesthetics, orthopaedics, geriatrics and therapies); delays in notifying key staff of #NOF admissions / Lack of clarity on appropriate clinical and discharge management of individuals with complicating factors, e.g. co-morbidities, dementia, social etc.
Lack of multidisciplinary working between orthopaedics, anaesthetics and care of the elderly physicians
Process of cancelling operations on medical grounds lacks consistency
Delay in initiating patient assessment and discharge planning and lack of dated milestones including a target discharge date; failure to agree realistic clear rehabilitation goals
Failure to initiate therapy regime within shortest period permissible
Inappropriate diagnostic pathways, lack of consistent criteria, delays awaiting results / No option for same-day surgery
No weekend trauma lists
Poor productivity and low utilisation of available trauma lists
Down-grading and de-prioritisation of #NOF patients
Failure to notify medical and therapy teams following surgery
#NOFs not transferred to medical/rehabilitation beds / Insufficient capacity for on-ward or rapid response therapy and assessment services, including weekends
Nursing staff lack specialist skill-set to support objectives of early mobilisation
No dedicated orthogeriatric/trauma rehabilitation beds
Lack of information and poor communication with patients, families and carers
Poor communication across acute and primary care/social services interface, lack of trust in and understanding of community service offering
Geographical variations in community rehabilitation services, inconsistent and uncoordinated patient care between locations and variations in transition points within pathway
No rapid-access to specialist clinical input to support decision-making, especially out of hours / Poor management of in-hospital falls risks; no routine risk-of-falls assessments
Lack of community programmes focused on healthy living, exercise and activity
Poorly-defined or inconsistent falls pathway; weak linkages to other services
Failure to systematically identify and manage high-risk populations
Generic measures to improve LoS
Agree a minimum dataset to include quality/outcomes measures and share within organisations and across the sector.
Develop and implement a fast track #NOF protocol; support clinical decision-making by junior doctors, nurses and therapists; pilot nurse-led admission
Use of multidisciplinary teams (MDTs)
Create a dedicated trauma/#NOF co-ordinator (nurse or health professional)
Streamline access to diagnostics, including nurse-led referral, non-urgent diagnostics to occur post admission / Agree robust fitness to operate criteria. Only cancel with consultant anaesthetist signoff.
Joint orthopaedic-anaesthetic team meetings to prioritise trauma lists
Streamline diagnostics pathways to accelerate decision to admit.
Create protocols for non-core diagnostics and reduce volume of pre-admission testing.
Initiate care planning on admission, with dated milestones for surgery, mobilisation and discharge.
Link to medical, therapy, discharge and social care teams on admission.
Ring-fence #NOF beds / Ad hoc weekend trauma lists, clear all pending #’NOFs by Friday
Incorporate #NOF pathway into broad programme to increase theatre utilisation and productivity
Conduct baseline audit of #NOFs, map patient pathway(s) and identify bottlenecks.
LoS on agenda of dedicated trust-wide forum, e.g. IPH / Rapid transfer from surgical to dedicated medical/orthogeriatric beds, with dedicated (and out of hours) therapies and nurse-led discharge
Standardisation of fitness for discharge criteria
Establish/strengthen community-based musculo-skeletal teams to include orthogeriatric input, follow-up systems and community rehabilitation
Introduce single point of access to streamline communication between secondary and community services, link with single assessment process
Introduce fast track assessment process
Ensure that therapy teams share information on treatment, to ensure continuity of care following discharge / Review falls on wards and adopt best practice
Use community healthy lifestyles and exercise initiatives run by local authorities and charities
Falls services to identify and target high-risk individuals