How Clinical Process Simulation Changed Hip Fracture Pathway

How Clinical Process Simulation Changed Hip Fracture Pathway in Torquay Andrew Fordyce, Rachel Blackshaw, Rob Lofthouse, Mike Swart Torbay Hospital 31 st May 2012 Cumberland Initiative 310512 1

Aim for Hip Fracture Pathway Reduce time from ER to surgery n Reduce pain before surgery n We have changed elective surgery in Torquay n Over 7 years no change in hip fracture n 31 st May 2012 Cumberland Initiative 310512 2

Old pathway Multiple hand overs n Evolved not planned n Thought to be in patients best interests n Accepted practice across UK n 31 st May 2012 Cumberland Initiative 310512 3

Old Hip Fracture Pathway Primary Care Paramedic ED Nurse ED Doctor Ward Nurse Ward Doctor Ward 24 -72 hr

New Hip Fracture Pathway Referral from Paramedic • Telephone trauma nurse • Start planning for surgery Pre. Operative Admission Intra. Operative Post. Operative Follow Up

Fractured Neck of Femur Pathway • Paramedic hand over to trauma nurse in ED • Bloods and nerve block by nurse • Is early op possible? Referral from Paramedic Pre. Operative Admission Intra. Operative • Patient and family informed, reassured and expectation set • Escort to XR and get Orthopaedic review Post. Operative Follow Up

Fractured Neck of Femur Pathway • Pre op preparation • Do the essential pre op • Anaesthetist, Critical Care, Trauma and Orthopaedics • Start planning post op care Referral from Paramedic Pre. Operative Admit to Theatre Complex Intra. Operative • Go to theatre complex • If no slot before 1600 hrs go to ward and first on the list next day Post. Operative Follow Up

Fractured Neck of Femur Pathway • IV paracetamo; , NSAIDS, LA, Avoid opiates Referral from Paramedic Pre. Operative Admit to OR Complex Intra. Operative • Prepare for early mobilisation and eating Post. Operative Follow Up

Fractured Neck of Femur Pathway Referral from Paramedic Pre. Operative Admit to OR • • • Early mobilisation Eat and drink Medical, physio and OT Daily MDT on ward Social Services Complex Intra. Operative • Regular oral analgesia • Paracetamol and NSAIDS • Avoidance of systemic opiates Post. Operative Follow Up

Fractured Neck of Femur Pathway Referral from Paramedic • • Pre. Operative Data collection Analysis of data Feedback to all Identify and fix problems Admit to OR Complex Intra. Operative Post. Operative Follow Up

What did we do to make this change?

We applied Lean Thinking n n n Specify Value Understand demand Understand the value stream Pull Flow Pursue Perfection Source: Womack, J. & Jones, D. (2003). Lean thinking: Banish Waste and Create Wealth in Your Corporation. New York: Free Press

What did we do? n Specify value n n No waiting No pain Survive and go home Data collection n n Demand Pain scores

Issue defined (customer perspective) “Patients wait too long and in pain for an operation”

We used Clinical Process Simulation “An interactive group learning tool enabling rapid common understanding and process change”

Who needs to be in the room? n n n Patients and relatives Paramedics ER Radiology OT Physio Pharmacy Orthopaedic surgeons Anaesthetists Ward & theatre nurses Discharge planners Operational manager Facilitator

Set up n n All the right people in the room Set the scene: n n n process review focussing on value, not ‘blame the people’ level the hierarchy Real people simulating their job, not role play

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What happened next? n n n Gossip came back during the session Gush of energy Many participants went straight out to make changes Redesigned the process of admission Ran a PDSA Ran another PDSA which never stopped

Why does process simulation work? n n n Common goal Team Task interdependence Create psychological safety Expose and break assumptions Talk and then ‘do’ (action focus) Kurt Lewin 1947

Results

Pain scores Average pain on movement (0 – 3 scale) n n Before changes 2. 75 (severe pain) After changes 0. 5 (mild pain)

Median Time to Theatre down from 48 to 19 hours in 18 months Project start Christmas snow & ice

Median Lo. S down from 10 to 7 Project start D&V, safeguarding, discharge beds full

Things we learnt n n Patients liked it Orthopaedic surgeons & Anesthesiologists Informal meetings, walk the pathway, fix the problems and report back Beriplex or Octaplex

Thank you andrew. fordyce@nhs. net http: //www. youtube. com/watch? v=6 OX 3 z 456 x. Dc 31 st May 2012 Cumberland Initiative 310512 26