The Development of an Acut
Fracture Ward
Mr J A Ballantyne
Cons Ortho Surgeon
The development of an acute hip fracture ward
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Background
Business Case
Intended benefits
Sustainability
Hip Fractures in Fife (1982-2009)
Hip Fracture Incidence; 65 and over; FIFE
500
9.00
450
8.00
400
7.00
300
5.00
250
4.00
200
3.00
150
2.00
100
50
1.00
0
0.00
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Hip Fractures
6.00
Hip Fractures
Rate per 1000
Hip Fracture Rate per 1000
350
NHS Fife Trauma configuration
Present
• 2 trauma wards
– 23 beds each
• All trauma admitted next
available bed
• Hip fractures distributed
across 2 wards
• Hip fracture resources
divided across 2 wards
– CoE (P/T Staff Grade, 1 CoE
session)
– AHP input limited to 5-6/7
Planned
• Acute Hip Fracture ward
• General trauma ward
• CoE resources concentrated on
acute hip fracture ward
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2 sessions CoE Cons
P/T CoE Staff Grade
2 ESP Fragility Nurses
Increased AHP input to allow 7
day service
– Weekly Ortho Con ward round
(3 dedicated consultants)
Background….an ongoing process beginning in 2009
2009: Introduced a hip fracture patient pathway
• Consultant engagement
2010: Introduced a Enhanced Care Area for Hip Fractures
• Patients post hip fracture surgery optimised
• Increased nursing care, careful fluid balance, reg. review
• Introduced with some naivety
• Staffing numbers incorrect
– Unable to complete intended assessments
• Required regular transfer of patients between bed spaces
– not good practice in the cognitively impaired
– Inefficient use of nursing staff
Our first attempt….why did they fail?
• Ward changes poorly planned
– Recognized need for improvement
– Failure to engage fully with MDT re changes
• Ortho Consultant engagement/interest?
• Limited CoE input
• Management buy in….
– Hip fractures not a government priority
– Other competing targets took priority
• Lack of national targets
– E&W had NHFD – tariff driven care
2012: Development of Orthogeriatric services for Patients Sustaining
Fragility Fractures in NHS Fife: the need to comply with national
standards
Best Practice In Hip Fracture care: The case for Orthogeriatrics in the care of fragility fractures: Published Guidance and Drivers for Change
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Blue Book
National Hip Fracture Database
Nice Guideline (June 2011)
Sign Guideline 111 (June 2009)
SHFA
Present Management of Hip Fracture in NHS Fife
What Care Model to adopt?
Recommended Model
Does Orthogeriatric Input make a difference?
What level of Orthogeriatric Consultant support is required?
Possible Models and Patient Flow
Benefits of Improved Orthogeriatric Levels of Care
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Cost savings to planned care directorate
Foundation Trainees Support
GMC response to patient safety concerns (May 2012)
Funding the Orthogeriatric Service
Conclusion
Conclusion
“The establishment of an orthogeriatric unit. This is the
preferred option and the current recommended model
of care from the BGS……. high level features in this sort
of model are pre op assessment, the potential
development of specialist roles such as hip fracture
nurses…………chances of a discharge home are felt to be
optimized using this model “
2013- present…..re-allocation of resources
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Started the development of an Acute Hip
Fracture ward
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Admitted under shared care
Admitted directly to the hip fracture ward
Return to ward post op
Post op rehab led by specialist MDT team
Care pathways
1 sessions CoE Cons time (MDT)
– 1 P/T CoE staff Grade
Ortho Staff Grade salary 1 (retiral)
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Appointment of 2 Fragility Nurse ESP
Work alongside CoE medical staff
Provide CGA, peri-op medical management
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Secondment HAN nurse to support training of
the ESPs
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Ortho Staff Grade salary 2 (retiral)
Staffing at this time
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Appoint CoE Consultant P/T
Work absorbed by Ortho Cons
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Regular MDT team meetings
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Additional CoE Cons session
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No applicants
Reflects national shortage CoE consultants
Alternative solutions preferred by local CoE Cons
Presently 2 CoE Cons Ward rounds
Cons Ortho Ward round weekly
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Additional to routine trauma ward rounds
Aim to provide consistancy of decision making by
a core of 3 Ortho Cons
….late 2013
• Made lots of local departmental changes to try and
improve service
– Converting surgical salaries to medical/nursing
• Still lacked the final impetus to take us to the acute
hip fracture ward
SOSDG Hip Fracture Care Work strand
• Scottish Standards of Care for hip fracture patients
(2013)
• National monthly snap audits
• Provided the drivers for change
• Evidenced areas we needed to do better
– Allowed business case to be made to address these areas
• Management engagement – national audit
– Well supported in making change
e-Health Information Services Department
Hip fractures admissions in FY 2009/10 to 2013/14 split by time of
admissions
45
40
35
30
25
20
15
10
5
0
2009-10
2010-11
2011-12
2012-13
2013-14
Day of the week of a Hip fracture procedure from
FY 2009/10 to FY 2013/14
70
60
2009-10
50
2010-11
40
2011-12
30
2012-13
20
2013-14
10
Monday
Tuesday Wednesday Thursday
Friday
Saturday
Sunday
Business Case for the acute hip fracture ward
Focused on areas in the snap audits
where we performed poorly
• LOSx
• Post Op mobilization
• CoE input
• Demonstrate areas of
improvement against
national data
• Comparison to National Hip
Fracture Guidelines
Acute Hip Fracture Ward
• Concentrate available resource
to single area
• Allow development of patient
care pathways
• Develop team dedicated to hip
fracture patient care
• Aim to reduce LOSx
– Reduce dependence on
downstream beds
– Increase patients discharged
directly home
• Cost savings in terms of hip
fracture care
SOSDG funding
Present
• OT 5 out of 6 day working
– Working to capacity
– Staffing levels not allow 7 day
input
• Physio 6 out 7
– Working to capacity
(Trauma/Elective)
– Input aimed at those DC
withing 48 hrs (ie ERP)
Planned
• Additional 2 generic AHP
assistants
– Allow 7 day input OT/Physio
• 2nd physio working Saturday
and Sunday
– Work with the assist AHPs to
increase ability to clinically
prioritise post op mobilisation
(elective/trauma)
• Increased Nurse staffing
levels
Measure impact
National Audit
Local Audit
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SOSDG Audit
LOSx
– Recognition of other factors
Physio time to initial assessment
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Physio – audit reasons for delay in first
assessment
OT – proportion assessment achieved on
day 1,2 and 3
Proportion of patients transferred to
downstream bed (present 51% - aim 20%)
Impact of hip fracture ward on ICASS
– 30% patient presently discharged
through ICASS
– 15% DC directly home
– Local audit ICASS/DC Hub
Audit of numbers of boarding patients
from other directorates
– Potential for remuneration form
emergency care and resultant true
cost saving to planned care
Sustainability
• Run as pilot for 1 yr
• Report back to Senior Management Team at 1yr
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Evidenced by reduced LOSx
Reduction in patient bed days for NOF♯
Increased numbers patients DC home
Increased use of ICASS
Show efficiency of use of current resources
• If benefits confirmed, commitment to recurring
funding agreed by NHS Fife
Ongoing challenges……..
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Limited CoE input well below levels required for these patients
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Social Care issues locally/lack of down stream beds
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More interesting trauma cases often take priority
Showing benefits of the ward beyond LOSx
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reduced LOSx savings offset by boarding patients form other directorates
Need to recognise the cost of boarding patients into trauma beds
Prioritisation of hip fractures on trauma list
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Reinforce the benefits of good care
Demonstrate the impact of increased medical input
Showing actual cost saving with improved care
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Potential impact on LOSx
Staff apprehension regarding ward change
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Alternative solutions using Fragility Nurse ESP
7 day consultant led CoE care still a dream
Demonstrating benefits of the softer end points eg quality of care, patient satisfaction
Softer outcomes may not be shown in terms of cost saving
Medical support of other Fragility Fracture patients
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Concentration of present resources on Hip fractures
Need to develop pathways of care for non hip fracture fragility patients
MDT effort……
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Nursing (Maureen Speedie, Eileen Hanlon, Dorothy Letham, Karen Peacock, Andrea
Bendowski)
OT (Elaine Murray)
Physios (Janet Macdonald, Liz McMullen, Karen Gray)
CoE (Jo Hadoke, Sue Pound, Morag Paterson, Marie Williams, John McKenzie)
Orthopaedic (Andy Ballantyne, Ed Dunstan)
Planned Care Management (Susan Fraser, Fiona Cameron)
Emergency Medicine (Maggie Currer)
Anaesthetics
SOSDG Audit Nurse (Jan Wood)
Thank you….
CoE requirements in an orthogeriatric ward
‘An estimate of two direct clinical care sessions per week for each 100 hip
fracture patients per year of senior Orthogeriatrician time is required to
provide a basic service.’
‘However, it is essential that there is a Consultant Geriatrician involved in the
day to day running of the service to provide continuity of care, in making
difficult decisions regarding fitness for theatre, in complex discharge planning
and in end of life decision-making.’
The involvement of two Orthogeriatricians sharing the workload along with
their other commitments should be considered and would provide a balanced
job plan and ensure adequate cross cover when necessary.’
June 2010 BGS Newsletter5