DEVELOPING AN
ENHANCED
7 DAY AHP SERVICE FOR
HIP FRACTURE PATIENTS
Colin Talbot-Heigh, Senior Orthopaedic Occupational Therapist,
Kirsteen Kelly, Team Lead Orthopaedic Physiotherapist,
Raigmore Hospital
September 2014
OVERVIEW
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CURRENT AHP SERVICE
PREVIOUS PILOT
DRIVERS BEHIND THE BID
THE BID
AIMS OF THE BID
WHAT WILL SUCCESS LOOK LIKE?
HOW WE ARE GOING TO ACHIEVE THIS?
OUTCOME MEASURES
AUDIT
POTENTIAL BARRIERS AND SOLUTIONS
CONCLUSION
CURRENT OCCUPATIONAL THERAPY AND
PHYSIOTHERAPY SERVICE
Mon-Fri 8.30-4.30 (OT and PT)
 Sat 8.30-1pm (limited OT and PT) for elective
patients
 Sun 8.30-1pm (limited PT) for elective
patients
 No weekend service for trauma/hip fracture
patients
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2013 PILOT
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Enhanced 7 day physiotherapy service
Primarily looking at elective surgeries
All hip fracture patients seen day 1 post-op
Increased number of patients discharged directly home
Able to meet some of the recommended guidelines re
physiotherapy assessment/mobilisation within 24 hours postop
Improved MDT working relationships
Improved staff satisfaction
Increased continuity of care
More equitable level of service for hip fracture patients
DRIVERS BEHIND THE BID
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Person Centred Approach
HQA (Highland Quality Approach) to improving patient flow
Evidence Based Practice/Professional Guidelines/Standards
Clinical Pathway Development/Implementation
Strategic drive towards 7 day service provision
Safe, Effective, Efficient, Equitable and Reliable Quality Care
Teamwork, Communication and Collaboration (MDT
approach)
THE BID
1.5 WTE band 6 Physiotherapist
1.0 WTE band 3 Physiotherapy HCSW
1.0 WTE band 5 Occupational Therapist
1.0 WTE band 4 Occupational Therapy HCSW
OVERALL AIM
To improve the quality of care, safety and
flow of patients admitted into ward 3A,
Raigmore Hospital, with a hip fracture.
SUB-AIMS
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To increase the number of patients going directly home following
hip fracture, by 50% and therefore reduce the number going onto
community hospitals
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Reduce the overall LOS for patients following hip fracture (including
community hospital stay)
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Reduce risk of further falls/injury and commence falls rehabilitation
immediately post-op (as appropriate)
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meet the SIGN/NICE/BOAST guidelines (in respect of therapy
intervention) for hip fracture patients
SUB-AIMS cont
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Ensure equitable level of Physiotherapy/Occupational
Therapy service for all hip fracture patients
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Develop an AHP clinical pathway to promote a standardised,
consistent approach to the management of patients in the
acute rehab phase of recovery
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Improve MDT approach/team working
WHAT WILL SUCCESS LOOK LIKE?
Improved quality of patient care by:
 Increased number of patients going directly home by 50%
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Reduced overall length of stay for patients post hip fracture
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All patients post hip fracture surgery will have a Physiotherapy assessment on day
1 and Occupational Therapy Assessment by day 3
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7 day physiotherapy/Occupational Therapy service for hip fracture patients
implemented
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Standardised pathway for Physiotherapy/Occupational Therapy post hip fractures
produced for Highland
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Standardised rehabilitation recommendations for Physiotherapists/Occupational
Therapists working in the acute phase of rehabilitation post hip fracture produced
for Highland
HOW ARE WE GOING TO ACHIEVE
THESE AIMS?
STANDARDISED
HIGHLAND
AHP
PATHWAY
OUTCOME
MEASURES
AUDIT
UPDATE
PATIENT
INFORMATION
BOOKLET
DAILY MDT
BOARD
ROUNDS
MDT
WORKING
UPDATE
ASSESSMENT
FORMS
TRAINING
&
EDUCATION
TRAUMA
STUDY
DAY
UK WIDE
PHYSIO
EMAIL
NOF
GROUP
OUTCOME MEASURES
NMS: New Mobility Scale
CAS: Cumulated Ambulatory Score
EMS: Elderly Mobility Scale
MBI: Modified Bartel Index
THE NEW MOBILITY SCORE (NMS)
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3 questions, looking at pre-fracture status
Maximum score of 9
NMS in addition to age and # type, provides valid prediction of in-hospital
outcome
Patients with a low pre-fracture NMS (NMS< or equal to 6) are 18 times more
likely not to regain independence or be discharged directly home than those with
a score of >6
Can be used as predictor of in-hospital rehab potential
NMS cut off point of 5/9 is a valid predictor of 1 year mortality, and 6 months
functional level
(Kristensen et al, 2010)
CUMULATED AMBULATORY SCORE
(CAS)
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Allows day-to-day measurement of patient’s basic mobility
Early post-op predictor of short-term outcome
Reliable and valid predictor for length of hospitalisation, 30 day mortality
and time to discharge status
Scored 0-6 each day
Scores from first 3 days post-surgery are combined to obtain 3 day CAS
3 day CAS of > or equal to 10 = 99% survival rate at 1 month, and 93% will
be discharged home
Reference: Foss, NB, Kristensen MT, Kehlet, H. Prediction of postoperative morbidity, mortality and rehabilitation in hip
fracture patients: the cumulated ambulation score. Clinical Rehabilitation, 2006 Aug;20(8):701-8.
AUDIT
Using data from 2012/2013 as a baseline:
 LOS (acute and community)
 Number of patients transferred for further rehabilitation
 Discharge destination
 Outcome measures on discharge (EMS, MBI)
At 120 days:
 Place of residence
 Mobility
 Dependency
 Further falls/fractures
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MDT audit (hip fracture nurse, OT and Physiotherapy)
Using modified proforma
POTENTIAL BARRIERS TO SUCCESS and HOW WE
WILL OVERCOME THESE
Lack of engagement/support from
OT/PT staff and within the wider
MDT
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Change to staff working hours
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Lack of space and equipment to do
rehabilitation on an acute ward
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Reduced staff awareness
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Sustainability
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Staff involved from the start and to
be active participants throughout
Joint working with MDT
Rota done for the year to allow staff
to plan
Look at use of gyms, facilities on the
rehab unit
Procurement of additional
rehabilitation equipment
Training sessions, regular feedback
for staff
Regular updates for MDT, ongoing
review, maintain momentum and
enthusiasm
Conclusion
By October 2015, we will have implemented an
enhanced 7 day Physiotherapy and Occupational
Therapy service which will improve the quality of
care, safety and flow of patients with a hip
fracture
(which we will hopefully get permanent funding for)
ANY QUESTIONS?
Kirsteen.kelly@nhs.net
Colin.Talbot-Heigh@nhs.net