How Clinical Process Simulation
Changed Hip Fracture Pathway in
Torquay
Andrew Fordyce, Rachel Blackshaw, Rob Lofthouse, Mike Swart
Torbay Hospital
31st May 2012
Cumberland Initiative 310512
1
Aim for Hip Fracture Pathway
Reduce time from ER to surgery
 Reduce pain before surgery

We have changed elective surgery
in Torquay
 Over 7 years no change in hip
fracture

31st May 2012
Cumberland Initiative 310512
2
Old pathway
Multiple hand overs
 Evolved not planned
 Thought to be in patients best
interests
 Accepted practice across UK

31st May 2012
Cumberland Initiative 310512
3
Old Hip Fracture Pathway
Primary Care
Paramedic
ED Nurse
ED Doctor
Ward Nurse
Ward Doctor
Ward
24-72hr
New Hip Fracture Pathway
Referral
from
Paramedic
• Telephone trauma nurse
• Start planning for surgery
PreOperative
Admission
IntraOperative
PostOperative
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
PreOperative
Admission
IntraOperative
• Patient and family informed, reassured and
expectation set
• Escort to XR and get Orthopaedic review
PostOperative
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
PreOperative
Admit to Theatre Complex
IntraOperative
• Go to theatre complex
• If no slot before 1600 hrs go to
ward and first on the list next day
PostOperative
Follow
Up
Fractured Neck of Femur Pathway
• IV paracetamo;, NSAIDS, LA, Avoid
opiates
Referral from
Paramedic
PreOperative
Admit to OR Complex
IntraOperative
• Prepare for early mobilisation and eating
PostOperative
Follow
Up
Fractured Neck of Femur Pathway
Referral from
Paramedic
PreOperative
Admit to OR
•
•
•
•
•
Early mobilisation
Eat and drink
Medical, physio and OT
Daily MDT on ward
Social Services
Complex
IntraOperative
• Regular oral analgesia
• Paracetamol and NSAIDS
• Avoidance of systemic opiates
PostOperative
Follow
Up
Fractured Neck of Femur Pathway
Referral from
Paramedic
•
•
•
•
PreOperative
Data collection
Analysis of data
Feedback to all
Identify and fix problems
Admit to OR
Complex
IntraOperative
PostOperative
Follow
Up
What did we do to make this
change?
We applied Lean Thinking






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?

Specify value




No waiting
No pain
Survive and go home
Data collection


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?











Patients and relatives
Paramedics
ER
Radiology
OT Physio Pharmacy
Orthopaedic surgeons
Anaesthetists
Ward & theatre nurses
Discharge planners
Operational manager
Facilitator
Set up


All the right people in the room
Set the scene:



process review focussing on value, not
‘blame the people’
level the hierarchy
Real people simulating their job, not role
play
31st May 2012
Cumberland Initiative 310512
18
What happened next?






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?






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)


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 LoS down from 10 to 7
Project start
D&V, safeguarding,
discharge beds full
Things we learnt




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=6OX3z456xDc
31st May 2012
Cumberland Initiative 310512
26