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How Clinical Process Simulation Changed Hip Fracture Pathway in Torquay

How Clinical Process Simulation Changed Hip Fracture Pathway in Torquay . Andrew Fordyce, Rachel Blackshaw , Rob Lofthouse , Mike Swart Torbay Hospital. Aim for Hip Fracture Pathway. Reduce time from ER to surgery Reduce pain before surgery We have changed elective surgery in Torquay

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How Clinical Process Simulation Changed Hip Fracture Pathway in Torquay

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

  2. 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 Cumberland Initiative 310512

  3. Old pathway • Multiple hand overs • Evolved not planned • Thought to be in patients best interests • Accepted practice across UK Cumberland Initiative 310512

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

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

  6. 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

  7. 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

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

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

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

  11. What did we do to make this change?

  12. 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

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

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

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

  16. 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

  17. 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

  18. Cumberland Initiative 310512

  19. 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

  20. 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

  21. Results

  22. Pain scores Average pain on movement (0 – 3 scale) • Before changes 2.75 (severe pain) • After changes 0.5 (mild pain)

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

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

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

  26. http://www.youtube.com/watch?v=6OX3z456xDc Thank you andrew.fordyce@nhs.net Cumberland Initiative 310512

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