Download Borders - Phillip Lunts - Demand & Capacity Planning

MSK & Orthopaedic Quality Drive
Programme
Philip Lunts
Head of Service
Improvement
Executive Lead for
Programme
Ali Mehdi
Head of Orthopaedic
Service
Clinical Lead for
Programme
The two work-strands from the
MSK Project that have had the
greatest impact for Borders
Patients:
• Work-strand 4: Hip fracture care
pathway
• Work-strand 5: Demand & Capacity
Modelling (DCAQ)
Work-strand 4: Hip #
Clinical Leads: Drs Antrobus &
Bennison
1.Frail Elderly Care bundle within acute care
•
Plan: to trial use of daily “single question in delirium” (SQID)
•
Aim: the earlier identification of patients who have developed
delirium during their hospital admission.
•
This allows for earlier investigation and treatment of delirium, leading
to improved patient experience, reduced symptoms and
complications and shorter hospital length of stay
•
Method: Nursing staff place “SQID” sticker in notes daily and answer
question “Is this person more confused than yesterday”. All patients
over the age of 65 should be included.
•
If answer is “Yes” – nursing staff inform the ward medical staff.
Medical staff then carry out AMT / 4AT / start delirium bundle as
appropriate
1. Care bundle: Frail Elderly
Comprehensive Geriatric
Assessment







Refer all patients for geriatric
assessment on admission
Refer to “blue sheet” / UPR for
geriatrician management plan
All patients mobilized day of surgery to
chair
All patients reviewed by
physiotherapist by day 1 post op
o
Mobility / balance / gait / falls risk
OT assessment starts day 1 post
admission.
Social work input as required
Complete nutritional / pressure area
assessment on admission
Reduce falls risk
On admission
oTake accurate falls history
including risk factors
oComplete nursing admission falls
assessment
Take action to reduce identified risks
Complete active stand
Treat postural hypotension if present
oIncrease oral fluids
oTEDS
oReview medication
Document visual acuity
Document AMT / 4AT
If urinary incontinence present:
oMSU
oPost void bladder scan
oBladder chart
Medication review /
analgesia
Analgesia as per preop. bundle.
oGive regularly
oReview regularly
Review all medications as per
polypharmacy protocol:
oValid indication?
oSymptomatic relief?
oVital hormone replacement?
oHigh risk combination?
oPoorly tolerated?
oNNT for benefit vs risks
Document reasons for changes in UPR
Ensure appropriate VTE prophylaxis
prescribed
Avoid / treat delirium
Complete AMT and 4AT on admission
Daily SQiD
o“Is this patient more confused than
yesterday”?
Start delirium bundle when identified (sticker)
Identify and treat causes
Reorientate patient regularly
Encourage mobility
Check hearing aids / spectacles
Avoid constipation
Maintain sleep pattern / fluid intake
Provide carers with delirium leaflet /
explanation
Do not
oCatheterize
oSedate routinely / restrain
oArgue with the patient
Assess bone health
Plan discharge
Prescribe and give vitamin D stat dose –
colecalciferol 100,000 units orally
o**check if peanut allergy**
If patient is over 80 years old start bone
protection:
oCalcium and vitamin D / alendronate
oRefer osteoporosis service if
contraindications (eg renal
impairment)
If under 80 years old request DEXA scan
Complete bone health risk factor checklist (on
“blue sheet”)
oIf high risk start bone protection
whilst results awaited
oIf low risk await DEXA result before
starting treatment
Set EDD on admission
Inform patient and carers of date and any
changes to this during admission
Refer to PT / OT on admission
Refer to social work as soon as need
identified
After first DME review
oUpdate EDD and anticipated place of
discharge
oPlace patient on community waiting
list if appropriate
All patients discussed at daily MDT board
round (update plan / EDD)
Day before
oEnsure IDL completed
oBook transport
oEnsure equipment / care ready
‘SQiD’ sticker: Single
Question in Delirium
Is this patient more confused than yesterday?
Date
Time
Name
Signature
2. Care bundle: anaesthetic
Anaesthetic ‘sticker’
HIP FRACTURE: Anaesthetic Review
Date:
Anticipated
YES  date and time
of surgery:
YES
IS PATIENT
FIT FOR
SURGERY?
Is this Patient
fit for
Surgery?
Reason for delaying
surgery:
Will benefits of
optimisation
outweigh risks of
delaying surgery?
 Give all medicines as prescribed
on kardex (unless crossed off)
 Adequate analgesia. Pain score
………./10
YES / NO - Follow trauma fasting
policy
Outcome required
for surgery to
proceed:
NO 
If extra
investigations
required will they
change patient
management?
YES / NO
Signed:
Time:
Print name:
 Adequate
analgesia
prescribed
Pain score: …………
/10
* Consider repeat
nerve block if pain
NRS >3
 Nerve block
repeat
Expected time to
fitness for surgery:
* Please review
every 24h
Using Demand and Capacity
• Established predicted demand and capacity
required
• Developed ongoing DCAQ modelling tool – updated
weekly
• Weekly ‘huddle’ – all ortho consultants plus
booking managers - review
– last week actual against predicted (and reasons)
– Last week theatre start times
– This week planned against required
– Outpatient clinic actual against predicted (NEW!)
Impact
• Excellent engagement with clinicians
• Shared ownership and solution of
problems
• competition – gold star of the week!
Next Steps
•Establish similar process for OPD
•Model demand from OPD vs capacity in real-time
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04/05/2014
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06/07/2014
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03/08/2014
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24/08/2014
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07/09/2014
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02/11/2014
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30/11/2014
07/12/2014
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28/12/2014
04/01/2015
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25/01/2015
01/02/2015
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22/02/2015
2015-03-01
2015-03-08
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2015-03-22
2015-03-29
2015-04-05
2015-04-12
2015-04-19
2015-04-26
45
Orthopaedic Theatre Activity
Huddle
Commenced
35
30
25
20
15
Cancellations due to
theatre staffing
No. Of Procedures
Staffing
resolved
5
Christmas
0
Expected No. Of Procedures
Linear (No. Of Procedures)
Virtual Fracture Clinic
•Virtual Trauma Meeting set up – avoids need for
additional staffing for service
•Direct Discharge recently commenced. Direct
discharge of:
Paediatric Clavicle
5th Metacarpal
5th Metatarsal
Mallet finger
Radial head
Torus/buckle
Ankle injury
ERAS Workstream
Average Length of Stay ERAS Patients - By Treatment Month
7
6
5
4
3
2
1
0
Mobilisation Post Op ERAS Patients
Mobilisation on day of surgery
(June 2013-September 2014)
(June 2013 - September 2014)
mobilised on day of
surgery
42%
50%
mobilised after post
op day 1
Mobilised after day of
surgery
42%
not recorded
54%
Mobilised on day of
surgery
Mobilised Post Op
Day 1
4% 4%
not recorded
4%