Session 2.8: Putting the patient at the heart of the pathway

1. Session 2.8:Putting the patient at the heart of the pathway

2. NHS Board Examples:Enhanced Recovery for patients undergoing hip and knee surgery– NHS Borders and Tayside Anticipatory Care Planning– NHS Forth Valley

3. Enhanced RecoveryWhat is it?"What does enhanced recovery have to offer patients and the NHS? In simple terms it does two things. It improves quality of care by helping patients to get better sooner after major surgery. Secondly it reduces length of stay with obvious benefits to the NHS"Professor Sir Mike RichardsEnhanced Recovery Partnership Programme Department of Health

4. Implementing Enhanced Recovery in OrthopaedicsA Mehdi, A Todd, D Sommerville, J Antrobus, K Lakie, N LearyBorders General Hospital, Melrose

5. SUB HEADING Traditional Approaches

6. SUB HEADING Established Practices

7. Patient Journey - Pre-assessment - Admission - Perioperative Care - Length of Stay - Post – Discharge - Overall Satisfaction

8. Pre-assessment - Duplication of info - No clear guidelines for Arthroplasty patients - Variation - Patients passive partners

9. Admission - 100% day before surgery admission - Anaesthetic review at admission - 20% cancellation - Mixed nursing

10. Ward to Theatre - Pre -LEAN theatres 52 mins- Post – LEAN theatres 46 mins- Inconsistent skills of surgical assistant- 1 anaesthetist per list

11. Perioperative Care 100% Urinary catheterisation100% HDU post opMedical Complications0% mobilised day of surgery 40% of arthroplasty patients received a blood transfusionNo standard DVT prophylaxisNo local data collection/audit

12. Length of Stay • Average length of stay for arthroplasty in the Borders – 7.7days (SAP Report 2009 • - Amongst longest LoS of all mainland Boards in Scotland

14. The Team

15. Orthopaedic Reduced Length of Stay, Project Charter V.1 Problem Statement Goals Reduce length of stay for elective orthopaedic patients Provide sufficient beds to accommodate all orthopaedic activity Increase orthopaedic throughput through theatres Improve patient experience Patients receiving elective major orthopaedic operations are having to stay longer in hospital than other areas. It is not possible to fully utilise extra operating time in Theatres due to lack of available orthopaedic beds Customer / Business Impact Measurements Customer Metric: In Process Metric Baseline Target Reduced length of stay Increased orthopaedic operations Improved patient experience measures National MSK Audit MARCH 2010 • Reduce length of stay from 7.6 days – 5 days • Increase list capacity to 4 joints/day In Scope Out of Scope Business Case Elective orthopaedic patients Pre-assessment Operating process Post-op pathway to discharge Reduce length of stay to benchmark target Introduce new technique (Enhanced Recovery) Create capacity to meet WT targets and repatriate Lothian activity Emergency pathway Referral processes ?Complex/orthogeriatric care Team Timeline • Kirk Lakie • Nigel Leary • Alison Todd • Trish Wintrup • Damon Somerville • Ali Mehdi • Karen Haughey • Jackie Bell • Physio • OT • Wilma Cruickshank • More.. Sponsor Hamish McRitchie Rachel Bacon Ross Cameron Data Gathering VSM Kaizen 13th August 2010 From 28th June From20th Sept – end Nov 2010

16. Means of Change - Draft pre-admission ICP - Management of patients expectations – CALEDONIAN TECH - Designated Anaesthetist at clinic - Review of patient information booklet – Passport to Care - Anaesthetic assessment in pre-assessment clinic

17. Cascading

18. Means of Change - Ward Nurse- direct bleep to theatre - Standardised anaesthetic protocol - Post op management guidelines implemented on Ward including ward doctors and HAN

19. Pre-assessment Anaesthetic rotas revised to fit pre-assessment clinic Introduction of Hip and Knee school Patients proactive partners

20. Admission - 75% patients admitted on day of surgery

21. Cancellations

22. Ward to Theatre - 12 ring fenced beds - Dedicated arthroplasty ward nurses - Consistent pathway approach

23. Ward to Theatre • - Over 90% of patients walk to theatre - Transfer to trolley in the Anaesthetic room - Single patient handover - Positive patient feedback for transfer process - ERAS LEAN theatres 34mins

24. Perioperative Care - 5% patients catheterised - 92% patients mobilised on day of surgery - 5% blood transfusions (Hb- 7.8-8.7) - VTE prophylaxis protocol - Audit database- opiate reduction- Excellent pain scores- 90%

25. 3 joints per day During Kaizen month Aim • ERAS Lean 3 - 4 joints per day comfortably with time to spare! (12 joints per week) • 3 joints per day with no overruns • Additional capacity avoids need for sendaways Sustainability Before • Pre Lean 1.8 joints per list (7 joints per week) • Post Lean 2.4 joints per list (9 joints per week) • Potential financial savings from sendaways

26. Length of Stay Median Length of Stay- 3 days (Ave-3.9 days)

27. Length of Stay Lowest MLoS of all Boards in Scotland -3 DAYS

28. Overall Satisfaction “Having experienced my first hip 17 months ago this 2nd experience on “assisted recovery” has been marvellous. Being awake during the operation was (surprisingly!) a great experience I was not sick (as was last time) and it was so good to get up out of bed and mobilise on the same day. NO CATHETER this time was a bonus. All staff very communicative and attentive at all times. Going home after 2 days will also enhance my recovery as I know I will sleep better!” Mrs EC (CHT) “I had a hip replacement to my left hip 2 years ago and was in for 6 days. I found the treatment much improved. The pain relief much better and mobility much quicker. Treatment was excellent” Mrs E McK (MMS) “All the Medical and Nursing staff have been excellent. The new procedures being put in place with regard to patient recovery are also excellent. The literature given to me prior to admission is first class Mr T S (JEP)

29. Borders Enhanced Recovery ProjectSummary - Big Challenge - Better Preassessment - More activity/ less cancellations - Medicalisation /intervention almost eliminated - Excellent pain relief - MLoS 3 days - Better patient journey - Massive savings?

30. Further reduction of complications Weekend Physio/OT Anaesthetic Rota Surgical support Maximisation of capacity Arthroplasty Practitioner Challenges

31. Sustainability Saving to invest Investment to save Broadening the scope of enhanced recovery The Future

33. Matthew Checketts • Consultant Anaesthetist • NHS Tayside

34. Progress to date – ERP 2011 • 15 sites out of 22 have now developed ERP programmes and are testing them with a further two due to start in the summer • 41% patients admitted on the day of surgery compared to 29% in 2010 • Length of stay in Scotland has fallen further with the median post operative day reducing from 5 to 4 days in less than one year • Urinary catheterisation has fallen from 35% to 26% • Blood transfusion has decreased especially following hip replacement from 14% to 11% • 90% of patients are mobile within 24 hours of surgery with 36% of patients within an ERP up on the day of surgery • 5% reduction in use of outpatient physiotherapy (84 New Patient Slots)

35. Anticipatory Care PlanningWhat is it?Anticipatory care planning is applied to support those living with a long term condition to plan for an expected change in health or social status. It also incorporates health improvement and staying well. In practical terms it is about adopting a “thinking ahead” philosophy of care that allows practitioners and their teams to work with people and those close to them to set and achieve common goals that will ensure the right thing, being done at the right time by the right person(s) with the right outcome.

36. Managing Complexity in the Community Anticipatory Care Planning Stuart Cumming August 2011

37. Overview • Benefits of Anticipatory Care Planning • Integrated working • Maintain independence • Support self management • Mainstream ACP principles • links with • Shifting the Balance • Long Term Conditions Collaborative • Quality Strategy • Reshaping Care for Older People • Change Fund

38. Rapidly progressive MS Communication, airway, mobility, care and nutritional issues Medication management and symptom control Childcare Carer Support Laura age 41 “Spending more…quality time with my children, family and friends” • Home adaptations • Telehealth • 24/7 care package • Primary Care Team • Complex Care Team • Local Authority

39. The exception or the norm…?

40. Ageing population and increasing Long Term Condition prevalence • Increased emergency admissions in elderly (>80) • Last 20 yrs – x10 increase in elderly with >3 admissions/yr • Consequent extended stay and delayed discharge • Increasing number of short, “avoidable” stays • Not desirable or sustainable in long term • Need for anticipatory “thinking ahead” approach to ongoing care to enable independence and awareness of options • Need to recognise the capability of primary care

41. The Changing Picture of Long Term and Palliative Care Bill age 76 • Self management/ management plan • Carer support • Hand held ACP • Domiciliary oxygen and compressor • pO2 monitoring • Single shared assessment • OOH notes - Preferred place of care - Rescue medication - Palliative Care Plan inc DNA CPR • Primary Care team • At risk register • Practice meeting • Pharmacy • Community Nursing • Specialist Nurse • Macmillan Nurse • Hospice • Education and training “ Working together…. understanding what’s going on ”

42. “Anticipatory Care Planning is a process of discussion between an individual and their care providers irrespective of discipline” (DOH 2007)or… • Doing the right thing for the right person at the right time with the right outcome – every time • Improve communication and 24/7 partnership working • Need to involve patient and family as partners in care • Anticipatory rather than reactive approach • Helps co-ordinate and shift the balance of care • Workforce – education, training, communication, capacity, planning • Align organisational priorities and attitudes and recognise differences

43. Shift the Balance in a considered way Not always straightforward but it can be done if planned

44. Multiple LTCs Fractured hip Main Carer in full time employment Wheelchair Delayed discharge issues Kathleen age 92 “ Being allowed home …. getting some of my independence back” • Care Package • Nursing Care • GP • Pharmacy • Crossroads • MECS • Community support

45. Who can benefit? Possible ACP Triggers • Situation • Long term housebound • Complex care package or in receipt of respite care • Entry to care home* or community hospital • After discharge from unplanned admission • Frequent OOH contacts • Carer stress • Condition • Deteriorating long term condition • Requiring specialist nurse • Attendance at memory clinic • Placed on palliative care *, dementia, learning disability or mental health register • Clinical Assessment • SPARRA(?>50) • Polypharmacy • Falls assessment • Recognised as vulnerable

46. Integrated Community Based CareRural North West Forth Valley Partnership Community based, multi agency approach to delivering integrated care Aims • Reduce hospital admissions and length of stay • Quicker more local response • Improve transitions between phases of care • Shifting the balance of care through streamlining and localising current referral routes focus on crisis care, rehab and reablement • Improve involvement of carers / families / communities

47. Community Nursing Team, GPs & Pharmacists Education Services & Housing Social Care, Care Management & Telecare PATIENT Mental Health Rehabilitation, Therapists & Podiatrists Health Improvement New Service Previous Service • Fragmented • Single agency • Multiple locations • Can delay discharge - Not locally provided Skill shifting & enhancement Co – location of MDT Joint agency training Joint management of MDT

48. Focus on Improving Communication People • Rapid response carers undertaking basic nursing and therapy tasks • Locally based joint agency centre • Links with care homes, rehab training, JIT, community transport, national park Technology • Digital Memory Pens • Video-conferencing / Skype - reduce meeting time • Talking Medicine labels • Tele-health monitoring • MECS

49. Case Study 1 – Anne age 82 “Able to do more for myself” Making differences • Lives alone • Struggling with personal care, transfers and cooking • ? Hospital admission • Rapid response started • Seen 4 times a day • Reducing with return to independence. Can now have a shower and dress, able to get out of bed without help

50. Case Study - Martin age 35 “ Getting out of hospital ASAP” • Complex Medical Condition • Referred because struggling at home due to infection – team due to start next day • Admitted overnight before seen • Liaised with fast track and once medically stable (2 days) returned home • Daily OT/PT input to rehab at home • Joint working with Reach FV clinical specialist physio and rehab consultant • Carers support 2 x day