Presentations Lessons Learnt Workshop May 4-5, 2004 - Sydney

1. The Health Roundtable New Zealand PresentationsLessons Learnt WorkshopMay 4-5, 2004 - Sydney

2. 1. Index of Presentations Improving Patient Care • Index of Stream 3c Presentations with Quick Links • Workshop Aims and Honour Code • Session. 3c. Planning the right care in Orthopaedics If you view this document as a “Slide Show”, clicking on the hyperlinked text (the turquoise and underlined text) will take you to that particular page in the report

3. 2. Persuasion 3. Decision 3. Decision 2. Workshop Aim AIM: SHARE INNOVATIONS TO IMPROVE HEALTHCARE Looking for differences! How to speed up action? 1.Knowledge 5. Confirmation The Roundtable Process 4. Implementation

4. 2. HRT Honour Code • All those who participated in the workshop and who have received this set of slides agreed to be governed by the following HRT Honour Code • No participant shall criticise the performance of other member hospitals, or use any of the information to the detriment of a fellow member. • No external distribution of data or conclusions based on Health Roundtable workshops or data is made without the consent of each person contributing materials.

5. Stream 3 - Improving Patient Care

6. Session 3c Topic: Planning the right care in Orthopaedics Best Practice Hip Surgery to Reduce LOSPresenter: Chris LowryHospital: Capital & Coast (Wellington) 4-5 May 2004Sydney

7. KEY PROBLEMS • LOS for Total Hip replacements reducing but not enough • Bed availability for elective surgery • No anaesthetic involvement with pre assessment • Patients all admitted prior to the day of surgery • Therapies involvement commenced post-operatively

8. INNOVATIONS IMPLEMENTED • Careful pre assessment Anaesthetic assessment Nursing assessment OT home visit • Discharge Planning Patient Education - set expectations “YOU WILL GET UP ON EVENING OF SURGERY” “IT WILL NOT HURT” LOS

9. INNOVATIONS IMPLEMENTED • Strengthened MDT management • Implemented weekend Physio and OT • The Anaesthetic • The surgery - fast, gentle, minimal soft tissue damage, accurate prosthetic replacement, short surgery - <45 mins • Recovery - early mobilisation, get the tubes out asap

10. HOW WE DID IT • Project Started: 1990’s - focus on continuous improvement • Project Champion: Surgeon - vision, leader in hip surgery, • Team Composition: Surgeons, Nurses, Physios, Anaesthetists, community workers • Resources Required:information, increased OT/Physio support • Special Funding:Nil

11. ALOS Resourced beds DOSA rate Current - 3-4 days 57 down to 20 0% now 99% OUTCOMES SO FAR

12. LESSONS LEARNT • Evolutionary change • Champion’s enthusiasm and vision brought the whole team along • Value of the WHOLE team • Patient expectation/education key to success

13. LESSONS LEARNT • What we recommend to other hospitals on this topic Identify focus that will impact on making the difference Continually look for ways to do better • What we would do differently Probably not a lot but we can do better!! • Better pain control • Stratify patients into groups • Not all patients can be hurried

14. HRT, Lessons Learnt Workshops 4-5 May, 2004, Sydney Session 3c Topic: Planning the right care in Orthopaedics Improving TJR LOS outcomes with Clinical pathways Presenter: Ian HarrisHospital: St Vincents Hospital (A212) 4-5 May 2004Sydney

15. KEY PROBLEMS • In 1994 the ALOS for elective joints at our hospital for elective joint replacements were: • THR - 15.5 days • TKR - 17.1 days • Non DOSA • large rehab delays

16. INNOVATIONS IMPLEMENTED • DOSA rate approx. 90% • Nurse to Nurse rehab referral. For War Memorial Hospital, NO rehab consult. • Pre-booking of beds at War Memorial & Sacred Heart, including out of area pts. • Pre-Preadmission clinic testing.

17. HOW WE DID IT • Project Started: 1994, rehab negotiations began in approx. 1995. • Project Champion: Meg Green. • Team Composition:NUM, NM Special Projects, Case Manager, Geriatricians, Rehab NUM’s, later SHRS Staff Specialists & CNC.

18. How we did it …2 • The main investment is time. • Provision of a good data collection/variance analysis tool is necessary. • The players were already there. • Feedback re problems, incorrect decisions vital.

19. LOS change

20. Outcomes…2 • Number of elective joints going to rehab. • DOSA rates. • Out of area rehab provision. • Implications.

21. LESSONS LEARNT • Establishing credibility of referrer. • Gain trust of Rehab provider. • It took approx. 4 years of effort & meetings just to get this. - Don’t give up.

22. Session 3c Topic: Planning the right care in Orthopaedics Addressing the challenges of Hip Surgery at The AlfredPresenter: Ms Lea PopeHospital: The Alfred 4-5 May 2004Sydney

23. KEY PROBLEMS 1. Surgery delays for # Neck of Femur patients • Snapshot 2003 - 44 patients reviewed • 34 patients (77%) delayed >24 hours • 22 patients (50%) delayed due to system issues • Average delay is 58 hours (some 5 days) • 2004 suggests some improvement but delays continue

24. KEY PROBLEMS 2. Delays in time-to-mobilise for #NOF patients • No weekend physiotherapy service for orthopaedic surgery 3. Long waiting lists for outpatient clinics • Waiting time for orthopaedic outpatient appointment was two years

25. INNOVATIONS IMPLEMENTED • Delays in surgery • Implementing prospective review of delays in emergency hip surgery to assess impact on patient outcomes • Research activity • ‘Does early mobilisation after hip fracture surgery accelerate recovery?’ • (funded project - completion date Dec 2004)

26. INNOVATIONS IMPLEMENTED • Long waiting lists for Orthopaedic outpatients • Physiotherapy Screening Clinic • Patients referred by GP’s for secondary management at The Alfred, screening for likely non-surgical management while awaiting surgical consultation • Musculoskeletal clinic • Review ‘routine’ patients triaged from GP letter by Rheumatologist

27. HOW WE DID IT • Physiotherapy Screening Clinic • Project Started: July 2003 • Project Champion: Leonie Oldmeadow • Team Composition: Physiotherapist & Orthopaedic Surgeon • Resources Required: Within resources • Special Funding: Nil

28. Physio Screening Clinic outcomes 2003 • GP letter  The Alfred • Letter triaged : •  Non surgical management  Physio screening clinic •  Surgical management  • Urgent appointment for surgical review • Early appt - < 6 weeks • Intermediate - 3-6 months • Routine - > 9 months ( attend Musculoskeletal clinic in interim)

29. Physio Screening Clinic outcomes 2003 • Of the 134 patients seen in 2003 in the Physio Screening Clinic • 70% were managed with physiotherapy (without the need for surgery) • 30% went on to see surgeon • Contributed to reduced waiting lists

30. LESSONS LEARNT • GPs very enthusiastic re this strategy • GP may nominate non-surgical assessment first • Patients very satisfied • Scope limited by resources • Still some issues with triaging from a letter - need face to face assessment

31. Session 3c Topic: Planning the right care in Orthopaedics Physiotherapy Triage of Low Back Pain Patients in Orthopaedic Outpatients Pilot ProjectPresenters:Cathy Nall, Director of Physiotherapy Kathleen Philip, Senior Musculoskeletal PhysiotherapistHospital: Austin Health HRT, Lessons Learnt Workshops 4-5 May, 2004, Sydney

32. KEY PROBLEMS • Long waiting times to first appointment for patients with low back pain to attend orthopaedic outpatient clinic. • Average waiting time March – August 2002, waiting time = 93.4 days or 13.35 weeks

33. INNOVATIONS IMPLEMENTED • Based on similar initiatives in UK • Experienced senior physiotherapist with post graduate qualifications in musculoskeletal physiotherapy assesses and manages patients with low back pain in accordance with a defined protocol which was developed in conjunction with the Unit Head, other orthopaedic surgeons in the unit and the PhysiotherapyDepartment

34. HOW WE DID IT • Project Started:12.9.02 • Project Champion: Cathy Nall, Director of Physiotherapy • Team Composition: • Kathleen Philip, Senior Musculoskeletal Physiotherapist • Roger Westh, Unit Head Orthopaedic Unit 3. • Resources Required: .1 eft Grade 4 physiotherapist • Special Funding: $7540 pa plus evaluation funding of $4000 from University of Melbourne

35. OUTCOMES SO FAR • Before physiotherapist March – August 2002, waiting time = 93.4 days or 13.35 weeks • With physiotherapist Sept 2002-Feb 2003, waiting time = 17.36 days or 2.48 weeks. Reduction of 72%

36. GP and Patient Satisfaction • Numbers did not reach statistical significance but useful qualitative data collected Radiological Investigations • Less investigations ordered for patients in physio triage model of care (26 cf 1)

37. LESSONS LEARNT • Challenges: • Developing multidisciplinary support and trust by orthopaedic surgeons in safety and effectiveness of physiotherapy assessment skills • Messages to others: • Ensure a very experienced physiotherapist is appointed to the role. • Work hard at developing teamwork and make the most of informal communication opportunities • Feedback information re patient outcomes

38. LESSONS LEARNT • What we would do differently: • Ensure more structured appointment template. Now 4 x ½ hr appointments for new patients and 8 x ¼ hr review appointments. • Ensure overbooking does not occur by others.

39. References Daker-White G, Carr AJ, Harvey I et al (1999) A randomised controlled trial. Shifting the boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health 53:643-650. Hocking, J and Bannister G (1994) The extended role of a physiotherapist in an outpatient orthopaedic clinic. Physiotherapy 80:281-284. Hourigan P and Weatherley C (1994) Initial assessment and follow-up by a physiotherapist of patients with back pain referred to a spinal clinic. Journal of the Royal Society of Medicine 87:213-213. Weale A and Bannister G (1994) Who should see orthopaedic outpatients – physiotherapists or surgeons? Annals of the Royal College of Surgeons, England 77 (supplement): 71-73.