The Supine Crucifixion

It can be life

changing but

now she has

an ally.

The term used by some

orthopods to describe the

frail patient experience of

waiting for hip fracture

repair.

DeliriumUTICardiacElectrolyte ImbalancesAnemiaStrokeWound InfectionPressure SoresUrinary Retention

PneumoniaDeep Vein ThrombosisDislocationPulmonary EmbolismAspirationGI BleedFixation breakdownIleusDeath

It’s Complicated

Provincial co-leads for the Hip Fracture

Redesign Project, Dr. Pierre Guy and Dr.

Kenneth Hughes have spearheaded a

provincial effort to improve hip fracture care.

The Royal Jubilee Hospital is a pilot site in the

effort to improve hip fracture care. Dr. Patrick

McAllister is Surgeon Lead. John Kristiansen is

QuaIity Improvement Lead.

BACKGROUND

Standards of Care • Surgery within 36 hours• Joint orthopaedic and geriatric care• Assessment protocols• Pre and post-operative cognition• Secondary fracture prevention• Falls and rehabilitation assessment• Data submitted to National Audit

Research

Over a 2 year period:• 15% reduction in mortality• 5% reduction in hospital stay= 60,000 bed

days• 12% more osteoporosis treatment• Cost of care reduced by $23,300,000

Result of UK Initiative

According to the last 5 months (100 patients) of data collection on hip fracture patients in RJH:She has a 66% chance of getting some complication.She has a 34% chance of getting a UTI.She has a 30% chance of getting delirium.She has a 14% chance of a cardiac complication.

Who’s

Rattling

The

Cage?

Ensure OrthopodAssesses Patient

in 2 Hours

Improve Patient Flow and Bed

Access

Reduce ER to OR

Time

Reduce Time For Medical Consult

Medical doctors educated re delay reversal anticoag

pathway

Ortho Dr to ensure patient placed on OR slate as soon as deemed appropriate

Make Hip # the priority Examine the process for getting patient on OR slate

Examine the difference in OR slate process for

weekends

Dedicated # hip ward and subacute rehabHOW

Key DriversChange Concepts

HOWHOW

WHYWHYWHY

Diagnostics in Emergency?

Critical: Ensure adequate OR Capacity and

Access

Consider fracture slate Sunday am

Hospitalist assesses in ER and

Co-Manages.

Increase Hospitalist

Participation

Clinical Order sets to increase efficiency

Increase Awareness of 48

hour limit

Two OrthopodsAssessing

an ECG

Increase hospitalist care and patient co-management of hip fracture patients by 60% within 4 months 1 year. The rate is currently 40%. Goal rate is 64%.

What We Are Aiming For

Orthopaedic and hospitalist leads engage their peers in changing how w2e deliver care

0%

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May June July August September October

Medical Consult on Admission

BASE LINE DATA 2013

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November December January February March April

Medical Consult on Admission

Resistance 2013-2014

Patient Complications

Keeping things in

Balance

Picking up the pieces

Or

Medical Co-ManagementHospitalists engaged to provide medical co-management with surgeon because patients could be followed throughout stay.

Multiple issues brought inconsistent levels of participation.

The variance of participation made the case for co-management more powerful. Beta test. Was it an obstacle or securement of the initiative.

Something happened… Data regarding early hospitalist consults was compiled, getting larger and difficult to ignore.

DATA

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10%

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100%

Medical Consult on Admission

Pt With Any Complications

One Goes Down,The Other Goes Up.Negative Correlation.

Think about it now…What is truly profound is the effect of the unseen filter which should seriously dampen this negative correlation in the previous slide.

Consults for hospitalists are requested by the orthopedic surgeon due to perceived medical issues and risks.

That means that the sample of patients in a specific month will have less consultations if they are perceived as low risk and more consultations if they are perceived as at greater risk.

Why then would complication percentages decline when the monthly sample is perceived as at greater risk by the orthopedic surgeon and increases in complication percentages when perceived at lower risk?

Worthy of note and truly profound is how great the negative correlation would be in the absence of the orthopedic selection of consultable patients.

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Delirium Admit consults

2013-2014 Delirium relative to consult on admit

One Goes Down,The Other Goes Up.Negative Correlation.

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90%

Medical Consult on Admission Cardiac Complications2014

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60%

UTI

UTI

UTIs as a percentage of the Monthly Total

Patients

Silver Alloy Catheter Intro.

UTI rates received a downward push relative to hospitalist consults but still seemed a bit unstable. The drive to remove urinary catheters early and the use of silver alloy catheters has helped to augment UTI reduction.

0%

5%

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40%

45% UTI Rate 2014

UTI Rate 2014

05

1015202530

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

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ob

er

No

vem

be

r

Average Length of Stay

0%

20%

40%

60%

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100%Ja

nu

ary

Feb

ruar

y

Mar

ch

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ril

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e

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gust

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tem

ber

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ob

er

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vem

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r

Dec

emb

er

Medical Consult on Admission

One Goes Down,The Other Goes Up.Negative Correlation.

2014

Average length of stay October/2013 –March/2014 = 23.8 daysAverage length of stay April/2014 –September/2014 = 18.8 days5 less bed days per hip fracture patient.Conservatively stated at 25 patients per month, bed days saved per year = 1500 bed days. How much is a bed day?

Outcome Measure

0%

10%

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30%

40%

50%

60%

70%

80%

90%

100% Medical Consult on Admission

Rate Over Last 8 Months = 74%

Outcome Measure

Balancing Measure• Geriatrics consults dropped as recorded during the same 4

month intervals in 2012, 2013, and 2014 .• The floor GP on rehab had a huge reduction in patient load

due to hospitalist increased involvement.• Staff nurses noted that medical aid and issue resolution was

quick and effective.• Hospitalists were likely on the unit and able to support

during times of acute emergency.

0%

10%

20%

30%

40%

50%

60%

2012 4 months 2013 4 months 2014 4 months

Geriatrics Sept. - Dec.

According to the last 4 months of data collection on hip fracture patients in RJH:She has a 66% 48% chance of getting some complication.She has a 34% 12.5% chance of getting a UTI.She has a 30% 19% chance of getting delirium.She has a 14% 2.5% chance of a cardiac complication.Crossed out number from one year ago. Same interval.

Percentages derived from data collected in the last 4 months .Aug 1 2014-Nov. 30 2014

We know we are making a difference. Thanks in part to the elephant in the room.

Contact Information

• John Kristiansen

• VIHA Surgical Services + NSQIP

QI Consultant

• (250) 727-4000 ext. 15569

• (250) 686-8681 Mobile

• John.Kristiansen@viha.ca

• N542 Victoria General Hospital