Benefits of a pathway: The experience of utilizing a NOF ... · Benefits of a pathway: The...

Benefits of a pathway: The experience

of utilizing a NOF pathway

Megan Yeomans – Clinical Nurse Consultant

Pain Team, Austin Health

Our health service

# NOF Presentations

2010-2011: 262

2011-2012: 246

Management of a # NOF Patient

2009- surgery-focused approach

Patient fits in with:

– a rigid system

–not a patient focused approach

– resulting in a poorer outcome for patient



Patient arrives in ED:

• XRs show #NOF…Patient fasted, given

some morphine

• Page Ortho Reg 11am….No Answer…

• Page Ortho Reg 1:30pm…Nurse from

theatre answers

• That registrar isnt on call, not sure who is

• Ring switch…right reg now paged …reg

rings ED…



ED

• ‘Got a NOF for you’

• Ortho Reg

• ‘What’s the UR?’….looks up XR on

computer…

• OK, Keep her fasted



– 8pm…

–….10pm…

–…Midnight…

–…..2am…



Theatre Nurse

• ‘Are you going to get to that NOF tonight?’

• Ortho Reg (scrubbed)

• ‘Hmmm, probably not, it’s getting a bit late’

• ‘Let’s put her on for tomorrow night’

• Theatre Nurse

• ‘Make sure you ring the ward to let them

know’

• Ortho Reg (scrubbed)

• ‘OK’



1 hour later…..Ward Nurse rings Ortho

Reg……

» Are you doing that NOF tonight??....

Ortho Reg

»Oh sorry….. No, feed her and fast her

from early breakfast!



Overnight…

• Ward nurse feeds patient & calls the resident

• Overnight Resident Looks at ED notes to

write admission

• 2.5mg morphine SC 4 hourly written up



Next Day…

• Patient

• Delirious…so morphine ceased

• Fasted all day

• Operation ‘bumped’ again next

night



3rd Day…

• Patient

• Delirium worsens

• Operation goes ahead that night



4th Day…

• Patient

• Severe Delirium with aggression

• Patient shackled



5th Day…

• Patient

• Patient remains delirious

• Patient noted to be hypoxic

• Bloods checked- patient anaemic

• CXR- Pneumonia



2 weeks later…

• Patient

• Delirium seems to have settled

• Family still say she is ‘not quite right’

• Now medically stable enough for

transfer to rehab

Objectives of this presentation

• To tell our story of why this project was initiated

• The diagnostic process

• What we learned

• The value of an organizational collaborative effort

• Designing and implementing a pain management plan

• Results and Ongoing Improvements

Information we were given

• Health Round Table Information

• DRG 108- Neck of Femur Fracture

• Austin Health had an average LOS >14 days

• The four exemplar hospitals average LOS around 8 days

• Aim – Reduce Length of Stay to that of exemplar hospitals

Background

Visit to another facility and a literature search revealed we needed:

1. Full time Head Of Orthopaedic Unit – implemented Sept 2009

2. More theatre sessions and better access for trauma –

implemented over 2009

3. Institute ortho-geriatric service – commenced February 2010

Orthogeriatric Service

– New full-time Orthogeriatric registrar

– Over seen by a senior geriatrician

• Involved in every patient >65yo with low-impact trauma #

• Cross-campus consultant-led 2x/week ward rounds

• Ortho in Rehab hospital

• Geriatric in Acute hospital

Move toward a patient centred approach

The patients needs have redesigned the

management of this injury and led to the

implementation of a clinical pathway by:

• Considering the patient experience

• Improving communication

• Improving system issues

• Tailoring pain management to the patients

individual needs

Top down commitment

• Attendance List List

• Executive- CEO, CMO, Executive Directors

• CSU/ Medical Directors

• Senior Clinical Staff- ED, Anaesthetists , Orthopedics

Geriatricians

• Austin By Design

• Physiotherapy

• Access, Care & Patient Flow coordinators

• Ward NUM

• Liaison nurses

• Theatre staff…and more

Review process- How are we managing these patients?

• File audit- 30 patient files

• Interview with patients and their families

• Walk Through

– Follow the patient journey from the front door to discharge.

– Chance for two way communication and to understand work

flows

» What works

» What doesn’t

Where we focused

– Time to theatre

– Fasting

– Pain management

– Delirium

Pain with # NOF Before and After Surgery

Pre operative: 44% pre op

Post operative: 42% severe pain (cog intact)

Morrison et al 2000 J Pain Sympt Mgt

How much pain?- identified in the patient files

“The pain scores were overall poorly documented”.

“Often comments were made by the physios and nurses in

the clinical notes about the patient experiencing ‘severe

pain, anxiety, confusion and being tearful’; this was often

not evident when compared with the pain scores ‘if they

were documented’.”

We focused on three main areas

• Three main areas

– ED

– Pre operatively

– Post operatively

The Three Main Areas- ED

Before

• No Standard Pain-relief

• Mostly narcotic-based

• Minimal use of blocks (<10%)

• No review of analgesia efficacy

• Multiple trips to Radiology (Hip & Chest)

• Gap from ED until drug chart written up (on ward)

The Three Main Areas- Pre op on the ward

• Admitted to the ward at various times of the

day.

• Orthopaedic staff in theatre so charts not

done

• Variable pain relief/not standard

• Fasted for varying lengths of time

• Analgesia usually ceased if patient became

confused

• Usually inadequate doses

• Intermittent/ infrequent doses

Patients arrived at various times

Often an adhoc approach to pain management

The Three Main Areas- Theatre

Pre

implementation

Pre

implementation

The next day

Three main areas: Post operative

Before

• No Standard Pain-relief

• PRN-Basis

• Usually no maintenance medications

• No formal review of analgesia efficacy

• Opioids ceased if patient became confused

• Patients not able to participate in physio due to pain.

Implementation of clinical pathway

Developed an integrated Clinical Pathway

ED Now

• Regular Paracetamol 1g TDS in elderly (Oral)

• Incremental boluses of Fentanyl to effect (or

Morphine)

• Regular pain scores on function

• Fascia Iliaca Blocks – done in >80% of patients

• Single xrays Chest and Hip – ordered as a package.

Post

implementation

Post

implementation

The Ward Now

• Care Pathway

• Pain Plan

• Hunger clocks

– High protein Supplements

• Delirium screening – Cognitive Assessment Method

• Orthogeriatricians now educated and adopting similar

analgesic prescribing for other patient groups

0-6 hours

Appropriate length of

fasting time

6-9 hours Confirm

theatre time with

theatre staff and ortho

reg

12 hours Definitive

plan required, call

ortho reg feed patient

if surgery is not

imminent

CONFUSION ASSESSMENT METHOD (CAM) adapted from Inouye SK, et al. Ann Intern med. 1990;113:941-8

A -

B -

C -

D -

Delirium = A+B (2points) A+B+C (3points) A+B+D (3points) A+B+C+D (4 points) Salliece Byford. CNS. Austin Health.

A ACUTE ONSET AND FLUCTUATING COURSE

Is there an acute change in mental status from the patient’s baseline? Does the persons behaviour fluctuate during the day (come and go) or increase and decrease in severity?

B

C D

Delirium

INATTENTION Does the patient have difficulty focusing their attention, for example, being easily distracted or having difficulty keeping track of what is being said?

DISORGANISED THINKING Is the patient’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from one subject to another?

ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the patient’s level of consciousness?

-- Vigilant (hyperalert) -- Lethargic (drowsy, easily aroused) -- Stupor (difficult to arouse) -- Coma (unarousable)

Delirium

Delirium

Pain Pathway

Post Operative Now

• Patient controlled analgesia:

– If patient cognitively intact, PCA mode +/- continuous infusion

– If patient cognitively impaired, a continuous infusion @5mcg/hr

– Both have clinician boluses to be given prior to movement.

• Nurses are already familiar with PCA

– Monitor regularly

– Pain at Rest

– Pain on Activity

– Sedation Score

– CAM (Delirium) Score

Pain Care Plan

• Guidance is given to PCA orders

• Step down analgesia

• Monitoring guidance

• Reassessment prompts

May 2009-March 2012

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Average Length of Stay (HRT Data)

Exemplars

A H

Project starts

Pain Plan

Starts

Top down commitment

• Attendance List List

• Executive- CEO, CMO, Executive Directors

• CSU/ Medical Directors

• Senior Clinical Staff- ED, Anaesthetists , Orthopedics

Geriatricians

• Austin By Design

• Physiotherapy

• Access, Care & Patient Flow coordinators

• Ward NUM

• Liaison nurses

• Theatre staff…and more

• Pain services asked to optimise analgesia… 18months later

Pain DOES matter!

Post-operative pain is associated with:

increased hospital length of stay; delayed ambulation and

long-term functional impairment

(Morrison 2003)

Acknowledgements to:

• Fiona Nielsen: Quality Coordinator Surgical Clinical

Services Unit

• Andrew Hardidge: Director of Orthopaedic Surgery

• Jane Trinca: Director of Acute Pain Service

• Ward 8N: Pain Champions

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