Implementing the OACCP at Dubbo Base Hospital

Craig Lennox Senior Orthopaedic Physiotherapist Dubbo Base Hospital May 2012

Dubbo

Dubbo

• Population: 42,108 (June 2011) • Average Age: 35.7 • 12.8% of population >65 years • 25% predicted to be >65 by 2036

Dubbo Base Hospital

• In the Western NSW Local Health District

• Referral centre for large geographical area

• People travel over 4 hours

Orthopaedics at DBH • Pool of visiting orthopaedic consultants,

primarily from Royal North Shore Hospital led by Dr Stephen Ruff

• 2 registrars on 6 month rotations • Elective joint replacement in 2011:

2011 TOTAL Age (av.) F:M (%) LOS (av.)

THR 87 73 51:49 5.4

TKR 84 66 60:40 4.6

Hip/Knee OA Management

January 2011 • People with hip/knee OA referred to Orthopaedic

Clinic • Put on waiting list or “wait and see”

– Occasional referrals to physiotherapy and told to “lose weight”

• No further pre-op management until surgical preadmission clinic

Hip/Knee OA Management • 6 weeks pre-op pre-admission clinic

– Nurse, anaesthetist, pain nurse, orthopaedic intern/resident assessments

– Physiotherapist assessment with provision of education and exercise sheet

• Joint replacement surgery – Inpatient physiotherapy, occupational therapy, nursing, social

work/ARC nurse, medical/orthopaedic management

• Discharged with outpatient physiotherapy referral, aids/home modifications, other services

• Orthopaedic review at 6 weeks and 12 months

Implementing the OACCP

• Goal for 2011 to begin a “Pre-Op” program for people electing total hip/knee replacement – Disease management and health education – Multidisciplinary team interventions – Aim to improve post-op results

• Independent planning began in January 2011 – Research on evidence for pre-op MDT interventions – Planning use of staff, facilities, tools

Implementing the OACCP • “Heard” similar groups existed at several

hospitals, including Nepean • Introduced via email to the OACCP • Plans modified to fit OACCP • Program proposed to and accepted by Dr

Ruff • Dubbo site incorporated in October 2011 • First assessment performed 16/11/11

Utilising Existing Resources

Utilising Existing Resources • Multiple staff members involved in

assessments: – Chronic Care

• Co-morbidity and medication screening • 6MWT, TUG, Hip:Waist Ratio, BMI

– Outpatient Physiotherapy • VAS, questionnaires review, objective measures,

goals, education – Physiotherapy Assistant

• Data entry

Utilising Existing Resources

• Referrals are made to new or existing sources: – New physiotherapist-run exercise and

hydrotherapy classes – Community health or private dietitians – Outpatient physiotherapy in peripheral areas

New Resources • Land-based Physiotherapy class

– Weekly 1-hour class, began 28/11/11 – Run by outpatient physiotherapist with

physiotherapy assistant – Incorporates bed, chair and standing exercises – Focus on strength, ROM, balance and

proprioception – Education, objective assessment and exercise

progression incorporated

New Resources

New Resources • Hydrotherapy Class

– No hydrotherapy at DBH, so agreement reached with local rehabilitation hospital

– Weekly 1-hour class began 27/2/12 – Run by DBH outpatient physiotherapist using

hydrotherapy pool at rehab hospital – Simple strength, ROM, balance and

relaxation exercises – Very popular

New Resources

Results • Classes currently full • Waiting list for both assessments and

classes • 4 people re-assessed

– 2 of 3 original goals acheived – 2 improved TUG and 6MWT – BMIs stable

Results • Subjectively, participants are very happy • Reporting

– Less pain – Improved function eg. ability to walk up stairs – One person now able to run short distances,

sit on the floor cross-legged, and on orthopaedic review decided he no longer wanted to go on the TKR waiting list

Success!

The Future • Chronic Care EEN leaving

– Reduced CC availability in short term – Increased load on outpatient physiotherapists

• More dietitian referrals – Increase use of available services

• Begin short education sessions – Half-hour weekly multidisciplinary education

including physiotherapist, occupational therapist, pain team

Craig Lennox Senior Orthopaedic Physiotherapist

Dubbo Base Hospital