Dr Abhaya Gupta

Consultant Physician

Carmarthen

8th February 2012

Question 1 What is special about Hip

fracture patients ?

Hip fractures • Common

• Costly !

• Complex patients

• Difficult decisions to make

• Best practice tariff- £445/case higher income in England if Trust achieves standards. An average unit treating 350 hip fractures/yr and meeting 90% of BPT will result in £140,000 additional income.

Complex patients • Average age 84 yr

• Falling for a reason

• Breaking bone for a reason

• Comorbidities

• High 1 yr mortality

• Issues- hyponatremia, Troponin, murmur, dialysis, ECG changes, COPD-home O2, diabetes, delirium, cognition, DNAR, pseudo-obstruction, alcohol, CRF,AF,CCF, anaemia

• Multiple drugs- ACEI, steroids, diuretics, PD, sleeping tab

• Aspirin, clopidogrel, warfarin

• Hip fracture is only one part of problem for patient !

• Despite complexity vast majority are operated

• Delays to theatre can increase mortality and morbidity - OPTIMISATION needed

• Rehabilitation issues after surgery

Journey of hip fracture patient A&E

• Doctor, Nurse

Orthopaedic ward

• Doctor, Nurse, Surgeon, Anaesthetist

Theatre

Ward

Rehabilitation - MDT

Question 2 What is the best place to keep these patients?

1. Orthopaedic ward?

2. Care of elderly ward ?

3. Acute hip unit- stroke/CCU model

- Well defined area

- Protocols

- Standardised management

- Trained staff- nurse,doctor

Analogy between hip fracture, stroke and MI Life threatening

Costly

Common

Incidence/activity easy to measure

Sec prevention implications

Acute issues- thrombolysis/time to surgery

Rehabilitation issues

CCU- 1970s

Acute stroke unit-1980s

Acute hip unit- 2010

Question 3 How to provide best uniform standardised care ?

NICE From admission offer patients a formal acute

orthogeriatric or orthopaedic ward based HIP FRACTURE PROGRAM which includes Orthogeriatric assessment, rapid optimisation of fitness for surgery, early identification of goals, continued co-ordinated OG and Multidisciplinary review.

The Main DH Message: A Systematic Approach to Falls and Fracture Care And Prevention

Carmarthen before June 2011 • DGH - >300 hip fractures /year- Carmarthen + Llanelli

hospitals

• 9 orthopaedic consultants

• Patients admitted to 3 areas of Trauma wards

• OG cover: liaison service-once weekly ward rounds with Trauma nurse

• Emergency medical issues dealt by medical registrar

• Lack of doctor in MDM

• Early postoperative rehab under orthopods

• Different thromboprophylaxis regimes

• No standard falls and osteoporosis management

• Lack of standard approach in dealing with common medical problems

• Significant issues in pre and postoperative care

• Failure to recognize and Act !

• Poor care shown in UK National audit

Opportunity for Change • Initiated by Orthopedic surgeons

• Refurbishment and relocation of wards

• Meetings held

• Management enthusiastic

• Single ward in medical block located

• 15 bedded Acute hip fracture unit since June 2011

• Same nursing staff from orthopedics

• One full time Consultant OG

• 1 junior orthopedic doctor + support from my medical juniors

• Specialist Trauma nurse

• Direct admission from A&E as fast track

• Clerking done in ward- clerking proforma

• Preoperative medical assessment- weekday by OG and medical registrar on weekends/BH

• 58 page Operational policy developed

• Fast track AE protocols developed

• Patient information leaflets developed

Average Time to Surgery (hours)

June – Dec 2010 June – Dec 2011

Total 168 163

Average 34 35

Median 25 26

Range 3-192 5-142

Pre-operative Medical Assessment

4%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

June -Dec 2010 (168) June - Dec 2011 (163)

(7)

(163)

Specialist Falls Assessment

0%

82%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

June -Dec 2010 (168) June - Dec 2011 (163)

(133)

91%98%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

June -Dec 2010 (168) June - Dec 2011 (163)

MDT Assessment

0%

85%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

June -Dec 2010 (168) June - Dec 2011 (163)

(138)

Mortality 8%

7%

0%

1%

2%

3%

4%

5%

6%

7%

8%

June -Dec 2010 (168) June - Dec 2011 (163)

(14)

(12)

June – Dec 2010 June – Dec 2011

Total 168 163

Average 16 14

Median 12 10

Range 1-90 2-120

Discharge Destination

2%8%

46%

27%

15%

2%07%

46%

30%

16%

1%0%

20%

40%

60%

80%

100%A

cute

Ho

spit

al

Dea

d

Ow

n h

om

e

Reh

ab U

nit

RC

/NH

/LTC

Oth

er

Acute Hip Unit • SHARED COLLABORATIVE care in ward

• OG-Identify and treat acute medical illness- optimise for early surgery

• Continuity of care right from admission (Acute ---- early rehab)

• OG led immediate postoperative rehabilitation

• Early mobilisation

• More systematic approach to fluid balance, thromboprophylaxis,drugs,continence

• Early identification of complications eg delirium

Acute Hip Unit • Cognitive assessment for all patients

• Falls assessment for all

• Osteoporosis assessment for all

• Food supplements

• Weekly MDT by OG- early discharge planning

• Complex ethical issues, DNR issues

• Effective use of resources eg Echo

• Ensure patient gets highest standard of care

constant OG presence in ward Better communication with MDT

More effective use of discharge resources

Improved staff morale

Maximises rehabilitation potential

Improved training opportunity for juniors- orthopedic and medical: New model of juniors working together !

Acute Hip Unit Pain control management being offered by

anaesthetists and AE Consultant

Improved efficiency and cost effectiveness

More organised and integrated services

Hip fractures no longer seen as surgical problem !

Real Team working and team building !

Summary A comprehensive fast track hip fracture ‘care

program’ now offered

Complex medical issues addressed right from admission to discharge by OG directly

Standardised care to ALL hip fractures

Evidence based practice and Quality care is offered now to all hospitalised hip fracture patients in new Acute Hip Unit at Carmarthen

NSF for Older People ‘At least one ward in an acute hospital should be

developed as a centre of excellence for orthogeriatric practice’

And Carmarthen is leading the way in Wales.

Carmarthen Hip Unit Team is working hard and smiling