INNOVATIONS TO INCREASE QUALITY AND DECREASE LENGTH OF STAY IN FOOT & ANKLE

SURGERY

Adam Ajis

Introduction

Modern NHS - Increase focus on quality

Every trust cares about quality

Beware Mid-Staffs

What is quality?

Clinical effectiveness, safety, patient experience

Patient centred

Introduction

Reducing LOS is linked to quality Improved patient experience Faster recovery & return to normal activity Improved safety Improved outcomes Increases capacity, efficiency & value £200 BPT uplift day case bunion surgery

Enhanced recovery programme Successfully applied to hip, knee & # NoF

Must be applied to all stages in patient pathway

Change in mindset

Day case surgery should be the ‘norm’

Safety in mind

GP Referral

An all systems review of patient

Medical conditions optimised

Get the patient involved early

1st OP Appt

Reinforce shared decision making

Agree a date for surgery

Discuss discharge, recovery & rehab

Start Integrated Care Pathway

1st OP Appt

Pre-op Assessment

Anaesthetic involvement

Risks identified – action plans made

Social circumstances taken into account – action plans made

Pre-op Assessment

Meet physiotherapists

Learn techniques of rehab

Have a range of patient specific options

Admission

Optimise hydration

CHO loading

Minimise starvation

Reinforce plan for early mobilisation – ward physio

Intra-operative Normothermia

Avoid opiates/N2O

Multimodal analgesia

Popliteal/ankle blocks

Minimally invasive techniques

Avoid drains & catheters

Use mini c-arm

Post-operative

Eat & drink asap

Analgesia

Mobilise asap Consider 7 day ward physio

Nurse led discharge

Integrated care pathway driven

Follow up

24 hr emergency contact number

Follow up telephone call

Emergency fast track OPD

Monitoring

PROMS MOXFQ SF-12

Patient satisfaction surveys

Risk management – near miss reporting

Care pathway usage

Reasons why day case failed

Regular meetings

Conclusion

Change in mindset

Streamlined effective pathways

Pt ready for surgery & us ready for pt

Best possible care during surgery

Post discharge support

Audit & monitoring