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National Model of Care for Trauma and Orthopaedic Surgery was launched in July 2015 by the then Minister for Health Leo Varadkar in a bid to standardise services across the country. According to the Model, there
is significant scope for treating more patients within the current system by standardising treatment pathways and ensur- ing that appropriate facilities are designated at the right time to the right patient. At the time, the document noted, interventions taking place at an orthopaedic outpatient clinic could vary from a relatively short time requirement for fracture diagnosis and treatment, to a considerable time requirement for complex cases, or for explanation of diagnosis and treatment options to patients and agreement on the treatment plan.
In many hospitals, orthopaedic outpatient clinics had large attendance figures and also frequently overran the expected timeframe in terms of appointments, resulting in lengthy de- lays for patients and inefficient service delivery.
According to the document, there are many ways in which to improve the delivery of care to trauma and orthopaedic patients. The Model states that there must be timely access to radiology examinations and other diagnostic investigations on an outpatient basis, while designated and protected beds, both for inpatients and day cases, where possible, must be made available. Admitting patients as inpatients is inappropriate when the procedure could be performed as a day case, the Model states.
CUH orthopaedic trauma service
As with most health service plans, implementation of the Model has been variable across different hospitals. A report produced by Cork University Hospital (CUH), obtained by the Medical Independent (MI), outlines the continued problems with the orthopaedic trauma service in the hospital, while producing recommendations to resolve these problems. Written by the hospital’s CEO, Mr Tony McNamara, the report was issued to the Orthopaedic Trauma Group and the Executive Management Board of CUH.
The report acknowledges the trauma department in the hospital is extremely busy. In the period January to October 2017 the service had 20,839 outpatients; 2,092 inpatient discharges; and 274 day case discharges. It had an average pre-operative length of stay of 2.06 days and an average post-operative length of stay of 6.79.
The report states that in 2017 recognition of the need for a change in the clinical pathway for unscheduled (emergency) patients led to the implementation of various initiatives to improve clinical pathways in CUH’s orthopaedic trauma service.
The implementation of a patient flow plan (PF17) has brought a reduction in the number of trolleys in the hospital’s emergency department (ED).
“In addition, since many orthopaedic trauma patients are >75 [years] and pose particular care and placement challenges for the hospital, it is important to note the progress made by PF17 in working towards sustained improvements in the management of this cohort of patients towards the stated ambition in PF17 of having no patient >75 years old waiting more than nine hours for a bed,” it states.
The report also acknowledges the 2015 National Model of Care as a “driver for change”, noting the Model sets out a small number of key indicators that are germane to the work of the CUH group specifically.
These measurements include the percentage of patients admitted to the orthopaedic ward within four hours of admission to the ED; the percentage of patients sent to surgery within 48 hours; and the percentage of patients seen preoperatively by a geriatrician.
“Measured against these standards, CUH does not perform well and suggests the need for a quality improvement programme, which the governance group is charged with developing.”
In respect to patients admitted to a ward within four hours of presentation at the ED, in 2016 less than two per cent of patients met this target in CUH against a national average of 14.4 per cent.
Also, only half of the orthopaedic trauma patients in CUH had their surgery performed within the recommended 48-hour period, against a national average of almost 73 per cent. The report states that the performance of the hospital in this regard is “suboptimal”.
“This data is presented, not in any way to apportion blame, but to highlight that the system is in urgent need to reform, that process need to change and that leadership at all levels have both responsibility and an opportunity to make a real contribution to improving the care and lives of these vulnerable patients.”
There are other issues that require change in the patient pathway and in the responsiveness of the hospital’s systems to support this pathway. These include the availability of NIQUIS [National Quality Assurance and Improvement System] data that allows comparison between the performance of the service in CUH relative to national norms. Another key issue is “the ex- traordinary levels of cancellation of patients scheduled for operation that is suboptimal in terms of patient care and reputationally damaging to the service and to the hospital”.
In September 2017 CUH’s Executive Management Board with the support of the surgical directorate and the department of orthopaedics established a structured review of the orthopaedic trauma service and the report includes a summary of their recommendations. The recommendations, which were developed by three sub-groups, are broken down into ED presentation/admission procedures; theatre management processes; and discharge planning.
In terms of ED presentations, the report recommends that patients presenting with a fractured hip will be seen by the ED medical team and using a pro-forma pathway modelled on the Canterbury hip fracture pathway, will have a determination made by that team as to admission status. In order to aid rapid patient flow and to help achieve the target of the national programme of having patients in an orthopaedic ward within four hours, it will be necessary to review the organisation and allocation of orthopaedic beds to facilitate consolidation in a single area. This might take the form of a dedicated orthopaedic ward with additional beds in the adjacent ward or a dedicated trauma floor to include orthopaedic and plastic trauma beds. Also, the report states that the number of orthopaedic trauma beds to be allocated will need to be determined since efficiencies in the management of those patients, following recommendations of the review, will reduce the number of beds required from the present number of 50, which is the average number of beds used, but can raise to 70 beds at times of peak demand. Following the consolidation of beds, the report argues the goal must be to maintain one or two beds in anticipation of hip fracture patients presenting to be managed by the orthopaedic team in consultation with the clinical nurse manager and bed management. This model already exists on one of the hospital’s wards. Also a new pathway was recommended to fast-track hip fracture patients to these beds.
Theatre management processes
According to the report, there is a consensus that much can be done to improve patient flow between wards and theatre and within the theatre complex itself. It points out that this is best indicated by the number of patients reported as “cancelled”, a process which often takes place despite patients being prepared for theatre.
Cork University Hospital
“Addressing the causes of the sub-optimality in theatre is a complex challenge involving issues as diverse as rosters, use of management information, process improvements and most of all leadership at multiple levels.”
In respect of arrangements for surgical and nursing staff in theatre, the report states there is a need for new rosters such that each consultant orthopaedic surgeon would work three or four days on-call, during which time they do not have other duties.
“This will provide for much needed continuity, casemix and scheduling oversight, governance and clinical leadership in the orthopaedic theatre.”
Nurse recruitment should be prioritised with the intention of developing a 24/7 on-site roster for the orthopaedic service with better continuity and increased on-site presence. Another recommendation is to implement scheduling arrangements to maximise the use of two theatres and the “block room” to increase patient throughput and to reduce the intra-operative time between cases. The report also recommends recommencing discussion on enhancing the role of portering staff in theatre by developing the theatre assistant grade and upskilling staff appropriately.
The average post-operative length of stay for patients in the CUH orthopaedic service is 6.79 days. According to the report, there are many reasons for this that are specific to CUH and are a result of “sub-optimality” in the transfer of patients for rehabilitation to other settings and the processes for discharge.
“It is clear that prima facie, there is a significant opportunity to save bed days by improving these processes,” according to the report.
To achieve improvements to discharge planning, it is recommended that new arrangements are implemented to consolidate orthopaedic trauma (and perhaps all trauma patients) in a single area to increase specialisation in the management of these patients. It is also recommended that an ortho-geriatrician should be appointed to work between CUH and South Infirmary Victoria University Hospital (SIVUH), Cork, on pathways for transfer, optimisation of protocols and interface with community services. The report also suggests ascertaining with colleagues in the community the possibility of having two convalescent beds ringfenced for orthopaedic trauma patients in Cork. Another recommendation is for the appointment of an advanced nurse practitioner for orthopaedic trauma services.
Resources and next steps
The CUH report states that implementing the recommendations represents a “very challenging” programme of work. However, it adds that if implemented successfully, these reforms have the potential to make a substantial contribution to the delivery of orthopaedic trauma services, but also to the performance and reputation of CUH.
While many of the recommendations can be achieved by means of an internal reorganisation of resources and changing work practices, the report does stress that some initiatives will need additional financing.
Now that the recommendations have been approved, the governing group will oversee the recommendations and the sub-groups will be maintained to assist with the process.
“These recommendations offer a unique opportunity to improve patient flow for orthopaedic trauma patients and in the process, to use the resources of the orthopaedic and related services in CUH, SIVUH and the community to a greater extent than the existing pathways offer,” the report concluded.
“This will require commitments from leadership at all levels of the service that has been demonstrated in the work of the group to date and it is vitally important that we work in uni- son with the national care programmes, the SSW Group, the Acute Hospitals Directorate and other stakeholders to implement this programme of initiatives.”
A spokesperson for CUH told MI that the report’s recommendations have already yielded benefits. As a result of the report, there was a reorganisation of beds, leading to improvements in patient flow and an improvement in the scheduling of patients for theatre.