megan white - concord hospital - don’t restrict my ability – an orthopaedic redesign project for...
TRANSCRIPT
Restricted Weight Bearing In
Orthopaedics
Megan White
Orthopaedic CNC, Concord Hospital
ANZONA President
Background
Ageing population
– Increased fragility fractures
– Common sites for fragility fractures include:
– Hip fractures
– Upper limb – humerus / wrist
– Lower limb – ankle fractures
– Periprosthetic fractures
– Clinical redesign project
– Patient Stories
– Extended LOS
– Bed blockage
– Limited subacute care
Diagnostics
Case for change:
In 2013/14 there were 4686 bed days occupied by RWB
patients leading to $4,686,000
4686 bed days – loss of 6 acute beds
Increased length of stay
Deconditioning
Reduced patient satisfaction
Patients Voice
I can’t believe how
easy it was to fall.. I
was playing Tennis,
now I just can’t
coordinate myself to
walk.. I was fit before
this fall
Staff Voice
Nurses slide
Medical / Surgical slide
Rehabilitation Consultant
Orthogeriatrician Consultant
Occupational Therapy
Social Worker
Physiotherapists
Nurses Interview What we do well Issues Do Better
Pressure area
care
Time consuming (full care) Psychological support
Nursing care Occupying acute bed –
increased outliers
Communication – be upfront
about LOS
Medical- brief interactions with
family and pt
Ortho team no set method of
communicating with NOK
Patient flow
Single rooms
Nursing handover – reduced
interaction
Institutionalised
Pain relief Diversional therapy
Constipation Better access to TCU / other
facilities
Deconditioning Specific accurate information
(written)
Suboptimal Model of care
(needs of pt)
Allied health – reduced physio
due to increase in elective and
increased needs
Need different approach to
acute beds
Mentality
Don't Restrict My Ability
Medical Interviews – Junior / Registrar
Frustrating – Doing GP / subacute work
Time consuming – write notes each day / increase list of inpts
(busy position)
Not the right place for them
Guilt – blood tests/ investigations in case pt. deteriorates
Worry about HAI’s – our aim is preventative medicine
Communication – Reg (Ortho) to Reg(O/G) not Intern to
Orthogeri
Complex discharge planning
Difficulty understanding admission criteria to subacute
Junior / Reg – hesitant to approach Consultant
Older pts – GP ring for rpt BMD, OP, medication r/v
Ortho reg don’t understand complexity of pt Don't Restrict My Ability
Key Issues Identified
Poor Communication Processes
– Postoperative notes / RWB terminology
– Communication with patient/ family
Patient experience
– Deconditioning / Boredom
– Reduced interaction with health professionals
Delayed Discharge
– Variances in admission criteria to subacute care
The NEW Patient Journey
Brochure
The NEW Patient Journey
Agreed Terminology
Term Definition Walking Aid
Progression
Non
weight
bearing
(NWB)
No weight allowed
through the limb
PUF, WPUF, Crutches
Stairs - Crutches
Touch
weight
bearing
(TWB)
Toe to the ground,
walking on an egg
shell.
WPUF, PUF, Crutches
Stairs - Crutches
Partial
weight
bearing
(PWB)
50% of body weight
allowed through the
affected limb
WPUF, PUF,4WW,
Crutches
Stairs - Crutches
Protected
Weight
Bearing
Weight bear as
tolerated through
limb, always
supported by a
walking aid
WPUF, PUF, 4WW,
Crutches Stairs –
Railing
The NEW Patient Journey
Family Conference
Short term goals
– Goals tailored individually
Long term goals
Discharge Planning
The NEW Patient Journey
Reconditioning Program
Occupational therapist
– 3 times a week function
Physiotherapist
– Daily hourly exercise class
– Circuit style
Nurses
– Encourage Independence
– Encourage exercises
– FIM scores
Medical Staff
– Encourage patients to participate
Results to Date
Staff satisfaction and Teamwork (across health professionals)
Staff are engaged in promoting mobility ad function
Staff encourage patients to participate in daily exercise class
Staff assist patients to reach their goals
Patient experience
– Patients identifying goals and encouraged when they are met
– Interaction with health professionals have increased
Other benefits
improved communication with other LHDs with discharge planning
Function has become an important benefit for recovery
Results to date continued
100 patients registered (Ethics approved)
Variety of fractures at times 2 limbs
Improved FIM score – improved function (weekly)
Improved patient satisfaction
Adverse 9% - 0.5%
Reduced 14 days off av. LoS
Lessons learned during the Implementation
Phase
Open communication and regular update sustains project
Good data collection
– Evidence!! Evidence !!
Role-modeling
Importance of equal input to promote optimal outcomes for
patients
Launch of the Model of Care
Acknowledgements
Tim Sinclair
Breda Doyle
Dr Jai Sungaran Orthopaedic VMO
Dr Peter Walker – HOD Orthopaedics
Dr Nichola Boyle – Orthogeriatrician
Dr Veena Raykar - Rehabilitation consultant
Sharne Hogan – Director of nursing
Priya Nathan – Physiotherapist
Katie Balderi – Occupational therapist and the Occupational department
Dev – Social Worker
Nursing staff on Ward 6 North – led by Natalie Shiel, Melinda Pestana
Orthopaedic surgeons / Registrars and Interns
Elizabeth Bryan – Performance unit SLHD