AcknowledgementsExecutive Sponsor: Dr Grant Rogers

Steering Committee: Dr Jason Tsung, Susan Freiberg, Wendy Howell, Chris Hanna

ACI CHR team: Lea Kirkwood, Bronwyn Paton,

ConclusionStrong governance and clinical leadership were key to this projects success. Several of the solutions are transferrable to other sites and are providing benefits to orthopaedic patients in general.

Case for changeWhen compared to peer hospitals during 2014/15, patients undergoing an elective hip or knee replacement at The Tweed Hospital were:

Staying longer:

Costing more:

1 in 10 re-presented

to ED within 21 days

6 in 10 patients were

not clear what to expect

Results

Objective 1

Project Team: Lynn Hopkinson, Dr Jason Tsung, Josie Bates, Mark Frost, Kirsty Sked, Jacque Ellem, Roz Wagner

GoalTo eliminate unwarranted clinical variation for patients receiving elective hip and knee replacements at The Tweed Hospital

ObjectivesReduce the average length of stay (ALOS) to below peer average by June 2017

90% of patients report the information provided preoperatively adequately prepared them for managing after discharge

MethodNSW Health Clinical Redesign Methodology was engaged as part of the ACI Centre for HealthCare Redesign Graduate Certificate program.

Sustaining changeAll solutions have been designed to be included as usual practice with local management ownership. All documents and protocols have been submitted through internal approval processes.

ContactLynn Hopkinson

NNSW LHD Manager Services Redesign

lynn.hopkinson@ncahs.health.nsw.gov.au

0427 521 048

Reducing length of stayfor elective hip and knee replacements

at The Tweed Hospital

110 bed days

135K

Diagnostics

root cause analysis

issues prioritisation

data analysis

coding audit

literature review

process mapping

patient tag‐a‐long

staff interview

patient interviews

Variable LOS indicates process variability which increases the mean LOS

Unplanned returns to ED can be prevented with improved discharge preparation – pain management is the most common reason

Disconnected processes between bookings and the preadmission clinics (PAC) leading to:

only 3 in 10 patients attending the mandatory Allied Health PAC

39% PAC appointments were rescheduled

“I knew what I had to take. I kept telling them but nobody listened. I had the wrong medications the whole way through – they’re still not right” Bill 81ys

“We had the modifications started but something got mixed up and they didn’t do them all. I had to stay in hospital a few days longer while they finished them”Annie 71yr

“I’ve never worked in a place with no daily meeting – it’s hard to know what's going on with patients' discharge plans” RMO

“The pain afterwards was incredible – it was fainting pain. Olive 75yr

Solutions❶ Restructure Pre-admission Clinic

Patient information booklets – multidisciplinary; ‘on team’ consistent message

Extended Allied Health preadmission clinic (PAC) with increased OT resources

Develop tracking system from booking to admission

❷ Medication Management

Pharmacist and JMO develop medication plan with patient on admission

Develop standardised aperient protocol

❸ Multidisciplinary Team Approach

Introduce multidisciplinary team meetings documented in EMR

Review and expand nursing care pathway to include allied health and commence preoperatively

❹ Pain Management

Develop evidence based pain protocol

Minimum standards for discharge pain medication

Documents and protocols Patient information booklets

Multidisciplinary care pathways

Pain management guidelines

Discharge pain medication patient brochure

ALOS for Total Knee Replacements exceeding target

ALOS for Total Hip Replacements exceeding target

86% of patients feel adequately prepared for managing after discharge

3.4

3.9

4.4

4.9

5.4

5.9

ALO

S D

ays

ALOS elective hip and knee replacements (uncomplicated)

I03B (hip) I04B (knee) Target

ED re-presentations reduced from 11% to 7.4 %

86% of patients have medication review by pharmacist and JMO preoperatively

Attendance at Allied Health Preadmission Clinic has increased from 35% to 100%

Preadmission appointments requiring rescheduling reduced from 39% to 11%

Standardised aperient protocol

Other benefits

Objective 2

242 bed days saved