Steve Fordham December 2016 QI@EMExeter Steve Fordham December 2016 @EMExeter

@EMExeter

@EMExeter

@EMExeter

Describe the patient?   What is the problem? What evidence is available to show that this is actually a problem? @EMExeter

104 Patients identified using the discharge code “Hip Dislocation” 102 Adult Patients confirmed Dislocated Hip Prosthesis 7 due to ED pressures 7 medically unfit 5 Failed reduction 1 patient refused Reduction of Dislocated Hip Prosthesis achieved in ED? No (20 Patients) Yes (82 Patients) 9 Discharged from ED 73 admitted 56 Discharged next day

What are we trying to accomplish (Aim)?   Stakeholders (consider the project from other perspectives) Methodologies PDSA: Plan/Do/Study/Act @EMExeter

Resus for Procedural Sedation Sleigh Crash 0645hrs 1 Ambulance 0729hrs 2 4 6 5 9 10 7 3 X-ray 1015hrs Resus for Procedural Sedation 0931hrs 0848hrs Majors 0824hrs Triage in RAT room 0820hrs ED attendance 0814hrs 1027hrs Hospital stay overnight Transfer to ward 1211hrs Ortho referral 1040hrs 12 13 Request for OT aids at home 1225hrs OT assessment 1150hrs Physio assessment 1037hrs 16 15 14 17 OPD follow-up: booked for 2/52 Transport home 1530hrs 11 8

How will we know that change is an improvement (Measure)   What change can we make that will result in an improvement (Change) @EMExeter

Secondary Drivers The Goals Action Balancing measures   Reduce admissions of patients following relocation of their Hip Prosthesis in ED Maintain patient care and safety Improve Patient Experience Improve Discharge Processes Improve Cost effectiveness Direct discharge from ED to patient’s own home Use of Procedural Sedation in ED if clinically appropriate Out-patient follow-up with original Orthopaedic consultant Improve flow in elective Orthopaedic admissions Reduce emergency admissions Increase availability of ward-based OT and physio To create a “Hip Dislocation Pathway” algorithm Primary Drivers Secondary Drivers The Goals Action That neither the medical need of the patient or the time spent in ED should be compromised by the use of the Hip Dislocation Pathway Balancing measures

How will we know that change is an improvement (Measure) Patient centred/how will this improve patient care - it is ok to use a surrogate marker of this.   What change can we make that will result in an improvement (Change) Choose the big wins from the process map Short pdsa cycles are better @EMExeter

Variation is natural and inevitable - aim of QI is to reduce variation over time The dimensions of Quality: Safe Effective Patient centred Timely Efficient Equitable QA vs QI - Assurance is measuring compliance with standards, Improvement is continually improving processes to meet standards @EMExeter

What is a quality QIP Made a difference to patients Started from a problem not a solution Used a recognised QI methodology Good narrative Good team work Based on good evidence Good planning Continuous measurement Iterative process Reflective @EMExeter

No planning What is NOT a good quality QIP Implementing a solution and not fitting it to a problem Solo player No evidence of engagement No evidence of reflection Based on making things cheaper A audit polished up or implementing a pro forma Just using a lot of tools with little understanding of the methodologies No planning @EMExeter

Happy Christmas www.emexeter.co.uk @EMExeter