Hip Replacements – improving the care pathway Measuring and monitoring patient outcomes in real time and in the longer term Lesley Hugill RGN BSc (Hons) DPSN Clinical Nurse Specialist Trauma & Orthopaedic Department UHCW NHS Trust lesley.hugill@uhcw.nhs.uk Name Lesley Hugill TitleOrthopaedic CNS Lower limb team - Hip nurse specialist Commenced my post in september 2008 my main project was to commence a hip arthroplasty surveillance service to standardise the departments follow up of THA and provide long term follow up / data UHCW specific questions (4) Oxford hip questions (12) ucla activity rating choose 1 of 10 EQoLhealth status questions (5) VAS 0 to 100 23 questions in total

UHCW Arthroplasty Virtual Surveillance Service Time line: 2004 a DoH policy research programme 2006 at UHCW virtual’ arthroplasty surveillance plan April 2008 The new Standard NHS Contract for Acute Services Jan 2009 this commenced at UHCW (post op) April 2009 DoH pre op PROMs commenced

Problem: Large volume of arthroplasty patients Large majority of patients satisfied, no problems Important to follow up patients to spot problems Heavy burden on clinic time to review large number of patients with low rate of problems.

Solution: Filter mechanism to screen all patients Select only problem patients for clinic

UHCW Arthroplasty Virtual Surveillance Service The process: Pre-op questionnaire completed using multiple Patient Reported Outcome Measures (PROMs) Surgery performed The Clinical Nurse Specialist (CNS) receives a monthly list CNS validates, then admin support mail merges and sends forms CNS checks if there are current x-ray views X-rays requested as per protocol.

UHCW Arthroplasty Virtual Surveillance Service Receive the returned forms & checks the x-ray date Questionnaires are transferred onto the patient’s e-form Secretaries are sent a quarterly ‘table of patients for virtual review’ The consultant/team then perform a virtual clinic, reviewing PROMS and x-rays Outcome is documented on hospital electronic record system, standard clinic letter to GP is generated Hip surveillance post op follow up.

UHCW Arthroplasty Virtual Surveillance Service The 1st year results Total patients = 209 Functional outcome response 178 (85.2%) Radiographic response 176 (84.2%) 2nd year (numbers) Data still being processed.

UHCW Arthroplasty Virtual Surveillance Service Consultants happy to be able to devote more clinic time to more needy patients Patients happy to know they are still under review without having to attend clinics Management happy with more efficient use of clinic time.

Problems and pitfalls: No admin support for virtual surveillance IPM/coding not correct CNS validating the info from CRRS Patients unable to complete the questionnaire (esp. Oxford score Q1) Patients not returning the questionnaires.

Problems and pitfalls (cont): Virtual clinic list not populated by secretary Virtual clinic list not reviewed by consultant Outcome not recorded by consultant Closing the loop – confirming reviews have taken place.

UHCW Arthroplasty Virtual Surveillance Service Beware risk of clinics becoming exclusively for unhappy patients Everyone needs some positive feedback! Routine protocol now real visit at 6/52 and one year, then virtual if OK.

UHCW Arthroplasty Virtual Surveillance Service Plans: Currently patient is sent paper form, returns paper form (printing and postage cost x 2) Staff copy data onto electronic form (staff time, potential for error) Hope to develop online form for patients to log on and directly enter their data onto our database.

References: Primary total hip replacement: a guide to good practice; 2006. British Orthopaedic Association. [London] Long-term follow up care recommendations after total hip and knee arthroplasty: results of the American Association of Hip and Knee Surgeons' member survey. Teeny SM, York SC, Mesko JW, et al. (2003) J Arthroplasty; 18:954 The Cost-effectiveness of Routine Follow-up After Primary Total Hip Arthroplasty. Bolz, KMD, Crawford, RW, Donnelly, B. et al. (2010) The Journal of Arthroplasty Vol. 25 No. 2. Guidance on the routine collection of Patient Recorded Outcome Measures (PROMs) 2009/2010 NHS. Department of Health

UHCW Arthroplasty Virtual Surveillance Service ? UNIVERSITY OF WA WICK UNIVERSITY OF WA WICK orthop orthop æ æ dics dics