How Clinical Process Simulation Changed Hip Fracture Pathway in Torquay Andrew Fordyce, Rachel Blackshaw, Rob Lofthouse, Mike Swart Torbay Hospital 31st May 2012 Cumberland Initiative

Aim for Hip Fracture Pathway Reduce time from ER to surgery Reduce pain before surgery We have changed elective surgery in Torquay Over 7 years no change in hip fracture 31st May 2012 Cumberland Initiative

Old pathway Multiple hand overs Evolved not planned Thought to be in patients best interests Accepted practice across UK 31st May 2012 Cumberland Initiative

Old Hip Fracture Pathway Primary Care Paramedic ED Nurse ED Doctor Ward Nurse Ward 24-72hr Ward Doctor

New Hip Fracture Pathway Referral from Paramedic Pre- Operative Admission Intra- Operative Post- Operative Follow Up Telephone trauma nurse Start planning for surgery

Fractured Neck of Femur Pathway Pre- Operative Admission Intra- Operative Post- Operative Follow Up Patient and family informed, reassured and expectation set Escort to XR and get Orthopaedic review Paramedic hand over to trauma nurse in ED Bloods and nerve block by nurse Is early op possible? Referral from Paramedic

Fractured Neck of Femur Pathway Pre- Operative Admit to Theatre Complex Intra- Operative Post- Operative Follow Up Go to theatre complex If no slot before 1600 hrs go to ward and first on the list next day Pre op preparation Do the essential pre op Anaesthetist, Critical Care, Trauma and Orthopaedics Start planning post op care Referral from Paramedic

Fractured Neck of Femur Pathway Pre- Operative Intra- Operative Post- Operative Follow Up Prepare for early mobilisation and eating IV paracetamo;, NSAIDS, LA, Avoid opiates Referral from Paramedic Admit to OR Complex

Fractured Neck of Femur Pathway Pre- Operative Intra- Operative Post- Operative Follow Up Regular oral analgesia Paracetamol and NSAIDS Avoidance of systemic opiates Early mobilisation Eat and drink Medical, physio and OT Daily MDT on ward Social Services Referral from Paramedic Admit to OR Complex

Fractured Neck of Femur Pathway Pre- Operative Intra- Operative Post- Operative Follow Up Data collection Analysis of data Feedback to all Identify and fix problems Referral from Paramedic Admit to OR Complex

What did we do to make this change?

We applied Lean Thinking Specify Value Understand demand Understand the value stream Pull Flow Pursue Perfection Source: Womack, J. & Jones, D. (2003). Lean thinking: Banish Waste and Create Wealth in Your Corporation. New York: Free Press

What did we do? Specify value No waiting No pain Survive and go home Data collection Demand Pain scores

Issue defined (customer perspective) “Patients wait too long and in pain for an operation”

We used Clinical Process Simulation “An interactive group learning tool enabling rapid common understanding and process change”

Who needs to be in the room? Patients and relatives Paramedics ER Radiology OT Physio Pharmacy Orthopaedic surgeons Anaesthetists Ward & theatre nurses Discharge planners Operational manager Facilitator

Set up All the right people in the room Set the scene: process review focussing on value, not ‘blame the people’ level the hierarchy Real people simulating their job, not role play

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What happened next? Gossip came back during the session Gush of energy Many participants went straight out to make changes Redesigned the process of admission Ran a PDSA Ran another PDSA which never stopped

Why does process simulation work? Common goal Team Task interdependence Create psychological safety Expose and break assumptions Talk and then ‘do’ (action focus) Kurt Lewin 1947

Results

Pain scores Average pain on movement (0 – 3 scale) Before changes 2.75 (severe pain) After changes 0.5 (mild pain)

Median Time to Theatre down from 48 to 19 hours in 18 months Project start Christmas snow & ice

Median LoS down from 10 to 7 Project start D&V, safeguarding, discharge beds full

Things we learnt Patients liked it Orthopaedic surgeons & Anesthesiologists Informal meetings, walk the pathway, fix the problems and report back Beriplex or Octaplex

Thank you 31st May 2012 Cumberland Initiative