MSK & Orthopaedic Quality Drive Programme Philip Lunts Head of Service Improvement Executive Lead for Programme Ali Mehdi Head of Orthopaedic Service Clinical Lead for Programme

The two work-strands from the MSK Project that have had the greatest impact for Borders Patients: Work-strand 4: Hip fracture care pathway Work-strand 5: Demand & Capacity Modelling (DCAQ)

Work-strand 4: Hip # Clinical Leads: Drs Antrobus & Bennison 1.Frail Elderly Care bundle within acute care Plan: to trial use of daily “single question in delirium” (SQID) Aim: the earlier identification of patients who have developed delirium during their hospital admission. This allows for earlier investigation and treatment of delirium, leading to improved patient experience, reduced symptoms and complications and shorter hospital length of stay Method: Nursing staff place “SQID” sticker in notes daily and answer question “Is this person more confused than yesterday”. All patients over the age of 65 should be included. If answer is “Yes” – nursing staff inform the ward medical staff. Medical staff then carry out AMT / 4AT / start delirium bundle as appropriate

1. Care bundle: Frail Elderly Comprehensive Geriatric Assessment Medication review / analgesia Avoid / treat delirium Refer all patients for geriatric assessment on admission Refer to “blue sheet” / UPR for geriatrician management plan All patients mobilized day of surgery to chair All patients reviewed by physiotherapist by day 1 post op Mobility / balance / gait / falls risk OT assessment starts day 1 post admission. Social work input as required Complete nutritional / pressure area assessment on admission Analgesia as per preop. bundle. Give regularly Review regularly Review all medications as per polypharmacy protocol: Valid indication? Symptomatic relief? Vital hormone replacement? High risk combination? Poorly tolerated? NNT for benefit vs risks Document reasons for changes in UPR Ensure appropriate VTE prophylaxis prescribed Complete AMT and 4AT on admission Daily SQiD “Is this patient more confused than yesterday”? Start delirium bundle when identified (sticker) Identify and treat causes Reorientate patient regularly Encourage mobility Check hearing aids / spectacles Avoid constipation Maintain sleep pattern / fluid intake Provide carers with delirium leaflet / explanation Do not Catheterize Sedate routinely / restrain Argue with the patient Reduce falls risk Assess bone health Plan discharge On admission Take accurate falls history including risk factors Complete nursing admission falls assessment Take action to reduce identified risks Complete active stand Treat postural hypotension if present Increase oral fluids TEDS Review medication Document visual acuity Document AMT / 4AT If urinary incontinence present: MSU Post void bladder scan Bladder chart Prescribe and give vitamin D stat dose – colecalciferol 100,000 units orally **check if peanut allergy** If patient is over 80 years old start bone protection: Calcium and vitamin D / alendronate Refer osteoporosis service if contraindications (eg renal impairment) If under 80 years old request DEXA scan Complete bone health risk factor checklist (on “blue sheet”) If high risk start bone protection whilst results awaited If low risk await DEXA result before starting treatment Set EDD on admission Inform patient and carers of date and any changes to this during admission Refer to PT / OT on admission Refer to social work as soon as need identified After first DME review Update EDD and anticipated place of discharge Place patient on community waiting list if appropriate All patients discussed at daily MDT board round (update plan / EDD) Day before Ensure IDL completed Book transport Ensure equipment / care ready

‘SQiD’ sticker: Single Question in Delirium Is this patient more confused than yesterday? Date Time Name Signature

2. Care bundle: anaesthetic

Anaesthetic ‘sticker’ HIP FRACTURE: Anaesthetic Review Date: Time: Anticipated date and time of surgery:  Give all medicines as prescribed on kardex (unless crossed off)  Adequate analgesia. Pain score ………./10 YES / NO - Follow trauma fasting policy Reason for delaying surgery: Will benefits of optimisation outweigh risks of delaying surgery? Outcome required for surgery to proceed:  Adequate analgesia prescribed Pain score: ………… /10 * Consider repeat nerve block if pain NRS >3  Nerve block repeat If extra investigations required will they change patient management? YES / NO Expected time to fitness for surgery: * Please review every 24h Signed: Print name: YES  YES IS PATIENT FIT FOR SURGERY? Is this Patient fit for Surgery? NO 

Using Demand and Capacity Established predicted demand and capacity required Developed ongoing DCAQ modelling tool – updated weekly Weekly ‘huddle’ – all ortho consultants plus booking managers - review last week actual against predicted (and reasons) Last week theatre start times This week planned against required Outpatient clinic actual against predicted (NEW!)

Excellent engagement with clinicians Impact Excellent engagement with clinicians Shared ownership and solution of problems competition – gold star of the week! Next Steps Establish similar process for OPD Model demand from OPD vs capacity in real-time

Virtual Fracture Clinic Virtual Trauma Meeting set up – avoids need for additional staffing for service Direct Discharge recently commenced. Direct discharge of: Paediatric Clavicle 5th Metacarpal 5th Metatarsal Mallet finger Radial head Torus/buckle Ankle injury

ERAS Workstream