1. 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
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

2. 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

3. 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.

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

5. 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.

6. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. References:
Primary total hip replacement: a guide to good practice; 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) /2010 NHS. Department of Health

17. UHCW Arthroplasty Virtual Surveillance Service?
UNIVERSITY OF WA WICK
UNIVERSITY OF WA WICK
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