1. © 2004-2007 Grey Bruce Health Network Fractured Hip Education Workshop (click to go to the desired section) Introduction to Workshop/Instructions Evidence-Based Care Program Fractured Hip Clinical Pathway Workshop

2. © 2004-2007 Grey Bruce Health Network Introduction This interactive workshop is designed to go along with a copy of the pathway. Keep it handy as you go through the workshop to engage in the required activities. This is a web-based workshop, and has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic.underlined like this At the bottom of each page are navigational buttons to help you move through the workshop. You can go through as much or as little of the workshop as you like at a time. If you have any questions about how to use this workshop or the individual pathways, feel free to ask the Evidence-Based Care Program or your Site Champion. Back to Start of Workshop NextBack

3. © 2004-2007 Grey Bruce Health Network These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop regional pathways and other evidence-based tools that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, and the Community Care Access Centre). It is hoped that these pathways will improve: Coordination of care through more communication across professions; Continuity of care, through increased linkages among hospitals and the CCAC; Clinical outcomes, through increased usage of best practices; and Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop NextBack

4. © 2004-2007 Grey Bruce Health Network Fractured Hip Pathway The Fractured Hip Pathway is intended for those patients admitted for a hip fracture, whether it is repaired or replaced.. The pathway package includes a clinical practice guideline and two stages: Acute Stage:  Pre-op, Post-op and Transferred Pts Pre-Printed Orders  Acute Stage package Community Care Stage: (to be used by CCAC care Providers)  Clinical Pathway  Patient Pathway  Patient Communication Form  Client Information Form Back to Start of Workshop NextBack

5. © 2004-2007 Grey Bruce Health Network FH Clinical Practice Guideline The Fractured Hip Clinical Practice Guideline is the “Scottish Intercollegiate Guidelines Network guideline for Prevention and Management of Hip Fracture in Older People”. It is a summary of the evidence used in the development of the pathway. The FH clinical practice guideline can be found on the GBHN website at www.gbhn.ca.www.gbhn.ca Back to Start of Workshop NextBack Back to beginning of FH section

6. © 2004-2007 Grey Bruce Health Network Pre-Printed Orders There are three sets of pre-printed orders for the FH pathway. The first are Pre-Op orders to be followed before the patient has surgery. It is assumed that a patient may go directly into surgery, or may wait up to 3 days for surgery, and so these orders are used in this time period. (see a copy)(see a copy) The second set of pre-printed orders are post-operative orders. (see a copy) They can be found in the ER, accessed from the www.gbhn.ca or the Order Sets websitewww.gbhn.ca There are also sets of pre-printed orders for receiving hospitals that have been developed for those patients that are transferred out of the hospital where they had surgery. These can be found in the medical/surgical units in each hospital, accessed from the www.gbhn.ca or the Order Sets website (see a copy)www.gbhn.ca(see a copy) Back to Start of Workshop NextBack Back to beginning of FH section

7. © 2004-2007 Grey Bruce Health Network FH Acute Stage Pathway If the patient comes from a long term care facility, you may receive a Client Information Form filled out. This has been developed to communicate the patients pre-fracture status to help with his/her recovery. The pathway should be started in the ER, and follow the patient up to the surgical unit. The first page of the FH pathway is a phased pathway, with the understanding that a patient may wait up to 3 days for surgery. This page is used until the patient is ready for surgery. While the patient is waiting for surgery, the Blaylock Discharge Planning Tool should be filled in. (see a sample) The score of the tool is based on the patient’s characteristics and helps determine where the patient will most likely go post-discharge.(see a sample) The rest of the Acute Stage of the FH pathway is a day-style pathway, meaning that each page outlines tasks for one 24 hour period, beginning at the start of the day shift and ending at the end of the night shift. Back to Start of Workshop NextBack Back to beginning of FH section

8. © 2004-2007 Grey Bruce Health Network FH Acute Stage Pathway The “Smiley Face” tool is taped to the wall in the patient’s room, and filled in by the physiotherapy department as exercise and mobility milestones are achieved post-operatively. All disciplines can refer to this tool when caring for the patient as a quick reference as to the abilities of the patient. (see a sample Smiley Face Tool)(see a sample Smiley Face Tool) On the Post-op Day of Surgery on the right hand side of the sheet is a place to enter the date. There are also three columns, these are the time frames for the shifts working during that day. Indicate the time you are working with the patient in the appropriate column. Then, as with the other pathways, using the column for your shift, initial tasks as they are completed, or enter N/A and initial if they are not applicable to the patient. For example, if it is the night shift and you are not doing any patient teaching, indicate N/A and initial in the section for Psychosocial/Education under “Review Patient Pathway” and “Review Total Hip Precautions”. Back to Start of Workshop NextBack Back to beginning of FH section

9. © 2004-2007 Grey Bruce Health Network FH Acute Stage Pathway This is repeated for each day of the pathway. Post-OP Day 1, Day2,Day 3, Day 4 and Post-Op Ongoing Care On a daily basis, the Discharge Criteria at the back of the pathway (2 nd last page) should be checked and initialed/dated if any of the criteria have been met. The patient is ready for discharge when these criteria have been met. Post-Op Day 1 at the top of the page has one of the Performance Indicators for this pathway, “ Antibiotics discontinued within 24 hours of surgery” input as “Met” or “Not Met” and initial. You will notice on Post-Op Day 3 of the pathway, that one of the assessments is that the patient is mentally stable. This was added because it is found that more than 40% of patients with a hip fracture have delirium. If the patient is not mentally stable, there is a tool to assess for delirium that needs to be filled in and scored. If the patient has delirium, on the back of the page is a checklist to help manage the delirium. (see a sample)(see a sample) Back to Start of Workshop NextBack Back to beginning of FH section

10. © 2004-2007 Grey Bruce Health Network Transferred Patients If the patient is discharged to a long term care facility, the Client Information Form should be filled in to send the facility information as to where the patient is at to help with further recovery.Client Information Form Approximately 50% of patients in for a FH will be transferred to a community hospital following surgery. If a patient is transferred to a hospital within Grey and Bruce counties, the following information must be sent to the receiving facility: Copy of Teaching Checklist Copy of Smiley Face Tool Copy of Discharge Criteria Copy of Blaylock Discharge Planning Tool Copy of the MAR sheet Copy of Physio Database Copy of Anticoagulant Record Back to Start of Workshop NextBack Back to beginning of FH section

11. © 2004-2007 Grey Bruce Health Network Receiving Site Orders and Transfer Information: The post-op orders for transferred patients can be used at the receiving facility, making any necessary changes depending on the day the patient is transferred. The patient should also arrive with the patient education materials and patient pathway that can be referred to for patient teaching. If not, there are extra copies of the education materials that can be found on the unit.patient education materials Back to Start of Workshop NextBack Back to beginning of FH section

12. © 2004-2007 Grey Bruce Health Network Ongoing Post-Op Care If a patient remains in hospital beyond 5 days post-op, there is a page following the 4 th day for ongoing post-op care. This page should be used until the patient achieves all the discharge criteria, and/or is discharged from hospital.ongoing post-op care There are three columns on the right hand side - one for each day the patient remains in hospital. Blank copies of this page can be inserted if the patient remains beyond the three day period. The date is entered at the top of each column, and the time of the shift you are caring for the patient below that (3 columns per day, for each shift). Each day begins at the start of the day shift and ends at the end of the night shift. Back to Start of Workshop NextBack Back to beginning of FH section

13. © 2004-2007 Grey Bruce Health Network Community Care Stage The Community Care Stage of the pathway is used for outpatient or CCAC physiotherapy, nursing and occupational therapy services following discharge. The Community Care Stage includes the following pieces: Clinical pathway for Nursing, PT and OT – one page with admission and discharge goals, used as a charting tool for documentation Nursing PT OT Client pathway – to be given to the patient to align expectations Client pathway Patient Communication Form – for the patient to bring to follow up appointments with the surgeon. Has a list of common questions that the therapist and patient need answered Patient Communication Form LEFS Functional Assessment Tool – to be filled in by the patient at the end of services. Score can be compared to expected goals to determine success of therapy. LEFS Functional Assessment Tool When the patient finishes services either from CCAC or Outpatients, a copy of the clinical pathway is copied and sent to the Evidence-Based Care Program for evaluation purposes. Back to Start of Workshop NextBack Back to beginning of FH section

14. © 2004-2007 Grey Bruce Health Network End of FH Section This is the end of the general information for the FH pathway. To get further information by trying the pathway on a sample patient, move to the Simulation portion of the FH workshop.Simulation Test your knowledge of FH by doing the FH quiz.FH quiz.

15. © 2004-2007 Grey Bruce Health Network Simulation Try it! John has had a fall at home. He arrives in the ER in GBHS - Southampton and is confirmed he has fractured his hip. It is determined he needs surgery to repair his hip, and a transfer to the GBHS - Owen Sound site is arranged. (just as an aside- if John had come from a LTC facility, he should come with the Client Information form filled in, to help you know where he was at pre-fracture). The Fractured Hip pathway is started by putting it on the chart, along with the Pre-Op Pre-Printed Orders once filled out by the attending physician. Find out where to find these at your site. When John gets to the unit, the Patient Pathway and Patient Education Materials can be given to him or his caregiver. If John is to have his hip replaced, the Total Hip Replacement booklet along with the Falls Prevention booklet should be given to him. If he is to have his hip repaired, the Fractured Hip booklet along with the Falls Prevention booklet should be given to him.Falls Prevention booklet Fractured Hip booklet Back to Start of Workshop NextBack Back to beginning of FH section

16. © 2004-2007 Grey Bruce Health Network Simulation cont’d In the time period he is waiting for surgery, the first phase of the pathway can be used. The first page are some basic instructions on how to use the pathway and a master signature sheet. The next page is the first phase of the pathway. The page includes the tasks to be completed before surgery. These should be initialed on the right-hand side of the page as they are complete. Notice there is room for up to 3 days on this sheet, with 3 shifts per day in columns (each day begins at the beginning of the day shift and ends at the end of the night shift). At the top of the first column, indicate the time frame you are caring for John. Take a look at the pathway.Take a look Back to Start of Workshop NextBack Back to beginning of FH section

17. © 2004-2007 Grey Bruce Health Network Simulation cont’d Notice some of the tasks on this page: Assessments: Assess for John’s pressure sore risk by using the Braden Risk Assessment tool. The results of the score you get will tell you how often this should be repeated and what should be done to manage this risk.Braden Risk Assessment tool Discharge Planning: This should be started as soon as possible, and one task in this section is to complete the Blaylock Discharge Planning Tool. By using this tool, a recommendation can be made about where John will be discharged to following surgery.Blaylock Discharge Planning Tool These tasks should be completed until John goes in for surgery. It should be done in Southampton if John remains there for a period of time, or in the Owen Sound hospital if this is where he is transferred immediately. When John finishes surgery, he will spend some time in the recovery room and then move to the surgical unit. Each care provider that cares for John will need to fill in the tasks completed through this process. Take a look at that page, “Post-Op Day 1” to familiarize yourself with the tasks.Post-Op Day 1 Back to Start of Workshop NextBack Back to beginning of FH section

18. © 2004-2007 Grey Bruce Health Network Simulation cont’d Once John is moved to the surgical unit, the “Smiley Face Tool” needs to be taped to the wall in his room. This is used by the physiotherapy department to track milestones with respect to mobility and exercises. Each milestone will be circled and dated as it is achieved. This will help all health care providers know John’s mobility status if they are in his room. “Smiley Face Tool” Back to Start of Workshop NextBack Back to beginning of FH section

19. © 2004-2007 Grey Bruce Health Network Simulation cont’d Performance Indicator Post–op Day 1 has the performance indicator we are tracking for this pathway – “Antibiotics Discontinued 24 hours post-op”. Let’s assume John’s antibiotics continued until 48 hours post-op, you would be entered as “Not Met” after the 24hrs post-op period had passed by the staff caring for him during that time frame. Back to Start of Workshop NextBack Back to beginning of FH section

20. © 2004-2007 Grey Bruce Health Network Simulation cont’d On each page of the pathway, you will notice a few consistent tasks under Psychosocial Support/Education. Each day you are asked to “Review the patient pathway” and “Review Hip Precautions”. You can use John’s patient education materials and patient pathway to help you with this, to ensure John and/or his caregiver understands what is happening in hospital, aligning expectations, and he is aware of the hip precautions he has following surgery, in particular if he has had his hip replaced.Review the patient pathway Not all tasks are applicable for all patients, or for all shifts. For example, during the night shift, you may not be teaching John. Under “Review Patient Pathway”, you can indicate N/A and initial. This is the case for any tasks that are not applicable for John. At the end of a day, there should be no blank boxes on the pathway page. Back to Start of Workshop NextBack Back to beginning of FH section

21. © 2004-2007 Grey Bruce Health Network Simulation cont’d Another consistent task is under Discharge Planning – “Assess Discharge Criteria Daily”. To do this, flip to the last page of the pathway, the Discharge Criteria. Each day, take a look at these goals. If any have been met, initial and date them. Once they have been met, John should be ready for discharge. Back to Start of Workshop NextBack Back to beginning of FH section

22. © 2004-2007 Grey Bruce Health Network Simulation cont’d This is repeated until the end of four days post-op. One important thing to notice on Post-op Day 3 – one of the tasks asked you to assess John’s mental status. If John is not mentally stable, he needs to be assessed for delirium. Up to 40% of hip fracture patients can have undiagnosed and/or poorly managed delirium, so this is an important thing to look for. We can do this by using the CAM tool. Take a look at it. Do a quick assessment of John and score him using this tool. If it shows he most likely has delirium, flip to the back of this page, where a delirium management checklist can be found. Using this, you can help manage and improve John’s delirium. Take a look at this tool in. (See a finished CAM tool)(See a finished CAM tool) Back to Start of Workshop NextBack Back to beginning of FH section

23. © 2004-2007 Grey Bruce Health Network Simulation cont’d At the end of the fourth day post-op, the Discharge Criteria need to be assessed to see if they have been met. If they have, John should be ready for discharge. Let’s assume John has not met the Discharge Criteria, and so cannot go home. He does not have independent transfers yet, nor can he ambulate independently on level ground. Back to Start of Workshop NextBack Back to beginning of FH section

24. © 2004-2007 Grey Bruce Health Network Simulation cont’d At the end of the fourth day post-op, the Discharge Criteria need to be assessed to see if they have been met. If they have, John should be ready for discharge. Let’s assume John has not met the Discharge Criteria, and so cannot go home. He does not have independent transfers yet, nor can he ambulate independently on level ground. Back to Start of Workshop NextBack Back to beginning of FH section

25. © 2004-2007 Grey Bruce Health Network Simulation cont’d Since John is from Southampton, it is determined he should be transferred to the GBHS - Southampton hospital site. When John is transferred, the following information needs to go with him to the transfer site:  Original of the Smiley face tool  Physio Database  Teaching checklist  Copy of Discharge Criteria  Copy of Discharge Planning Tool  Copy of the MAR sheet  Anticoagulation record When John arrives in Southampton, the Acute Stage of the pathway will continue, along with the Pre-printed orders for Transferred Patients.Pre-printed orders for Transferred Patients Staff in the Southampton site will continue to use the Acute pathway until John has met all the indicators on the Discharge Criteria. Back to Start of Workshop NextBack Back to beginning of FH section

26. © 2004-2007 Grey Bruce Health Network Simulation Cont’d If John stays more than 5 days post-op, he will use the final phase of the in-hospital pathway, Ongoing Post-op care. It should be used until all discharge criteria have been met.Ongoing Post-op care If John remains in hospital beyond the three days listed on the pathway page, insert a blank page of the ongoing post op care page behind this page and continue using the pathway until all the discharge criteria have been met or John is discharged home. If John were to be discharged to a LTC facility, the Client Information Form should be filled in to let the facility know where John is at for them to continue his recovery. Client Information Form Back to Start of Workshop NextBack Back to beginning of FH section

27. © 2004-2007 Grey Bruce Health Network Simulation Community Care Stage Let’s assume that John is discharged home, but requires outpatient physiotherapy services. In this case, the Community Care Stage of the pathway begin. The therapist in the Southampton site will use the Community Care Stage Clinical pathway to aid in the care for John. She/he will assess him at admission to services and at discharge to determine if he has met the goals on the pathway. Community Care Stage Clinical pathway She/he will give John the patient pathway to help explain to John what the goals are for therapy.patient pathway Back to Start of Workshop NextBack Back to beginning of FH section

28. © 2004-2007 Grey Bruce Health Network Simulation Community Care Stage Cont’d When it is time for John’s follow up appointment at 6 and 12 weeks, the Patient Communication Form will be given to John to give to the surgeon and get important questions answered about his status. He needs to return this form to the therapist so therapy can be adjusted accordingly.Patient Communication Form If John were to go to CCAC services, the same process would be followed, and started again if John is transferred to outpatient physiotherapy. When John is discharged from services either from CCAC or Outpatients, a copy of the clinical pathway is sent to the Evidence- Based Care Program for evaluation purposes. Back to Start of Workshop NextBack Back to beginning of FH section

29. © 2004-2007 Grey Bruce Health Network FH Quiz 1. There are 2 stages to the FH pathway – what are they? 2. What are the inclusion criteria for this pathway? 3. What type of a pathway is this pathway? A) Day B) Phase C) Both 4. What is the Smiley Face Tool? Where does it go? 5. What goes with the patient if he/she is transferred? 6. When is the Continuing Post-op Care Phase used? What do you do if the patient remains in hospital beyond the first 3 days in this phase? 7. What is the Community Care Stage used for? Back to Start of Workshop Answers Back Back to beginning of FH section

30. © 2004-2007 Grey Bruce Health Network FH Quiz - Answers 1. There are 2 stages to the FH pathway – what are they? Acute Stage, Community Care Stage 2. What are the inclusion criteria for this pathway? Patients who have fractured their hip, whether it is a hip replacement or a hip repair 3. What type of a pathway is this pathway? A) Day B) Phase C) Both – This is both a phase and a day pathway, with the first page being a phase of up to 3 days, and the remaining a day type, which means each page is for one day in hospital, and finally a continuing-post op care phase, which is a phase type- pathway. 4. What is the Smiley Face Tool? Where does it go? The Smiley Face Tool should be taped to the patient’s wall and show all health care providers how far the patient has progressed with respect to mobility and exercise. Back to Start of Workshop NextBack Back to beginning of FH section

31. © 2004-2007 Grey Bruce Health Network 5. What goes with the patient if he/she is transferred? The a copy of the Physio Database,the Teaching Checklist, the Discharge Criteria, the Discharge Planning Tool, the MAR sheet, the Anticoagulant record, the original of the Smiley Face Tool should go with the patient, along with any other documentation that will assist in transition of care. 6. When is the continuing post-op care phase used? What do you do if the patient remains in hospital beyond the first 3 days in this phase? This is used if all discharge criteria have not been met at 5 days post –op and the patient needs to stay in hospital longer. It is a phase type pathway with one phase, and the patient remains on this phase until the discharge criteria have been met. If this is longer than 3 days, blank photocopied sheets can be inserted and used until the variances have been resolved. 7. What is the Community Care Stage used for? This is used for outpatient physiotherapy or CCAC services the patient receives following hospital discharge. If you have had difficulty with any of these questions, go back through the material on this pathway and/or contact the Evidence-Based Care Program or ask your Site Champion any other questions you have. FH Quiz - Answers Back to Start of Workshop Back Back to beginning of FH section