1. 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

2. 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)

3. 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

4. 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

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

6. 2. Care bundle: anaesthetic

7. 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 

8. 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!)

9. 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

11. 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

12. ERAS Workstream