International Journal of Health Care Quality Assurance The new neck of femur fracture target: experience in a district general hospital Edward Britton William Nash
Article information:
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To cite this document: Edward Britton William Nash , (2014),"The new neck of femur fracture target: experience in a district general hospital", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 36 - 43 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-03-2012-0032 Downloaded on: 31 January 2016, At: 04:55 (PT) References: this document contains references to 17 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 188 times since 2014*
Users who downloaded this article also downloaded: Husayn Al Mahdy, (2014),"Quality of coroner's post-mortems in a UK hospital", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 25-35 http://dx.doi.org/10.1108/IJHCQA-07-2012-0073 Cecilia Mercieca, Sara Cassar, Andrew A. Borg, (2014),"Listening to patients: improving the outpatient service", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 44-53 http://dx.doi.org/10.1108/ IJHCQA-03-2012-0033 Joshua Berman, Elizabeth Limakatso Nkabane, Sebaka Malope, Seta Machai, Brian Jack, William Bicknell, (2014),"Developing a hospital quality improvement initiative in Lesotho", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 15-24 http://dx.doi.org/10.1108/IJHCQA-01-2012-0010
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IJHCQA 27,1
The new neck of femur fracture target: experience in a district general hospital
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Edward Britton and William Nash Department of Orthopaedics, Southend University Hospital, Southend-on-Sea, UK
Received 21 March 2012 Revised 26 September 2012 Accepted 21 December 2012
Abstract Purpose – The hip fracture “best practice tariff” (BPT) came into effect in April 2010. It advocated two key improvements: surgery within 36hrs of arrival in the emergency department; and multi-disciplinary care directed by ortho-geriatrician from admission to discharge. The aim of this paper is to look at the 36 hours to operation target and its implications for orthopaedic department trauma service staff in a busy district general hospital, and to evaluate the measures implemented to meet the target. Design/methodology/approach – Trauma-list data, collected from a theatre management system, was compared with trauma patients placed on elective and emergency lists, before and after designated daily trauma lists were implemented. Findings – After a designated daily trauma list was introduced, a significant rise (from 56 per cent to 85 per cent) became evident in the proportion of patients operated on within 36hrs, between November 2010 to February 2011, while hip fracture cases managed on the elective list fell from 24 per cent to 17 per cent. Practical implications – Despite adding a half-day trauma list, the trauma service has insufficient capacity to achieve the new BPT for all hip fracture patients in the hospital. Therefore, there is a significant knock-on effect for managing patient overspill on elective services. Will the significant changes in service provision designed to achieve this BPT be cost effective? Originality/value – This paper aims to answer how busy department staff address an issue that professionals in every English hospital are facing. Keywords Organisational performance, Clinical guidelines, Capacity management Paper type Case study
International Journal of Health Care Quality Assurance Vol. 27 No. 1, 2014 pp. 36-43 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-03-2012-0032
Introduction Timely, efficient and co-ordinated multi-disciplinary neck of femur (NOF) fracture patient management can reduce morbidity and mortality (Fox et al., 1994; Holt et al., 1994; Rogers et al., 1995; Sexson et al., 1987; Villar et al., 1986; Zuckerman et al., 1995). Several guidelines advocating this approach have been published (Hip fracture – NICE, 2011; Blue book – BOA, 2007). However, their implementation in the UK has been patchy. Recently, the issue was addressed by new government incentives, the “best practice tariff” (BPT) for hip fractures that came into effect in April 2010, which meets the commitment to High Quality Care for All in Lord Darzi’s (2008) NHS Next Stage Review. To achieve BPT, Lord Darzi advocated two key improvements: (1) Time to surgery within 36 hours from arrival in an emergency department or diagnosis to anaesthesia start time.
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(2) Involving an ortho-geriatrician: . patients receive joint care by a consultant geriatrician and orthopaedic surgeon; . patient is admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia practitioners; . patient is assessed by a consultant geriatrician in the peri-operative period (within 72 hours of admission); and . postoperative geriatrician-directed care includes: multi-professional rehabilitation team and fracture prevention assessments (falls and bone health). The BPT incentive is £445 per patient treated, which is greater than the “base tariff” (i.e. the payment a provider receives for not doing best practice. Achieving this target benefits the patient by decreasing pre-operative stay, which significantly decreases post-operative stay (Thomas et al., 2001). Increased income from BPT and the money saved by shorter hospital stays contributes greatly to hospitals with tight financial restraints and therefore could improve hospital services. Our organisation is a busy district general hospital serving South East Essex. The area has a 330,000 population – 25 per cent are retired, which is 4 per cent above the national average (ONS, 2001). This older population may explain why our region is among highest estimated NOF fractures rates. The new incentive’s implications for our hospital will mean that if achieved in 90 per cent of cases, it will be worth an estimated £228,686 (0.9 x 571 x 445). Our orthopaedic trauma service aims to deal with all musculoskeletal traumas, such as fractures, without burdening the emergency lists reserved to deal with general surgical emergencies and life or limb threatening conditions or the elective lists. At present there is a daily half-day trauma list from Monday to Saturday and an extra half-day list per week specifically for complex upper-limb cases. The National Hip Fracture Database (2010) shows that our hospital admits 571 hip-fracture patients annually. At present, we are not achieving BPT in two key areas – 56 per cent of cases getting to theatre within 36 hours and 81.5 per cent within 48 hours. While only 6.8 per cent have pre-operative assessment by a geriatrician, 43.7 per cent have “bone health medication” assessment and 18.3 per cent have a falls assessment. With such drastic improvements needed, a significant change was required. An efficient and effective fractured NOF pathways was recently implemented by our hospital staff with the ortho-geriatrican’s help and a second ortho-geriatrican has been employed. However, this article looks at a major hurdle – implementing the 36 hours to operation target into the acute trauma service. To address this problem, a designated half-day trauma list has been introduced. We hope by auditing the NOF patients, we will: quantify problem severity; evaluate some measures implemented to help us achieve the new target; and identify alternatives to achieve operating on all NOF fractures with 36 hours. Method Data covering August 2009 to July 2010 were collected retrospectively from the hospital theatre information system and repeated for four-months from November 2010 to February 2011, when a designated Sunday trauma list was implemented. Data
The new neck of femur fracture target 37
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were an anonymous summary, removing the need for ethical approval. The theatre information system requires the dataset to be complete, including: . total trauma cases undergoing surgery; . total NOF fractures undergoing surgery; . average cases per trauma list; . cases undergoing surgery outside the designated trauma list; . orthopaedic trauma making-up the emergency list; . NOF fracture cases in the emergency list undergoing surgery; and . NOF fracture cases undergoing surgery elective lists. Data were expressed as monthly totals for the trauma, elective and emergency theatre lists. Data comparisons were made using the student t-test (Excelw Microsoft corporation) with difference considered significant at the p , 0.05 level. Data were also collected from the hospital’s national hip fracture database co-ordinator; i.e. patients meeting the BPT time to theatre criterion in each data collection period. Results Total trauma cases undergoing surgery from August 9 to 10 was 1,903. Total NOF fractures requiring surgery from August 9 to July 10 was 442. The mean cases operated on per trauma list were 3.16. Half the hospital’s (operative) trauma workload is dealt with on designated trauma theatre lists, with 32 per cent completed on the emergency lists and the remaining 17 per cent on elective lists where there is space or where space is created through cancellations (Appendix). Focusing on fracture NOF patients shows a greater proportion being dealt with on designated trauma (64 per cent) and elective lists (24 per cent) compared to general trauma. If we exclude weekends and bank holidays then the figures change – only 2 per cent of NOF cases were on weekday emergency lists, leaving 71 per cent on designated trauma and 27 per cent on elective lists. When we repeated our data collection during the four-month period after designated Sunday trauma lists were introduced, we saw similar proportional figures for emergency and elective lists compared to the previous year (emergency 30.2 per cent vs 31.6 per cent previously; elective 21.3 per cent vs 17.6 per cent previously). There was no statistical difference in the total operative trauma cases per month on either the emergency list (45.3 vs 50.2 previously, p . 0.05) or the elective lists (32.0 vs 27.8 previously, p . 0.05) although actual trauma cases were lower for the repeat data collection period (150 vs 159 previously, p , 0.05) (Figure 1). When we looked at fracture NOF cases specifically, overall numbers increased per month from 36.8 to 42 although this was not a significant increase ( p . 0.05).We see that significantly more cases per month are performed on the trauma lists with 33 (79 per cent) cases per month vs 23.7 64 per cent) previously, p , 0.01. On the emergency list there was only 1.8 (4 per cent) fracture NOF cases per month compared with 4.5 (12 per cent) previously ( p , 0.05). Fracture NOF cases on the elective list reduced from 8.7 cases per month (24 per cent) to 7.3 (17 per cent) although this was not a significant decrease (p . 0.05) (Figure 2). We re-examined figures from the National Hip Fracture Database (locally) after the Sunday trauma service was introduced and saw a significant rise in
The new neck of femur fracture target
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Figure 1. All trauma cases by list type
Figure 2. Fracture NOF cases by list type
patients undergoing surgery within 36hrs – 56 per cent to 85 per cent from November 2010 to February 2011 (National Hip Fracture Database (NHFD), 2011). Discussion Delivering good care for patients with hip fracture is challenging and involves many health professionals including surgeons, anaesthetists, ortho-geriatricians, nurses and
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rehabilitation staff. The British Orthopaedic Association/British Geriatric Society BOA-BGS Blue Book care standards for patients with fragility fractures and the National Hip Fracture Database audit (NHFD) encourages fracture unit staff to develop interdisciplinary services for rehabilitation and secondary prevention to improve matters for these patients. The BOA-BGS Blue Book second edition confirms that delivering care to rising fragility fracture patients (BGS, 2010) is paramount. While efficient and effective fracture NOF pathways will no doubt help to improve patient care, a major hurdle will be incorporating these patients into an acute orthopaedic trauma service that covers several cases requiring operative intervention with varying urgency. Rising trauma cases, European Working Time Directive restrictions, NCEPOD recommendations and elective commitments makes it a challenging task to achieve the correct balance. Our audit shows that our present trauma service: a daily half-day trauma list, seven days per week since adding the Sunday list in November 2011, with an extra half-day list per week, specifically for complex upper limb cases, is running beyond capacity and relies heavily on utilising emergency and elective lists. Introducing an additional Sunday trauma list has not addressed this problem; however, it has significantly reduced the time to surgery for NOF patients and increased those undergoing surgery within the trauma list (increased from 64 per cent to 79 per cent). It is clear that if you are to receive BPT regularly then you cannot habitually rely on the NOF patient overflow treated in elective lists and emergency list within NCEPOD recommended hours alone. While there is scope for improving theatre efficiency (an average 3.16 cases per list) this alone would not provide sufficient time to keep up with the present trauma demand. More theatre time is required, which needs to be flexible as demand varies. Additional trauma lists would be one way; however this has significant implications financially and for theatre personnel (surgical, anaesthetic, nursing and sterile services) workload and theatre space. Clinical governance involves clinicians maintaining high standards and managers providing adequate resources (RCP, 1999). Unless more theatre time is made available for trauma surgery then the only way to improve our trauma practice is to cancel elective operations, which is unsatisfactory (Lankester et al., 2000). Elective cases are significantly more financially rewarding to hospital managers than trauma patients and also subject to targets that if not achieved may result in financial penalty. Therefore, if the 36 hours to operation target is to be achieved for most patients then trauma theatre staff must become more efficient, or more flexible time must be made available during evenings or weekends to clear the trauma backlog. This flexible time must occur almost daily to accommodate fluctuating total fracture NOF patients arriving in the department daily. In the period immediately after introducing designated Sunday trauma lists, staff were managing to get 85 per cent of fracture NOF patients to theatre within 36 hrs owing to clinical organisation, front-line staff efforts and consistent throughput over the weekends. While this significantly improved the 2010 figures, we show that there is space to improve trauma services for NOF patients. One operating efficiency improvement is using theatres from 8am. The current set-up at our hospital has an emergency theatre staffed 24hrs; however, operating between 12am and 8am is restricted to “life and limb” threatening cases. However, from 8am to 9am only 23 emergency theatre cases were done in year. We suggest that unused on-call staff should ensure the trauma list starts at 8am rather than the normal
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0900 to 0930, thereby ensuring maximum efficiency. However, using quiet times by emergency theatre staff challenges cross-team organisation especially as each team are so close to the morning handover. Unfortunately, this would only go a short way to improving the service and the only effective way to consistently achieve BPT is to increase the trauma sessions. The strain on the trauma lists may worsen in the coming months when NICE guidelines for hip fracture are produced. If the guidance recommends cemented implants and total hip replacements within the fracture population (as the current NICE, 2011 draft guidelines do) then theatre time demand for NOF cases will increase. There are factors that we have not addressed in the study, particularly the knock-on effects on the non-NOF fracture patients who are delayed when they go to theatre at the fracture NOF patients’ expense? Given the increased profile BPT has given to NOF patients, there is an element that they are given greater priority when organising theatre lists; however this is always done clinically and impossible to measure with our data. We did not account for case complexity and the external influence on case selection for each list lies with the anaesthetic team and the operating surgeon’s clinical interest. The supplementary Sunday-trauma list cost-efficiency has not been discussed. Comparing list costs vs increased income from the BPT would be short-sighted without considering other factors like bed use, hospital stay and knock-on effects on those department staff who also use the Sunday emergency-list. While it is clear from the literature that achieving the BPT is good for the NOF patients (Fox et al., 1994; Holt et al., 1994; Rogers et al., 1995; Sexson et al., 1987; Villar et al., 1986; Zuckerman et al., 1995), it is however difficult to assess whether the changes needed to achieve this BPT is truly cost-effective and an incentive to push managers into making the changes. The extra trauma list in our example is unlikely to be equally reproducible in other sites owing to the complexity of local systems involved in getting patients from the accident and emergency department to the operating theatre. Indeed, hospital trauma-list studies showed no correlation with mortality or the difference in 48hr delay rates (Kalson et al., 2009). While more capacity to operate on trauma patients increases any hospital manager’s ability to meet NOF specific targets, such as the BPT, there are several other local drivers. Appropriate review and timely admission in the emergency department along with ortho-geriatric review will impact significantly on surgery timing. Conclusions Our hospital trauma service has insufficient capacity to accommodate trauma demand and fluctuations, despite introducing a Sunday trauma service in November 2010. Managing the patient overspill has a significant knock-on effect on the elective service, which has been reduced but not eliminated by adding a Sunday trauma list. Using the emergency list staff when free, particularly when the morning session starts is one way to ensure trauma list efficiency; however, as fracture NOF workload increases, trauma operating time will have to grow to accommodate the extra workload especially if hospital staff are to meet BPT targets. While it is clear from the literature that achieving BPT is good for the NOF patients, it is, however, difficult to assess whether the changes needed to achieve BPT is cost effective and enough of an incentive to push hospital managers into making the changes.
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References British Geriatric Society (BGS) (2010), “BGS Newsletter - June 2010”, available at: www.bgsnet. org.uk (accessed April 2011). British Orthopaedic Association (BOA) (2007), “The care of patients with fragility fractures”, available at: www.nhfd.co.uk (accessed April 2011). Darzi, A.W. (2008), “High quality care for all: NHS Next Stage Review final report”, available at: www.doh. gov.uk (accessed April 2008). Fox, H.J., Pulah, J., Prothero, D. and Bannister, G.C. (1994), “Factors affecting the outcome after proximal femoral fractures”, Injury, Vol. 25, pp. 297-300. Holt, E.M., Evans, R.A., Hindley, C.J. and Metcalfe, J.W. (1994), “1000 femoral neck fractures: the effect of pre-injury morbidity and surgical experience on outcome”, Injury, Vol. 25, pp. 91-95. Kalson, N.S., Mulgrew, E., Cook, G. and Lovell, M.E. (2009), “Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?”, Annals of the Royal College of Surgeons of England, Vol. 91 No. 4, pp. 292-295. Lankester, B.J., Paterson, M.P., Capon, G. and Belcher, J. (2000), “Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation”, Annals of the Royal College of Surgeons of England, Vol. 82 No. 5, pp. 322-326. National Hip Fracture Database (NHFD) (2010), NHFD National Report 2010, available at: www. nhfd.co.uk (accessed April 2011). National Hip Fracture Database (NHFD) (2011), “Local interrogation of National Hip Fracture Database” (accessed April 2011). National Institute of Clinical Excellence (NICE) (2011), “The management of hip fractures in adults”, available at: www.nice.org.uk (accessed June 2011). Office for National Statistics (ONS) (2001), Census 2001 Local Authority Profiles, available at: www.statistics.gov.uk/census2001 (accessed April 2011). Rogers, F.B., Shackford, S.R. and Keller, M.S. (1995), “Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low impact falls”, The Journal of Trauma, Vol. 39, pp. 261-265. Royal College of Physicians (RCP) (1999), “Physicians maintaining good medical practice: clinical governance and self-regulation”, Royal College of Physicians, London. Sexson, S.B. and Lehner, J.T. (1987), “Factors affecting hip fracture mortality”, Journal of Orthopaedic Trauma, Vol. 1, pp. 298-305. Thomas, S., Ord, J. and Pailthorpe, C. (2001), “A study of waiting time for surgery in elderly patients with hip fracture and subsequent in-patient hospital stay”, Annals of the Royal College of Surgeons of England, Vol. 83 No. 1, pp. 37-39. Villar, R.N., Allen, S.M. and Barnes, S.T. (1986), “Hip fractures in healthy patients: operative delay versus prognosis”, British Medical Journal, Vol. 293, pp. 1203-1204. Zuckerman, J.D., Skovron, M.L., Koval, K.J., Aharanoff, G. and Frankel, V.H. (1995), “Post-operative complications and mortality associated with operative delay in older patients who have a fracture of the hip”, The Journal of Bone and Joint Surgery (American Volume), Vol. 77, pp. 1551-1556. Corresponding author William Nash can be contacted at: [email protected]
Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions
124 cases (20.7) 21 cases (3.5) 17 cases (2.8) 18 cases (3) 180 (30)
– – – –
– – – – 12pm) 5pm) 9pm) 9am)
12pm) 5pm) 9pm) 9am) 4 2 1 0 7
cases (2.4) cases (1.2) case (0.6) case (0) (4)
35 cases (8) 15 cases (3) 3 cases (1) 1 case (0.2) 54 (12.2)
Emergency list usage for NOF fractures
331 cases (17) 90 cases (5) 84 cases (4) 97 cases (5) 602 (32)
Notes: Amounts shown in brackets are per cent
August 2009 to August 2010 Session 1 (9am – 12pm) Session 2 (2pm – 5pm) Session 3 (5pm – 9pm) Session 4 (9pm – 9am) All sessions November 2010 to February 2011 Session 1 (9am – 12pm) Session 2 (2pm – 5pm) Session 3 (5pm – 9pm) Session 4 (9pm – 9am) All sessions
Emergency list usage for all trauma
Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions
Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions – – – –
– – – –
12pm) 5pm) 9pm) 9am)
12pm) 5pm) 9pm) 9am)
16 cases (9.5) 13 cases (7.7) 0 cases (0) 0 cases (0) 29 (17.2)
61 cases (14) 42 cases (10) 1 case (0.2) 0 cases (0) 104 (24)
Elective list usage for NOF fractures
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Appendix. Theatre usage by session and theatre type (trauma/emergency/elective) for trauma and NOF fracture cases
The new neck of femur fracture target 43
Table AI.
This article has been cited by:
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1. David Hawkes, Jonathan Baxter, Claire Bailey, Gemma Holland, Jennifer Ruddlesdin, Alun Wall, Philip Wykes. 2015. Improving the care of patients with a hip fracture: a quality improvement report. BMJ Quality & Safety 24, 532-538. [CrossRef]
Article information:
Downloaded by CHALMERS UNIVERSITY OF TECHNOLOGY At 04:55 31 January 2016 (PT)
To cite this document: Edward Britton William Nash , (2014),"The new neck of femur fracture target: experience in a district general hospital", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 36 - 43 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-03-2012-0032 Downloaded on: 31 January 2016, At: 04:55 (PT) References: this document contains references to 17 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 188 times since 2014*
Users who downloaded this article also downloaded: Husayn Al Mahdy, (2014),"Quality of coroner's post-mortems in a UK hospital", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 25-35 http://dx.doi.org/10.1108/IJHCQA-07-2012-0073 Cecilia Mercieca, Sara Cassar, Andrew A. Borg, (2014),"Listening to patients: improving the outpatient service", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 44-53 http://dx.doi.org/10.1108/ IJHCQA-03-2012-0033 Joshua Berman, Elizabeth Limakatso Nkabane, Sebaka Malope, Seta Machai, Brian Jack, William Bicknell, (2014),"Developing a hospital quality improvement initiative in Lesotho", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 15-24 http://dx.doi.org/10.1108/IJHCQA-01-2012-0010
Access to this document was granted through an Emerald subscription provided by emerald-srm:115318 []
For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download.
The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm
IJHCQA 27,1
The new neck of femur fracture target: experience in a district general hospital
Downloaded by CHALMERS UNIVERSITY OF TECHNOLOGY At 04:55 31 January 2016 (PT)
36
Edward Britton and William Nash Department of Orthopaedics, Southend University Hospital, Southend-on-Sea, UK
Received 21 March 2012 Revised 26 September 2012 Accepted 21 December 2012
Abstract Purpose – The hip fracture “best practice tariff” (BPT) came into effect in April 2010. It advocated two key improvements: surgery within 36hrs of arrival in the emergency department; and multi-disciplinary care directed by ortho-geriatrician from admission to discharge. The aim of this paper is to look at the 36 hours to operation target and its implications for orthopaedic department trauma service staff in a busy district general hospital, and to evaluate the measures implemented to meet the target. Design/methodology/approach – Trauma-list data, collected from a theatre management system, was compared with trauma patients placed on elective and emergency lists, before and after designated daily trauma lists were implemented. Findings – After a designated daily trauma list was introduced, a significant rise (from 56 per cent to 85 per cent) became evident in the proportion of patients operated on within 36hrs, between November 2010 to February 2011, while hip fracture cases managed on the elective list fell from 24 per cent to 17 per cent. Practical implications – Despite adding a half-day trauma list, the trauma service has insufficient capacity to achieve the new BPT for all hip fracture patients in the hospital. Therefore, there is a significant knock-on effect for managing patient overspill on elective services. Will the significant changes in service provision designed to achieve this BPT be cost effective? Originality/value – This paper aims to answer how busy department staff address an issue that professionals in every English hospital are facing. Keywords Organisational performance, Clinical guidelines, Capacity management Paper type Case study
International Journal of Health Care Quality Assurance Vol. 27 No. 1, 2014 pp. 36-43 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-03-2012-0032
Introduction Timely, efficient and co-ordinated multi-disciplinary neck of femur (NOF) fracture patient management can reduce morbidity and mortality (Fox et al., 1994; Holt et al., 1994; Rogers et al., 1995; Sexson et al., 1987; Villar et al., 1986; Zuckerman et al., 1995). Several guidelines advocating this approach have been published (Hip fracture – NICE, 2011; Blue book – BOA, 2007). However, their implementation in the UK has been patchy. Recently, the issue was addressed by new government incentives, the “best practice tariff” (BPT) for hip fractures that came into effect in April 2010, which meets the commitment to High Quality Care for All in Lord Darzi’s (2008) NHS Next Stage Review. To achieve BPT, Lord Darzi advocated two key improvements: (1) Time to surgery within 36 hours from arrival in an emergency department or diagnosis to anaesthesia start time.
Downloaded by CHALMERS UNIVERSITY OF TECHNOLOGY At 04:55 31 January 2016 (PT)
(2) Involving an ortho-geriatrician: . patients receive joint care by a consultant geriatrician and orthopaedic surgeon; . patient is admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia practitioners; . patient is assessed by a consultant geriatrician in the peri-operative period (within 72 hours of admission); and . postoperative geriatrician-directed care includes: multi-professional rehabilitation team and fracture prevention assessments (falls and bone health). The BPT incentive is £445 per patient treated, which is greater than the “base tariff” (i.e. the payment a provider receives for not doing best practice. Achieving this target benefits the patient by decreasing pre-operative stay, which significantly decreases post-operative stay (Thomas et al., 2001). Increased income from BPT and the money saved by shorter hospital stays contributes greatly to hospitals with tight financial restraints and therefore could improve hospital services. Our organisation is a busy district general hospital serving South East Essex. The area has a 330,000 population – 25 per cent are retired, which is 4 per cent above the national average (ONS, 2001). This older population may explain why our region is among highest estimated NOF fractures rates. The new incentive’s implications for our hospital will mean that if achieved in 90 per cent of cases, it will be worth an estimated £228,686 (0.9 x 571 x 445). Our orthopaedic trauma service aims to deal with all musculoskeletal traumas, such as fractures, without burdening the emergency lists reserved to deal with general surgical emergencies and life or limb threatening conditions or the elective lists. At present there is a daily half-day trauma list from Monday to Saturday and an extra half-day list per week specifically for complex upper-limb cases. The National Hip Fracture Database (2010) shows that our hospital admits 571 hip-fracture patients annually. At present, we are not achieving BPT in two key areas – 56 per cent of cases getting to theatre within 36 hours and 81.5 per cent within 48 hours. While only 6.8 per cent have pre-operative assessment by a geriatrician, 43.7 per cent have “bone health medication” assessment and 18.3 per cent have a falls assessment. With such drastic improvements needed, a significant change was required. An efficient and effective fractured NOF pathways was recently implemented by our hospital staff with the ortho-geriatrican’s help and a second ortho-geriatrican has been employed. However, this article looks at a major hurdle – implementing the 36 hours to operation target into the acute trauma service. To address this problem, a designated half-day trauma list has been introduced. We hope by auditing the NOF patients, we will: quantify problem severity; evaluate some measures implemented to help us achieve the new target; and identify alternatives to achieve operating on all NOF fractures with 36 hours. Method Data covering August 2009 to July 2010 were collected retrospectively from the hospital theatre information system and repeated for four-months from November 2010 to February 2011, when a designated Sunday trauma list was implemented. Data
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were an anonymous summary, removing the need for ethical approval. The theatre information system requires the dataset to be complete, including: . total trauma cases undergoing surgery; . total NOF fractures undergoing surgery; . average cases per trauma list; . cases undergoing surgery outside the designated trauma list; . orthopaedic trauma making-up the emergency list; . NOF fracture cases in the emergency list undergoing surgery; and . NOF fracture cases undergoing surgery elective lists. Data were expressed as monthly totals for the trauma, elective and emergency theatre lists. Data comparisons were made using the student t-test (Excelw Microsoft corporation) with difference considered significant at the p , 0.05 level. Data were also collected from the hospital’s national hip fracture database co-ordinator; i.e. patients meeting the BPT time to theatre criterion in each data collection period. Results Total trauma cases undergoing surgery from August 9 to 10 was 1,903. Total NOF fractures requiring surgery from August 9 to July 10 was 442. The mean cases operated on per trauma list were 3.16. Half the hospital’s (operative) trauma workload is dealt with on designated trauma theatre lists, with 32 per cent completed on the emergency lists and the remaining 17 per cent on elective lists where there is space or where space is created through cancellations (Appendix). Focusing on fracture NOF patients shows a greater proportion being dealt with on designated trauma (64 per cent) and elective lists (24 per cent) compared to general trauma. If we exclude weekends and bank holidays then the figures change – only 2 per cent of NOF cases were on weekday emergency lists, leaving 71 per cent on designated trauma and 27 per cent on elective lists. When we repeated our data collection during the four-month period after designated Sunday trauma lists were introduced, we saw similar proportional figures for emergency and elective lists compared to the previous year (emergency 30.2 per cent vs 31.6 per cent previously; elective 21.3 per cent vs 17.6 per cent previously). There was no statistical difference in the total operative trauma cases per month on either the emergency list (45.3 vs 50.2 previously, p . 0.05) or the elective lists (32.0 vs 27.8 previously, p . 0.05) although actual trauma cases were lower for the repeat data collection period (150 vs 159 previously, p , 0.05) (Figure 1). When we looked at fracture NOF cases specifically, overall numbers increased per month from 36.8 to 42 although this was not a significant increase ( p . 0.05).We see that significantly more cases per month are performed on the trauma lists with 33 (79 per cent) cases per month vs 23.7 64 per cent) previously, p , 0.01. On the emergency list there was only 1.8 (4 per cent) fracture NOF cases per month compared with 4.5 (12 per cent) previously ( p , 0.05). Fracture NOF cases on the elective list reduced from 8.7 cases per month (24 per cent) to 7.3 (17 per cent) although this was not a significant decrease (p . 0.05) (Figure 2). We re-examined figures from the National Hip Fracture Database (locally) after the Sunday trauma service was introduced and saw a significant rise in
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Figure 1. All trauma cases by list type
Figure 2. Fracture NOF cases by list type
patients undergoing surgery within 36hrs – 56 per cent to 85 per cent from November 2010 to February 2011 (National Hip Fracture Database (NHFD), 2011). Discussion Delivering good care for patients with hip fracture is challenging and involves many health professionals including surgeons, anaesthetists, ortho-geriatricians, nurses and
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rehabilitation staff. The British Orthopaedic Association/British Geriatric Society BOA-BGS Blue Book care standards for patients with fragility fractures and the National Hip Fracture Database audit (NHFD) encourages fracture unit staff to develop interdisciplinary services for rehabilitation and secondary prevention to improve matters for these patients. The BOA-BGS Blue Book second edition confirms that delivering care to rising fragility fracture patients (BGS, 2010) is paramount. While efficient and effective fracture NOF pathways will no doubt help to improve patient care, a major hurdle will be incorporating these patients into an acute orthopaedic trauma service that covers several cases requiring operative intervention with varying urgency. Rising trauma cases, European Working Time Directive restrictions, NCEPOD recommendations and elective commitments makes it a challenging task to achieve the correct balance. Our audit shows that our present trauma service: a daily half-day trauma list, seven days per week since adding the Sunday list in November 2011, with an extra half-day list per week, specifically for complex upper limb cases, is running beyond capacity and relies heavily on utilising emergency and elective lists. Introducing an additional Sunday trauma list has not addressed this problem; however, it has significantly reduced the time to surgery for NOF patients and increased those undergoing surgery within the trauma list (increased from 64 per cent to 79 per cent). It is clear that if you are to receive BPT regularly then you cannot habitually rely on the NOF patient overflow treated in elective lists and emergency list within NCEPOD recommended hours alone. While there is scope for improving theatre efficiency (an average 3.16 cases per list) this alone would not provide sufficient time to keep up with the present trauma demand. More theatre time is required, which needs to be flexible as demand varies. Additional trauma lists would be one way; however this has significant implications financially and for theatre personnel (surgical, anaesthetic, nursing and sterile services) workload and theatre space. Clinical governance involves clinicians maintaining high standards and managers providing adequate resources (RCP, 1999). Unless more theatre time is made available for trauma surgery then the only way to improve our trauma practice is to cancel elective operations, which is unsatisfactory (Lankester et al., 2000). Elective cases are significantly more financially rewarding to hospital managers than trauma patients and also subject to targets that if not achieved may result in financial penalty. Therefore, if the 36 hours to operation target is to be achieved for most patients then trauma theatre staff must become more efficient, or more flexible time must be made available during evenings or weekends to clear the trauma backlog. This flexible time must occur almost daily to accommodate fluctuating total fracture NOF patients arriving in the department daily. In the period immediately after introducing designated Sunday trauma lists, staff were managing to get 85 per cent of fracture NOF patients to theatre within 36 hrs owing to clinical organisation, front-line staff efforts and consistent throughput over the weekends. While this significantly improved the 2010 figures, we show that there is space to improve trauma services for NOF patients. One operating efficiency improvement is using theatres from 8am. The current set-up at our hospital has an emergency theatre staffed 24hrs; however, operating between 12am and 8am is restricted to “life and limb” threatening cases. However, from 8am to 9am only 23 emergency theatre cases were done in year. We suggest that unused on-call staff should ensure the trauma list starts at 8am rather than the normal
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0900 to 0930, thereby ensuring maximum efficiency. However, using quiet times by emergency theatre staff challenges cross-team organisation especially as each team are so close to the morning handover. Unfortunately, this would only go a short way to improving the service and the only effective way to consistently achieve BPT is to increase the trauma sessions. The strain on the trauma lists may worsen in the coming months when NICE guidelines for hip fracture are produced. If the guidance recommends cemented implants and total hip replacements within the fracture population (as the current NICE, 2011 draft guidelines do) then theatre time demand for NOF cases will increase. There are factors that we have not addressed in the study, particularly the knock-on effects on the non-NOF fracture patients who are delayed when they go to theatre at the fracture NOF patients’ expense? Given the increased profile BPT has given to NOF patients, there is an element that they are given greater priority when organising theatre lists; however this is always done clinically and impossible to measure with our data. We did not account for case complexity and the external influence on case selection for each list lies with the anaesthetic team and the operating surgeon’s clinical interest. The supplementary Sunday-trauma list cost-efficiency has not been discussed. Comparing list costs vs increased income from the BPT would be short-sighted without considering other factors like bed use, hospital stay and knock-on effects on those department staff who also use the Sunday emergency-list. While it is clear from the literature that achieving the BPT is good for the NOF patients (Fox et al., 1994; Holt et al., 1994; Rogers et al., 1995; Sexson et al., 1987; Villar et al., 1986; Zuckerman et al., 1995), it is however difficult to assess whether the changes needed to achieve this BPT is truly cost-effective and an incentive to push managers into making the changes. The extra trauma list in our example is unlikely to be equally reproducible in other sites owing to the complexity of local systems involved in getting patients from the accident and emergency department to the operating theatre. Indeed, hospital trauma-list studies showed no correlation with mortality or the difference in 48hr delay rates (Kalson et al., 2009). While more capacity to operate on trauma patients increases any hospital manager’s ability to meet NOF specific targets, such as the BPT, there are several other local drivers. Appropriate review and timely admission in the emergency department along with ortho-geriatric review will impact significantly on surgery timing. Conclusions Our hospital trauma service has insufficient capacity to accommodate trauma demand and fluctuations, despite introducing a Sunday trauma service in November 2010. Managing the patient overspill has a significant knock-on effect on the elective service, which has been reduced but not eliminated by adding a Sunday trauma list. Using the emergency list staff when free, particularly when the morning session starts is one way to ensure trauma list efficiency; however, as fracture NOF workload increases, trauma operating time will have to grow to accommodate the extra workload especially if hospital staff are to meet BPT targets. While it is clear from the literature that achieving BPT is good for the NOF patients, it is, however, difficult to assess whether the changes needed to achieve BPT is cost effective and enough of an incentive to push hospital managers into making the changes.
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References British Geriatric Society (BGS) (2010), “BGS Newsletter - June 2010”, available at: www.bgsnet. org.uk (accessed April 2011). British Orthopaedic Association (BOA) (2007), “The care of patients with fragility fractures”, available at: www.nhfd.co.uk (accessed April 2011). Darzi, A.W. (2008), “High quality care for all: NHS Next Stage Review final report”, available at: www.doh. gov.uk (accessed April 2008). Fox, H.J., Pulah, J., Prothero, D. and Bannister, G.C. (1994), “Factors affecting the outcome after proximal femoral fractures”, Injury, Vol. 25, pp. 297-300. Holt, E.M., Evans, R.A., Hindley, C.J. and Metcalfe, J.W. (1994), “1000 femoral neck fractures: the effect of pre-injury morbidity and surgical experience on outcome”, Injury, Vol. 25, pp. 91-95. Kalson, N.S., Mulgrew, E., Cook, G. and Lovell, M.E. (2009), “Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?”, Annals of the Royal College of Surgeons of England, Vol. 91 No. 4, pp. 292-295. Lankester, B.J., Paterson, M.P., Capon, G. and Belcher, J. (2000), “Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation”, Annals of the Royal College of Surgeons of England, Vol. 82 No. 5, pp. 322-326. National Hip Fracture Database (NHFD) (2010), NHFD National Report 2010, available at: www. nhfd.co.uk (accessed April 2011). National Hip Fracture Database (NHFD) (2011), “Local interrogation of National Hip Fracture Database” (accessed April 2011). National Institute of Clinical Excellence (NICE) (2011), “The management of hip fractures in adults”, available at: www.nice.org.uk (accessed June 2011). Office for National Statistics (ONS) (2001), Census 2001 Local Authority Profiles, available at: www.statistics.gov.uk/census2001 (accessed April 2011). Rogers, F.B., Shackford, S.R. and Keller, M.S. (1995), “Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low impact falls”, The Journal of Trauma, Vol. 39, pp. 261-265. Royal College of Physicians (RCP) (1999), “Physicians maintaining good medical practice: clinical governance and self-regulation”, Royal College of Physicians, London. Sexson, S.B. and Lehner, J.T. (1987), “Factors affecting hip fracture mortality”, Journal of Orthopaedic Trauma, Vol. 1, pp. 298-305. Thomas, S., Ord, J. and Pailthorpe, C. (2001), “A study of waiting time for surgery in elderly patients with hip fracture and subsequent in-patient hospital stay”, Annals of the Royal College of Surgeons of England, Vol. 83 No. 1, pp. 37-39. Villar, R.N., Allen, S.M. and Barnes, S.T. (1986), “Hip fractures in healthy patients: operative delay versus prognosis”, British Medical Journal, Vol. 293, pp. 1203-1204. Zuckerman, J.D., Skovron, M.L., Koval, K.J., Aharanoff, G. and Frankel, V.H. (1995), “Post-operative complications and mortality associated with operative delay in older patients who have a fracture of the hip”, The Journal of Bone and Joint Surgery (American Volume), Vol. 77, pp. 1551-1556. Corresponding author William Nash can be contacted at: [email protected]
Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions
124 cases (20.7) 21 cases (3.5) 17 cases (2.8) 18 cases (3) 180 (30)
– – – –
– – – – 12pm) 5pm) 9pm) 9am)
12pm) 5pm) 9pm) 9am) 4 2 1 0 7
cases (2.4) cases (1.2) case (0.6) case (0) (4)
35 cases (8) 15 cases (3) 3 cases (1) 1 case (0.2) 54 (12.2)
Emergency list usage for NOF fractures
331 cases (17) 90 cases (5) 84 cases (4) 97 cases (5) 602 (32)
Notes: Amounts shown in brackets are per cent
August 2009 to August 2010 Session 1 (9am – 12pm) Session 2 (2pm – 5pm) Session 3 (5pm – 9pm) Session 4 (9pm – 9am) All sessions November 2010 to February 2011 Session 1 (9am – 12pm) Session 2 (2pm – 5pm) Session 3 (5pm – 9pm) Session 4 (9pm – 9am) All sessions
Emergency list usage for all trauma
Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions
Session 1 (9am Session 2 (2pm Session 3 (5pm Session 4 (9pm All sessions – – – –
– – – –
12pm) 5pm) 9pm) 9am)
12pm) 5pm) 9pm) 9am)
16 cases (9.5) 13 cases (7.7) 0 cases (0) 0 cases (0) 29 (17.2)
61 cases (14) 42 cases (10) 1 case (0.2) 0 cases (0) 104 (24)
Elective list usage for NOF fractures
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Appendix. Theatre usage by session and theatre type (trauma/emergency/elective) for trauma and NOF fracture cases
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Table AI.
This article has been cited by:
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1. David Hawkes, Jonathan Baxter, Claire Bailey, Gemma Holland, Jennifer Ruddlesdin, Alun Wall, Philip Wykes. 2015. Improving the care of patients with a hip fracture: a quality improvement report. BMJ Quality & Safety 24, 532-538. [CrossRef]
