clinical pathway for geriatric hip fracture...ghf clinical pathway inclusion criteria: geriatric hip...
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ENHANCEMENT OF ACUTE SERVICE IN
KCC ON CLINICAL PATHWAY FOR
GERIATRIC HIP FRACTURE
Elaine Wong WY
Queen Elizabeth Hospital
7 May 2012
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BACKGROUND
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In KCC, there are around 800 cases admitted for
geriatric hip fracture (GHF) each year, contributed
to around 14% of the total admission in O&T
annually
Patients are admitted as emergency cases, usually
with multiple medical problems and the change in
mobility level after accident causing long stay and
occupancy burden
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Average LOS (day) of Fracture Hip (All Care type)
12 12.8 13.7 13.8 14.612.2 11.9 12 11.8 11.9
19.119.9
21.2 2221.6
17.5 17.4 17.3 17.3 17.3
00
5
10
15
20
25
30
35
40
Jan 09 -
Dec 09
Apr 09 -
Mar 10
Jul 09 -
Jun 10
Oct 09 -
Sep 10
Jan 10 -
Dec 10
Jan 09 -
Dec 09
Apr 09 -
Mar 10
Jul 09 -
Jun 10
Oct 09 -
Sep 10
Jan 10 -
Dec 10
KCC HAAcute Conv
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Cardiac problem
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Chest infection, urinary retention
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Urinary retention, DVT
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Social problems
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Urinary problem
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PROBLEM IDENTIFIED FOR PROLONGED LOS
Pre-op (QEH): medical problems (cardiac) & medical consultation
Post-op (QEH): medical problems, chest infection, urinary retention, DVT
Post-op (KH): social problem, urinary retention
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MEETING WITH GERIATRIC HIP FRACTURE TEAM
O&T department, QEH
Rehabilitation Team, KH
Physiotherapy Department,
QEH and KH
Occupational Therapy
Department, QEH and KH
MSW, QEH and KH
Relative
MSW
OT
PT
Nurse
Doctor
Patient
Multi-disciplinary Approach
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OBJECTIVES
1. Review the roles of each discipline in the care path of GHF patient
2. Standardize patient journey and facilitate discharge process
3. Achieve the KPI of more than 70% of case operated within 2 days
4. Decrease Length of Stay (LOS) both in acute and convalescence phase
5. Identify problems that prolonged the average LOS and the corresponding solutions
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Trial Without Catheter (TWOC) Program
med
ical
pro
ble
m
rete
ntio
n
of u
rine
so
cia
l p
rob
lem
Liaise with medical colleagues for better
support both in pre-op and post-op stage
Early refer to MSW in acute hospital to
facilitate discharge planning
PROBLEM INTERVENTION
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KCC CLINICAL PATHWAY ON GERIATRIC HIP
FRACTURE (ACUTE)
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GHF CLINICAL PATHWAY
Inclusion Criteria: Geriatric hip fracture > 65 years old
Exclusion Criteria:
1. All hip fracture happened and transfer in from other department
2. All pathological fracture cases
3. Fracture Hip treated conservatively
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New Initiatives in Clinical Pathway (Acute)
Medical Standardize pre-operative workup
Streamline medical support in pre-op and post-op stage
Phone contact to update relative for intra-op progress on OT day
TWOC protocol
Discuss rehabilitation and discharge planning with patient
and relatives on post-op day 2-4
Nurse Nursing assessment on Functional Prognosis Predictive
Score (FPPS) --Discharge Triage
Initiate referral to MSW if patient live alone or carer at night
only
Refer Occupational therapist if FPPS = 5-7
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New Initiatives in Clinical Pathway (Acute)
PT Comment on rehabilitation potential and discharge plan
Provide pre-discharge preparation if patient direct home
OT Initiate ADL assessment and training as indicated
Perform Home Discharge Readiness Assessment if FPPS 5-7
MSW Provide intervention in acute phase
Referral to MSW/KH or relevant agency for further follow up
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REVIEW PERIOD
28th August 2011 to 31st March 2012
Number of cases with completed pathway: 386
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PERCENTAGE OF INDICATED PATIENTS OPERATED ≤
2 DAYS AFTER ADMISSION
80
73 7370
76
50
62
0
10
20
30
40
50
60
70
80
2011年9月 2011年10月 2011年11月 2011年12月 2012年1月 2012年2月 2012年3月
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LENGTH OF STAY
14.6
8.2
10.8
13
11.8 11.6 11.5
14
0
2
4
6
8
10
12
14
16
2010 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12
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0
10
20
30
40
50
60
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 50 60
66% of GHF cases discharged within 11 days in acute hospital
Days
No. o
f case
DISTRIBUTION OF CASES IN ALOS
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REASONS FOR ALOS>11 DAYS
70%
8%
7%
5%10%
Medical
Surgical
Social
Await KH bed
Others
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KH
Home /OAH
others
DISCHARGE DESTINATION
299 (77%)
76 (20%)
11 (3%)
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REFER MSW ON ADMISSION
MSW Referral on admission
Others
28%
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REFER TO OT IF FPPS=5-7
7%
93%
refer to OT
Others
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0
10
20
30
40
50
60
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 50 Days
75% of GHF cases discharged to KH within 11 days in acute hospital
No. o
f case
DISTRIBUTION OF ALOS FOR CASES
DISCHARGE TO KH
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32% of GHF cases discharged home / OAH within 11 days in acute hospital
No. o
f case
Days
DISTRIBUTION OF ALOS FOR CASES
DIRECT DISCHARGE HOME/ OAH
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DISTRIBUTION OF ALOS FOR ALL CASES
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ESSENCE OF CLINICAL PATHWAY
A clinical pathway is supposed to provide protocols and guidelines for the majority of cases to follow through
Reasons from the outliners are inevitable, therefore should be consider to be excluded statistically
And we consider our pathway to be a success as the majority (>70%) of cases were discharged within 11 days (HA benchmark = 11.9 days)
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THE ROAD AHEAD
Clinical pathway is a tool to continuous monitor
care effectiveness and clinical outcomes
Through identifying patient care problem and
re-engineering the management process with
new initiatives, we have established a new care
model on GHF patients
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THANK YOU
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Dr Shen Wan Yiu
Dr Lee Kin Bong
Ms Law Kam Yin
Ms Wong Kin I
Mr Tsang Ka Kit
O&T Department
Physiotherapist
Occupational Therapist
Medical social worker
Consultant of Trauma
Team, O&T
AC of Trauma, O&T
Dep. DOM of O&T
WM of O&T C3
NC of O&T
KCC
KCC
KCC
KCC
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MSW REFERRAL PATH Admission of GHF
Nursing assessment
-social background assessment
Home Alone or
carer at night only?
Discharge to pre- injury
destination
Refer MSW
Social needs assessment
Provide information
–Placement
–Home carer
–Financial assistance
–Community
–rehabilitation network
Refer case manager
Liaise communication of information among
case MO, Ward Nurse, MSW, Patient &
Relatives
Confirm an appropriate discharge strategy
Follow progress of Discharge management
Any Discharge
problem?
Discharge +/- community support
Initiate (MDCC)
Multi-disciplinary Case conference
NO
YES
YES
NO
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FUNCTIONAL PROGNOSIS PREDICTIVE
SCORE