Keefai Yeong
Hazel Watters
Radcliffe Lisk
Best Practice Tariff –
How we achieved our results
Outline of talk
Introduction to Ashford and St Peter’s
Orthogeriatric team
Best Practice Tariff
Achieving the goals
Financial implications
Top tips
Location
Ashford Hospital
St Peter’s Hospital
Ashford and St Peter’s Hospitals
Ashford Hospital, Middlesex St Peter’s Hospital, Chertsey
Number of # NOFs in 2009 and 2010
2009 - 102010 - 11
372
442
320
340
360
380
400
420
440
460
Orthogeriatric Team at ASPH
2 Orthogeratricians
11 orthopaedic surgeons
16 junior doctors
Trauma coordinator
Hip Fracture Nurse
Dedicated physios
OTs
Targets:
Improve care in the Orthopaedic Wards
Achieve the Best Practice tariff
Best Practice Tariff
Aim
To reduce unexplained variation in quality and
universalise practice
Key Characteristics :
Surgery within
36 hours +
Involvement
of Ortho-
geriatricians
Best Practice Tariff
Our half of the deal…
1. Admitted under joint care
2. Admitted using an assessment protocol that is
jointly agreed
Joint clerking proforma
INCLUSION CRITERIA:
Mechanical fall with obvious hip pain
Shortening / external rotation
Observations stable
EXCLUSION CRITERIA:
MEWS Score above 3
Major trauma
CVS unstable
Section 1
Medical history and assessment undertaken and documented by A/E Dr
Section 2
Admission observations MEWS score Waterlow Score
ECG ECG Checked
Section 3
Cannula inserted Bloods taken FBC/FRAC/COAG/Group & Save
Section 4
Intravenous fluids - 1000ml Sodium Chloride + 20mmols potassium chloride over 10hours
Section 5 All patients to be prescribed IV Morphine and Paracetamol. If pain score 0-1
administer IV paracetamol, if score 2-3 administer IV morphine and Paracetamol
Pain Score documented Analgesia – IV Morphine titrated as per protocol
Fascia Iliaca Block if appropriate Complete Pink NOF drug chart
Section 6
X rays AP & Lateral hip Chest
Section 7
Complete analgesia on pre printed pink prescription # NOF charts, if patient is suitable to be fast
tracked to Rowley Bristow Ward
Section 8
positive hip fracture – patient can be fast tracked
If negative hip fracture or unclear – patient should not be fast tracked until X-ray has been
reviewed by a Senior grade (orthopaedic)
Pre transfer observations completed
FAST BLEEP NOF CALL 2222 (STATE MALE/FEMALE)
Out of hours 19:30hrs – 07:30hrs contact CNSP bleep 5001/5380
Section 9
IF ALL CRITERIA HAVE BEEN MET AND THERE ARE NO EXCLUSION CRITERIA - THE
PATIENT HAS REMAINED STABLE – THEY THEN CAN BE TRANSFERRED TO A HIP
FRACTURE ASSESMENT BAY (JUNIPER WARD):
IF THE PATIENT UNSTABLE THEY MUST BE MEDICALLY STABILISED BY A&E PRIOR TO
BEING TRANSFERRED TO THE WARD.
Please document why patient could not be fast tracked…………………………………………..
………………………………………………………………………………………………………………..
Orthopaedic clerking
History of Presenting Complaint
What Happened Where/Why/How? E.g. Tripped, L.O.C., Fell inside/outside
Previous Fractures/Falls
Previous Falls in the last 12 months
Injuries sustained/Areas of pain
Does the cause of the fall need investigating Yes/No
If so how?
Parameter What to do CHECKED
1 Dehydrated? Ensure safe rapid rehydration. Set up IVI- Via an
IVAC
2 K+ < 3.4 See A to Z. Supplement K+.
3 Na+< 129 See A to Z. (We may accept if <129, especially if
evidence that it is chronic.)
4 Cr > 200 See A to Z. Ensure hydration and not in retention.
Start fluid balance chart.
5 G&S Please document result of antibody screen. If
screen is positive please request 2 unit Xmatch
6 Hb < 10g/dl See A to Z
If transfused we must have a check Hb.
7 Platelets <120 See A to Z.
8 INR > 1.5 See A to Z.
A to Z Troubleshooting guide
Courtesy of the Royal Berkshire and Portsmouth Hospitals
9 Temp >37.9C Take cultures, start antibiotics if clinically indicated.
Patients with significant untreated sepsis may be
turned down.
10 ECG Must be sinus rhythm or AF with rate < 100.
See A to Z.
11 Pacemaker? Arrange a pacemaker check before theatre if
indicated.
12 Systolic
murmur?
See A to Z. In general patients do not need an
ECHO before urgent trauma surgery.
13 MI or
arrhythmia?
Seek review from cardiology. See A to Z.
14 > 6 hours on
the floor?
Test urine for myoglobin. Renal function must be
available. Ensure hydration.
15 Chest
infection?
Do not cancel surgery. Start antibiotics. See A to Z.
16 Notes? If patient has old notes – PLEASE GET THEM! If
notes are not available, please obtain patient
summary from GP.
A to Z Troubleshooting guide
Courtesy of the Royal Berkshire and Portsmouth Hospitals
Osteoporosis Assessment
BMI<19 □ Steroids □
Xs EToH □ Previous Fragility # □
Smoking □ Premature Menopause □
Sedentary □ Rheumatoid Arthritis □
Parental history □
Considered for
Bisphosponate/Strontium
Yes No If no why not? Reason for prescribing strontium:
Prescribed Ca & Vit D? Yes No If no why not?
Referred for Dexa? Yes No If no why not?
Osteoporosis assessment
Medical Falls Assessment
Medication Review? □ Postural BP’s? □
Visual Assessment? □ History of Syncope? □
ECG reviewed? □ AMT (day 7) □
Likely cause of falls
Referral for Specialist Investigation
24 hour tape H.U.T Echo
Medical falls assessment
Our half of the deal…
1. Admitted under joint care
2. Admitted using an assessment protocol that is
jointly agreed
3. Perioperative assessment by a geriatrician
(within 72 hours)
4. Post operative geriatrician directed
MDT rehabilitation
Fracture prevention assessments (falls and bone
health)
Geriatric achievements (%)
0
36
80
89100 100 100100
0
10
20
30
40
50
60
70
80
90
100
Joint Protocol Orthogeriatric
Review
Falls
Assessment
Bone Health
2009/10
2010/11
Getting the patient to theatre within 36
hours Getting the patient to
theatre within 36
hours
EQuIP Programme Sept 2010
Efficiency Quality Innovation and Productivity
Based on Lean Principles, high level support
Key Objectives
Achieve standards of care set out in the Blue Book,
including achieving the 36 theatre target.
Set up a facilitated agreed pathway for patients with
fractured neck of femur
Improve patient experience and outcome
Improve length of stay
Achieve the best practice tariff
Value Stream Analysis (VSA)
Involves all stakeholders across the pathway
“Unpicking” current pathway
Future state
Action plan
Just Do it events
Rapid Improvement Events
Initial State Go No Go
A Delivery
B Quality
C Cost D Human Dimension
Reflections: 1) Superspell
1%
6%
-4%
-6%
-4%
-2%
0%
2%
4%
6%
8%
Apr
-08
May
-08
Jun-
08
Jul-0
8
Aug
-08
Sep-
08
Oct
-08
Nov
-08
De
c-08
Jan-
09
Feb-
09
Mar
-09
Apr
-09
May
-09
Jun-
09
Jul-0
9
Aug
-09
Sep-
09
Oct
-09
Nov
-09
De
c-09
Jan-
10
Feb-
10
Mar
-10
Apr
-10
May
-10
Jun-
10
Jul-1
0
Aug
-10
Sep-
10
28 day readmission rates for #NOF patients to all specialties April 2008 to September 2010
UCL Mean LCL
1%
6%
-4%
-6%
-4%
-2%
0%
2%
4%
6%
8%
Apr
-08
May
-08
Jun-
08
Jul-0
8
Aug
-08
Sep-
08
Oct
-08
Nov
-08
Dec
-08
Jan-
09
Feb-
09
Mar
-09
Apr
-09
May
-09
Jun-
09
Jul-0
9
Aug
-09
Sep-
09
Oct
-09
Nov
-09
Dec
-09
Jan-
10
Feb-
10
Mar
-10
Apr
-10
May
-10
Jun-
10
Jul-1
0
Aug
-10
14 day readmission rates for #NOF patients to all specialties April 2008 to August 2010
UCL Mean LCL
7%
31%
0%
0%
5%
10%
15%
20%
25%
30%
35%
Ap
r-0
9
Ap
r-0
9
May
-09
May
-09
May
-09
Jun
-09
Jun
-09
Jul-
09
Jul-
09
Au
g-0
9
Au
g-0
9
Sep
-09
Sep
-09
Oct
-09
Oct
-09
No
v-0
9
No
v-0
9
No
v-0
9
De
c-0
9
De
c-0
9
Jan
-10
Jan
-10
Feb
-10
Feb
-10
Mar
-10
Mar
-10
Ap
r-1
0
Ap
r-1
0
May
-10
May
-10
May
-10
Jun
-10
Jun
-10
Jul-
10
Jul-
10
Au
g-1
0
Au
g-1
0
Weekly crude mortality rates for # NOF patients April 2009 to August 2010
UCL Mean LCL
4%
24%
0%
0%
5%
10%
15%
20%
25%
30%
35%
Apr
-09
Apr
-09
May
-09
May
-09
May
-09
Jun-
09
Jun-
09
Jul-
09
Jul-
09
Au
g-0
9
Aug
-09
Sep
-09
Sep
-09
Oct
-09
Oct
-09
No
v-0
9
Nov
-09
Nov
-09
De
c-0
9
De
c-0
9
Jan
-10
Jan
-10
Feb
-10
Feb
-10
Mar
-10
Mar
-10
Apr
-10
Apr
-10
May
-10
May
-10
May
-10
Jun-
10
Jun-
10
Jul-
10
Jul-
10
Au
g-1
0
Aug
-10
Weekly pressure ulcer rates for # NOF patients April 2009 to August 2010
UCL Mean LCL
47%
96%
0%
0%
20%
40%
60%
80%
100%
120%
Apr
-09
Apr
-09
May
-09
May
-09
May
-09
Jun-
09
Jun-
09
Jul-0
9
Jul-0
9
Aug
-09
Aug
-09
Sep-
09
Sep-
09
Oct
-09
Oct
-09
Nov
-09
Nov
-09
Nov
-09
Dec
-09
Dec
-09
Jan-
10
Jan-
10
Feb-
10
Feb-
10
Mar
-10
Mar
-10
Apr
-10
Apr
-10
May
-10
May
-10
May
-10
Jun-
10
Jun-
10
Jul-1
0
Jul-1
0
Aug
-10
Aug
-10
Weekly rates for # NOF patients returning to own home/sheltered housing April 2009 to August 2010
UCL Mean LCL
24.49
46.52
2.46
0
10
20
30
40
50
60
Ap
r-0
9A
pr-0
9A
pr-0
9A
pr-0
9M
ay
-09
Ma
y-0
9M
ay
-09
Ma
y-0
9M
ay
-09
Jun
-09
Jun
-09
Jun
-09
Jun
-09
Jul-
09
Jul-
09
Jul-
09
Jul-
09
Au
g-0
9A
ug
-09
Au
g-0
9A
ug
-09
Au
g-0
9S
ep
-09
Se
p-0
9S
ep
-09
Se
p-0
9O
ct-
09
Oc
t-0
9O
ct-
09
Oc
t-0
9O
ct-
09
No
v-0
9N
ov
-09
No
v-0
9N
ov
-09
De
c-0
9D
ec
-09
De
c-0
9D
ec
-09
Jan
-10
Jan
-10
Jan
-10
Jan
-10
Jan
-10
Fe
b-1
0F
eb
-10
Fe
b-1
0F
eb
-10
Ma
r-1
0M
ar-
10
Ma
r-1
0M
ar-1
0A
pr-1
0A
pr-1
0A
pr-1
0A
pr-1
0M
ay
-10
Ma
y-1
0M
ay
-10
Ma
y-1
0M
ay
-10
Jun
-10
Jun
-10
Jun
-10
Jun
-10
Jul-
10
Jul-
10
Jul-
10
Jul-
10
Jul-
10
Au
g-1
0A
ug
-10
Au
g-1
0
Weekly average length of stay for #NOF patients April 2009 to August 2010
UCL Mean LCL
Currently only 5 day/week rehabilitation
SPC Surgery within 24 hours Apr 09 - Aug 10
0:00
48:00
96:00
144:00
192:00
240:00
288:00
336:00
384:00
432:00
Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10
UCL Mean LCL
43% of patient operated within 24
hours (Apr10 – Aug10)
SPC Superspell Length of Stay (June09 - Apr10 *complete data only, 37
patients, 2 outliers excluded)
48.79
116.75
0
0
20
40
60
80
100
120
140
Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10
UCL Mean LCL
Target State
Reflections:
Go No Go
A Delivery B Quality
C Cost D Human Dimension To reduce average length of hospital stay (spell) &
therefore superspell
To increase the number of patients operated
on within 24 hours
% of patients returning to own
home/sheltered accommodation
Mortality, Re-admissions & Pressure
Ulcers
43%
85%
25
Days 8
Days
ASPH Simple
Case
ASPH
Complex
Case
35
Days
Superspell
(incl. Community)
%
Days
7% 5%
4%
%
Mortality
2%
Pressure Ulcers
47% 55%
%
Act Tgt Act Act
Act
Tgt Tgt
Act Tgt Act Tgt Tgt Act Tgt
17
Days
63
Days
Residential
Home
Patient
25
Days
30.5
Days
Act Tgt
Re-admissions
1.8% 1.8%
Act Tgt
16 days
average
target overall
Priority List Orthopaedic Trauma
1 Life or Limb Trauma
2 NOF Fracture
3 Acute Paediatric
4 In Patients
5 Ambulant
6 Chronic
Time to theatre within 36 hrs (%)
EQuIP Sept
36 Hours 24 Hours
Financial implications
Best practice tariff (BPT)
Before EQUIP After EQUIP
Q1 Q2 total Q3 Q4 total
No of pts
achieving BPT
44 62 106 88 83 171
Actual no of
patients
90 85 175 110 96 206
Percentage 48.8% 72.9% 60.5% 80% 86% 83%
Extra income generated after EQuIP = £20470
% achieving BPT at ASPH 2010
48
73
8085
0
10
20
30
40
50
60
70
80
90
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Total generated 2010/11 = £123710 @ £445 extra per patient
% achieving BPT at ASPH 2011
85
0
10
20
30
40
50
60
70
80
90
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Total generated 2011 = £67640 @ £890 per patient
Cost of running an EQuIP programme
Cost of attendees £18009
Venue hire & refreshments £5956
Total £23965
The benefits of a geriatrician
You can’t get BPT without one (or two)!
Reduction in length of stay (hence cost saving)
Reduction in mortality
Funnel plot for mortality
SPH
The benefits of a geriatrician
You can’t get BPT without one (or two)!
Reduction in length of stay (hence cost saving)
Reduction in mortality
Reduction in complaints
No of complaints Elm and Juniper Wards
14
10
0
2
4
6
8
10
12
14
2009-2010 2010-2011
Top Tips on how to achieve BPT
1. Employ a geriatrician (or two)
2. Clerking proforma
- Audit
- Optimise patients from presentation
3. Prioritise NOFs
Acknowledgements
Anaesthetic Department – Martin Raymond
Orthopaedic Department
Kevin Newman (Lead Trauma Surgeon)
David Elliott (Divisional Director)
Hazel Watters (Trauma Coordinator)
Helen Grimsey (Hip fracture Nurse)
Thank you.