1. DEVELOPING AN ENHANCED 7 DAY AHP SERVICE FOR HIP FRACTURE PATIENTS Colin Talbot-Heigh, Senior Orthopaedic Occupational Therapist, Kirsteen Kelly, Team Lead Orthopaedic Physiotherapist, Raigmore Hospital September 2014

2. OVERVIEW CURRENT AHP SERVICE PREVIOUS PILOT DRIVERS BEHIND THE BID THE BID AIMS OF THE BID WHAT WILL SUCCESS LOOK LIKE? HOW WE ARE GOING TO ACHIEVE THIS? OUTCOME MEASURES AUDIT POTENTIAL BARRIERS AND SOLUTIONS CONCLUSION

3. CURRENT OCCUPATIONAL THERAPY AND PHYSIOTHERAPY SERVICE Mon-Fri 8.30-4.30 (OT and PT) Sat 8.30-1pm (limited OT and PT) for elective patients Sun 8.30-1pm (limited PT) for elective patients No weekend service for trauma/hip fracture patients

4. 2013 PILOT Enhanced 7 day physiotherapy service Primarily looking at elective surgeries All hip fracture patients seen day 1 post-op Increased number of patients discharged directly home Able to meet some of the recommended guidelines re physiotherapy assessment/mobilisation within 24 hours post- op Improved MDT working relationships Improved staff satisfaction Increased continuity of care More equitable level of service for hip fracture patients

5. DRIVERS BEHIND THE BID Person Centred Approach HQA (Highland Quality Approach) to improving patient flow Evidence Based Practice/Professional Guidelines/Standards Clinical Pathway Development/Implementation Strategic drive towards 7 day service provision Safe, Effective, Efficient, Equitable and Reliable Quality Care Teamwork, Communication and Collaboration (MDT approach)

6. THE BID 1.5 WTE band 6 Physiotherapist 1.0 WTE band 3 Physiotherapy HCSW 1.0 WTE band 5 Occupational Therapist 1.0 WTE band 4 Occupational Therapy HCSW

7. OVERALL AIM To improve the quality of care, safety and flow of patients admitted into ward 3A, Raigmore Hospital, with a hip fracture.

8. SUB-AIMS To increase the number of patients going directly home following hip fracture, by 50% and therefore reduce the number going onto community hospitals Reduce the overall LOS for patients following hip fracture (including community hospital stay) Reduce risk of further falls/injury and commence falls rehabilitation immediately post-op (as appropriate) meet the SIGN/NICE/BOAST guidelines (in respect of therapy intervention) for hip fracture patients

9. SUB-AIMS cont Ensure equitable level of Physiotherapy/Occupational Therapy service for all hip fracture patients Develop an AHP clinical pathway to promote a standardised, consistent approach to the management of patients in the acute rehab phase of recovery Improve MDT approach/team working

10. WHAT WILL SUCCESS LOOK LIKE? Improved quality of patient care by: Increased number of patients going directly home by 50% Reduced overall length of stay for patients post hip fracture All patients post hip fracture surgery will have a Physiotherapy assessment on day 1 and Occupational Therapy Assessment by day 3 7 day physiotherapy/Occupational Therapy service for hip fracture patients implemented Standardised pathway for Physiotherapy/Occupational Therapy post hip fractures produced for Highland Standardised rehabilitation recommendations for Physiotherapists/Occupational Therapists working in the acute phase of rehabilitation post hip fracture produced for Highland

11. HOW ARE WE GOING TO ACHIEVE THESE AIMS?

12. MDT WORKING STANDARDISED HIGHLAND AHP PATHWAY OUTCOME MEASURES UPDATE PATIENT INFORMATION BOOKLET TRAINING & EDUCATION UK WIDE PHYSIO EMAIL NOF GROUP TRAUMA STUDY DAY UPDATE ASSESSMENT FORMS DAILY MDT BOARD ROUNDS AUDIT

13. OUTCOME MEASURES NMS: New Mobility Scale CAS: Cumulated Ambulatory Score EMS: Elderly Mobility Scale MBI: Modified Bartel Index

14. THE NEW MOBILITY SCORE (NMS) 3 questions, looking at pre-fracture status Maximum score of 9 NMS in addition to age and # type, provides valid prediction of in-hospital outcome Patients with a low pre-fracture NMS (NMS 6 Can be used as predictor of in-hospital rehab potential NMS cut off point of 5/9 is a valid predictor of 1 year mortality, and 6 months functional level (Kristensen et al, 2010)

15. CUMULATED AMBULATORY SCORE (CAS) Allows day-to-day measurement of patient’s basic mobility Early post-op predictor of short-term outcome Reliable and valid predictor for length of hospitalisation, 30 day mortality and time to discharge status Scored 0-6 each day Scores from first 3 days post-surgery are combined to obtain 3 day CAS 3 day CAS of > or equal to 10 = 99% survival rate at 1 month, and 93% will be discharged home Reference: Foss, NB, Kristensen MT, Kehlet, H. Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score. Clinical Rehabilitation, 2006 Aug;20(8):701-8.

16. AUDIT Using data from 2012/2013 as a baseline: LOS (acute and community) Number of patients transferred for further rehabilitation Discharge destination Outcome measures on discharge (EMS, MBI) At 120 days: Place of residence Mobility Dependency Further falls/fractures MDT audit (hip fracture nurse, OT and Physiotherapy) Using modified proforma

17. POTENTIAL BARRIERS TO SUCCESS and HOW WE WILL OVERCOME THESE Lack of engagement/support from OT/PT staff and within the wider MDT Change to staff working hours Lack of space and equipment to do rehabilitation on an acute ward Reduced staff awareness Sustainability Staff involved from the start and to be active participants throughout Joint working with MDT Rota done for the year to allow staff to plan Look at use of gyms, facilities on the rehab unit Procurement of additional rehabilitation equipment Training sessions, regular feedback for staff Regular updates for MDT, ongoing review, maintain momentum and enthusiasm

18. Conclusion By October 2015, we will have implemented an enhanced 7 day Physiotherapy and Occupational Therapy service which will improve the quality of care, safety and flow of patients with a hip fracture (which we will hopefully get permanent funding for)

19. ANY QUESTIONS? Kirsteen.kelly@nhs.net Colin.Talbot-Heigh@nhs.net