What happens in Bas Vegas stays in Bas Vegas…..Maintaining Low Mortality: The Basildon Experience NHFD March 12th 2014

Dr Luke Hounsom

Consultant Orthogeriatrician

Basildon University Hospital

• Medium-sized 667 bedded Major Acute DGH with on site cardiothoracics.

• One of the first 10 Foundation Trusts

• Subserving approx 400,000

• 7% non-white ethnic minorities

• 93.3% bed occupancy (2012)

• SHMI 113 for non-elective

• HSMR 105

Breaking new ground in hip fractures •1980’s

• Dr Gill Jenner appointed as an

Orthogeriatrician

• Developed a rehabilitation ward

LIONEL COSIN

Breaking new ground in hip fractures •2002

• Centralisation of wards

• Allowed for some preoperative assessment and the development of

‘hip fracture nurses’

Breaking new ground in hip fractures •2006

• NHS Institute secondment

• Set out the importance of perioperative care in the context of a Multidisciplinary team

Breaking new ground in hip fractures

•2007

• Dr Shilpa Raje appointed as a Perioperative Orthogeriatrician

• Developed services on the Trauma wards

LINFORD BULPHAN

Basic Patient Journey

A&E

Trauma Wards

Theatre

Rehabilitation

Home

Mortuary

Care

Basic Team Structure

Joint Admission Protocol

Linford Bulphan

Orthopaedic FY1 x2 FY2 x1

Orthopaedic FY1 x2 FY2 x1

Orthogeriatric Consultant (NOF)

Consultant (non-NOF) Geriatric Medicine StR

PT OT

PT OT

NOF Facilitator Nurses

Tier 3 CCG Fracture neck of femur (Hospital admitted patients)

Q1 – Q4 2012/13 Dr Foster

Peer Episodes Spells Superspells SAR SAR low SAR High

SWE PCT 824 593 483 117.44 108.14 127.33

B&D PCT 415 182 177 103.31 88.81 119.51

Mortality 2013-2014

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

Jan

-13

Feb

-13

Mar

-13

Ap

r-13

May

-13

Jun

-13

Jul-

13

Au

g-13

Sep

-13

Oct

-13

No

v-13

Dec

-13

Jan

-14

Feb

-14

in-hospital mortality

30 day mortality

Rate of Spinal Anaesthetics

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

In-hospital fractures and pressure sores (2013-2014)

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

Hip Fracture Demographics 2013-2014 Walking Aids Number Percentage

Without aids 156 43.2

One aid 87 24.1

2 aids or frame 111 30.7

Wheelchair or bedbound

7 1.9

Admitted from

Own home/supported living 280 77.6

RH 56 15.5

NH 7 1.9

In Hospital 6 4.4

Hip Fracture by ASA

ASA Number Percentage

1 6 1.7

2 79 21.9

3 192 53.2

4 69 19.1

5 3 0.8

UNK 12 3.3

Hip Fracture Demographics 2013-2014

Age Range Number Percentage

>60 < 70 21 5.8

70-80 81 22.4

80-90 176 48.8

> 90 83 23.0

Type of Fracture

Intracapsular 226 66.6

Intertrochanteric 105 29.1

Sub-trochanteric 30 8.3

Hip Fracture Metrics

Metric

Time to ward 9.8 hours

Time to Theatre 35.1 hours (31.1 National)

Length of Stay 16.2 days (19.0 National)

Pre-op Assessment

318 (88.1%) (71.2 National)

Bone Protection 357 (98.9%)

Falls Assessment 358 (99.2%)

What we do well

• VTE Prophylaxis (just over 98%)

• Continuity of care (weekly Trauma Consultant, NOF Facilitator Nurse Specialists)

• Patient flow (NOF proforma and dedicated receiving trauma wards)

• Pressure Sores (2.8%: 2013-2014)

• C.Diff (14 Q1 2013) MRSA bacteraemia rates (2 in the last year)

• Nutrition (dedicated Nutrition pathway)

• Dedicated Trauma Theatre sessions

• Weekly MDT (dedicated OT PT Dietician)

The future

• Managing in-hospital(NHS) injurious falls (4.3: 2013-2014)

• 7 day services

• Reoperation rates

• Is the maintained low mortality related to relative lower frailty?

Thanks Any Questions?