1

Orthopaedic Trauma

Focus Report

November 2011 Mark Common Director of Improvement & Business Support Betsi Cadwaladr University Health Board

2

WHAT IS A FOCUS REPORT? |

Each month the Board receives a series of reports which highlight overall progress against a range of indicators, across the Quality & Safety agenda. The indicators are numerous and cover multiple Clinical Programme Groups. This is positive as it gives a view of progress across the University Health Board. The Focus report is designed to complement the agenda by providing an insight into a clinical theme or area every month.

Focus On reports in 2011-2012 look at a service or theme which was approved for the production. The report covers a wide range of areas which span across the University Health Board’s agenda, which can include the areas listed below;

3

Other areas are included where they are relevant to the Focus On report. The following examples are a short list of areas which have been presented in previous Focus On reports. They can include;

Services provided by our partner organisations such as;

• social services departments in Unitary Authorities, • Welsh Ambulance Services NHS Trust,

Or the valuable contributions which are made by third sector organisations to support the public sector works, for example;

• local hospice provision, or • national support organisations such as Diabetes UK working in North Wales.

The production of the Focus On reports uses existing data wherever possible, to avoid strain on the service and to avoid duplication of effort. The report offers the Clinical Programme Group the use of the resources available within the Improvement & Business Support team to gather information from across the health and social care sector to draw a picture of health across North Wales. The results from the analysis can be used to inform local improvement initiatives and, more broadly, operational plans for the future.

Outcomes from the Focus On report

The Focus On report provides a level of detail to the Quality & Safety committee which is in more detail than typical performance reports. The production of the report also gives Clinical Programme Groups the opportunity to use the Improvement & Business Support team to coordinate a detailed report into a particular disease or service which supports the operational management of that service.

Focus On reports often look at areas where no monthly reporting exists, which allows the Clinical Programme Group to demonstrate key issues affecting the service, whilst also allowing the Quality & Safety committee to scrutinise the work ongoing within the theme or area.

The Focus On Report provides an in depth study of an area at a point in time. It is intended to be informative but will not provide a comprehensive account of all associated services or elements of the service. The introductory section of these reports aims to inform readers of the scope and limitations.

4

FOCUS ON TRAUMA REPORT |

This Focus On report looks in depth at Trauma, it follows the changing pattern of focus reports which began in April 2011. The change in emphasis is away from clinical specialties, and focuses more on themes which span across specialties and Clinical Programme Groups. However this month’s report focuses on Trauma services across North Wales.

A broad overview is given including trends in :

• Disease prevalence (including bone density, and the incidence of fractures) • Wider determinants of health which can lead to falls and fractures • Primary care information from Quality & Outcomes Framework • Numbers of outpatients attendances for children • Diagnostic imaging activity • Radiographer led reporting • Trends in emergency admissions • Efficiency benchmarking information • Clinical Quality & Safety Benchmarking information • North Wales patients who are treated in England • Current initiatives across the Trauma teams within the University Health

Board

Trauma is presented here in the November report. The next report for January 2012 report will focus on Emergency Medicine across the University Health Board.

The focus on report is coordinated by the Surgical and Dental Clinical Programme Group and Improvement and Business Support Team of the University Health Board, however it would not be possible to write this report without the clinical input from clinicians working with the Clinical Programme Groups, Diagnostic Services, Nursing professionals, Allied Health Professionals, Technical and Scientific staff, significant contributions from Public Health Wales and other staff. Whilst each member of staff cannot be credited here individually, they are thanked for their contribution in informing the Health Board’s senior staff here.

5

THE TRAUMA FOCUS REPORT | EXECUTIVE SUMMARY

The key messages from the report are contained below;

• The North Wales population broadly follows the Welsh average, however there is variation in the older age groups, with North Wales having a higher percentage of older people in its population.

• The number of older people in North Wales is expected to rise significantly by 2025.

• Orthopaedic trauma has a large cost to the economy, across Wales, hip fractures lead to a total cost to Health and Social Services of £84 million each year.

• Mortality from unintentional falls is higher in North Wales compared to the rest of Wales.

• The University Health Board has a falls prevention plan, and is actively leading in reducing harm from falls through the 1,000+ collaborative.

• Emergency Department attendances for fractures increased by 2.1% in 2009-2010 compared to the previous year.

• Fracture attendances at Emergency Departments have a monthly trend in terms of volume, with fracture attendances rising over the spring/summer months

• A similar pattern exists for outpatients, when split by age, it’s actually more younger people fracturing in the spring/summer and older people having fractures in the winter . The report outlines the differences in detail.

• Diagnostic imaging supports fracture services across North Wales and this area has demonstrated real improvements in radiographer reporting over the last few years, utilising extended roles.

• Ward developments include a pilot of Orthopaedic Practitioners to assist patient flow through secondary care in admitting, assessing and planning patient care through their inpatient stay.

• During June 2010 to July 2011 – upper limb trauma accounted for 21% of all emergency orthopaedic admissions, femur fractures accounted for 19% and lower limb excluding femur fractures accounted for 18%.

• Work on the 1,000+ fracture neck of femur pathway shows development and the scope for the pathway to be extended to other areas of trauma.

• The organisation is contributing to the work undertaken both by the Trauma Audit & Research Network (TARN) and the National Hip Fracture Database (NHFD) however there is scope for the organisation to make much better use of the information which is fed back.

• Surgical Site Infection numbers have fallen, however the rate has increased.

• Risk Adjusted Mortality figures produced indicate a good level of 90 compared to the normalised index of 100 (lower is better).

6

TRAUMA

This report presented here relates to the provision of NHS healthcare for patients presenting with trauma North Wales and for North Wales residents who are treated in England. This report covers the treatments offered by the University Health Board’s clinical teams.

WHAT IS A FRACTURE?

This section comprises a brief description of what fractures are, how they are grouped and described to aid the reader in the remainder of the report. The term fracture and ‘break’ are used synonymously in the report. Firstly, fractures can be grouped on the type and severity of break within the bones continuity.

a) Open – this is where the bone has pierced the skin and is exposed to outside environments.

b) Closed – this is where the bone has not pierced the skin.

The fracture is then classified into:

i. Simple – there are two bone fragments ii. Wedge – there is a wedge segment of bone fractured iii. Complex – there are many fragments of bone iv. Spiral – the fracture spirals down the length of the bone v. Oblique – the fracture is along an oblique slanting line to the bones axis vi. Transverse – the fracture is in the transverse slanting plane to the bones axis vii. Avulsion – a segment of the bone is completely detached viii. Compression – where two bones are forced together (usually in the spine) ix. Green stick – usually found during infancy where the bones are still softer.

The bone bends causing the outside edge of the bone to fracture.

These terms are used throughout the remainder of this report and so are briefly introduced here. The term ‘trauma’ in this report refers exclusively to Orthopaedic trauma.

PUBLIC HEALTH | AGE PROFILE

The current age profile of the population of BCUHB is fairly similar to Wales as a whole. However, as the population pyramid below illustrates, the proportions in many of the older age groups within the BCU population are higher than in the Welsh population. This is shown in Figure 1 below.

7

Population Pyramid BCU Health Board and Wales, midy ear estimates 2007.

Source: Public Health Wales Observatory 2009 Demographic Profile Betsi Cadwaladr UHB

As Figure 2 below illustrates, current projections see a rise in the older population (over 75 years) of BCU residents from 61,000 (9% of the total population) in 2006 to 115,000 (15% of the total population) in 2031.

Figure 2: Population Projections BCU Health Board

Source: Public Health Wales Observatory 2009 Demographic Profile Betsi Cadwaladr UHB

8

Figure 3 and Table 1 below show the population projections for the LHB taken from the 2006 Welsh Assembly Government Local Authority Population Projections. These forecast a significant increase in the populations aged 60-74 and 75+.

Figure 3: Population projections for BCULHB 2006-2031.

0

1 0 0

2 0 0

3 0 0

4 0 0

5 0 0

6 0 0

7 0 0

8 0 0

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

Estimated population (thousands) x

7 5 + 6 0 - 7 4 2 5 - 5 9 1 5 - 2 4 0 - 1 4

D a t a s o u r c e : S ta t i s t i c a l D i r e c t o r a t e , W e ls h A s s e m b ly G o v e r n m e n t / O N S

2 0 0 6 - b a s e d p o p u l a t i o n p r o j e c t io n s f o r B e t s i C a d w a l a d r U n i v e r s i t y L H B , p e r s o n s : 2 0 0 6 t o 2 0 3 1

Table 1: Population projections for BCULHB 2006-203 1.

Change from 2010 Change from 2010 Age group 2010

2015 Number % 2025 Number %

0-14 115400 116100 700 0.6 119000 3600 3.1

15-24 83700 81500 -2200 -2.6 76600 -7100 -8.5

25-59 300600 303800 3200 1.1 299400 -1200 -0.4

60-74 124900 133100 8200 6.6 141100 16200 13.0

75+ 64000 71300 7300 11.4 101600 37600 58.8

Total 688600 705800 17200 2.5 737700 49100 7.1

Table 1 above identifies an overall N Wales population increase between 2010 and 2015 of 17,200 residents (+2.5%), however the increases in residents aged 60-74 is 8,200 (+6.6%) and 75+ years is 7300 (11.4%). These disproportionate increases in older people are even more significant in the projections for 2025.

Since the incidence and prevalence of many orthopaedic conditions is higher in the older age group, the ageing population in North Wales is likely to lead to significant increases in future need and demand for services. Increasing age is associated with frailty, disability and loss of independence which can lead to an increase in the risks associated with unintentional falls and hip fracture.

Fractures are an important cause of pain, disability and death. The vast majority of fractures and injuries in older people are the result of falls. Table 2 and Table 3 mortality from unintentional falls by county in North Wales for the period 2000-2009

9

for all ages and those aged 65 years and over respectively. It can be seen that death rates from unintentional falls are much higher in those aged 65 years and over.

Table 2: Mortality from unintentional falls, rate per 100,00 0 persons, all ages, North Wales, 2000-2009

Table 3: Mortality from unintentional falls, rate p er 100,000 persons aged 65 years and over, North Wales, 2000-2009

Osteoporosis, which is a disease characterised by a reduction in bone mass and density, increases the risk of fracture when an older person falls. Osteoporotic fractures occur most commonly in the hip, spine and wrist. Vertebral fractures due to osteoporosis can cause loss of height, curvature of the spine and chronic back pain.

One in two women and one in five men over 50 will experience an osteoporotic fracture. Over 12,000 osteoporotic fractures occur in Wales each year, 4,200 of which are hip fractures. 7% of people die within a month of this injury, with 25% dying within the following year. Half of survivors fail to regain their pre-fracture level of independence. (Welsh Assembly Government. National Service Framework for older people in Wales. 2006).

Hip (neck of femur) fracture is the most common serious injury related to falls in older people. In Wales, hip fractures lead to a total cost to Health and Social Services of £84 million each year. One third of this cost is for acute care, and two thirds for social and medical aftercare necessary in the first two years after the injury. Table 4 and Table 5 show hospitalisation rates for hip fractures in BCU HB for all age and those aged 85+ respectively. Please note that discharge rates and bed use rates are per 100,000 population.

10

Table 4: Hospitalisation for fractured neck of femu r, all persons, all ages, 2002-2007

2002 2003 2004 2005 2006 2007

Discharge numbers 821 813 777 775 817 795

Discharge rate 123.2 121.5 115.7 115.4 121.4 117.6

Average no. of beds used 55.9 54.7 56.5 73.8 71.3 75.6

Beds use rate 8.4 8.2 8.4 11.0 10.6 11.2

Average stay 24.9 24.5 26.6 34.8 31.9 34.7

Source: eHealthShow

Table 5: Hospitalisation for fractured neck of femu r, all persons, 85 years+, 2001-2007

2002 2003 2004 2005 2006 2007

Discharge numbers 354 321 282 310 349 326

Discharge rate 2,263.9 2,093.3 1,836.5 1,941.1 2,085.2 1,867.2

Average number of beds used 25.7 24.0 23.6 32.5 34.7 32.7

Beds use rate 164.2 156.8 153.5 203.6 207.2 187.1

Average stay 26.5 27.3 30.6 38.3 36.3 36.6

Source: eHealthShow

Fracture incidence and costs will rise by over 1% per annum simply as a result of the ageing of the Welsh population. Figure 4 shows the forecast demand for hip fracture to 2025, by age group.

Fig 4 – Forecast demand for Hip Fracture to 2025, b y age group.

11

Application of current level of hospital activity t o population projections, number of people having at least one hip fracture,

North Wales resident population, all persons source: PEDW, NPHS

0

200

400

600

800

1000

1200

1400

1600

Baseline(averageof 2004-

06)

2009 2012 2015 2018 2021 2024 2027

Num

ber

of p

eopl

e

00-14 15-64 65-74 75-84 85+

Public health strategies aim to reduce the incidence and the impact of falls. These include actions to encourage appropriate weight-bearing and strength enhancing physical activity, to promote healthy eating (including adequate intake of calcium) and to reduce smoking in the general population. Access to regular sight and eye health checks are also important as poor vision is often a factor in falls (Welsh Assembly Government. National Service Framework for older people in Wales. 2006).

FALLS & FALLS PREVENTION

The LHB covers almost a third of Wales’ landmass and is the largest in terms of population and geography. It has 678,500 people in the area, with 136,795 aged 65 or over, of which 37,986 are over the age of 80.

It is estimated that 35% of the over 65s and 45% of the over 80s will fall each year, and that 60% of people living in residential homes will fall repeatedly. 3% of people who fall will be admitted to an in-patient bed1. Based on our currently population and age profile it is estimated that 34,583 falls will occur in the

1Department of Health, Falls and fractures: Developing a local joints strategic needs assessment, 2009.

12

over 65s and a further 17,094 falls in the over 80s, resulting in approximately 1,550 admissions.

The Health Board continues to spread and sustain improvements in care for patients through its strategic theme ‘Making it Safe’ in order to reduce harm. Falls prevention in the acute setting is supported through the development of Transforming Care programmes, whose aim is to improve the experience for patients whilst in hospital, including safety and quality of care and in a community setting this is supported through the implementation of the 1000 Lives Plus Campaign, ‘Reducing Harm from Falls’ through the use of its Trigger, Assessment, Intervention and Monitoring Bundles.

FALLS PREVENTION STRUCTURE

A Falls Prevention Structure has been agreed which will provide the overarching governance framework for falls prevention across secondary, community and primary care services.

BCU HB BOARD

Patient Safety Steering Group

Chair: Assistant Medical Director – Central

Falls Executive TeamChair: Regional Director

Public Health North Wales

Falls AcuteOperational Team

Chair: Associate Chief of Staff (Nursing)

Therapies and Clinical Support

FRONTLINE TEAMS, SERVICES & LOCALITIES(Fall Preventions Alliances)

Strategic Nursing & Midwifery Group

Chair: Director of Nursing

Falls Community Operational TeamChair: Consultant

Physician – Care ofThe Elderly

Falls, Bone Health & Syncope GroupChair: Consultant Physician – Care of

The Elderly

Falls Executive Team

The purpose of the executive team will be to scrutinise reliability of compliance, lead spread of good practice, remove barriers and report progress to Board of Directors.

Membership of the Falls Executive Team includes:

• Executive Director Public Health North Wales

13

• Associate Chief of staff nursing, therapies and clinical support • Chief of staff nursing, therapies and clinical support • Consultant physician – care of the elderly • Modernisation Improvement Lead

Community Operational Team

The Community Team is responsible for overseeing the delivery of Falls services in North Wales, focusing in particular on outcomes, which will be set by Health and Local Authority stake holders. The Community Team is accountable to the Board of Directors of the University Health Board via the Falls Executive Team and will also report to the Patient Safety Steering Group.

The work of the community operational team will be to provide leadership, commitment and operational support to implement changes in relation to preventing falls in the community and to facilitate Local Health Board compliance with external standards; good practice guidance; and legislation in relation to falls in this setting.

Acute Operational Team

The Acute Operational Team will provide leadership, commitment and operational support to the CPG’s to standardise High Impact changes in relation to patients in acute medical and surgical inpatient areas.

To facilitate LHB Board compliance with external standards; good practice guidance; and legislation in relation to falls in acute ward areas. The group is accountable to the Strategic Nursing and Midwifery Committee which is chaired by the Director of Nursing, Midwifery and Patient Services and the BCU Falls Executive Team.

The Community/Acute Operational Teams meet on a regular basis and membership of either team may be further extended with the agreement of the respective clinical lead and Chair.

Progress to date

The executive team is undertaking an in-depth review of all work related to falls management/prevention across BCUHB, Local Authority and the Third Sector. This will provide a directory of services which can be assessed to show delivery or performance to date against local and national priorities defined within the LHB‘s five year plan and Strategic Direction.

The introduction of the Integrated Care Pathway and work undertaken as part of releasing time to care resulted in a reduction of in-patient falls on Erddig Ward, Ysbyty Maelor, per 1000 0ccupied bed days.

14

In-patient Fall Reduction Rate

As a result of this the integrated care pathway documentation has been introduced across BCUHB, on all surgical and medical wards, in an acute and community setting. This includes a Risk Assessment, Falls Care Pathway and Essential Care after an Inpatient Fall. The acute operational team are currently developing an audit plan for monitoring implementation of the pathway.

Baseline data on in-patient falls has been collated and this has identified the need to further develop fields within Datix in order to capture contributory factors, multiple falls and outcomes, to enable further analysis and development of appropriate interventions. This is being taken forward by the acute operational team.

The Falls Clinic – based at Ysbyty Maelor has a falls register and is specifically using the intervention bundle and has plans in place to introduce the monitoring bundle.

The National Exercise Referral Scheme (NERS) which is based on both the Falls Management Exercise Programme and OTAGO exercise programme (which has been shown to reduce falls2) is currently in operation across North Wales, within the local authority areas of Anglesey, Wrexham, Gwynedd and Conwy. The NERS programme is tailored to an individuals’ functional and fall specific needs and

2 Campbell A, Robertson M, et al. (1997) Randomised controlled trial of a general practice program of home based exercise to prevent falls in elderly women. British Medical Journal 315: 1065-9].

15

improves strength, balance, endurance, flexibility, co-ordination and functional movement. Plans are currently being developed to take this forward within Flintshire.

The operational community team have adapted the health boards Integrated Care Pathway for use in Care Homes. This is currently being piloted in Five Care Homes for a period of six months and is being supported by Medicines Management, District Nursing Teams, Welsh Ambulance Service and the Wrexham NERS team.

The operational community team are also taking forward plans for the introduction of a falls register within the community, linking in with community hospitals, GP Out-of-Hours, local authority, intermediate care and the Welsh Ambulance Service.

ROYAL SOCIETY FOR THE PREVENTION OF ACCIDENTS

The work on preventing accidents goes beyond the remit of the National Health Service, and it is worthy to note the work undertaken by third sector voluntary organisations such as the Royal Society for the Prevention of Accidents (ROSPA). The work of the organisation is worthy to note in this report.

ROSPA is a registered charity and has led the cause of accident prevention in the UK and around the world for over 90 years. More than 13,500 people die as a result of accidents across the UK each year. There are millions of other injuries. Accidents cause loss and suffering to the victims and their loved ones, employers and UK society as a whole. The society promotes safety and the prevention of accidents at work, at leisure, on the road, in the home and through safety education.

16

EMERGENCY DEPARTMENT ATTENDANCES

The following sections look at the numbers of Emergency Department (ED) attendances by day, for trauma injuries. The information is sourced from the Emergency Department information systems, which collect the initial provisional diagnosis of the patient attending. The report analyses the following trends in orthopaedic trauma attendances at emergency departments across North Wales.

• Annual trends • Monthly trends (i.e. noting seasonality) • Daily trends (i.e. noting trends which are seen each week)

The section on monthly trends includes a statistical process control chart for analysing the differences in fracture attendances between months. Colleagues unfamiliar with statistical process control charts are invited to review the information on why they should be used and why they are advocated in the NHS in the appendix.

Annual Trends

The annual trends in Emergency Department Attendances for fracture patients are shown for the part three year period from April 2009 to September 2011.

2009-10 2010-11 2011-12

(Apr-Sep only)

Attendances 13,018 13,304 6,811

The number of attendances increased by 286 between 2010-2011, an increase of 2.1%.

Monthly Trends

The impact of the seasons is clearly shown in the number of attendances for Emergency Departments. The number of attendances is shown here by month in the table below.

A M J J A S O N D J F M 2009-2010 1145 1261 1220 1152 1234 1189 1022 917 1023 1031 779 1045 2010-2011 1169 1249 1234 1177 1257 1210 1096 1006 1078 890 845 1093 2011-2012 1239 1093 1079 1171 1198 1031

17

Two separate charts are shown here. The first chart shows the trend in monthly fracture attendances at ED, in a simple line chart. The second shows a more detailed Statistical Process Control chart, which offers a more detailed analysis of the data.

1) Line Chart for ED Fracture Attendances

The data shows an increase in the number of orthopaedic trauma patients attending ED during the summer months. This means that most fractures is actually higher in the summer months than the winter months. During the winter months, up to 400 less fractures attend the emergency departments compared to the summer peaks in attendances.

2) Statistical Process Control a. Statistical Process Control – what is it?

Statistical Process Control charts show whether or not the variation shown is part of normal seasonal variation, or if something else is causing a change. What is normal is described as a control limit. There are two control limits, the first showing how high the data normally goes, the Upper Control Limit, and the second showing how low the data normally goes, the Lower Control Limit. A more detailed explanation can be found in the appendix.

If a Health Board's data falls outside its control limits, it means that the rate differs from its average (mean) rate by more than is likely to be due to chance, and special

18

causes are more likely to be responsible. Such a result should prompt an investigation into the possible cause. This is typically either a true high or low rate or may have arisen through changes in how data is reported.

b. Statistical Process Control Chart

The chart below shows the number of attendances again by month, however with upper and lower control limits added. An average (mean) line is also shown. A detailed discussion follows.

Statistical Process Control chart for monthly Fract ure attendances

April 2009 to September 2011

The Upper and Lower control limits show the range of normal variation that would be expected in fracture attendances. The chart shows that although a seasonal pattern exists in the summer, that the peaks do not fall outside what would normally be expected for ED fracture attendances. However, when looking at the lowest points in the chart, a pattern emerges in that each lowest point (February) shows a decrease in the number of fracture attendances, and that this low point falls on the threshold of the lower control limit. This suggests that a factor beyond normal seasonality is affecting the low number of fractures. The need for further analysis is indicated.

Colleagues will note that the Upper and Lower control limits change (become narrower). This indicates that the process is becoming more stable, and less likely

19

to vary significantly. So far in 2011 the variation is significantly less, and therefore the upper and lower control limits are relatively close to the average.

Statistical Process Control charts also allow for the annual average (mean) to change. As can be seen in the previous chart, the annual average is reset every 12 months to show a consistent comparison.

Daily Trends in Attendances

This section looks at the attendances by day from the 1st April 2009 to the 30th September 2011. The pattern of ED attendances for fractures is also affected by day of the week, with higher figures reported at the weekend and the ‘extended weekend’ days (i.e. Friday to Monday).

TRAUMA AUDIT & RESEARCH NETWORK (TARN)

The three acute emergency departments across the University Health Board all participate in the Trauma Audit & Research Network. The research network is a web audit, research and improvement tool.

The network provides, for the first time, important information about the rates of survival for patients who have been injured and treated at different hospitals across England and Wales. It also provides information about the benefits of certain kinds of treatment.

20

It should be noted that the information TARN publishes is based on contributions from staff working in the University Health Board. The data is scored for quality, and this was classed as a moderate improvement in 2011. This means that the organisation submitted fewer than expected injuries since January 2008, however data collection issues have now been resolved and the number of submissions has increased.

Comparative information for all the three sites across the University Health Board is not available for the production of the report. A key recommendation from this report is that the information submitted to TARN is used proactively in discussions between the Orthopaedic teams and the Emergency Department teams across the three sites.

TRAUMA OUTPATIENT ATTENDANCES

Patients who attend the Emergency Department are typically followed up in an outpatient department headed by a Trauma & Orthopaedic surgeon across the University Health Board.

Annual Trends in New Trauma Attendances

Annually, over the last four years the trend has been mixed. After the first baseline year (2007-2008) trauma outpatient attendances fell back slightly by 1%. However in the following two years attendances increased annually by an average of 3%. This means that the position in 2010-2011 showed a 6% increase overall.

Financial Year Number of New Attendances

2007-2008 12,820

2008-2009 12,675

2009-2010 12,995

2010-2011 13,573

The annual percentage change in trauma attendances varies by site. The following table shows the changes compared to the previous year. The largest annual change during the last four year (full financial year) was at the Ysbyty Wrexham Maelor site, which reported a 14% increase in attendances in 2009-2010 compared to the previous year. The Ysbyty Gywnedd sites reported an 8% increase in 2010-2011 compared to the previous year. The annual change in attendances at Ysbyty Glan Clwyd increased by 3% in the same period.

21

Annual Growth Rate changes by site 2007-2011

Ysbyty Gywnedd Ysbyty Glan Clwyd Ysbyty Wrexham Maelor

2007-08 - - -

2008-09 2% -1% -5%

2009-10 -3% -1% 14%

2010-11 8% 3% 2%

Monthly Trends in clinic attendances

The following section outlines the monthly trends in outpatient clinic attendances across the University Health Board for orthopaedic trauma outpatients. Only first attendances are discussed here due to data quality issues in identifying reliable, robust and comparable follow up attendance figures.

New Trauma clinic attendances (April 2007-September 2011)

Financial Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2007-2008

1,154 1,235 1,122 1,112 1,139 1,034 1,262 954 817 1,015 956 1,020

2008-2009

1,011 1,136 1,155 1,136 1,074 1,157 1,178 869 897 1,032 871 1,159

2009-2010

1,125 1,106 1,239 1,152 977 1,235 1,059 968 1,070 993 890 1,181

2010-2011

1,121 1,148 1,247 1,229 1,163 1,220 1,138 1,034 1,071 1,039 918 1,245

2011-2012

1,186 1,240 1,256 1,172 1,245 1,173 402

Patients attending fracture clinic for the first time also shows a seasonal pattern. Figures are averaged by month over the period April 2007-March 2011 and shown in the following table and chart. The information is shown as the average number of daily attendances3.

3 The average number of daily attendances is used to adjust for the fact that calendar months range from 28 to 31 days. This introduces a small bias in monthly data, and so using the average number of attendances by day balances this out.

22

Average Monthly Attendances – April 2007-March 2011 by month

J F M A M J J A S O N D

BCU 132 130 149 187 189 201 187 181 194 163 128 124

The information shows that the number of attendances rises in April and remains high, peaking at an average of 201 trauma outpatients per day during June. The number of attendances then falls back to lower levels from November onwards.

The reasons for the trend in attendances being higher in the summer is due to a combination of many factors, however it has been noted4 that there is a relationship between the number of sunlight hours and the incidence of fracture. This describes a relationship where the more sunlight hours available, the more members of the public spend in outdoor activities, and therefore there is a corresponding increase in the number of fractures attending hospitals and outpatient departments.

4 The author of the report is grateful for Mr A O’Kelly pointing this out (personal correspondence).

23

Age

The variation in age for outpatient attendances across North Wales shows that the majority of fracture outpatients are in the younger age groups. The following table and chart show the variation in age by month, in 20 year age groups.

Age

Month 0-19 20-39 40-59 60-79 80-99 100-119 Grand Total

1 903 994 975 868 337 2 4079

2 1093 885 765 646 241 5 3635

q3 1629 1072 917 699 283 5 4605

4 2058 1301 1063 859 314 2 5597

5 2205 1363 1059 873 361 4 5865

6 2171 1405 1126 946 370 1 6019

7 2047 1331 1187 887 343 6 5801

8 1816 1337 1166 925 348 6 5598

9 2033 1356 1153 918 356 3 5819

10 1777 1188 978 791 300 5 5039

11 1184 926 740 688 284 3 3825

12 959 868 872 844 308 4 3855

Grand Total 19875 14026 12001 9944 3845 46 59737

24

The variation shows the trends across the year by age group. There are several trends in motion at the same time:

• The youngest age group 0 years to 19 years old show a considerable increase in attendances in March which rises to a peak in the summer months. The younger age groups are responsible for the overall increases over the summer months.

• The first adult age group cohort (20 years to 39 years) show a similar pattern, with decreases in the late autumn and winter months followed by increases each spring and peaks over the summer periods. However the overall numbers of attendances are lower.

• The elderly population group (60-79) shows a very different pattern, with attendances rising in the winter December and January months.

• The very elderly population age group of 80-99 years shows a pattern with relatively little variation compared to the previous age groups, however it shares a similarity with the elderly age group by reporting an increase in the December month.

The age group not discussed above, those aged 40-59 years shows a combination of the two patterns. The first shows a rise over the summer months. The second shows a rise in December and January.

25

Weekly Clinics

The number of weekly clinics in Orthopaedics varies across the University Health Board. On average there are;

• 7 fracture clinics per week at Ysbyty Gywnedd • 6 fracture clinics per week at Ysbyty Glan Clwyd • 5 fracture clinics per week at Ysbyty Wrexham Maelor

26

DIAGNOSTIC IMAGING

The diagnostic imaging element of the patient pathway for trauma patients is key. Clinicians working with trauma rely heavily on quick, accurate and reliable images to diagnose orthopaedic trauma.

Many trauma patients will have an x-ray (referred to also as plain film – although now departments work digitally). Pictures of scans are available quickly through the Picture Archiving and Communication System (PACS), which can display images in different locations. Images are also reviewed by members of the Imaging Department and this is an area which has shown a safe expansion of roles recently, as described in the following section on radiographer led reporting below.

The request for a patient scan may originate from a medic working in the Emergency Department or a member of the Orthopaedic Team working on-call on the ward. As such no robust numerical information is available for the production of this focus on report. This is because it is not possible at present to identify trauma patients, as both the Emergency Department referred patients and the Orthopaedic Team referred patients include non-trauma workload. A project to match patient admissions to diagnostic imaging requests is ongoing.

Trauma patients are also regularly scanned using Computerised Tomography (CT), for more complex trauma injuries. CT is available 24 hours a day (within one hour’s notice) on request by the Emergency Department staff on all three sites across the University Health Board.

The usage of Magnetic Resonance Imaging for trauma patients is relatively rare, as most orthopaedic patients are elective. MRI is not available 24 hours a day across the University Health Board.

Radiographic support is available to operating surgeons working in theatre on a 24 hour a day basis. This means that surgeons can call on radiographers to take diagnostic images during surgery, and review the results of those images.

RADIOGRAPHER LED REPORTING

This section outlines how the services to support diagnostic imaging for trauma patients is improving. Ten years ago, most patients with a trauma injury would attend the imaging department for an x-ray which would be performed by a radiographer. Then, the image would be sent to a consultant radiologist for interpretation and a report would be produced. A new development in diagnostic imaging allows for fully trained radiographers to undertake reporting for trauma cases.

27

Background History

It has been long recognised that radiographers could differentiate between normal and abnormal images5. The ‘Red Dot System’ (RDS) has been developed, whereby the radiographer conducting the radiographic examination would place a red dot on the radiograph to highlight an abnormality and help reduce the number of overlooked abnormalities in the Emergency Department (ED). The RDS has remained relatively unchanged in its rationale since its introduction in the1980’s.

Role Extension & Clinical Training

Numbers of studies conducted on the accuracy of radiographers performing the RDS showed radiographers to be experienced at detecting abnormalities and become the foot hold into radiographers’ formally reporting on ED radiographs. In the late 1990’s Universities developed and formalised training with a recognised post graduate qualification to set the standard to report an ED radiograph.

In 2000 The Royal College of Radiologists (RCR) national audit recognised that the lack of trained radiologists, increasing and a more complex workloads, put a strain on diagnostic imaging departments resulting in long delays in the report turnaround time.

A document jointly produced by the RCR and The Society and College of Radiographers (ScoR) -Team Working within Clinical Imaging: A contemporary view of the skills mix, identifies skill mix to provide cost effective care in a timely manner, however it emphasises the need to ensure staff members are educated and trained to provide a safe and effective clinical service.

The SCoR Medical image interpretation by radiographers: Definitive guidance (2010), states “research studies consistently show that reports made by properly trained reporting radiographers are concordant with reports of consultant radiologists”.

As with all delegated roles a robust protocol must be in place to ensure best practice and consistency of care. The undertaking of image interpretation is covered by the University Health Board’s arrangements for clinical negligence; the CPG medical director is legally accountable for the safe provision of service. It is advisable that the radiographer is also a member of the SCoR or holds other professional indemnity insurance.

5 Swinburne in the Lancet (1971) however before this interestingly the 1922 Society of Radiographers Articles of Association prohibited radiographers from expressing an opinion on the images they produced.

28

All radiographer reports issued are on standalone basis and issued/validated by the radiographer solely. In the occasional case of a complex examination the radiographer may discuss findings and issue a dual report.

All reporting radiographers are work within agreed protocols, which encompass a robust audit programme. Personal audit is advocated, the exact logistics of which is protocol dependant, however the Radiology CPG has safe practices in place, which include CPG discrepancy meetings, feedback of errors from both within and outside of the CPG.

For colleagues who would like to know further information, a reporting radiographer based at YGC, has audited the reporting practices for all specialities across Wales, for an MSc dissertation. Feedback from questionnaires reflected the qualifications and utilisation of reporting radiographers. North Wales had more time allocated to reporting than the rest of Wales, however the mean number of patient visits reported was in the middle. This may reflect other advanced practice performed for example, teaching. The best report turnaround time was in North Wales. Please contact Vicky Freeman for further details6.

BCU Radiology CPG practices

At present, Ysbyty Gywnedd, Ysbyty Glan Clwyd and Wrexham Maelor all have reporting radiographers that report on ED radiographs in broadly similar numbers and scope of practice.

Patient Journey Comparisons

Ten years ago the patient experience via the ED would be to be;

• Assessed by a nurse • Assessed and referred by a doctor • Radiographer perform the radiographic examination • Patient return to ED, assessed and treated by doctor • All radiographs reported by consultant • Report sent on subsequently to the ED - dependant on the report turnaround

time

Today the patient experience would be;

• Assessed/referred by nurse or doctor • Radiograph performed by a radiology assistant practitioner or radiographer • Patient return to ED, assessed and treated by nurse/doctor

6 The authors of this report thank the contributions from dissertations produced by Maria Manfredi and Jan Davies, Radiographers at the University Health Board.

29

• The reporting radiographers traditionally report on trauma based ED referrals of the bony skeleton from the shoulder to fingers and pelvis to toes. (It is of interest to note that the majority of these images are normal,)

• The consultant radiologist reports on chest radiographs (which account for over 1/3rd of the ED referrals), abdomens and spines.

• All report sent on subsequently to the ED - dependant on the report turnaround time

Staffing Levels

All three sites have one full time equivalent reporting radiographer which is supported by three suitably qualified radiographers at band 7 and band 8A. (The 8A radiographers are recognised for managerial responsibilities and principle radiographer for reporting (Ysbyty Glan Clwyd) and PACS (Ysbyty Gywnedd). The service runs in working hours on weekday’s at all three acute sites. Ysbyty Glan Clwyd has a dedicated radiographer reporting service, Ysbyty Gywnedd and the Maelor report on an ad Hoc basis.

Future Improvements

The merger of the three imaging departments will perpetuate the benchmarking, standardisation and unifying/extending scope of practice in due course. The unification of all three sites by the new Picture and Archiving Communication System will help to drive and achieve this outcome.

Previous Audit (2009) at Ysbyty Glan Clwyd shows the reporting radiographers reported approximately 15,000 examinations per annum which is approximately one third of all ED requests and all the locality Minor Injury Unit (MIU) workloads. The work done is equivalent in numbers to one radiologist however it must be stressed that the ED reporting is the easiest and quickest examinations to report.

This figure has incrementally increased year on year reflecting the increasing use of radiographic imaging.

Benefits of Radiographer Led Reporting

The principle benefit to be realised to the reporting of ED images by radiographers within the radiology CPG is the cost effectiveness, increasing radiologist time and availability for more complex imaging and improving the report turnaround time for the ED, which in turn has a better patient outcome.

Other important outcomes at some sites across the Health Board are the team working associated with the extended role, we are properly supporting by the radiology consultants and have become a source of advice to radiographers, but also doctors and nurses in the ED and MIU’s. A further outcome of advanced

30

practice has been the development of image interpretation teaching that we deliver regularly to medical students and radiographers and occasionally to ED doctors.

The next major achievement for BCU, would be recognition of ‘Hot Reporting’ radiographs. For example, when the examination is performed the radiograph is immediately reported to improve patient outcome across the whole patient journey not just in individual CPGs7.

HOSPITAL ADMISSIONS | BED COMPLEMENT

Each of the three acute sites has an inpatient trauma ward. This section looks at the numbers and usage of the beds on each of the three sites. The trauma wards are Pantomime Ward at the Ysbyty Wrexham Maelor site and Ward 3 at the Ysbyty Glan Clwyd site. The trauma ward at Ysbyty Gywnedd changed during the last three years from Beuno Ward to Conwy Ward. The change took place on the 6th January 2011. The number of staffed beds on each of the three sites varies;

• 23 beds at the Ysbyty Gywnedd site • 30 beds at the Ysbyty Glan Clwyd site • 21 beds at the Ysbyty Wrexham Maelor site

Staffing levels in whole time equivalents8 (WTE) were reported9 at the same time:

• 26 on the Ysbyty Gywnedd trauma ward • 36 on the Ysbyty Glan Clwyd trauma ward • 27 on the Ysbyty Wrexham Maelor trauma ward

Bed occupancy for the trauma wards during the period April 2009 to October 2011 was on average;

• 81% for the Ysbyty Gywnedd Trauma Ward • 86% for the Ysbyty Glan Clwyd Trauma Ward • 78% for the Ysbyty Wrexham Maelor Trauma Ward

Colleagues are asked to note that the bed occupancy figures are for the trauma wards only, and therefore may include some non-trauma patients (for example, complex elective orthopaedic patients). Similarly the figures do not include trauma patients who are not sleeping on the ward.

7 This is reflected in the Case Study –Plain film, Pinderfields General Hospital, Wakefield. Radiographer-led Hot reporting in A&E. 8 Figures are rounded to the nearest whole number 9 The period used is August 2010 to be consistent with Orthopaedic review data.

31

TRAUMA | EXTENDED ROLES

Background

The senior medical & management team within the Clinical Programme Group at the

Ysbyty Gywnedd site developed the concept of suitably trained and experienced

nursing staff being employed to carry out the duties historically only undertaken by

junior doctors. These duties include assessing patients physically and by taking a

medical history, carrying out routine tests, making a differential diagnosis to present

to the registrar/consultant, manage patient’s co-morbidities during their in-patient

stay and carrying out the instruction of the consultant. Not only did this concept

address the issue of increased expenditure on locum doctors, but it also aimed to

provide improved consistency of quality of care by having highly trained and qualified

members of staff in key roles who were less likely to move on to other posts and

hence more likely to reduce the risk of errors. The plan is that these roles will

complement medical care, enhance patient’s care pathway and lead to quicker,

consistently high quality care for all orthopaedic trauma patients.

Academic Training

A competency based approach to assessment, along with structured university and

in-house teaching can provide the necessary skills and knowledge to achieve these

goals.

Three Orthopaedic Trauma Practitioners were employed in June 2010. Two of the

practitioners were enrolled into the advanced nursing practice (ANP) MSc

programme at Bangor University. A third had already completed the taught

component of this programme and was able to progress to the enhanced ‘in-house’

training programme, described below.

The academic programme contains modules specific to advancing practice safely

and namely includes modules on Independent Prescribing, Clinical Assessment,

Diagnosis and Treatment. The practitioners have also all undertaken our Advanced

Life Support programme and attended the ATLS programme.

32

Supervised Clinical Training – Year 1

The plan is for the posts to train for 2-3 years in order to gain the key knowledge and

skills required to practice at the level of a junior doctor. The practitioners are

assigned to two of the orthopaedic consultants and work alongside the FY2/SHO

gaining confidence and support in such duties as clerking and physical assessment,

examination as well as the practical skills of phlebotomy, cannulation,

catheterisation, electrocardiograms, blood result interpretation and other clinical

duties.

As well as the University based studying, there has been an intense focus on training

within the department, consisting of weekly sessions on all aspects of orthopaedic

injuries and conditions for which they are tested on at regular intervals. Trainees also

accompany the ortho-geriatrician to gain knowledge and understanding about care of

the elderly medicine. Professional development portfolios are used as evidence of

practices learnt or been involved with that can be discussed with the clinical

supervisors.

Every 4 weeks the practitioners work the on-call weekend with the consultant’s

teams, under direct supervision where they assist in the diagnosis, management and

treatment of trauma patients. This offers key benefits as the nursing background

complements the medical role by incorporating an holistic approach. With such

increased pressure on beds and length of stay, it is imperative that any contributory

factors or preventing measures to rehabilitation and discharge can be highlighted

and addressed at an early stage to enhance the patients stay and recovery.

Supervised Clinical Training Year 2

It is widely accepted that many orthopaedic patients (especially hip fracture patients)

have wider health problems other than their fracture.

In order to provide assurance for safety and training, prior to full implementation of

this role, trainees are commencing placements under the direct supervision of the

medical clinicians from December 2011. This placement will incorporate cardiology,

respiratory, acute medicine and endocrinology. Throughout this placement the

practitioners compile clinical logs, discussing them with consultant mentors. This

placement will provide the experience and skills of dealing with other conditions, co-

33

morbidities and emergency situations. The placements also assist in enhancing the

knowledge of pharmacology from outside of the specific field of practice within

orthopaedics.

In line with the current University Health Board’s policy on Non-Medical Prescribing,

practitioners are required to undertake a minimum of 72 hours training per additional

‘field’ which practitioners transcribe and prescribe medicines for.

The further expectation is that these roles will continue to complement and enhance

patient’s care pathway and that a competency based approach to assessment, along

with structured university and in-house teaching can provide the necessary skills and

knowledge to fulfil these roles.

Benefits

There are many potential benefits to patients, clinicians and nursing staff to this new

and innovative approach. The benefits to patients are that they are assessed by an

experienced orthopaedic clinical practitioner who has been extensively trained and

supervised to manage orthopaedic trauma patients during their pathway. The benefit

to clinicians is that they can provide a consistent, competent and structured

environment for future trainee doctors that pass through the department, hopefully

improving their knowledge of orthopaedics.

34

HOSPTIAL ADMISSIONS FOR TRAUMA

Clinical Site of Trauma

This section looks at which part of the body suffers orthopaedic trauma. The sites are described using the International Classification of Diseases’ clinical coding manual.

July 2010 to June 2011

The key messages from the most recent year’s data are described below:

• Upper limb trauma accounts for 21% of all admissions • Lower limb trauma accounts for 19% of all admissions • Fractured femur accounts for 18% of all admissions • Head injuries account for 8% of all admissions • Spinal trauma injuries account for 7% • Hand trauma injuries account for 7% • Trauma to the foot accounts for 2%

It should be noted for head trauma injuries are admitted to Orthopaedics in Ysbyty Gywnedd and Ysbyty Glan Clwyd but not at Ysbyty Wrexham Maelor.

The table below shows the patterns across the year for admissions by the part of the body suffering orthopaedic trauma.

Trauma Admissions by Site of Trauma – July 2010 to June 2011

Site J A S O N D J F M A M J Total Upper limb 111 134 88 88 59 99 54 69 92 120 90 92 1096 Lower limb 97 105 87 72 78 95 89 94 64 79 83 65 1008 Femur 72 78 73 66 84 84 86 80 67 87 86 62 925 Unspecified site

40 29 30 26 39 28 33 25 44 38 54 29 415

Head 44 34 30 34 34 29 28 45 33 49 35 12 407 Spinal 34 29 34 35 38 25 26 31 34 45 32 27 390 Hand 31 33 32 43 25 26 23 15 41 39 38 38 384 Foot 11 24 21 11 9 14 8 3 8 21 13 17 160 Pelvis 18 16 17 17 11 9 9 12 10 13 13 11 156 Infection following procedure

13 2 9 9 5 7 4 13 4 10 9 12 97

Mechanical complications

7 4 6 12 9 6 5 11 9 5 6 8 88

Complication of prosthesis 9 1 6 4 6 5 8 3 4 2 3 7 58

Chest 6 3 3 4 4 4 3 2 5 5 4 3 46

35

Site J A S O N D J F M A M J Total Infection following Trauma

0 0 4 1 1 0 0 0 0 4 1 0 11

Haemorrhage or Haematoma complications

0 1 0 2 0 2 0 0 0 2 1 1 9

Cardiac 1 0 1 0 2 0 0 0 2 2 0 0 8 Other10 1 1 4 2 3 3 0 0 4 7 1 0 26

FRACTURE NECK OF FEMUR PATHWAY

Amongst elderly patients, hip fractures are associated with an in-hospital mortality rate of 7–14%, and profound temporary and sometimes permanent impairment of independence and quality of life. As the elderly population increases, the number of hip fractures globally is expected to exceed 7–21 million annually over the next 40–50 years with significant costs to health care systems.

The recently published hip fracture guideline from NICE emphasised the importance of early treatment of hip fracture patients.

Hip fracture surgery is often subject to delay in comparison with other operations. Surgery is considered the best form of pain relief. Postponement of surgery prolongs pain and carries an increased risk of complications.

Background

Hip fracture is a major public health issue due to an ever increasing ageing population (the National Hip Fracture Database reports the average age of a person with hip fracture as 84 in men and 83 in women). About 10% of people with a hip fracture die within 1 month and about one-third within 12 months. Most of the deaths are due to associated conditions and not the hip fracture itself, reflecting the high prevalence of co morbidity. Because the occurrence of fall and fracture often signals underlying ill health, a comprehensive multidisciplinary approach is required from initial fall to subsequent follow-up, including the transition from hospital to community.

The Delivery and Support Unit (DSU) was established by the Welsh Assembly Government in December 2005, as outlined in the Welsh Health Circular WHC (2005) 097. The primary role of the DSU is to provide health communities in Wales with enhanced support and performance management tools and techniques to 10 This includes; Complications (Other), Infection , Neurology, Wound disruption, Urology, Abdomen Complications (Anaesthetic), complications of procedure, Complications of Surgical/medical care , Complications of Trauma, Prosthetic complications, Vascular complications

36

enable NHS Wales to achieve improved performance levels. BCUHB has committed to work with the DSU to improve the care delivered to fracture neck of femur patients across North Wales; the aim being to provide the best possible care to this very vulnerable group of patients by focusing on 5 key stages of their journey.

a. Pre admission to Emergency Department b. Care in the Emergency Department c. Admission to ward and optimisation d. Recovery and reablement e. Discharge

a. Pre admission to Emergency Department

This focuses on the initial assessment by the emergency ambulance crew who will ascertain whether a fractured hip is suspected. They will administer pain relief and hydration provided if required and appropriate. They will ensure that the emergency department is given prior warning of arrival.

b. Emergency Department

When the patient arrives in the emergency department they should be assessed within one hour of their arrival which should include their nutritional status, vital observations, reason for fall, pain score and whether they have received adequate analgesia, general history including any previous falls and their mobility. There should be a clinical assessment including bloods, ECG and x-ray. Once fracture has been confirmed and that there are no other medical conditions that should take priority, they should be transferred to the trauma ward (within 2 hours of arrival in the emergency department)

c. Admission To Ward And Optimisation

Once on the ward the patients should receive assessment by the following:

i. Orthopaedic surgeon ii. Senior/Consultant anaesthetist iii. Orthogeriatrician/Care of the elderly physician iv. Trauma co-ordinator v. Physiotherapist vi. Occupational therapist vii. Pain team

This is to ensure that the patient is optimised prior to surgery and that any co-morbidities is assessed and considered prior to surgery. The aim would be to get the patient to the operating theatre within 24 hours of admission or within 36 if co-morbidities need further stabilisation.

37

d. Recovery and Reablement

The key to this stage is the involvement of the multidisciplinary team. It is reliant on good communication with the patient and their relatives or carers from day one of admission. Patients are encouraged to take a proactive role in their recovery to promote independence with the ultimate goal of being able to return to their previous level of function and previous place of residence. A planned discharge date is agreed with the multidisciplinary team, the patient and their family/carers early in the pathway within the target average length of stay of 17 days. (Inclusive of the acute and rehabilitation stage of care and will include the time that a patient remains an inpatient in any peripheral hospital)

e. Discharge

Between one half and two thirds of hip fracture patients have experienced a prior fracture. This could and should have served as a trigger for assessments of both osteoporosis and falls risk to reduce the incidence of secondary fracture. The pathway stipulates that patients should receive both these risk assessments prior to discharge from hospital or as soon as possible after discharge.

Developing the Pathway in the University Health Boa rd

Three groups have been set up to deliver the pathway on the three main sites. They are multidisciplinary with key members identified to lead on the 5 stages of the pathway. Progress from each site is monitored by the chair of each group who is the main driver on each site. A baseline audit undertaken by the DSU has identified shortfalls which have been developed into an action plan. Progress on the action plan is monitored by the improvement teams. It is planned to undertake another audit by the DSU in early 2012

The bed remodelling exercise has provided the Surgical & Dental CPG with opportunities to consider the possibility of developing a fractured neck of femur unit within the trauma wards with early involvement of the orthogeriatrician. The Ysbyty Glan Clwyd site currently does not have an orthogeriatrician appointed but the PCSM CPG are in the process of submitting a bid to be able to provide this service in the future.

There are areas of good practice demonstrated across the health board that now need to be shared and embedded on all three sites.

38

HIP FRACTURE PATIENTS

This section looks at the services provided to patients who attend hospital with a hip fracture. Data is available for historical periods on request, only 2009/2010 data is shown here for brevity.

Ysbyty Gywnedd

Ysbyty Glan Clwyd

Ysbyty Wrexham Maelor

Indicator 2009/10 2009/10 2009/10 Number of admissions with a hip fracture (Using Primary diagnosis codes: S72.0 & S72.1)

234 430 233

Fracture Neck of Femur (S72.0) 152 304 191

Pertrochanteric Fracture (S72.1) 82 126 42

Average length of stay for hip # patient in acute fracture ward Based on primary diagnosis codes: S72.0 & S72.1

13.0 10.0 12.8

Number of Orthogeriatric sessions in fracture ward

5 0 2.5

Presence of social worker assigned to fracture service Y/N

Yes No Yes

Average time to surgery for hip fracture patients (Hours)

37.0 Not

Available 34.6

The information shows that he number of admissions with a hip fracture varies across the three sites, with the most admissions at the Ysbyty Glan Clwyd site. The number of hip fractures admitted to the other two sites is similar at 234 for Ysbyty Gywnedd and 233 for Ysbyty Wrexham Maelor.

Ysbyty Wrexham Maelor reported the highest percentage of fracture neck of femur admissions at 191(82%). Of the fractures admitted to Ysbyty Glan Clwyd some 304 (71%) were diagnosed with a fracture neck of femur, whilst the number at Ysbyty Gywnedd was lower at 82(65%).

The availability of orthogeriatric support to the trauma wards is shown in the table, with Ysbyty Gywnedd reporting the most availability. This area is highlighted as an

39

area which the Clinical Programme Group is taking forward as an improvement measure in the next year.

The average time waiting for surgery is a development measure, and recording systems are being put into place during 2011. The information available at August 2010 records that at the Ysbyty Gywnedd site patients wait an average of 37 hours from admission to surgery, whilst at Ysbyty Wrexham Maelor patients wait 34.6 hours.

40

HIP FRACTURE DATABASE

The National Hip Fracture Database (NHFD) is a clinically led, web-based audit of hip fracture care and secondary prevention in England, Wales, Northern Ireland and the Channel Islands. Its aim is to improve such care.

• All 191 of the eligible hospitals are now registered with NHFD. 98% participate by regularly uploading case records in a standard dataset format. Hospitals receive benchmarked feedback that enables clinicians and managers to monitor and improve the care they provide.

• Around 76% of the estimated 70,000 cases occurring annually are now documented by NHFD. The total number of cases recorded since its launch in 2007 is now over 132,000, making the NHFD the largest and fastest-growing national hip fracture audit in the world.

• Care is audited against six standards: prompt admission to orthopaedic care; surgery within 48 hours and within normal working hours; nursing care aimed at minimising pressure ulcer incidence; routine access to orthogeriatric medical care; assessment and appropriate treatment to promote bone health; and falls assessment. Since April 2009 additional indicators of surgery within 36 hours – have been included to meet the needs of the Best Practice Tariff initiative. Colleagues are asked to note that this differs from the NHS Wales development target of surgery within 48 hours.

The National report outlines those hospitals participating in the audit, whilst all three acute hospitals sites are described as participating in the audit, Ysbyty Gywnedd and Ysbyty Wrexham Maelor submitted enough cases to be included for comparative purposes in the report. Ysbyty Glan Clwyd is identified as having submitted data but not sufficient for comparative purposes. Information for the Countess of Chester is available and is included in the report. Robert Jones & Agnes Hunt is not included as it is a predominantly elective centre for North Wales patients.

The information is reproduced with kind permission from the National Hip Fracture Database.

41

Wales Audit Results (Published 2011)

Hospital Estimated number of cases (facilities audit)

Cases submitted

% Cases submitted / facilities audit estimate

% Data completion

% Admitted to OW in 4 hours

% Surgery within 48 hours (BB2)

% Treated without surgery

% Arthro-plasties cemented

% Assessed by geriatrician

% Bone medication at admission

Mean (SD) acute stay length (days)

Mean (SD) Trust post-acute stay length (days)

Countess of Chester Hospital

320 309 96.6 87.6 48.2 84.8 4.5 54.2 32.7 20.1 21.3

(16.7) 1.2

(4.9)

Gwynedd Ysbyty, Bangor

275 162 58.9 92.0 61.1 95.7 2.5 88.6 44.4 14.8

12.6 (11.2)

21.9 (28.1)

Maelor Hospital, Wrexham

230 230 100.0 93.8 0.0* 93.7 6.5 50.0 40.4 15.7

12.5 (9.6)

16.8 (27.5)

Overall Wales 3,034 2,186 72.1 92.2 30.3 80.1 4.5 63.7 25.7 11.1

19.4 (19.5)

15.8 (31.1)

Overall National 61,202 53,443 87.3 92.3 48.2 86.0 2.8 68.2 42.5 11.7

16.4 (14.2)

4.8 (14.1)

The data shows that overall the Maelor audited all cases, whilst at Ysbyty Gywnedd approximately 60% of cases were audited. Of those which were audited, data quality was above 90%.

42

Admitted to the Orthopaedic Ward in under 4 hours

At the Ysbyty Gywnedd site 61.1% of patients were admitted to the trauma ward within 4 hours of attending. For the Ysbyty Wrexham Maelor site the data was not included for this indicator.

Surgery within 48 hours

At the Ysbyty Gywnedd site 95.7% of patients had surgery within 48 hours, whereas the figure was marginally lower at the Ysbyty Wrexham Maelor site at 93.7%

Treated without surgery

Some patients will not be treated with surgery for a hip fracture and this group will normally include those patients where the fracture is already in alignment for healing, or those patients who have pre-existing medical conditions which prevent them from having surgery or are too frail to undergo an operation with anaesthetic. This figure was 2.5% of admissions for Ysbyty Gywnedd patients and 6.5% for Ysbyty Wrexham Maelor patients.

Arthroplasties Cemented

An arthroplasty is a surgical repair of a joint. Polymethyl methacrylate is a plastic that may be used to hold arthroplasties in place. It is introduced into the reamed bone before prostheses are inserted. The ‘cement’ sets in a few minutes. The cementing of arthroplasties reduces postoperative pain and improves mobility. Some 88.6% of arthroplasties were cemented at the Ysbyty Gywnedd site, whilst 50% were cemented at the Ysbyty Wrexham Maelor site.

Assessed by a geriatrician

This indicator outlines the percentage of patients who are assessed by a geriatrician. There were 44.4% of patients assessed by a geriatrician at the Ysbyty Gywnedd site and 40.4% assessed at the Ysbyty Wrexham Maelor site. Whilst this is good compared to the rest of Wales, compared to the rest of the UK the indicator remains at the average level.

43

Bone protection medication

Those patients who were offered bone protection medication on admission was 14.8% at the Ysbyty Gywnedd site and 15.7 at the Ysbyty Wrexham Maelor site. All Wales levels for the same period were lower at 11.1% and across the UK the average was 11.7%. Figures are not age adjusted.

TRAUMA OPERATING THEATRES

The topic of operating department usage by Trauma teams could justifiably result in an entire report on the topic, however this report only provides broad summary figures on how operating theatres are currently configured and used across North Wales for orthopaedic trauma patients.

The number of consultants participating in the on call rota (as at August 2010) was

• Ysbyty Gywnedd – 7 during the week, 8 at weekends • Ysbyty Glan Clwyd – 7 at all times during the week • Ysbyty Wrexham Maelor – 10 at all times

The number of trauma list theatre sessions per week was;

• Ysbyty Gywnedd – 14 lists per week • Ysbyty Glan Clwyd – 13 lists per week • Ysbyty Wrexham Maelor – 7 lists per week

44

ORTHOPAEDIC SURGICAL SITE INFECTION

The University Health Board submits surgical site infection data for orthopaedic joint replacements and for caesarean sections to the Welsh Healthcare Associated Infection Programme.

Surgical site infections (SSI) are a substantial cause of mortality and morbidity among hospitalised patients. Studies on orthopaedic surgical site infections have shown them to result in considerable increases in lengths of stay, high re-hospitalisation rates, and significant reductions in health-related quality of life.11 Complications of types of infections have high human and financial costs12.

The data across Wales has been analysed and reported to the Health Board as improving in both areas in 2009-10 compared to 2008-09. Both areas also show better performance than the all Wales average. The table below shows the improvement in performance and the comparison with the all Wales position.

Hips & Knees

The following table shows information for the numbers and rate of primary (first time) hip and knee arthroplasty infections in 2009 and 2010.

Total forms received

Valid forms

No. of inpatient SSI

No. of post- discharge SSI

Overall SSI Rate

Elective Primary Hip Arthroplasty 590 590 0 5 0.8%

01/01/2009 to 31/12/2009

Elective Primary Knee Arthroplasty

683 683 4 8 1.8%

11 1. Whitehouse JD et al. The impact of SSI following orthopaedic surgery at a community hospital and a university hospital: Adverse quality of life, excess length of stay and extra cost. Infection Control & Hospital Epidemiology 2002; 23: 183-189.

2. Donoghue MA & Allen KD. Costs of an outbreak of wound infections in an orthopaedic ward. Journal of Hospital Infection 1992; 22: 73-79.

12 4. Horan T et al. CDC Definitions of Surgical Site Infections, 1992: A modification of CDC Definitions of Surgical Wound Infections. Infection Control & Hospital Epidemiology 1992; 13: 606-608.

45

Total forms received

Valid forms

No. of inpatient SSI

No. of post- discharge SSI

Overall SSI Rate

Elective Primary Hip Arthroplasty 525 521 0 8 1.5%

01/01/2010 to 31/12/2010

Elective Primary Knee Arthroplasty

440 439 2 3 2.1%

The table shows that the numbers of infections are low overall and that the overall rates for hips increased from 0.8% to 1.5%. The Welsh average for hips in 2010 was 1.7%. Performance against the target for knees rose from 1.5% to 2.1% The Welsh average was 2.2%.

46

CLINICAL BENCHMARKING | EFFICIENCY

The following efficiency indicators are available online through the Signpost clinical benchmarking website. Each area or indicator benchmarks the area’s performance against a clinically selected peer group.

Orthopaedic Trauma - Efficiency Benchmarking Table

BCUHB Ysbyty Gywnedd Ysbyty Glan Clwyd Ysbyty Wrexham MaelorOutpatient DNA Rate 8.40% 10.9% 8.3% 6.3% Outpatient New to Follow Up Ratio 1:2.0 1:2.0 1:2.0 1:2.1 Data Quality 79.0% 69.8% 98.2% 96.5%

The efficiency indicators are available online through the Signpost clinical benchmarking website. Each area or indicator benchmarks the area’s performance against a clinically selected peer group.

Data Quality

Typically, specialties reporting over 90% data quality can be relied upon for accurate data for performance reporting purposes. In reporting Orthopaedic Trauma figures, West reported data quality indicators of less than 90%, which means that caution should be used in interpreting the results from other indicators.

Did Not Attend Rates

Figures for outpatient Did Not Attend rates are lower than the peer group (8.9%) across all two areas of the Health Board, ranging from 6.3% to 8.3%. However, West outpatient DNA rate is above the peer at 10.9%.

New to Follow Up Rates

New to Follow up ratios are indicators which state that on average for every new patient there are a certain number of follow up appointments. So, a ratio of 1:2.4 reports that for every new outpatient there are 2.4 follow up appointments. The ratios across North Wales vary from 2.0 to 2.1, all over the peer group ratio of 1.8.

47

CLINICAL BENCHMARKING | QUALITY AND SAFETY

This section reports on a range of indicators available through the online clinical benchmarking tool. Colleagues will be familiar with most of the indicators used which have been presented in previous month’s report. Figures for the University Health Board represent Orthopaedic consultants only. The peer group used is the rest of Wales, the period used is July 2010 to June 11.

Orthopaedic Trauma Clinical Benchmarking Table

BCU

Ysbyty Gywnedd

Ysbyty Glan Clwyd

Ysbyty Wrexham Maelor Peer

Mortality 1.73% 1.35% 1.79% 2.50% 2.16% Risk Adjusted Mortality 2011 90 84 71 98 76 Misadventure Rate 0.00% 0.00% 0.00% 0.00% 0.10% Complication Rate – Treated 5.7% 3.8% 7.3% 9.30% 7.4% Complication Rate – Attributed 2.1% 1.8% 3.4% 2.60% 3.1% Readmissions 5.8% 5.0% 5.6% 7.4% 8.00% Average length of stay (emergency) 6.8 5.2 6.7 10.0 8.3

Mortality – Crude & Risk Adjusted

Colleagues are asked to consider both indicators when examining mortality rates. Figures for mortality range from 1.35% to 2.50% compared to a peer group of 2.16%. The mortality rates are lower than the peer group in two areas of the organisation. When risk factors are included in the calculation, the Risk Adjusted Mortality Index (RAMI), figures are still lower than the normalised index of 100. The peer group reports an index of 76, whereas a rate of 98 was reported for the East area of the Health Board.

Complications Attributed

The Complication rate (Attributed) was below the peer (3.1%) in two areas of the organisation in BCUHB, ranging from 1.8% in the West to 2.6% in the East area. The Complications attributed in the Central area of the Health Board is slightly higher than the peer at 3.4%.

48

Complications Treated 13 and Misadventure Rates

The Complication rate (Treated) was below the peer (8.0%) in two areas of the organisation in BCUHB, ranging from 3.8% in the West to 9.3% in the East area. The Misadventure rate was 0.00% across the Health Board, in line with the peer rate of 0.10%.

Readmissions

Readmission rates are below the peer (8.0%) in all areas of the Health Board. However, the readmission rate for the Centre is actually 1% lower than shown as CHKS has not taken in to account transfers between the sites post operatively for rehabilitation.

Average Length of Stay

The Average Length of Stay for the Western and Centre areas is lower than the peer (8.3). The Average Length of stay in the Eastern area of the Health Board is higher than the peer at 10 days.

IMPROVEMENT PLANS – ORTHOPAEDIC TRAUMA

Fracture Neck of Femur

The first pathway to be prioritised is the FNOF pat hway, the benefits will be realised across other pathways

• Fracture Neck of Femur Pathway development & localisation across North Wales which will include

• Pre A&E (for example Ambulance Treatments) • ED (Stabilisation of the patient & triage ) • Admission to Ward & optimisation of the patient – including improving time to

admission, including the broadening of admission rights to trained clinical staff • Surgery within 24 hours • Recovery & Re-ablement • Discharge

General pathway improvements

• Focus on the improvement of Post-operative pathways, including the development of timescales with local authority partners,

49

• Improve the efficiency of re-ablement pathways

Orthogeriatrician

• Equalise access to services across North Wales, in partnership with the Medical Clinical Programme Group

• Fully utilising the existing clinical sessions provided by orthogeriatricians to support trauma pathways

• The development of a shared care model with the orthogeriatrician team to ensure that the underlying comorbidities frequently associated with age related fractures are addressed as well as the orthopaedic elements of the patients need

Orthopaedic Nurse Practitioners

• Evaluate the current pilot in Ysbyty Gywnedd, including an evaluation of the clinical effectiveness and safety of the pilot

• Explore the opportunities offered across North Wales

Extended Scope Practitioners

• Explore the use of ESPs in trauma clinics, in order to release medical staff time for treatment of patients, supporting the delivery of the EWTD and Deanery recommendations

Theatre

• Improvement of theatre utilisation within Trauma, including turnaround time. • Explore current medical rotas for supporting trauma • Implementing the spread of enhanced recovery to trauma

Poly trauma

• Review the configuration polytrauma (patients with multiple trauma) referral pathways for patients in North Wales.

Diagnostic Imaging

• Radiographer led reporting (A Kemp – Vicky - extended across North Wales)

Social Care Services

• The agreement of a shared pathway which actively plans for discharge at the point of admission.

• The agreement of common operational arrangements (Llinos Thomas)

50

ALTERNATIVE EXECUTIVE SUMMARY

The diagram below provides an alternative executive summary of the document. The word cloud is created using a text-analysis tool, which counts how many times each word appears in this document. This provides an at-a-glance summary about this document.

51

APPENDIX | WHAT IS STATISTICAL PROCESS CONTROL

Explanation of Statistical Process Control (SPC) Ch arts 14

SPC charts assume that rates within a Health Board will be largely similar over time. They present the data in a Health Board in relation to what would be expected, based on the average (mean) rate for the Health Board and calculated statistical process control limits for the time period.

These control limits, derived from plus or minus 3 standard deviations from the average (mean), represent the range of variation in rates of data that might be expected to occur in a Health Board due to chance alone. The control limits for a Health Board may change from month to month, depending on changes in the sample size.

SPC charts allow the distinction to be made between natural variation (rates that fall within the limits) and special cause variation, where something unusual is occurring in a Health Board (rates that fall outside the limits).

If a Health Board's data falls outside its control limits, it means that the rate differs from its average (mean) rate by more than is likely to be due to chance, and special circumstances are more likely to operate. Such a result should prompt an investigation into the possible cause, which could be a true high or low rate or may have arisen through changes in how data is reported.

As well as investigating when rates fall outside the control limits, investigations should be prompted when certain trends in the data are observed.

Example

This section illustrates the use of Statistical Process Control and how they can be interpreted. These trends are listed below and should be read in conjunction with Figure 1. The example shows quarterly all Wales rates of MRSA bacteraemias per 1000 occupied bed days. This indicator is used purely as an example and is in no way related to the Orthopaedic Trauma services provided by the University Health Board.

14 This explanation is based on the excellent explanation of Statistical Process Control by the Welsh Health Associated Infection Programme, and uses the example shown there. Further details can be found at : http://www.wales.nhs.uk/sites3/page.cfm?orgid=379&pid=13438

52

Figure 1. Example Statistical Process Control Chart

Trends in an SPC Chart to Prompt an Investigation

• Eight consecutive values on the same side of the mean i.e. in zones A, B or C or in zones D, E or F

• Any 12 of 14 consecutive values on the same side of the mean i.e. in zones A, B or C or in zones D, E or F

• Three consecutive values in either the top third or bottom third of the expected range i.e. in zone A or F

• Five consecutive values in the top two thirds or bottom two thirds of the expected range, i.e. in zones A or B or in zones E or F

• Thirteen consecutive values in the middle thirds of the expected range i.e. in zones C and D.

• Eight consecutive values either increasing or decreasing. • Cyclic or periodic behaviour.

The occurrence of the above trends should prompt an investigation into their possible causes since:

Trends 1 to 4 may indicate an improvement or deterioration in infection control.

Trend 5 may indicate an improvement in the consistency of application of infection control measures.

53

Trend 6 may indicate improving or deteriorating application of control measures.

Trend 7 may indicate an underlying pattern to changes in the application of control measures that repeats itself at regular intervals, such as seasonality.

The overall mean rate for all Welsh Health Boards will also be plotted on each Board's SPC chart, for comparison purposes.

APPENDIX | CONTRIBUTORS

As noted at the start of this report, the Focus On report could not be completed without valuable contributions from areas across the health, social care and voluntary care sectors. A list of contributors has been compiled below.

Surgical and Dental Clinical Programme Group

Barry Williams, Surgical Services Manager

Radiology Clinical Programme Group

Pat Youds, Associate Chief of Staff, Radiography

Vicky Freeman, Superintendent Radiographer (Reporting)

John Collins, Head of Systems & Information, Radiology Clinical Programme Group

Public Health Wales

Robert Atenstaedt, Consultant in Public Health Medicine

Claire Jones, Public Health Intelligence Specialist

Improvement & Business Support

Mark Common, Director for Improvement & Business Support

Jill Newman, Associate Director for Improvement, Service Transformation and Business Support.

Rich Gillett, Head of Performance Assurance and Business Intelligence

Strategic Planning

Robin Wiggs, Head of Planning

Kathryn Williams, Planning Information Analyst

Informatics

Lynne Edwardson, Senior Information Analyst

54

Mel Baker, Clinical Information Analyst

Ken Belton, Clinical Information Analyst

Jake Hemmings, Information Analyst

Pamela Peters, Performance Analyst

Mike Williams, Information Analyst

Gareth Griffiths, Information Analyst, NHS Wales Information Service

Daniel Hughes, Information Analyst, NHS Wales Information Service.

Private Companies

Mrs Heather Walker, CHKS Clinical Benchmarking.

Third Sector

National Hip Fracture Database staff

Trauma Audit & Research Network staff

Credit

The contributors listed above have all contributed directly to the production of the report, however some key contributors to certain sections are worthy to note:

Public Health Wales Colleagues who have produced the online observatory for health statistics.

Welsh Health Associated Infection Programme staff who contribute information on surgical site infections.

The statisticians at Stats Wales, who provide the population and demographic information for some sections of this report.

Contributors not listed above may have been omitted through oversight.