trajectoire Fracture de hanche - anglais

Improving hip fracture care by using the Bone and
Joint Canada toolkit to reduce delays and
improve clinical processes for an aging population
Stéphane Lemire, MD, MSc, FRCPC
Martin Lamarre, MD
Étienne Belzile, MD, FRCSC
(Centre for Excellence on Aging, CHU de Québec)
(Chief Medical Officer, HSFA, CHU de Québec)
(Department of Orthopaedic Surgery, CHU de Québec)
The CHU de Québec (Centre hospitalier universitaire de Québec) is an important health care center . It is
rd
1
currently the 3 largest in Canada .
One of its 5 hospitals, Hopital Saint-François-d’Assise (HSFA), has a capacity of over 250 beds.
- The orthopedic surgery department provides more than 375 hip fracture surgeries annually, which represents
50% of the hip fracture volume in the region.
- The volume of surgery and the ALOS had increased significantly in recent years
*Most hip fracture patients are frail elderly
*Multidisciplinary management known to reduce delirium and improve functional outcome.
1 The CHU de Québec is the result of the merger of the CHUQ and CHA, effective in July 2012.
Pre-fracture
P
A
T
I
E
N
T
P
A
T
H
W
A
Y
Fracture
Pre-surgery
Surgery
Emergency
department (HSFA)
Home
Anaesthesiae
Hip fracture and
ambulance transport
Retirement
Home
Surgery
Post-surgery
Geriatric medicine
+/- other consultant
Inpatient
unit
In-hospital rehab
Admission from other
location
Long term care
Hospital
AC Discharge
ALC
status
Rehab facility
Community
Hip fracture
Discharge
Assisted
living
Follow up with GP
+/- referral spec
LTC (NH)
Follow-up with
surgeon
An analysis of the hip fracture patient care pathway was
conducted according to the guidelines in the toolkit : inefficiencies at the
preoperative, operative, and post-operative level were identified
- Care coordination / integration inefficient between hospital and : GP, community interventions for frailty, falls and OP; patient needs; rehabilitation facilities
- Length of stay almost 30 days
- Standard patient care procedures did not exist
- Communication amongst inter-professional team member was regularly unsatisfactory
- Pain undertreated
- Preop eval inefficient
- 60% of surgeries within 48 h
G
A
P
S
- Pain undertreated
- Inefficient OR scheduling
- Variable surgical approach
- 30% pts had limited WB
- Low use of preventive care
*Delirium
*Immobilisation syndrome
*Iatrogenic effect of meds
*Iatrogenic loss of function
- Low falls risk intervention
- Low OP treatment rates
- Low falls risk intervention
- Low OP treatment rates
Under the leadership of the hospital chief medical officer (ML), and
within his scope, we sought to implement the toolkit recommendations to
better care for elderly patients with hip fracture.
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V
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I
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- Clear organisational priority towards achieving "Hospital Elder Life Program" status
- Working groups representative of the clinicians involved in hip fracture care were created
*animation by CEO, synthesis by project manager
- General objectives in line with the Bone and Joint Canada Toolkit were established
- Staff and MD training regarding basic principles of elderly care
- Emphasis on pain control
- Preop eval streamlined
- Aim for surgeries within 48 h
- ? Previous fctal status (SW)
- Futur : linkage with GP
- Emphasis on pain control
- Surgical priorities adjusted
- Surgery for early WB
- Futur : better care transitions
- Early mobilization
- Early multi-disciplinary eval
Significant improvements occurred at the organizational level, resulting Iincrease in patient flow.
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E
G
Y
F
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C
H
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N
G
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B
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F
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365 hip fx per year
Chx <48h : 60%
WB freedom : 76%
11 redo at FUP - 1 Y (3%)
ALOS : 29 days
OT consult : 2,4 j
53 hip fx audit (June 2012)
Chx <48h :
%
The)need)for)change)was)emphasized)considering):
@)standards)of)care)summarized)in)the)toolkit)
@)nega=ve)impact)of)the)current)situa=on)on)pa=ents
Senior)management)(CMO),)clinical)directors,)and)staff)
were)involved.))
Staff)received)training)and)tools)suppor=ng)prac=ce)
Gradual)implementa=on)!
WB freedom : 83%
ALOS : 16 days
OT consult : 9,8 j
Staff Satisfaction : Survey underway
Patient Satisfaction : Survey underway
L
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O
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L
E
A
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N
T
Involvement)of)relevant)stakeholders)was)key)to)this)project.)
Involving)staff)in)decisions)and)sharing)feedback)was)useful.
Rapid)changes)can)be)achieved)using)a)mul=disciplinary,)
clinical)workgroup)structure;)=mely)follow@up)is)essen=al.!
The)Bone)and)Joint)Canada)toolkit)was)useful)in)guiding)
teams)towards)best)prac=ces.)
www.boneandjointcanada.com
Contributions / Thanks
The dedicated members of the inter-professionnal working groups (CHU de Québec), especially Ms Sandra Grenier, nurse and project manager
Bone and Joint Canada, especially Ms Rhona McGlasso and the members of the province of Québec working group for BJC
FORCES program (Martin Lamarre)
Declaration of interests :
SL : Presentations paid for by Novartis and Amgen. Advisory roles for Johnson and Johnson, Mediamed Technologies, Raymond-Chabot-Grant-Thornton, Bell-Nordic.
ML : None
EB : Presentations paid for by Bayer, Bristo-Myers-Squibb, Pfizer, Zimmer. Research funding paid for by Stryker, Smith and Nephew, IRSC (federal governement funding)
©2013