Looking at ways to create better value care within our hospitals is a big topic of discussion across Australia. Leading Better Value Care is concerned with delivering low cost, proactive and high value care.
As Chief Investigator of a Leading Better Value Care project at Maridulu Budyari Gumal, Jacqueline Close is focused on reducing the time-to-surgery for hip fracture patients. This is an area that’s also a priority for the NSW Ministry of Health.
Jacqueline will carry out this work at four Maridulu Budyari Gumal partner hospitals: Prince of Wales, St George, Sutherland and Liverpool.
She has an ambitious goal: to ensure that 85% of hip fracture patients undergo surgery within 48 hours of arriving at Hospital. Jacqueline aims to achieve this by the end of 2020.
The true cost of hip fractures
Hip fracture is the most serious and costly injury suffered by older people. 25% of patients die within the first year, 50% don’t function at the level they used to, and for 11%, a fracture signals the end of independent living.
The direct and indirect financial costs are also enormous, amounting to hundreds of millions of dollars each year.
As Jacqueline says, “there is no benefit in delaying people access to theatres. The longer you delay someone, the greater their risk of complications.”
For hip fracture patients, most of whom are in their 80s, complications include clots in their legs and lungs, pneumonia and pressure sores and impact on how well they recover after surgery.
Improving time-to-surgery is the humane thing to do.
How to improve time-to-surgery
Improving time-to-surgery relies on getting several variables right: data, the relationship between clinicians and managers, and efficient medical assessment and management. It also relies on hospitals setting aside dedicated orthopedic times in theatre.
Access to data is critical to Leading Better Value Care for hip fracture patients. Jacqueline encourages the use of real time data to identify what the issues are. This data is shared with clinicians and managers to make the necessary changes to process.
2. Clinicians and managers
Jacqueline has identified that access to theatres is one of the biggest challenges for the partner hospitals. “The surgeons are willing to get on and operate,” she explains, “they just can’t get access to theatres.”
It’s her intention to work with managers to look at how hip fracture patients are prioritised in comparison to other patients. She will also look at approaches that improve efficiencies in theatres.
3. Medical assessment and management
Inconsistencies in the way blood thinning agents are managed lead to delays in theatre. Jacqueline is creating a pathway for managing anti-coagulation to address this.
“We also want to make sure there are no unnecessary medical delays in getting access to theatres.” To that end, Jacqueline will ensure that admitted patients are assessed quickly and that anything that needs to be done from a medical perspective is also addressed immediately.=
This will ensure nothing gets in the way of hip fracture patients receiving surgery within 48 hours.
4. Orthopedic trauma times
Having dedicated orthopedic trauma times is one solution to ensuring patients receive care in a timely manner. It means hospitals can prioritise hip fracture patients during allocated times each day of the week, ideally.
Jacqueline says that implementing this at the Prince of Wales hospital has made all the difference. It means they can keep on top of patients’ pain and avoid fasting them for extended periods.
The benefits of improved time-to-surgery
The main driver for improving time-to-surgery is the positive impact it will have on patients’ lives. However, the reality is it will also reduce length of stay and save money. “But that’s not the driver,” Jacqueline stresses, “the driver is actually it’s better for patients.”
Better for patients
The average age of a hip fracture patient is 84.40% of these patients will already have an existing cognitive impairment. 30% of them come from residential aged care facilities. They are some of the most vulnerable, frail people in our hospital systems.
“Our goal is to make sure we advocate for them,” says Jacqueline.
Little things make a difference
It’s why she and her team are trying to get patients’ carers involved. Having a carer accompany patients to the theatre is comforting, and a less traumatic experience for someone who has dementia or may be delirious. Jacqueline is also encouraging hospitals to allow family into the recovery wards to care for older patients.
These are all little touches that provide that extra bit of support and reassurance to already frail patients.
Pain relief is humane
Operating on a hip fracture patient is the most effective form of pain relief. It’s not acceptable to leave people waiting for surgery. There is nothing a patient can do until their hip fracture is operated on. They can’t mobilise. They can’t get out of bed.
As Jacqueline points out: “It’s inhumane to leave somebody with a broken hip in bed, in pain, fasted, and waiting for surgery.”
Better for the bottom line
The financial payoffs of improved time-to-surgery are secondary to the patient outcomes, but they can’t be ignored.
There is no financial benefit to delaying surgery. The reality is there are a finite amount of resources in the health system. So, it’s important that limited resources are used effectively.
“Better care costs less, that’s the bottom line.” Jacqueline continues, “For every day that you delay surgery, you add on two days in terms of the recovery period.” This has an impact on the patient, the hospital’s resources and budget.
What’s next for better value care?
The work Jacqueline is doing is focused on four hospitals. She is confident that learnings from these four local hospitals, will translate to the New South Wales level and across other states.
The idea is to learn from other hospitals that are doing better and share their successes in return. “It’s very easily translatable and scalable,” Jacqueline assures.