Improving Orthopaedic Trauma Patient Flow in Cork University Hospital

Cork University Hospital is the referral centre for all Orthopaedic trauma for a population of over 500,000 in its’ catchment area and hospital leadership have implemented a number of significant initiatives to improve flow for patients using this service that are elaborated on here.

The hospital is constantly challenged to improve flow for all emergency patients who present to our Emergency Department each year (c. 65,000) of which c. 20,000 require admission – 10% of which require admission for Orthopaedic related care. In this regard, in 2017, hospital leadership accepted that the flow for those patients for both admissions from ED and time to theatre was not in accordance with the standards set by the National Orthopaedic Trauma Programme and needed to be improved. As an instance, the National Programme has set a target that every Orthopaedic patient presenting with trauma at ED should be transferred to a bed within four hours of presentation and this was not being achieved.

In addition, the flow of patients to theatres was not sufficiently streamlined and patients were not being operated on within the 48 hour target set by the National Programme.

Similarly there were delays in relation to the provision of rehabilitation services for Orthopaedic trauma patients who required those services in one of two other hospitals in Cork city that provide rehabilitation services. This dependence on other hospitals to accept referrals, led to delays in patients transferring from the hospital for on-going rehabilitation services, thereby increasing inefficiencies in the patient pathway and lost bed days.

In order to address these issues, an Orthopaedic Trauma Group was established in the Autumn of 2017 and it commissioned a Lean review into the patient pathway that identified opportunities for service efficiencies, while adding value to the patient journey, including the following;

• Streamlining the flow for Orthopaedic trauma patients in the Emergency Department to dedicated trauma beds;
• Identification of opportunities to improve the scheduling of theatre cases for patients;
• Implementing improved processes that could substantially save bed days in the hospital;
• Recognising potential for reduction in cancellation of theatre cases that cause patient dissatisfaction and reputational damage to the hospital;
• Achieving reductions in the variation in lengths of stay between Orthopaedic surgeons;
• Implementing improvements in the streamlining of patients for rehabilitation services in other hospitals.

The outcome of the Lean review and recommendations for improvement were presented to the governance group comprising representatives of clinical, nursing, therapy and executive leadership following which an implementation plan was developed to address those recommendations. These ranged in complexity from simple changes in the pathway for Orthopaedic trauma patient flow, to the concentration of trauma beds that were previously dispersed throughout the hospital. This latter change was implemented at the end of 2017 and allows for the management of all Orthopaedic trauma patients on a single 60 bed floor together with Plastic Surgery trauma patients.

The results in the intervening 5 months (Table 1) have been very encouraging in respect of the flow of Orthopaedic trauma patients within and out of the ED to the trauma floor, in the transfer of patients from the Orthopaedic ward to theatre for surgery and in the management of patients on the Trauma ward.

Figure 1

Performance Data for Orthopaedic Trauma Patients November 2017 - March 2018

Recognising that more needs to be done to meet all standards, medical, nursing and therapy staff report that continuity of care has been greatly enhanced and there is now consistency of approach to the management of patients that is greatly improved on that which pertained prior to these changes.

In relation to the standard that all Orthopaedic trauma patients presenting at ED should be admitted to a bed within four hours, hospital leadership has decided that at least one bed must be kept free for the admission of hip fractures at any time and later this year it is intended that an Orthopaedic trauma assessment service will be initiated that will allow streaming of patients out of ED.

In addition, there are a number of further improvements being made to the process for the scheduling of theatre cases in order to bring increased transparency to Orthopaedic theatre lists, to allow for improved allocation of theatre staff and to provide for increased use of expensive theatre time. The target is to achieve the standard set by the national Orthopaedic Trauma Programme of having all patients (who are clinically suitable) operated on within 48 hours of admission to the trauma floor.

Finally the hospital has now recruited an Ortho-Geriatrician whose brief will include ensuring that all patients > 60 years of age are seen by a Physician during their admission and receive a falls assessment prior to discharge.

One of the learning points from this initiative is the collective capacity of multi-disciplinary change teams to effect change where there is a commitment to making interventions that will improve care. In this regard the involvement of the Orthopaedic trauma team in the Lean process was particularly important in identifying those activities on the patient journey that did not add value to patient care. Ultimately the goal must be to ensure that every intervention that is made in the patient pathway must contribute to patient care and to shortening length of stay while improving quality.

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J.A. McNamara

Chief Executive Officer