Transcript Length of Stay Project

International Society of
Orthopaedic Centres
Length of Stay Project - Hamburg
April 2013
Robert Cusack
St Vincent’s & Mater Health, Sydney, Australia
International Society of Orthopaedic Centres
Length of Stay Project
ARTH.
KNEE
PROC
(INCL
ACL)
TKR
(PRI.)
THR
(PRI.)
HEMI
KNEE
REV.
TKR
REV.
THR
BTKR
ARTH.
SHOUL
& / OR
STAB.
HIP
SCOPE
BACK /
NECK
SPINAL
SURG.
R/O FIX
. DEV.
HIP /
FEMUR
PROC.
ANKLE
A/DES.
TEN.
REPAIR
– KLINIK
(GERMANY)
2.2
(112)
10.2
(1498)
9.5
(2043)
N/A
14.6
(547)
15.2
(963)
N/A
3
(120)
N/A
7.7
(387)
7.5
(325)
6.6
(36)
N/A
11
(76)
N/A
IRCCS – RIZZOLI
(ITALY)
2.9
(569)
10.7
(596)
9.7
(1261)
N/A
11
(154)
12
(239)
N/A
3.8
(874)
N/A
N/A
12.8
(379)
2.1
(1492)
N/A
2.1
(590)
0
(0)
CAMPBELL
CLINIC
(USA)
0.16
(628)
N/A
N/A
5.7
(3)
N/A
N/A
N/A
0.17
(505)
0.25
(6)
0.30
(58)
N/A
0.10
(244)
0.15
(78)
N/A
0.23
(217)
ROYAL .
HOSPITAL
(UK)
0.4
(428)
10.5
(484)
10.7
(643)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
11.6
(704)
1.8
(362)
5.9
(356)
N/A
N/A
IRCCS –
GALEAZZI
(ITALY)
2.3
(1445)
5.2
(1216)
5.7
(878)
N/A
N/A
7.6
(178)
4.6
(40)
1.3
(691)
2
(1)
4.5
(811)
N/A
1.8
(652)
N/A
N/A
N/A
SKANE .
(SWEDEN)
1.3
(1735)
4.8
(546)
4.8
(572)
N/A
N/A
9.1
(165)
6.1
(34)
1.4
(898)
N/A
5.8
(413)
8.6
(281)
3.9
(4930
9.6
(1207)
4.9
(423)
N/A
THE MATER
(AUST)
0.4
(884)
6.6
(714)
6.4
(686)
5.7
(66)
N/A
9.4
(71)
7.5
(161)
1.35
(274)
0.6
(78)
1.4
(70)
N/A
0.3
(221)
0.5
(78)
N/A
1.6
(72)
HOSP. FOR .
SURG (US)
1.86
(1243)
3.87
(3235)
3.63
(3155)
2.49
(505)
N/A
5.0
(453)
4.51
(423)
2.04
(1105)
N/A
2.52
(764)
N/A
6.97
(546)
(18)
N/A
2.72
(207)
SCHULTHESS
KLINIK
(SWITZ)
3.4
(182)
12.1
(522)
9.3
(761)
N/A
12.7
(96)
11.0
(147)
N/A
2.9
(1370)
N/A
11.1
(641)
N/A
10.2
(475)
4.5
(124)
2.4
(482)
N/A
SINT MAARTENS.
(NETHER)
1.0
(409)
5.0
(577)
5.0
(465)
4.0
(111)
N/A
10.0
(235)
5.0
(144)
2.0
(180)
1.0
(30)
2.0
(121)
N/A
1.0
(388)
4.0
(170)
N/A
2.0
(80)
Day/Month/Year
Footnote to go here
Page 2
LOS results based upon type of
procedure
16
14
12
10
ENDO – KLINIK (Germany)
IRCCS – RIZZOLI (Italy)
8
6
4
CAMPBELL CLINIC (USA)
ROYAL NAT. HOSPITAL (UK)
IRCCS – GALEAZZI (Italy)
SKANE UNI. (Sweden)
THE MATER (Aust)
2
HOSP. FOR SPEC. SURG (US)
SCHULTHESS KLINIK (Switz)
0
SINT MAARTENS. (Nether)
LOS results based upon type of
procedure
ENDO – KLINIK (Germany)
IRCCS – RIZZOLI (Italy)
CAMPBELL CLINIC (USA)
ROYAL NAT. HOSPITAL (UK)
IRCCS – GALEAZZI (Italy)
SKANE UNI. (Sweden)
THE MATER (Aust)
HOSP. FOR SPEC. SURG (US)
SCHULTHESS KLINIK (Switz)
SINT MAARTENS. (Nether)
14.6
12.7
12.1
10.7
10.5
10.2
6.6
3.4
2.9
2.3
2.2
1.86
1.3
1
0.4
0.16
5.2
5
4.8
3.87
11
10.7
9.7
9.5
9.3
6.4
5.7
5
4.8
3.63
5.7
4
2.49
15.2
12
11
10
9.4
9.1
11.1
12.8
11.6
11
10.2
7.6
7.5
7.7
5.8
5
6.1
5
4.6
4.51
3.8
3
2.9
2.04
2
1.4
1.35
1.3
0.17
4.5
2
1
0.6
0.25
2.52
2
1.4
0.3
8.6
7.5
6.97
6.6
3.9
2.1
1.8
1
0.3
0.1
9.6
5.9
4.5
4
4.9
2.4
2.1
0.5
0.15
2.72
2
1.6
0.23
0
ENDO – KLINIK (Germany)
IRCCS – RIZZOLI (Italy)
CAMPBELL CLINIC (USA)
IRCCS – GALEAZZI (Italy)
SKANE UNI. (Sweden)
THE MATER (Aust)
HOSP. FOR SPEC. SURG
(US)
SCHULTHESS KLINIK (Switz)
Day/Month/Year
Education patient/carer/family.
Pain management.
Anaesthetic protocols minimise use of sedation.
Mobilisation - day 1 or asap.
Clinical Pathways.
Pre Admission Clinic.
Discharge Planning services.
Day of Surgery Admission
DOSA.
Pre-operative classes.
Rehabilitation.
Current practices utilised affecting
LOS
X
√
√
√
X
√
√
X
√
√
X
√
√
√
√
√
√
X
√
√
X
√
√
√
√
√
√
X
√
√
X
√
√
√
X
√
√
X
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
X
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
X
√
√
√
√
√
√
X
√
√
Footnote to go here
Page 5
BEST PRACTICE
Factors affecting Length of Stay
Pre-operative classes:
Rehabilitation (type of rehabilitation i.e. inpatient):
Day of Surgery Admission DOSA (please specify % of orthopaedic patients):
Discharge Planning services:
Pre Admission Clinic:
BEST PRACTICE
Factors affecting Length of Stay (continued)
DVT/PE screening
Clinical Pathways:
Mobilisation:
Anaesthetic protocols (general, spinal, regional, sedation etc):
Pain management:
Education - patient/carer/family (advice of LOS and expected discharge date
FACTORS AFFECTING L.O.S
PRE-ADMISSION:
Minimum two weeks before admission
Advantages:
Pre op screening of risk factors and co-morbidities
Appropriate work up of medications and necessary diagnostic tests
Avoid cancellations or adverse events during admission
Commence a pre-hab program including muscle training, strength,
endurance
Opportunity for education sessions for patient and carer (option on-line)
Discharge plans commenced and discussed with patient
Anaesthetist not having to see patient prior to surgery on the day of op
Disadvantages
Patients have to attend another day
Anaesthetists having to attend another day
Need to provide physical space to conduct the assessments
FACTORS AFFECTING L.O.S
DAY OF SURGERY ADMISSION:
Effective use of reminder calls prior to admission assist this process
Advantages:
Less time in hospital away from home, family or work for patients
Less chance of hospital acquired infection or other adverse events eg falls
Cost savings
Higher throughput opportunities from increased bed capacity
Disadvantages
Physical space requirement to admit patients to DOSA Centre
Patient and family expectations/satisfaction may not be as high
Anaesthetist has to conduct patient review if there has been no pre
admission clinic attendance
Pre op tests may not have been done
Additional movement of patient belongings to inpatient room
FACTORS AFFECTING L.O.S
DISCHARGE PLANNING:
Commence at doctors surgery, re-enforced at PAC and continued throughout hospital stay
Involvement of family in discharge planning including equipment needs and home preparation
Having and all areas working to an agreed hospital wide time of discharge
Discharge gains are more effective if discharge metrics are measured in hours not days
Advantages:
Ensures patient and family are adequately prepared for discharge expectations
More likely to achieve expected discharge date and avoid delays
Assists scheduling and resource utilisation
Improved continuity of care and outcomes for patient
Cost savings
Higher throughput opportunities from increased bed capacity
Disadvantages
Needs significant co-ordination on all related aspects eg ward rounds, diagnostic tests, pharmacy,
normalising weekends, transport, rehab etc to ensure optimal discharge timing achieved
FACTORS AFFECTING L.O.S
Early MOBILISATION:
Mobilise day of surgery – this includes sitting on the side of the bed /
standing by the bed or walking around the bed
Commence with 1 session PT on day of surgery, increasing to 3 sessions PT
on subsequent days
Advantages:
Reduced risk of DVT’s and PE’s
reduced risk of respiratory and GIT complications
Quicker recovery by patients and able to progress to a rehab program
sooner
Potential shorter length of stay
Cost savings
FACTORS AFFECTING L.O.S
ANAESTHESIA OPTIONS :
Use of spinal anaesthetic with or without regional and / or sedation for total
joint replacement rather than general anaesthetic
Use of brachial plexus blocks for upper limb procedures
Advantages:
Less time under general anaesthesia (risks) minimised effects on heart/lung
GIT tract/brain. Less fluid retention likely
Much earlier mobilisation possible on day of surgery
Reduced chance of DVT/PE
Quicker recovery
Shorter length of stay
Cost savings as less resources used
Higher throughput opportunities from increased bed capacity
Better pain management post-op
Disadvantages
Anaesthetist needs to be comfortable with the approach
FACTORS AFFECTING L.O.S
CLINICAL PATHWAYS:
Advantages:
Particularly suited to higher volume procedures
Allows standardisation and resulting efficiencies
Reduced variation
Potential higher patient satisfaction as care team offer consistency of
service
Potential shorter length of stay
Cost savings
Disadvantages
Doctors may not feel it allows individual approach for patient
FACTORS AFFECTING L.O.S
REHABILITATION:
Advantages:
Faster attainment of short term functional goals / milestones
Access to an individualised program
Higher mean Functional Independence Measures (FIM) in shorter time periods
Shorter LOS in the acute and rehabilitation facilities
Disadvantages:
Access to external rehabilitation facilities may be delayed due to bed
availability
May not be able to be followed by other specialists (ie: cardiologists)
FACTORS AFFECTING L.O.S
PAIN MANAGEMENT:
Advantages:
 Oral pain relief enables mobilisation without causing drowsiness
 Able to be specified to individual needs
 Oral medication is less invasive and makes mobilisation easier (ie: no IV poles
or lines)
Disadvantages:
 One protocol does not suit all patients
 Oral medication takes longer to reach “peak” dosage
 Needs to be monitored and tailored off
FACTORS AFFECTING L.O.S
EDUCATION:
Advantages:
 Ensures patient and family are adequately prepared for hospitalisation and
discharge expectations
 More likely to achieve expected post-operative goals and avoid delays
 Education on return to activities of living following hospital discharge
 Ensures safety whilst hospitalised and on return home following discharge (ie:
falls prevention)
Disadvantages:
 Lack of information may increase the LOS due to lack of preparedness
by both patient and family
 Education time requirements directly impact patient treatment time –
if not done pre-admission
 Additional cost
FACTORS AFFECTING L.O.S
PRE OP CLASSES:
Advantages:
 Patient undergoing a Pre-hab program will have improved muscle
strengthening and range of motion
 Functional level post-operatively is greater – early return to activity
General cardiovascular condition may be greater
Disadvantages:
 Cost
FACTORS AFFECTING L.O.S
DVT/PE SCREENING:
Risk Assessment to efficiently target patients most in need
Use of mobile dopplers rather than transfer to a lab should be assessed
Advantages:
 Need for screening could be reduced through the use of mechanical
compression devices, compression stockings, early mobilisation and anticoagulant therapy
 Allows for diagnosis and treatment
Disadvantages:
 Shown not to be useful until after Day 3 however many facilities have
discharge early than this
 Diagnosis may require intervention which potentially may impact LOS
 Additional costs of screening and transport
Key differences in current operations
utilised affecting LOS
Hospital for Special Surgery (USA) offers the most types of rehabilitation inpatient acute and subacute rehabilitation facilities,
intensive rehabilitation and
standard home rehabilitation programs,
outpatient physical therapy and
home with no services needed
Pre-admissions –
Most completed over the telephone
The Mater (Aust) provides 90% face to face
Pain Medication –
Most used a mix of oral and IV type medication
Hospital for Special Surgery (USA) focuses on medication that provides
minimum sedation, minimum weakness
Day/Month/Year
Footnote to go here
Page 19
Key differences in current operations
utilised affecting LOS (cont.)
Anaesthetic ProtocolsMost hospitals responded by stating that this was dependant on the type of
surgery
The Mater (Aust) stated that sedation is rarely used
The Hospital for Special Surgery (USA) stated that only regional anaesthetic
is used as much as possible
Day/Month/Year
Footnote to go here
Page 20
General discussion and questions