Leading change

The senior matron in the surgical division at Chesterfield Royal Hospital NHS Foundation Trust led on the redesign of clinical pathways for patients having elective orthopaedic arthroplasty procedures. The new pathways have resulted in improved outcomes, experiences and use of resources across the surgical division.

Where to look

The ward matron identified unwarranted variation in the care of arthroplasty patients between the hospital wards and teams for both pre-and post-operative patients. Specifically, the ward matron noted the Trust had a higher incidence of patients remaining in hospital post-operation for up to 6-7 days, whilst best practice guidance suggests this should be 3-5 days. Early mobilisation supports early recovery and reduces risks of complications.

What to change

The surgical directorate at Chesterfield Royal Hospital NHS Foundation Trust provides a range of outpatient and inpatient services including the provision of 96 surgical beds and a day surgery suite. The surgical ward matron and therapy lead identified through auditing patient outcomes, patient flow on the wards and length of stay data that:

• There were delays in referrals for a pre-operative ortho-geriatrician assessment, which at times led to on-the-day cancellations of operations and often longer lengths of stay.
• Some patients were developing confusion post-operatively. Within existing clinical pathways there was no pre-emptive clinical treatment plan in place to support this change in care needs. This could be both distressing for patients and families, but also could have resource implications such as the need for enhanced observations to prevent the person from falling.
• Quality enhanced supervision for these principles needed standardising.
• There was a need to promote a culture of rehabilitation earlier in surgical pathways. As soon as a patient returns from theatre, they can be supported to regain their independence.

How to change

The ward matron visited other hospitals where effective clinical pathways were already in place to identify learning opportunities and to formulate plans for Chesterfield Hospital. An audit of current practice at Chesterfield was conducted to highlight areas of compliance with evidence based practice and where opportunities for development were. The agreed programme in the surgical directorate included:

• The introduction of an arthroplasty nurse role: offering support and practical advice to arthroplasty patients before surgery and supporting staff to complete pre- and post-operative care plans and assessments for each patient. The nurse also supported longer term care planning with referrals to the ortho-geriatrician and social care services when support needs were identified.
• The introduction of a consultant and patient agreed expected discharge date for all patients at the point of assessment (Discharge to Assess model).
• Training provision for senior ward staff and therapy instructors so that they were skilled to initiate the patient’s first physiotherapy session, early in post-operative care, to support a quicker recovery.
• Raise awareness of the evidence base for actively promoting safe patient mobilisation post-operatively.
• Reviewing general patient information and advice.
• Developing clinical pathways for orthopaedic arthroplasty patients.
• Establishing a culture of positively supported rehabilitation across all departments supporting orthopaedic arthroplasty patients.

Adding value

Better outcomes – In 12 months, the average length of stay for arthroplasty patients has reduced by 1.2 days. This suggests that patients are better prepared for their operations, are receiving better therapeutic care post-operation and are returning to their baseline quicker. Consequentially, the flow of elective patients through the system. An increased number of patients are being reviewed pre-operatively by the ortho-geriatrician because of the new pathways which enhances operative and post-operative planning, providing clear care/treatment plans tailored to the patient’s needs and informing nursing and physiotherapy staff of these needs. Staff are also now better equipped to identify patients at risk of developing post-operative delirium and put plans in place to reduce and manage these symptoms accordingly.

Better experience – Patients have expressed feeling well prepared for their surgery, suggesting the new pathways and services are being implemented successfully.

Better use of resources – Fewer patients have needed enhanced supervision since the redesigned pathways have been implemented. Their pre-operative planning and care/treatment plans have supported the nursing staff to re-allocate time resources. This may have associated reductions in cost to the ward for additional staffing. Due to thorough pre-operative planning, the number of on-the-day cancellations has also been reduced significantly which is having a positive impact on experiences as well as waiting list times.

Challenges and lessons learnt for implementation

A multi-disciplinary approach to addressing the variation has been key to success.

Pre-operative preparation is essential to improving outcomes. The delirium assessments and plans have been invaluable and staff knowledge has vastly improved in this area.

Find out more

For more information contact:

• Andrea Staley, Divisional Head of Nursing for Surgery, Chesterfield Hospital NHS Foundation Trust, andreastaley@nhs.net