What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

During the Covid-19 pandemic, critical care capacity expanded to manage the increase demand on the service. Additional capacity was created by using theatre recovery and other areas to develop satellite ITU pods. Operating department practitioners and ward nursing staff worked across these sites to deliver care to the range of patients in support of the existing ITU workforce. Upskilling of practitioners has provided a flexible workforce and has improved interdepartmental understanding and teamwork. Critical care bed occupancy remains high with reduced capacity for elective surgical workload as we face further COVID-19 surges. Complex orthopaedic patients are currently admitted to critical care and are at risk of cancellation. Many of these patients do not require advanced organ support and could be treated on an orthopaedic enhanced care unit. This would enable surgery to continue despite high demand for ICU beds. A perioperative nurse practitioner would enable this transition to take place.

What does your project aim to achieve?

The project aims to deliver a ward based enhanced care area for patients undergoing complex orthopaedic surgery to avoid cancellation due to lack of ITU bed. There is a significant backlog of patients on the waiting list with some patients waiting for a considerable amount of time for their operation. Delay in surgery negatively impacts on quality of life and places additional demands on support services. The target population includes higher risk patients whose physical health deteriorates due to lack of mobility making perioperative care more challenging. The additional enhanced care capacity would reduce cancellation rate, maintain skill levels amongst practitioners and optimise post operative care. The provision of a dedicated perioperative practitioner would facilitate set up, deliver consistent and safe clinical care and enhance ward staff training. Key preoperative and postoperative data would be collected along with cancellation rate and any patient safety events.

How will the project be delivered?

Following discussion in the Orthopaedic Big Room (Flow Coaching Academy), a multidisciplinary group including clinical and managerial representatives from orthopaedics, critical care and anaesthetics met to review the project. The meeting was very positive and key concepts were discussed including appropriate case mix, medical and nursing staffing, equipment, guidelines, escalation and de-escalation policies. A change in practice creates an inevitable degree of uncertainty and patient safety is of paramount importance to the group. Considerable focus has been placed on the deteriorating patient and how this situation would be managed. A structured review process headed by a perioperative nurse practitioner would provide reassurance and consistency to the unit and assist with the development of a cohesive multidisciplinary team. The overall cost of the enhanced care area would be balanced by savings generated by avoiding short notice cancellations and facilitating surgery to reduce the demand on support services.

How is your project going to share learning?

The learning gained from the project would be widely shared. In addition to the Q community, the project details would be presented regionally and nationally via the Centre for Perioperative Care (CPOC). The various phases of the project would be broken down and made accessible along with quality and business related outcome data. External teams would be encouraged to make contact with the Trust for further information. There is national need (NHSI/CPOC) to develop surgical and specific orthopaedic postoperative enhanced care units and knowledge gained would assist with the set up of similar units. The concept of the enhanced care unit at Portsmouth was developed in the Orthopaedic Big Room and the methodology used to implement change is shared with the Flow Coaching Academy.