What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

Problem:

80,000 people fracture their hip every year, which costs £1.9 billion and requires 1.8 million hospital bed days every year. Fracture rate is expected to double by 2050 leading to a crisis in emergency care.

Hip fractures have a Best Practice Tariff, with hospital and national outcomes recorded on the National Hip Fracture Database. Urgent and emergency NHS care is also measured against standards, which have recently changed (the 4 hour standard is replaced with other measures.)

Long stays in ED  can contribute to harm (REDUCE study Patel et al 2022) and delayed EAC. This can cause low morale in staff who may feel  their skills are not being utilised appropriately.

Change:

We aim to eliminate delays in  EAC  through system re-design. We will train the MDT to recognise NOF fractures, deliver nerve blocks, admit patients, and use Lean methods to bypass the standard flow.

Partnership:

An MDT (surgeons, orthogeriatricians, physiotherapist, nurse, patient)

What does your project aim to achieve?

• Reduce delays in accessing EAC for patients with acute neck of femur fractures (audit).
• Improve routine care processes (eg time to frailty assessment) – (audit)
• NHS staff feel there is a better use of their time and skills – interview)
• NHS staff feel the culture within the ED has improved and there is a collaborative commitment to the co-produced lean process – ( interview)

Staff training is needed to achieve these aims:

Nerve blocks – we costed a surgical registrar to train staff for 3 hours a week for 4 weeks – Staff need to be observed 5 times before they are signed off -On average 6 admissions a day = 1 person trained

The  surgeon and Physiotherapist delivering this work (research fellows) will be

• Supervised by a lean specialist (at no cost for 2 1/2 days per month for 3 months, then 6 half days over 6 months – extra supervision is available if needed)
• Bought out for 3 extra days to complete lean training (at no cost)

How will the project be delivered?

The emergency pathway for fractured NOF will be audited (3 months):

1. Acute frailty service offered to all patients with fractured NOF
2. Frailty assessment
3. Orthogeriatric review within 72 hours
4. Surgery within 36 hours 
5. Monitoring of vital signs

The Research Fellows will familiarise themselves with lean tools in ED

Interventions (3 months):
 
Defining value
Structured interviews with staff (10 minutes) to identify views on service redesign/best use of time/skills
Value stream mapping
Training of Advanced Nurse Practitioners to deliver nerve blocks and complete BPT checklist – a pinch point in moving patients to the ward
Creating flow
Evaluate direct admission to ward from ambulance and a dedicated area for Advanced Nurses to complete blocks
Establishing pull an admitting ward ‘pulls’ patients when a bed is free rather than waiting for ED to ask for a bed
Continuous improvement
Use PDSA cycles to improve 5 S’s of lean – eg reorganise storage areas for frailty assessment equipment

Re audit (3 months)

How is your project going to share learning?

·         Post updates via Q community forums

·         Attend Q events/webinars

·         Host a webinar on the project via the Trusts webinar series

·         Internal Trust newsletter/Trust patient and staff newspaper –  UHB connect

·         Discussion forums with well established UHB patient groups (eg clinical research ambassador group – CRAG) with help to discuss project progress with patients via the ARC WM PILAR network

·         Publish in BMJ Open Quality

·         Present at a relevant conference