Introduction

The Department of Health determined that, from April 2011, Trusts would not be paid for emergency readmissions within 30 days of discharge. The purpose of our project was to identify factors associated with such readmissions and implement plans for improvement.

Hip fractures are estimated to cost the NHS over £2 billion per year and, with an ageing society, this is likely to increase. Rehabilitation and discharge planning in this population can be met with significant delays and prolonged hospital stay leading to bed shortages for acute and elective admissions. Planning care for these patients relies on a multidisciplinary approach with allied healthcare providers. The number of hip fracture patients in our hospital averages between 450–500/annum, the second largest number in the North West. The current average length of stay for the hip fracture patients is 22.9 days.

We evaluated the impact and performance of a pilot early supported discharge service (ESD) for patients admitted with a hip fracture. The pilot period commenced 22 September 2014 for 3 months and included an initial phase to set up the service and supporting processes, followed by the recruitment of 20 patients during the pilot period. The length of stay and post-discharge care was reviewed.

The journey of 20 patients was evaluated. The length of stay was dramatically reduced from an average of 22.9 days to 8.8 days in patients on the ESD pathway. Family feedback showed excellent results with communication regarding the ESD pathway and relatives felt the ESD helped patients return home (100% positive feedback).

Prolonged recumbency adversely affects the long-term health of these patients leading to significant morbidity such as pressure sores, respiratory tract infections and loss of muscle mass leading to weakness. Mortality is also a significant risk for these patients. Longer hospital stays lead to disorientation, institutionalisation and loss of motivation. Enhancing self-efficacy has been shown to improve balance, confidence, independence and physical activity. This pilot has proven that the Fracture Neck of Femur ESD service can significantly reduce the length of hospital stay and also deliver excellent patient and family feedback. The benefits of patients with a lower length of stay, with effective rehabilitation in hospital and within the home, will provide significant benefits to the Wirral healthcare economy.

The purpose of this study was to measure the effect of the implementation of a LEAN continuous process improvement initiative on the waitlist in an ambulatory pediatric orthopaedic clinic. LEAN is a set of principles that guide organizational thinking and form a comprehensive approach to continuous process improvement. In 2016, our health centre began its journey towards becoming a LEAN organization. The health centre's Strategy and Performance portfolio collaborated with the Orthopaedic Clinic Team to facilitate a Value Stream Analysis, which mapped the clinic process from referral to discharge from care. This informed the plan for targeted improvement events designed to identify and reduce non-value added activity, while partnering with patients and families to share their experiences with care in the clinic. Improvement events included: In-Clinic Patient Flow; Scheduling Process Review; Standardized Triage Process; Clinician Schedule; 5-S Large Cast and Sample Exam Rooms; Booking Orthopedics Clinic; and Travelling and Remote Care. During each event, solutions were identified to improve the patient experience, access, and clinic flow. These solutions have been standardized, documented, and continuously monitored to identify additional improvement opportunities. Comparison of wait-list and percentage of new patients seen within target window was performed from August 2017 to December 2018. The LEAN initiative resulted in a 48% decrease in wait-list for new patients, which translated to an improvement from 39% to 70% of new patients seen within their target window. There was a 19% decrease in the 3400+ patient wait-list for follow-up appointments, an 85% reduction in follow-up patients waiting past their target date for an appointment, and the number of patients waiting over a year beyond their target appointment improved from over 300 patients to 0 patients. There was a 15% improvement in average length of clinic visit. Without the addition of new resources, the implementation of a LEAN continuous process improvement initiative improved the waitlist for new patients in an ambulatory pediatric orthopaedic clinic by almost 50%. Solutions identified and implemented through the LEAN process have contributed to unprecedented improvements in access to care. In fulfilling one of the LEAN theory principles to “pursue perfection”, the paediatric orthopaedic clinic team has embraced a culture of continuous improvement and continues to use LEAN tools such as daily huddles and visual management to monitor solutions and identify gaps

Introduction: Failure to meet rehabilitation targets after total knee replacement is the main reason for delayed discharge in our orthopaedic unit. Low haemoglobin levels are associated with increased length of stay possibly due to poor participation in physiotherapy and delayed attainment of the functional goals necessary for safe discharge. This report describes the rehabilitation of patients with post operative haemoglobin levels between 7.1–8g/dL and provides a comparison with individuals rehabilitating with much higher levels. Materials and Methods: Case notes of 64 primary total knee replacements over the period January – October 2007 (10 months) were reviewed in a comprehensive retrospective analysis. All aspects of care were standardised. Joint replacements were performed using recognised surgical techniques and implants. Patients were given access to a minimum of two physiotherapy sessions each day, 6 days a week. Typical gait re-education began with the delta rolator frame progressing to walking sticks, stair assessment and finally discharge. Care pathways, operative and medial notes were reviewed for postoperative haemoglobin levels, complications and achievement of functional physiotherapy targets. Results: 8 of 64 patients were found to have a postoperative haemoglobin level bellow 8g/dL (sample average 10.2g/dL). 3 of these patients underwent transfusion for levels bellow 7g/dL and were excluded from further analysis. 5 patients began rehabilitation with haemoglobin levels between 7.1–8g/dL. All 5 mobilised with the delta frame on post op day one, progressed to sticks between days two to four and managed a stairs assessment on postoperative days two to five with an average inpatient stay of six days. Conclusion: These gains were almost identical to the overall sample average suggesting that in isolation, haemoglobin levels between 7.1–8g/dL do not significantly impede postoperative rehabilitation. It would seem there is no justification for ‘top up’ transfusions to expedite rehabilitation after joint replacement surgery in this patient group