Restricted Weight Bearing In

Orthopaedics

Megan White

Orthopaedic CNC, Concord Hospital

ANZONA President

Background

Ageing population

– Increased fragility fractures

– Common sites for fragility fractures include:

– Hip fractures

– Upper limb – humerus / wrist

– Lower limb – ankle fractures

– Periprosthetic fractures

– Clinical redesign project

– Patient Stories

– Extended LOS

– Bed blockage

– Limited subacute care

Diagnostics

Case for change:

In 2013/14 there were 4686 bed days occupied by RWB

patients leading to $4,686,000

4686 bed days – loss of 6 acute beds

Increased length of stay

Deconditioning

Reduced patient satisfaction

Patients Voice

I can’t believe how

easy it was to fall.. I

was playing Tennis,

now I just can’t

coordinate myself to

walk.. I was fit before

this fall

Staff Voice

Nurses slide

Medical / Surgical slide

Rehabilitation Consultant

Orthogeriatrician Consultant

Occupational Therapy

Social Worker

Physiotherapists

Nurses Interview What we do well Issues Do Better

Pressure area

care

Time consuming (full care) Psychological support

Nursing care Occupying acute bed –

increased outliers

Communication – be upfront

about LOS

Medical- brief interactions with

family and pt

Ortho team no set method of

communicating with NOK

Patient flow

Single rooms

Nursing handover – reduced

interaction

Institutionalised

Pain relief Diversional therapy

Constipation Better access to TCU / other

facilities

Deconditioning Specific accurate information

(written)

Suboptimal Model of care

(needs of pt)

Allied health – reduced physio

due to increase in elective and

increased needs

Need different approach to

acute beds

Mentality

Don't Restrict My Ability

Medical Interviews – Junior / Registrar

Frustrating – Doing GP / subacute work

Time consuming – write notes each day / increase list of inpts

(busy position)

Not the right place for them

Guilt – blood tests/ investigations in case pt. deteriorates

Worry about HAI’s – our aim is preventative medicine

Communication – Reg (Ortho) to Reg(O/G) not Intern to

Orthogeri

Complex discharge planning

Difficulty understanding admission criteria to subacute

Junior / Reg – hesitant to approach Consultant

Older pts – GP ring for rpt BMD, OP, medication r/v

Ortho reg don’t understand complexity of pt Don't Restrict My Ability

Key Issues Identified

Poor Communication Processes

– Postoperative notes / RWB terminology

– Communication with patient/ family

Patient experience

– Deconditioning / Boredom

– Reduced interaction with health professionals

Delayed Discharge

– Variances in admission criteria to subacute care

The NEW Patient Journey

Brochure

The NEW Patient Journey

Agreed Terminology

Term Definition Walking Aid

Progression

Non

weight

bearing

(NWB)

No weight allowed

through the limb

PUF, WPUF, Crutches

Stairs - Crutches

Touch

weight

bearing

(TWB)

Toe to the ground,

walking on an egg

shell.

WPUF, PUF, Crutches

Stairs - Crutches

Partial

weight

bearing

(PWB)

50% of body weight

allowed through the

affected limb

WPUF, PUF,4WW,

Crutches

Stairs - Crutches

Protected

Weight

Bearing

Weight bear as

tolerated through

limb, always

supported by a

walking aid

WPUF, PUF, 4WW,

Crutches Stairs –

Railing

The NEW Patient Journey

Family Conference

Short term goals

– Goals tailored individually

Long term goals

Discharge Planning

The NEW Patient Journey

Reconditioning Program

Occupational therapist

– 3 times a week function

Physiotherapist

– Daily hourly exercise class

– Circuit style

Nurses

– Encourage Independence

– Encourage exercises

– FIM scores

Medical Staff

– Encourage patients to participate

Results to Date

Staff satisfaction and Teamwork (across health professionals)

Staff are engaged in promoting mobility ad function

Staff encourage patients to participate in daily exercise class

Staff assist patients to reach their goals

Patient experience

– Patients identifying goals and encouraged when they are met

– Interaction with health professionals have increased

Other benefits

improved communication with other LHDs with discharge planning

Function has become an important benefit for recovery

Results to date continued

100 patients registered (Ethics approved)

Variety of fractures at times 2 limbs

Improved FIM score – improved function (weekly)

Improved patient satisfaction

Adverse 9% - 0.5%

Reduced 14 days off av. LoS

Lessons learned during the Implementation

Phase

Open communication and regular update sustains project

Good data collection

– Evidence!! Evidence !!

Role-modeling

Importance of equal input to promote optimal outcomes for

patients

Launch of the Model of Care

Acknowledgements

Tim Sinclair

Breda Doyle

Dr Jai Sungaran Orthopaedic VMO

Dr Peter Walker – HOD Orthopaedics

Dr Nichola Boyle – Orthogeriatrician

Dr Veena Raykar - Rehabilitation consultant

Sharne Hogan – Director of nursing

Priya Nathan – Physiotherapist

Katie Balderi – Occupational therapist and the Occupational department

Dev – Social Worker

Nursing staff on Ward 6 North – led by Natalie Shiel, Melinda Pestana

Orthopaedic surgeons / Registrars and Interns

Elizabeth Bryan – Performance unit SLHD