Benefits of a pathway: The experience of utilizing a NOF pathway. Megan Yeomans Clinical Nurse Consultant Pain Team, Austin Health

Transcription

1 Benefits of a pathway: The experience of utilizing a NOF pathway Megan Yeomans Clinical Nurse Consultant Pain Team, Austin Health

2 Our health service # NOF Presentations : : 246

3 Management of a # NOF Patient surgery-focused approach Patient fits in with: a rigid system not a patient focused approach resulting in a poorer outcome for patient

4 Management of a # NOF Patient surgery-focused approach Patient arrives in ED: XRs show #NOF Patient fasted, given some morphine Page Ortho Reg 11am.No Answer Page Ortho Reg 1:30pm Nurse from theatre answers That registrar isnt on call, not sure who is Ring switch right reg now paged reg rings ED

5 Management of a # NOF Patient surgery-focused approach ED Got a NOF for you Ortho Reg What s the UR?.looks up XR on computer OK, Keep her fasted

6 Management of a # NOF Patient surgery-focused approach 8pm.10pm Midnight..2am

7 Management of a # NOF Patient surgery-focused approach Theatre Nurse Are you going to get to that NOF tonight? Ortho Reg (scrubbed) Hmmm, probably not, it s getting a bit late Let s put her on for tomorrow night Theatre Nurse Make sure you ring the ward to let them know Ortho Reg (scrubbed) OK

8 Management of a # NOF Patient surgery-focused approach 1 hour later..ward Nurse rings Ortho Reg» Are you doing that NOF tonight??... Ortho Reg»Oh sorry.. No, feed her and fast her from early breakfast!

9 Management of a # NOF Patient surgery-focused approach Overnight Ward nurse feeds patient & calls the resident Overnight Resident Looks at ED notes to write admission 2.5mg morphine SC 4 hourly written up

10 Management of a # NOF Patient surgery-focused approach Next Day Patient Delirious so morphine ceased Fasted all day Operation bumped again next night

11 Management of a # NOF Patient surgery-focused approach 3 rd Day Patient Delirium worsens Operation goes ahead that night

12 Management of a # NOF Patient surgery-focused approach 4 th Day Patient Severe Delirium with aggression Patient shackled

13 Management of a # NOF Patient surgery-focused approach 5 th Day Patient Patient remains delirious Patient noted to be hypoxic Bloods checked- patient anaemic CXR- Pneumonia

14 Management of a # NOF Patient surgery-focused approach 2 weeks later Patient Delirium seems to have settled Family still say she is not quite right Now medically stable enough for transfer to rehab

15 Objectives of this presentation To tell our story of why this project was initiated The diagnostic process What we learned The value of an organizational collaborative effort Designing and implementing a pain management plan Results and Ongoing Improvements

16 Information we were given Health Round Table Information DRG 108- Neck of Femur Fracture Austin Health had an average LOS >14 days The four exemplar hospitals average LOS around 8 days Aim Reduce Length of Stay to that of exemplar hospitals

17 Background Visit to another facility and a literature search revealed we needed: 1. Full time Head Of Orthopaedic Unit implemented Sept More theatre sessions and better access for trauma implemented over Institute ortho-geriatric service commenced February 2010

18 Orthogeriatric Service New full-time Orthogeriatric registrar Over seen by a senior geriatrician Involved in every patient >65yo with low-impact trauma # Cross-campus consultant-led 2x/week ward rounds Ortho in Rehab hospital Geriatric in Acute hospital

19 Move toward a patient centred approach The patients needs have redesigned the management of this injury and led to the implementation of a clinical pathway by: Considering the patient experience Improving communication Improving system issues Tailoring pain management to the patients individual needs

20 Top down commitment Attendance List List Executive- CEO, CMO, Executive Directors CSU/ Medical Directors Senior Clinical Staff- ED, Anaesthetists, Orthopedics Geriatricians Austin By Design Physiotherapy Access, Care & Patient Flow coordinators Ward NUM Liaison nurses Theatre staff and more

21 Review process- How are we managing these patients? File audit- 30 patient files Interview with patients and their families Walk Through Follow the patient journey from the front door to discharge. Chance for two way communication and to understand work flows» What works» What doesn t

22 Where we focused Time to theatre Fasting Pain management Delirium

23 Pain with # NOF Before and After Surgery Pre operative: 44% pre op Post operative: 42% severe pain (cog intact) Morrison et al 2000 J Pain Sympt Mgt

24 How much pain?- identified in the patient files The pain scores were overall poorly documented. Often comments were made by the physios and nurses in the clinical notes about the patient experiencing severe pain, anxiety, confusion and being tearful ; this was often not evident when compared with the pain scores if they were documented.

25 We focused on three main areas Three main areas ED Pre operatively Post operatively

26 The Three Main Areas- ED Before No Standard Pain-relief Mostly narcotic-based Minimal use of blocks (<10%) No review of analgesia efficacy Multiple trips to Radiology (Hip & Chest) Gap from ED until drug chart written up (on ward)

27 The Three Main Areas- Pre op on the ward Admitted to the ward at various times of the day. Orthopaedic staff in theatre so charts not done Usually inadequate doses Intermittent/ infrequent doses Variable pain relief/not standard Fasted for varying lengths of time Analgesia usually ceased if patient became confused

28 The Three Main Areas- Theatre Patients arrived at various times Often an adhoc approach to pain management

29 Pre implementation Pre implementation

30 The next day

31 Three main areas: Post operative Before No Standard Pain-relief PRN-Basis Usually no maintenance medications No formal review of analgesia efficacy Opioids ceased if patient became confused Patients not able to participate in physio due to pain.

32 Implementation of clinical pathway

33 Developed an integrated Clinical Pathway

34 ED Now Regular Paracetamol 1g TDS in elderly (Oral) Incremental boluses of Fentanyl to effect (or Morphine) Regular pain scores on function Fascia Iliaca Blocks done in >80% of patients Single xrays Chest and Hip ordered as a package.

35 Post implementation Post implementation

36 The Ward Now Care Pathway Pain Plan Hunger clocks High protein Supplements Delirium screening Cognitive Assessment Method Orthogeriatricians now educated and adopting similar analgesic prescribing for other patient groups

37 0-6 hours Appropriate length of fasting time 6-9 hours Confirm theatre time with theatre staff and ortho reg 12 hours Definitive plan required, call ortho reg feed patient if surgery is not imminent

38 CONFUSION ASSESSMENT METHOD (CAM) adapted from Inouye SK, et al. Ann Intern med. 1990;113:941-8 A A - ACUTE ONSET AND FLUCTUATING COURSE Is there an acute change in mental status from the patient s baseline? Does the persons behaviour fluctuate during the day (come and go) or increase and decrease in severity? B B - INATTENTION Does the patient have difficulty focusing their attention, for example, being easily distracted or having difficulty keeping track of what is being said? C D C - DISORGANISED THINKING Is the patient s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from one subject to another? Delirium D - ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate the patient s level of consciousness? -- Vigilant (hyperalert) -- Lethargic (drowsy, easily aroused) -- Stupor (difficult to arouse) -- Coma (unarousable) Delirium = A+B (2points) A+B+C (3points) A+B+D (3points) A+B+C+D (4 points) Salliece Byford. CNS. Austin Health.

39 Delirium

40 Pain Pathway Delirium

41 Post Operative Now Patient controlled analgesia: If patient cognitively intact, PCA mode +/- continuous infusion If patient cognitively impaired, a continuous Both have clinician boluses to be given prior to movement. Nurses are already familiar with PCA Monitor regularly Pain at Rest Pain on Activity Sedation Score CAM (Delirium) Score

42 Pain Care Plan Guidance is given to PCA orders Step down analgesia Monitoring guidance Reassessment prompts

43 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May 2009-March Average Length of Stay (HRT Data) Pain Plan Starts 10 Days Project starts Exemplars A H 2 0

44 Top down commitment Attendance List List Executive- CEO, CMO, Executive Directors CSU/ Medical Directors Senior Clinical Staff- ED, Anaesthetists, Orthopedics Geriatricians Austin By Design Physiotherapy Access, Care & Patient Flow coordinators Ward NUM Liaison nurses Theatre staff and more Pain services asked to optimise analgesia 18months later

45 Pain DOES matter! Post-operative pain is associated with: increased hospital length of stay; delayed ambulation and long-term functional impairment (Morrison 2003)

46 Acknowledgements to: Fiona Nielsen: Quality Coordinator Surgical Clinical Services Unit Andrew Hardidge: Director of Orthopaedic Surgery Jane Trinca: Director of Acute Pain Service Ward 8N: Pain Champions

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