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Orthopaedic supportive discharge team, Ashford and St Peter's NHS Foundation Trust

Excellence in Patient Care Award 2017 – Lancet research award

The orthopaedic supportive discharge (OSD) team's research at Ashford and St Peter's NHS Foundation Trust looked into a common clinical problem: caring for patients with a fractured neck of femur. It tested an early supportive discharge strategy involving a multidisciplinary team in the hospital and in the community. 

Here the team offers advice on overcoming challenges and leading a successful research project.

What were your project’s key outcomes and successes and how has it improved care for patients?

Patients with a fractured neck of femur spend a significant amount of time in hospitals, recuperating after the acute event and undergoing rehabilitation. This model of care consumes a lot of resources, increases the risk of institutionalisation and may lead to hospital related harm.

The conclusions drawn from the project enabled cost effective and efficient improvement of care. Home to home discharge improved from 53.95% to 66.3% and length of stay for patients reduced from 21.5 days (pre-intervention) to 14.03 days (with the national average being 19.8%.) As a result, there was a significant reduction in the percentage of patients sent to the rehabilitation ward from 44.2% to 23.6%. As the OSD team also take a significant number of other orthopaedic patients this has allowed us to close 22 of our trust’s rehabilitation beds in July 2015. 

Who was involved?

Led by two consultant orthogeriatricians, the multidisciplinary team (MDT) is made up of a team leader, a physiotherapist, nurses, occupational therapists (OTs), therapy technicians and therapy assistants. Also involved were the director of musculoskeletal services, associate director of therapies and trauma coordinator.

How can others replicate your learning and successes?

  1. Ensure a realistic aim is set at the outset. Collect data on outcomes and complications from day one to help drive improvement.
  2. Start small and build the team up over time. This will be less of a financial risk from your trust.
  3. Set up easy access to medical advice or clinics from secondary care to provide a resource and a reference point for the team.
  4. Ensure other stakeholders eg GP and community providers are involved in the planning of the service.
  5. Seek patient feedback to help improve the service.

How did you overcome any challenges?

GP concerns

Some GPs had concerns that patients will be discharged prematurely into the community, resulting in increased workload associated with caring for 'secondary care patients in a primary care setting'. Engagement meetings were held with GP leads to provide information on the service and to clarify responsibilities. We set up fast track clinics to help reassure the GPs further. In the first year of service, GPs were only called out 17 times out of the 178 patients discharged with OSD.

Who, what and how much?

In setting up this service, we found it challenging to decide who should form part of the MDT, what their exact roles entail and how much this was going to cost. We did this using the improvement methodology, recruiting the core members (physio/nurse and OTs) initially and fine tuning it as we learnt more about the service we were delivering.

For instance, the team has upgraded their therapy assistants (TAs) from band 3 to band 4. Having two band 4 staff has helped to increase OSD capacity further as they were trained to work across professions. Patients could be now be discharged by band 4 using criteria-based discharge parameters instead of having to be signed off by one of the seniors. The TAs have been skilled up to manage post-op wounds and simple dressings, releasing  the band 6 nurse to review more complex wounds.

Productivity and efficiency

The team has increased their capacity by spending less time on the ward duplicating assessments, clustering their visits and reducing paper trails. We initially underestimated the role of the nurse in the team and have now recruited another band 6 and a part time band 6 nurse. 

Improving length of stay (LOS) further

Some patients could not be discharged safely as they have personal care needs. The OSD team now work closely with reablement and healthcare at home teams if patients require personal care. More recently, the OSD have started providing a once-a-day personal care service as part of the rehabilitation process, reducing our reliance on third party providers and further improving our LOS. We have also started doing PDSVs.

What does winning the Excellence in Patient Care Award mean for your project and your team?

Winning the award has enabled the trust executive team to value the service of the OSD team. It has also made our OSD team very popular, having further interest from regional trusts who are planning to visit us. We were also invited to present at the Regional South West Orthogeriatric Network meeting, which we did on 18 May.

The Excellence in Patient Care Awards 2018 will open later this summer.