An opportunity to hear how service redesign positively impacts on the patient experience and improves outcomes for both the patient and NHSScotland. Showcasing examples of changes to pathways of care in orthopaedics and community support for people with complex and chronic conditions.

1. Session 2.8: Putting the patient at the heart of the pathway

2. NHS Board Examples: Enhanced Recovery for patients undergoing hip and knee surgery – NHS Borders and Tayside Anticipatory Care Planning – NHS Forth Valley

3. Enhanced Recovery What is it? "What does enhanced recovery have to offer patients and the NHS? In simple terms it does two things. It improves quality of care by helping patients to get better sooner after major surgery. Secondly it reduces length of stay with obvious benefits to the NHS" Professor Sir Mike Richards Enhanced Recovery Partnership Programme Department of Health

4. Implementing Enhanced Recovery in Orthopaedics A Mehdi, A Todd, D Sommerville, J Antrobus, K Lakie, N Leary Borders General Hospital, Melrose

5. SUB HEADING Traditional Approaches

6. SUB HEADING Established Practices

7. Patient Journey - Pre-assessment - Admission - Perioperative Care - Length of Stay - Post – Discharge - Overall Satisfaction

8. Pre-assessment - Duplication of info - No clear guidelines for Arthroplasty patients - Variation - Patients passive partners

9. Admission - 100% day before surgery admission - Anaesthetic review at admission - 20% cancellation - Mixed nursing

10. Ward to Theatre - Pre -LEAN theatres 52 mins - Post – LEAN theatres 46 mins - Inconsistent skills of surgical assistant - 1 anaesthetist per list

11. Perioperative Care 100% Urinary catheterisation 100% HDU post op Medical Complications 0% mobilised day of surgery 40% of arthroplasty patients received a blood transfusion No standard DVT prophylaxis No local data collection/audit

14. The Team

16. - Draft pre-admission ICP - Management of patients expectations – CALEDONIAN TECH - Designated Anaesthetist at clinic Means of Change - Review of patient information booklet – Passport to Care - Anaesthetic assessment in pre-assessment clinic

17. Cascading

18. - Ward Nurse- direct bleep to theatre - Standardised anaesthetic protocol - Post op management guidelines implemented on Ward including ward doctors and HAN Means of Change

19. Pre-assessment Anaesthetic rotas revised to fit pre-assessment clinic Introduction of Hip and Knee school Patients proactive partners

20. Admission - 75% patients admitted on day of surgery

21. Cancellations

22. - 12 ring fenced beds - Dedicated arthroplasty ward nurses - Consistent pathway approach Ward to Theatre

23. - Positive patient feedback for transfer process - ERAS LEAN theatres 34mins Ward to Theatre - Over 90% of patients walk to theatre - Transfer to trolley in the Anaesthetic room - Single patient handover

24. Perioperative Care - 5% patients catheterised - 92% patients mobilised on day of surgery - 5% blood transfusions (Hb- 7.8-8.7) - VTE prophylaxis protocol - Audit database- opiate reduction- Excellent pain scores- 90%

26. Length of Stay Median Length of Stay- 3 days (Ave-3.9 days)

27. Lowest MLoS of all Boards in Scotland - 3 DAYS Length of Stay

28. Overall Satisfaction “ All the Medical and Nursing staff have been excellent. The new procedures being put in place with regard to patient recovery are also excellent. The literature given to me prior to admission is first class Mr T S (JEP) “ I had a hip replacement to my left hip 2 years ago and was in for 6 days. I found the treatment much improved. The pain relief much better and mobility much quicker. Treatment was excellent” Mrs E McK ( MMS ) “ Having experienced my first hip 17 months ago this 2 nd experience on “assisted recovery” has been marvellous. Being awake during the operation was (surprisingly!) a great experience I was not sick (as was last time) and it was so good to get up out of bed and mobilise on the same day. NO CATHETER this time was a bonus. All staff very communicative and attentive at all times. Going home after 2 days will also enhance my recovery as I know I will sleep better!” Mrs EC ( CHT )

29. Borders Enhanced Recovery Project Summary - Big Challenge - Better Preassessment - More activity/ less cancellations - Medicalisation /intervention almost eliminated - Excellent pain relief - MLoS 3 days - Better patient journey - Massive savings?

35. Anticipatory Care Planning What is it? Anticipatory care planning is applied to support those living with a long term condition to plan for an expected change in health or social status. It also incorporates health improvement and staying well. In practical terms it is about adopting a “thinking ahead” philosophy of care that allows practitioners and their teams to work with people and those close to them to set and achieve common goals that will ensure the right thing, being done at the right time by the right person(s) with the right outcome.

36. Stuart Cumming August 2011 Managing Complexity in the Community Anticipatory Care Planning

39. The exception or the norm…?

43. Shift the Balance in a considered way Not always straightforward but it can be done if planned

56. Other pieces of work….

57. Falls Pathways Polypharmacy Whole System Working - Patient journeys Facilitated Self Management Effective Information Sharing

58. Supporting People with Long Term Conditions to Self Manage The Self Care Toolkit My Support Plan

60. Working Smarter with Electronic Communication GP /DN Consultation ECS / ePCS / KIS GP OOH Service Patient Electronic Clinical Record Hospice A+E, CAU SRI SAS

62. Thank you