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Lisk R, Yeong K, Fluck D, Robin J, Fry CH, Han TS. An orthogeriatric service can reduce prolonged hospital length of stay in hospital for older adults admitted with hip fractures: a monocentric study. Aging Clin Exp Res 2023; 35:3137-3146. [PMID: 37962765 PMCID: PMC10721690 DOI: 10.1007/s40520-023-02616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The Blue Book (2005), recommended guidelines for patients care with fragility fractures. Together with introduction of a National Hip Fracture Database Audit and Best Practice Tariff model to financially incentivise hospitals by payment of a supplement for patients whose care satisfied six clinical standards), have improved hip fracture after-care. However, there is a lack of data-driven evidence to support its effectiveness. We aimed to verify the impact of an orthogeriatric service on hospital length of stay (LOS)-duration from admission to discharge. METHODS We conducted a repeated cross-sectional study over a 10 year period of older individuals aged ≥ 60 years admitted with hip fractures to a hospital. RESULTS Altogether 2798 patients, 741 men and 2057 women (respective mean ages; 80.5 ± 10.6 and 83.2 ± 8.9 years) were admitted from their own homes with a hip fracture and survived to discharge. Compared to 2009-2014, LOS during 2015-2019, when the orthogeriatric service was fully implemented, was shorter for all discharge destinations: 10.4 vs 17.5 days (P < 0.001). Each discharge destination showed reductions: back to own homes, 9.7 vs 17.7 days (P < 0.001); to rehabilitation units: 10.8 vs 13.1 days (P < 0.001); to residential care: 15.4 vs 26.2 days (P = 0.001); or nursing care, 24.4 vs 53.1 days (P < 0.001). During 2009-2014, the risk of staying > 3 weeks in hospital was greater by six-fold and pressure ulcers by three-fold. The number of bed days for every thousand patients per year was also shortened during 2015-2019 by: 1665 days for discharge back to own homes; 469 days with transfer to rehabilitation units; 1258 days for discharge to residential care, and 5465 days to nursing care. Estimated annual savings (2017 costs) per thousand patients after complete establishment of the service was about £2.7 m. CONCLUSIONS Implementation of an orthogeriatric service generated significant reductions in hospital LOS for all patients, with associated cost-savings, especially for those discharged to nursing care.
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Affiliation(s)
- Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Christopher Henry Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD, UK
| | - Thang Sieu Han
- Department of Endocrinology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK.
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK.
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The First Modified Delphi Consensus-Building Exercise on Surgical Ward Rounds in the United Kingdom National Health Service. World J Surg 2023; 47:1348-1357. [PMID: 36811667 DOI: 10.1007/s00268-023-06945-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The ward round is an integral part of everyday surgical practice. It is a complex clinical activity that requires both sound clinical management and communication skills. This study reports the results of a consensus-building exercise on the common aspects of the general surgical ward rounds. METHODS The consensus-building committee involving a range of stakeholders from 16 United Kingdom (UK) National Health Service trusts took part in this consensus exercise. The members discussed and suggested a series of statements concerning surgical ward round. An agreement of ≥ 70% among members was regarded as a consensus. RESULTS Thirty-two members voted on 60 statements. There was a consensus on fifty-nine statements after the first round of voting, and one statement was modified before it reached consensus in the second round. The statements covered nine sections: a preparation phase, team allocation, multidisciplinary approach to the ward round, structure of the round, teaching considerations, confidentiality and privacy, documentation, post-round arrangements, and weekend round. There was a consensus on spending time to prepare for the round, a consultant-led round, involvement of the nursing staff, an MDT round at the beginning and end of the week, a minimum of 5 min allocated to each patient, utilisation of a round checklist, afternoon virtual round, and a clear handover and plan for the weekend. CONCLUSION The consensus committee achieved agreement on several aspects concerning the surgical ward rounds in the UK NHS. This should help improve the care of surgical patients in the UK.
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Fluck B, Yeong K, Lisk R, Watters H, Robin J, Fluck D, Fry CH, Han TS. Changes in Characteristics and Outcomes of Patients Undergoing Surgery for Hip Fractures Following the Initiation of Orthogeriatric Service: Temporal Trend Analysis. Calcif Tissue Int 2022; 110:185-195. [PMID: 34448887 PMCID: PMC8784364 DOI: 10.1007/s00223-021-00906-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
The Blue Book published by the British Orthopaedic Association and British Geriatrics Society, together with the introduction of National Hip Fracture Database Audit and Best Practice Tariff, have been influential in improving hip fracture care. We examined ten-year (2009-2019) changes in hip fracture outcomes after establishing an orthogeriatric service based on these initiatives, in 1081 men and 2891 women (mean age = 83.5 ± 9.1 years). Temporal trends in the annual percentage change (APC) of outcomes were identified using the Joinpoint Regression Program v4.7.0.0. The proportions of patients operated beyond 36 h of admission fell sharply during the first two years: APC = - 53.7% (95% CI - 68.3, - 5.2, P = 0.003), followed by a small rise thereafter: APC = 5.8% (95% CI 0.5, 11.3, P = 0.036). Hip surgery increased progressively in patients > 90 years old: APC = 3.3 (95% CI 1.0, 5.8, P = 0.011) and those with American Society of Anaesthesiologists grade ≥ 3: APC = 12.4 (95% CI 8.8, 16.1, P < 0.001). There was a significant decline in pressure ulcers amongst patients < 90 years old: APC = - 17.9 (95% CI - 32.7, 0.0, P = 0.050) and also a significant decline in mortality amongst those > 90 years old: APC = - 7.1 (95% CI - 12.6, - 1.3, P = 0.024). Prolonged length of stay (> 23 days) declined from 2013: APC = - 24.6% (95% CI - 31.2, - 17.4, P < 0.001). New discharge to nursing care declined moderately over 2009-2016 (APC = - 10.6, 95% CI - 17.2, - 2.7, P = 0.017) and sharply thereafter (APC = - 47.5%, 95%CI - 71.7, - 2.7, P = 0.043). The rate of patients returning home was decreasing (APC = - 2.9, 95% CI - 5.1, - 0.7, P = 0.016), whilst new discharge to rehabilitation was increasing (APC = 8.4, 95% CI 4.0, 13.0; P = 0.002). In conclusion, the establishment of an orthogeriatric service was associated with a reduction of elapsed time to hip surgery, a progressive increase in surgery carried out on high-risk adults and a decline in adverse outcomes.
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Affiliation(s)
- Ben Fluck
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Hazel Watters
- Department of Orthogeriatrics, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK.
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Carpenter A, Vora SM, Kestenbaum S, Thompson A, Devine M, Tenison E, Quicke E, Liang K, Deibel F. Afternoon ward rounds: bad for patients, bad for doctors? Future Healthc J 2019; 6:118-122. [PMID: 31363518 PMCID: PMC6616176 DOI: 10.7861/futurehosp.6-2-118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hospital medicine in the UK is under unprecedented pressure, with increasing demand on physicians as well as challenges in recruiting new doctors into the physicianly specialties. We sought to assess the prevalence of the afternoon ward round and its effect on those undertaking them. We sampled each hospital within our postgraduate region, surveying junior doctors working on inpatient medical wards. We surveyed roughly two-thirds of eligible doctors, -finding that 30% of juniors had some commitment, of varying frequency, to ward rounds beginning after 1.00pm. Of the -doctors involved in afternoon ward rounds, the majority felt they contributed to late finishes, delayed discharge of -patients, reduced team efficiency and reduced job -satisfaction. Just under 80% felt they were less likely to consider a career in hospital medicine as a result The afternoon ward round lives on, and we should not -underestimate its effect. Low junior doctor morale coupled with high work intensity can lead to burnout as well as -impairing the effectiveness of the clinical service. Clinical -leaders should consider leaving this practice in the past so we can cope with the challenges of the future.
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