Quality and Safety improvement in Total Joint Replacement service of Yan Chai Hospital Ms MAK Wai-ping Advanced Practice Nurse Yan Chai Hospital
Total Joint Replacement Centre Yan Chai Hospital The second Total Joint Replacement Centre in Hong Kong Services started in October 2011 18 total joint replacement beds Annual total joint replacement surgery: 500 cases
Total Joint Replacement Centre Yan Chai Hospital A one-stop multidisciplinary centre providing: Pre-admission service Surgery Comprehensive post-operative care Fast track rehabilitation programme
Total Joint Replacement Centre Yan Chai Hospital New initiatives have been adopted to achieve following objectives: To ensure quality services To enhance patients safety To shorten patients length of stay To increase patients satisfaction To increase staff satisfaction
Total Replacement Centre Yan Chai Hospital New initiatives: 1. A peri-operative blood management protocol for total joint replacement surgery 2. Multi-disciplinary Pre-admission Services
Total Joint Replacement Centre Yan Chai Hospital New initiative (1): A peri-operative blood management protocol for total joint replacement surgery
Blood Management Risks of blood transfusion include: Transmission of diseases Allergic reaction Fluid overload Bacterial infection Clerical error Increase length of stay Increase cost
Blood Management Previous studies: Pre-operative Haemoglobin (Hb) level is a major predictor of the risk of blood transfusion.
Blood Management Type & Screen (T&S) investigation needs advanced admission.
Blood Management Pre-operative measure: No T&S for Primary Unilateral Total Knee Replacement surgery if pre-operative Hb > 11gm/dl
Blood Management Intra-operative measures: Meticulous haemostasis Diathermy for dissection Low pressure drain / No drain
Blood Management Post-operative measure: Monitor Hb closely Blood would be cross-match and given only if post-operative Hb < 8gm/dl.
Results From 1 st October 31 st December 2011: Primary Unilateral Total Knee Replacement Received Blood Transfusion Blood Transfusion Rate 97 2 2.06% No increase in co-morbidities
Results Compared with literature: Chance of transfusion after Total Joint Replacement Pre-operative Hb Chance of transfusion <10g 90% 10-13.5g 40% - 60% >13.5g 15% - 25% Our result: Pre-operative Hb Transfusion rate 13.4g 9.09% (10 to 16.1g)
Total Replacement Centre Yan Chai Hospital New initiative (2): Multi-disciplinary Pre-admission Services
Multi-disciplinary Pre-admission Services A series of multi-disciplinary preadmission services are provided at out-patient setting.
Multi-disciplinary Pre-admission Services Orthopaedic Specialty Nurse: Patient Education
Multi-disciplinary Pre-admission Services Orthopaedic Specialty Nurse: Assessment Scoring
Multi-disciplinary Pre-admission Services Anaesthetist: Pre-operative assessment
Multi-disciplinary Pre-admission Services Orthopaedic Surgeon: Explain Operation Sign Consent
Multi-disciplinary Pre-admission Services Medical Social Worker Occupational Therapist Physiotherapist
Multi-disciplinary Pre-admission Services Medical Social Worker: Support Assistance
Multi-disciplinary Pre-admission Services Occupational Therapist: Home Visit Assistive Device
Multi-disciplinary Pre-admission Services Physiotherapist: Education Training
Results After implementation of multidisciplinary team approach: The average length of stay dropped from 15 to 9 days.
No. of Patients C e n t r e Length of Stay (Oct-Dec 2011) 35 30 25 20 15 10 5 0 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 >D14 Days
Results 97% of patients have expressed excellent or good satisfaction to the services.
Results Patients have found the education session very useful & well-illustrated. By clearing patients doubts, their anxiety levels were reduced.
Results Early communication between staff & patients allows: Build-up trust & rapport Early anticipation of potential discharge problems Home modification need Increase patients compliance
Results As a dedicated team, the morale and communication have also improved among all team members.
Staff Satisfaction Rate C e n t r e Staff Satisfaction Survey of Pre-Admission Services Team (April 2012) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Questions Strongly Disagree Disagree Agree Strongly Agree
Conclusions The low blood transfusion rate is very supportive for eliminating: The need for routine T&S Blood transfusion related complications
Conclusions Hospitalization cost Patient s length of stay Risk of potential error Patient safety Patient satisfaction
References Callaghan, J. J. & Spitzer, A. I. (2000). Blood management and patient specific transfusion options in Total Joint Replacement surgery. The Iowa Orthopaedic Journal, 20, 36-45. Ditmyer, M. M., Topp, R. & Pifer, M. (2002). Preparation for orthopaedic surgery. Orthopaedic Nursing, 21(5) September/October 43-54. Geier, K. (2000). Improving outcomes in elective orthopaedic surgery: A guide for nurses and total joint arthroplasty patients. Orthopaedic Nursing, 19(Suppl), 10-21.
References Mitchell, M.(2000). Nursing Intervention for preoperative anxiety. Nursing Standard, 14(37), 40-43. Wong, M. K., Lee, O. B., Ko, P. S. Leung, M. F., Lam, J. J. & Cheng, A. (2004). Preoperative haemoglobin level as a predictor for blood transfusion in elective Total Joint Replacement. Journal of Orthopaedic Surgery (Hong Kong), 8(1), 22-27.
Acknowledgement Dr WAI Y L (COS/O&T/YCH) Dr WONG Y C (CON/O&T/YCH) Dr LEE Q J (AC/O&T/YCH) Dr YEUNG S T (RS/O&T/YCH) Ms CHUNG Elsa (DOM/O&T/YCH)
Thank You!