The head of the Orthopaedic Surgery Department in Sydney’s Liverpool Hospital chose to investigate variation in management of hip fracture because it makes up a large part of the department’s activity, and it is a high-risk condition. Providing surgery within 48 hours of presentation if no clinical contraindication exists, and the patient prefers surgery, was identified as the first priority for attention because it improves clinical outcomes, and it is part of the Australian Clinical Care Standard for hip fracture. 

Addressing this issue also helps the hospital meet Action 1.7 of the NSQHS Governance Standard because it involves following a Clinical Care Standard.

The department already contributes data to the Australian and New Zealand Hip Fracture Registry (ANZHFR), which monitors practice according to the Hip Fracture Care Clinical Care Standard. The Registry online portal includes a dashboard showing the hospital’s results in seven aspects of care specified in the clinical care standard, and the annual report of the ANZHFR shows each contributing hospital’s performance, as well as the state/territory and national averages. 

As a starting point, the head of department asked the orthopaedic registrar to present the hospital’s Registry results, and the state and national averages from the latest annual report, at the monthly department meeting.

Review of three month’s data showed that only 50% of the hospital’s patients with hip fracture underwent surgery within 48 hours, compared to the national average of 77%. The department felt this poor result needed to be addressed urgently, and a team made up of orthopaedic surgeons, nurses, and geriatricians was created to investigate the issue and find potential solutions.

The department also noted that their total length of stay for hip fracture patients was well above average, and it was possible that the delays to theatre were contributing to the overall increase in total length of stay.

After the Clinical Nurse Consultant ruled out errors in data entry as a factor, the team met to discuss the possible reasons for the delays in surgery. A comparison of the reasons for delay in the hospital, compared with national averages in the registry annual report, showed that:

• The proportion of delays due to patients being medically unfit for surgery, or lack of surgeon availability, were similar to those in other hospitals
• Length of stay in the emergency department was also similar 
• A lack of theatre availability was substantially higher than the national average. 

A discussion about theatre access highlighted a number of areas for improvement. Patients presenting on Fridays or the weekend had the greatest delays because no theatre time was allocated on Saturdays or Sundays for hip fracture surgery. The group also noted that patients with hip fracture often had their surgery cancelled when cases seen as more urgent were brought into the hospital. This contributed to delays, and also led to prolonged and unnecessary fasting for patients.

The group made a case to the hospital manager for introducing a Sunday morning theatre list dedicated to hip fracture surgery. They presented the hospital’s performance compared with the national average, and against the clinical care standard quality statements.

The hospital manager determined that reducing delays in surgery for hip fracture was a priority for improving patient care, and introduced the additional, dedicated theatre time.

Follow up monitoring showed a reduction in delays to surgery, and the hospital became close to the national average. Reports generated from the hip fracture registry portal are discussed at a quarterly meeting between the orthopaedic surgery and geriatric departments, and are included in the hospital’s regular safety and quality reports to the Board. 

The department continues to check that delays to surgery are minimised, and is focussing on the quality indicators for pain management in the hip fracture clinical care standard next.

The head of the stroke unit selected discharge planning as a priority after a patient was readmitted with a second stroke following discharge without secondary prevention medication.

Apart from reducing the risk of another stroke, formal discharge planning can improve the coordination of services and reduce long-term unmet needs for people who have had a stroke. It is also part of the Clinical Guidelines for Stroke Management and the Acute Stroke Clinical Care Standard, so improving practice in this area would help the hospital meet Action 1.27 of the NSQHS Clinical Governance Standard. 

The hospital already contributes to the Australian Stroke Clinical Registry (AuSCR), so no new data collection would be needed. Benchmark, national and state data are also available for comparison, from sources including AuSCR and The Stroke Foundation.

The Stroke Unit’s Head of Department and Clinical Nurse Consultant decided to review the hospital’s AuSCR data for the previous year, along with national and state data. They chose two of the indicators related to discharge planning as their initial focus:

• Care plan provided at discharge
• Discharged on an antihypertensive medicine.

The Clinical Nurse Consultant generated a report from the online AuSCR portal. The hospital was close to average for most indicators but performed poorly on the measures of discharge planning. 

Only 49% of patients had a care plan on discharge after a stroke, compared to the national average of 59% and the benchmark of 95%. And 60% were discharged on antihypertensive medication, compared to the national average of 70%.

After ruling out data errors as a factor, the Clinical Nurse Consultant presented the results at a meeting of clinical staff who contribute to discharge planning for stroke patients. The group included medical, nursing, pharmacy and allied health staff.

The group decided differences in case mix, structure or resources of the hospital did not explain the poor results. They identified several aspects of processes and practice that were contributing to inconsistent discharge care planning:

• Lack of awareness, compounded by rotation of staff
• Lack of an appropriate template
• Inconsistent prescribing of secondary prevention medication.

At a follow up meeting to discuss strategies to improve discharge planning, the group agreed to a range of changes:

• Senior medical, nursing and allied health staff to raise discharge care planning for stroke patients on all ward rounds over the following two weeks, and to lead education sessions on the importance of discharge care planning in the following month
• Discharge care planning to be included in orientation of new staff
• The checklist for leaving hospital in the Stroke Foundation booklet ‘My stroke journey’ to be used as a template for discharge planning
• Recommendations and evidence for secondary prevention medication to be added to bedside charts as a reminder
• Pharmacy staff to alert the medical team if secondary prevention medications are not included in discharge medications.

Follow up after three months showed a small improvement in both indicators, but the hospital was still below the national averages. To improve discharge planning further, a stroke ‘in-reach’ team of medical and allied health practitioners was formed to review all stroke patients before discharge.

Review after a further three months showed that the hospital had reached the national averages for percentage of stroke patients with a discharge plan and for prescription of secondary prevention medication. Results for all indicators from the registry are reviewed every quarter at a multidisciplinary stroke meeting. Priorities for new quality improvement initiatives are also discussed in light of the hospital’s performance in comparison to national and state data.