Clinical strategy update
MSK Transformation Programme
The ROH continues to lead the Birmingham and Solihull MSK Transformation Programme along with partners across the ICS, in public health, and the voluntary sector.
Key highlight:
A new system-wide MSK pathway has been agreed (see below) which will streamline referral routes into services, as well as standardising clinical decision making and supporting patient access to information, advice and guidance about their condition(s).
Programme Summary:
The programme is made up of five key streams, which are each supported with representation from each BSOL NHS provider.
Standardising High Level Clinical Pathways
A series of MSK pathway development workshops were held in November 2021 across hips & knees, spinal, shoulder, foot & ankle and hand – focussing on high volume, low complexity conditions. You can read a summary of those workshops here.
The programme has commenced a 6 month pilot for a new clinical decision making tool called Orthopathways. The programme will be deployed in primary care to ensure patients are referred to the most appropriate services in secondary, tertiary and/or community care. Representatives from each sub-speciality (across ROH/UHB/BCHC) are now meeting to build in the specifics for each condition into the digital tool.
Patient information
The patient information stream is evaluating existing patient information across the region and looking to review and standardise the advice and guidance available to patients. This stream is also evaluating accessibility of patient information and how we can improve this.
Digital Supported Self-Management
The digital group are in the process of procuring a new patient-facing, supported self-management app; Getubetter. The app would be ‘prescribed’ in primary care, and support patients with short- and long-term conditions. The app provides different methods of day-to-day pain relief, as well as evidence-based exercises and stretches to support their specific condition. The app is personalised to track a patient’s progress and provides feedback directly into the patient’s health record. It will also direct patients with red-flag symptoms to emergency care. The app can be used as treatment in its own right, or to support a patient waiting for other treatment types such as surgery.
Health Promotion & Prevention
The BSOL ICS has recently commissioned a regional Population Health Needs Assessment, which will provide population specific health related data and outcomes. This is due to be completed in April 2022. The results of which will help further develop the aims of the Health Promotion & Prevention team, who are in the meantime working with stakeholders (such as the Commonwealth Games, Occupation Health providers, Versus Arthritis and other third sector charities).
Workforce
The final stream of the programme aims to develop the MSK clinical workforce across the region, starting with a gap analysis of the existing workforce. This stream is also developing an ‘MSK Academy’, which will be an integrated hub of MSK excellence that delivers accessible education and information to our patients, carers, community, as well as specialised training for MSK practitioners.
Quality improvement and audit update
The below chart shows the number of Clinical Audit/Service Evaluation projects registered of December 2021.
There was one completed project in November 2021:
The overall observations identified from the findings are:
Areas of good practice:
- 90% of Patients were comfortable on the day of operation.
- All were patients had some form of physiotherapy on Day 1.
- Most of the patient’s pain were reasonably controlled on Day 1.
Areas for improvement:
- Needs to implement enhanced recovery pathway.
- Role for pre-emptive analgesia needs to be investigated.
- Local infiltration by Surgeons needs to be uniform.
- Post analgesia should not alter by the ward doctors without pain review.
The Clinical Audit was presented at the Anaesthesia Clinical Audit Meeting on 28th September 2021.
An audit of acute kidney injuries at the ROH
Acute kidney injury (AKI) is an abrupt reduction in renal function that leads to increased morbidity and length of stay. It is largely preventable in surgical patients and has NICE guidelines in place to aid in optimising treatment.
This audit was carried out by RRT between 1st July 2020 and March 2021 and looked at all AKIs that were identified by blood results on PICS. It looked at compliance with guidance regarding recognition, escalation and management of AKI.
Overall, 91 AKIs were identified over nine months of which the majority were aged over 65 years old. The most important modifiable risk factor was that almost half of the patients had hypotension recorded prior to the AKI. By being more aggressive treating low blood pressure with IV fluids, we might be able to reduce kidney injury and improve outcomes.
Almost all of the patients (82%) had a fluid balance recorded prior to the AKI with 60% had a documented episode of oliguria. Of these only 60% were escalated to medical or RRT staff. This shows that we are good at monitoring urine output but not so good at recognition of oliguria and escalating it to the correct staff. Therefore, we would recommend increasing education of the staff who record and document urine output of when to escalate it. Unfortunately, PICS does not pick up on oliguria and issue a warning as it does for other vital parameters.
Going forward, we will look at flagging up those patients at risk via the new electronic pre-operative record so that they can be looked at more closely during their stay. We would encourage more aggressive treatment of low blood pressures, even if they don’t trigger hypotensive scores on NEWS and aim to increase knowledge on the wards of oliguria and escalation.