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Theme: Evidence for Policy and Practice
Andrew Fordyce (Consultant Oral & Facial Surgeon and Clinical Systems Engineer) and Michael Swart (Consultant in Anaesthesia and Critical Care Medicine) at Torbay Hospital asked PenCHORD to assess the true impact of their changes by determining what are the short and long term outcomes of Fractured Neck of Femur patients whose wait for surgery has been reduced, in comparison with the short and long term outcomes of patients before the changes were implemented. Specifically, they wanted us to assess whether the changes have led to more patients going home or into independent care, rather than into community hospitals and care homes, as they suspected that the improved pathway and minimisation of patients’ deterioration post-surgery could lead to improved patient outcomes. They also wanted us to produce a visual simulation model that demonstrated the nature of the pathway changes implemented.
Patient data for 405 patients before the pathway changes were made in November 2010 (hereafter referred to as 'Pre PC' patients) and 424 patients after the changes were made (hereafter referred to as 'Post PC' patients) was supplied by Torbay Hospital. Records were anonymised before being given to PenCHORD, and contained;
Data analysis was conducted on the entire data set.
The Visual Simulation model was built using Simul8 and Excel. Simul8 was used to develop two deterministic Discrete Event Simulation models - one to visualise the old fractured neck of femur pathway at Torbay Hospital, and one to visualise the new pathway. Excel was used to construct the interface that users interact with to populate the model, and which presents the results. The Simul8 models read inputs from the Excel file at the start of the simulation, and export the results to the Excel file at the end of the simulation.
Despite a clear reduction in the average wait for surgery from admission, and a significant increase in the proportion of patients that received their operation on the same day they were admitted, both the short-term discharge outcomes and longer term outcomes for patients appear to have been unaffected by the fast-track fractured neck of femur pathway changes. This implies there has been no change in patient outcomes as a result of the pathway changes, at least in terms of the proportion of patients that end up in dependent care longer term. This result is perhaps somewhat unsurprising when we find that the proportion of patients re-admitted to hospital within 12 months was near-identical both before and after the change.
The visual simulation model offers a way of visualising the structural differences between the two pathways, along with the potential resource burdens in each pathway. In particular, even when running the simulation with largely arbitrary (but consistent) parameterisations, the activity maps show a reduction in burden on A & E in the new pathway, as most of the tasks and processes are taken over by the Trauma Ward and, in particular, the nominated Trauma Coordinator for the patient. From a practical point of view, this may offer support to the fast track pathway implementation, as the burden of time and resource is centred primarily around the clinical department that is best equipped to take responsibility for these patients from admission to discharge.
Whilst the results of this analysis have not found a definitive improvement to the short-term and long-term outcomes of fractured neck of femur patients with a reduction to the pre-operative waiting time, further work that partners this programme with Enhanced Recovery, or which otherwise seeks to reduce the post-operative length of stay, may prove more fruitful. Alternatively, the quantification of a patient's outcome may be unsuitable for measuring the success of this project, and measures such as QALYs may be more appropriate for determining the success of the changes to the pathway for fractured neck of femur patients.