1. Mr. Raphael Hau MBBS FRACS FAOrthoA Orthopaedic Surgeon, Box Hill Hospital Director of Orthopaedic Surgery, The Northern Hospital Moving Towards Standardised & Monitored Clinical Management. What are the key considerations?

2. Why? How? Requirements? 3. Delay > 1 day increases in-hospital mortality Bottle, BJM, 2006 Delay increases 30-days mortality Holt, J Bone Joint Surg Br, 2010. Carretta, Int Orthop, 2010 Delay > 48hours increases 120-days & 6-months mortality Clement, J Bone Joint Surg Br, 2011. Maggi, Osteoporos, 2009 Delay > 2 calendar days increases 1 yr mortality Zuckerman, JBJS A, 1995 Delay > 7 days increases 1 yr mortality Maheshwari, J Ortho Surg, 2011 4. Reduces major medical complications Hoenig H et al, Arch Int Med. 1997; 157:513-20. Verbeek DOF et al, Int Orthopaedics. 2008; 32:13- 18. Reduces length of stay Hommel A et al, Injury. 2008 June 12 Improves rehabilitation at 3 months Villar et al, BMJ 293:1203-1204, 1986 Improves ability to return to independent living Al-Ani AN et al, JBJS (Am) 2008; 90:1436-42 5. Reduces mortality, pressure ulcers and pneumonia Simunovic N et al, CMAJ 182(15): 1609-16, 2010. 6. Code NOF in orthopaedic paradise Emergency physician, Geriatrician, Orthopaedic surgeon, Anaesthetist, Cardiologist, Haematologist, Radiographer miraculously appear Theatre free! Real world 7. Delays in patient optimization Delays in theatre availability 8. Lack of co-ordination & co-operation: mostly Lack of resources: often some degree Lack of knowledge: rarely 9. Tick boxes Guidelines Agreed plans Fast track clinical care Audit tool 10. Geriatrics / Medicine Orthopaedics Emergency Anaesthetics Haematology Cardiology Nephrology Theatre Ortho Ward Rehab Ward Physiotherapy Orthotics Administrators 11. A&E Ambo calls: Alert in charge A&E physician, Ortho, Geriatricians, Ortho co-ordinator High energy trauma: trauma call Admission: time noted Joint admission Geriatrics / Orthopaedics Age limit ? 12. NOF burger: FBE/U&E/Vit D/Group & Hold +/- INR/clotting ECG/CXR/Charnley pelvis XR/ AP lat Hip Xray Femur if subtrochanteric fracture identified CT head protocol Triage ? Nurse practitioner ? Doctor ? How are requests made? How are patients transferred? 13. A&E senior Confirms diagnosis Exclude CVA, AMI, PE, arrhythmia, pneumonia, other fractures, pathological fractures Fascia iliacus block / regional anaesthesia Before or after Xrays IDC +/- CSU m/c/s 14. Orthopaedics Confirm diagnosis Organise additional imaging Organise implant Book theatre Anaesthetic referral Plan: fasting, anti-coagulation 15. Geriatricians / Physicians Correctable cause for fall Assess and correct co-morbidities Poly-pharmacy Analgesia Liaise with Anaesthetics and Orthopaedics Liaise with other medical specialties 16. Nursing care Oximetry +/- Oxygen TEDs Foot pumps DVT prophylaxis Air mattress Book bed 17. Analgesia / Anti-emetics Geriatrician? Anaesthetic ? Pain team involvement? When? Next round? As soon as case booked? Guidelines 18. Passport Bloods Imaging Analgesia VAS Orthopaedic plan Anaesthetic R/V Geriatrician R/V 19. Anaemia Anti-coagulation Volume depletion Electrolyte imbalance Uncontrolled diabetes / heart failure Correctable Arrhythmia or ischaemia Chest infection / exacerbation COPD 20. Anaemia / Electrolyte Imbalance Hb / Na / K / Glucose vs Co-morbidities Who checks? Who decides? Who corrects? To what level? Fluid depletion Who checks / decides / corrects? 21. Anaesthetics Fitness for surgery Specific end point to achieve Planned review BD? Geriatricians / physicians Fitness for surgery Specific end point to achieve Planned review BD? 22. Agreed Indications to defer surgery AMI or evolving ischaemia Pulmonary oedema Fulminant sepsis Not contra-indications Hyponatraemia Hypokalaemia Aortic sclerosis / Pan systolic murmur 23. Warfarin for Atrial fibrillation Prothrombinex ? How much ? When ? Vitamin K ? How much ? Route ? Repeat INR ? Protocol from Haematology Aortic valve / recurrent DVT / CVA Haematology referral 24. Analgesia / Anti-emetics DVT prophylaxis Pressure care Chest physio Bowel regime Orientation Co-ordinate medical reviews Fasting clock 25. Transfer from regional centres Investigations, Analgesia DVT prophylaxis Bed priority Mode of transport and urgency Dialysis patients Before or after theatre? 26. When is it optimal? Patient ready As soon as possible In-hours Consultants present ICU / HDU available if required 27. As soon as possible Advantage Decreased mortality & complications Disadvantage May be late in the day 28. No increase in mortality Bosma et al, JBJS 92B: 110-115, 2010 Decreases dexterity and increases error Taffinder et al, Lancet 352: 1191, 1998 29. Advantages: Staff awake and alert More help available Consultants more likely to be present Disadvantages: Competes with electives May delay theatre 30. Decreases after hours work Jennings et al, Ann R Coll Surg Eng 81:65-68 Decreases delay and post op morbidity Elder et al, Injury, Int J Care Injured 36: 1060-1066, 2005 Decreases cancellations and fasting Wixted et al, J Orthop Trauma 22:234236, 2008 31. Improves cancellations, supervision & after hour work Delays operating and increases length of stay Aide et al, JOS 17(3): 301-4, 2009 32. As soon as possible Dedicated trauma lists Staffed by consultants In hours Frequency? After hours? Does not reduce elective Twilight 1800-2200 Controlled hours 33. Requirements Will Co-operation and co-ordination Monitoring and re-assessment Resources Extra theatre time 34. Mr. Raphael Hau MBBS FRACS FAOrthoA Orthopaedic Surgeon, Box Hill Hospital Director of Orthopaedic Surgery, The Northern Hospital Moving Towards Standardised & Monitored Clinical Management. What are the key considerations?