The development of an overnight total hip replacement programme The short stay hip replacement programme commenced in 2004 when Mr Hugh Apthorp, an Orthopaedic Surgeon working at the Conquest Hospital in Hastings, developed a programme to significantly reduce the amount of time spent in hospital for patients undergoing a total hip replacement. Mr Apthorp currently has the lowest average length of stay nationally for this operation (2.7 days). Approximately 67% of his patients experience a maximum 2 day stay in hospital compared to 3% nationally. The care that his team provides is safe, provides high levels of patient acceptance and feedback and saves money.
Mr Hugh Apthorp Consultant Orthopaedic Surgeon Conquest Hospital
The development of the program In 2004, Mr Apthorp led the development of a multidisciplinary approach to the implementation of the overnight hip replacement programme, including patients, carers, clinical staff and management. The improvements in care were achieved through a variety of both clinical and process changes. These included the following: • • • • • • •
Elimination of his waiting list by agreeing admission dates with patients (and planned discharge dates) at the first consultation ensuring the adherence of treatment to the 18 week pathway; Raising patient and carers expectations about their potential rate of recovery with improved information; The introduction of a new minimally invasive surgical (MIS) technique involving a smaller incision which has many benefits resulting in less damage to the tissue, less pain, less blood loss and faster recovery time; Utilisation of innovative anaesthetic techniques; Superb pre and post hospital planning; Recognition of the value of team building in the delivery of patient focused care; The development of an innovative, efficient, cost effective outreach model of care, which provides a seamless transition of care from the hospital into the community and increases continuity of care for patients
Impact of the program Over the last 4 years it has been possible to demonstrate that the service is safe, cost effective and sustainable. The programme has led to sustained reductions in length of stay with improved clinical outcomes, reduced the requirement for beds and resulted in financial savings. Changes were introduced progressively resulting in a gradual reduction in length of stay. The distribution below demonstrates that for 2008/9 the average time spent in hospital for elective hip replacement varied from 2.7 days for Mr Apthorp’s patients to 23.7 days1. Primary Hip Replacement Length of Stay by England Consultants 2008/09 Elective Admissions, OPCS W371, W381, W391, source: HES extract 25 24 23 22 21 20
H Apthorp Other Cons Top Decile Top Quartile Median
19 18 17 16 15 14 13
Hugh Apthorp average length of stay : 2.7 days
12 11 10 9 8 7 6 5 4 3 2 1 0 1
Please note that Orthopaedic Surgeons having undertaken less than three hip replacements during the 12 month period analysed have been excluded from the analysis.
Despite the considerable reduction in length of stay, Mr Apthorp’s re-admission rate remains below the SHA average (5.5% compared to regional average of 7.1%.) and 98.5% of patients treated through the programme rate their experience as good or excellent. Approximately 50% of Mr Apthorp’s patients are discharged the day following their surgery as evidenced by the run chart below. Trust 4 Site A Primary Hip Replacement Patients Last 100 Discharged for Consultant A by Discharge Date 20 19
Mean UCL
18 17 16 15 14 Length of Stay (Days)
13 12 11 10 9 8 7 6 5 4 3 2
1 day
1 21/03/09 23/03/09
13/03/09
26/02/09
01/02/09 08/02/09 12/02/09 14/02/09 19/02/09
17/01/09
27/11/08 29/11/08 02/12/08 09/12/08 15/12/08 19/12/08 25/12/08 27/12/08 15/01/09
10/10/08 23/10/08 07/11/08 14/11/08 18/11/08
27/09/08
12/09/08
11/08/08 16/08/08
26/06/08 27/06/08 28/06/08 03/07/08 16/07/08 25/07/08 26/07/08
11/06/08 13/06/08
0
67% of Mr Apthorp’s patients have a maximum 2 night stay in hospital. This compares to 3% nationally. % of Hip Replacements Discharged within 2 Days of Admission 70%
60%
50%
Hugh Apthorp % patients discharged within 2 days : 67%
H Apthorp Consultants <10 Operations Consultants >=10 Operations Mean Top Quartile Top Decile
40%
30%
20%
10%
0%
The Trust in which Mr Apthorp works has estimated that the programme has had the following impact:• Annual reduction of 600 bed days utilised by hip replacement patients treated by Mr Apthorp; • Associated annual savings of nearly £180,000 per annum (based on a bed day cost of £290) • Additional length of stay reductions for patients undergoing joint replacements (due to process changes being applied to a broader group of patients); • Enabled the number of beds within the unit to be reduced by 25%.
Initial SHA estimates suggest that approximately 12,000 bed days could be saved (resulting in an estimated cost saving of £3.5 million) if all Orthopaedic surgeons operating within Kent, Surrey and Sussex reduced their average length of stay to Mr Apthorp’s current average. About Mr Apthorp Mr Apthorp has been a Consultant for ten years working in a small District General Hospital on the South Coast. He trained at St Bartholomew’s and St Thomas’ Hospitals before taking up his post as Consultant. He specialises in complex primary and revision hip replacements. He performed the second highest number of hip replacements for the NHS in Kent, Surrey and Sussex in 2008. He was the first in the country to carry out a day case hip replacement and the first in the world to discharge a patient home the day after a double hip replacement. Mr Apthorp has made a bid to the Regional Innovation Fund proposing the spread of the short stay hip replacement innovation across South East Coast. Support provided by South East Coast Quality Observatory One of the requirements outlined in High Quality Care for All (published in June 2008) was the necessity for each region to establish a formal Quality Observatory, building on existing analytical arrangements, to: 1. enable local benchmarking; 2. support the development of metrics; 3. assist with the identification of opportunities to support frontline staff innovate and improve; Quality Observatories have access to a really rich range of datasets and can provide comparative analysis (by organisation, site, service and individual clinician) which evidences variation in practice across and within organisations. Examples of analysis undertaken by the South East Coast Quality Observatory are contained within this case study. Further information and links to each regional Quality Observatory can be found at the following website : www.qualityobservatory.nhs.uk Contact Details For further information, please contact: Mr Hugh Apthorp, Consultant Orthopaedic Surgeon, East Sussex Hospitals NHS Trust (hugh.apthorp@esht.nhs.uk)