Crisis and Complex Care
The transdiciplinary team conducting a huddle, discussing hip fracture patient Mdm K’s care plan

Medical emergencies and accidents happen. Situations such as a heart attack, stroke or broken bone are highly distressing to patients and their families. At Yishun Health, our mission is to respond with speed and skill to tackle acute issues, ensuring that medical treatment is given in a timely manner.

This is important because early, accurate diagnosis and prompt interventions are key to resolving medical issues before complications develop. Beyond this, our programmes support patients in their recovery as well. As illustrated by the Hip Fracture Service (HFS), rehabilitation, prevention as well as patient education are all integral aspects in our seamless, patient-centric care model. Over the last year, we have introduced and made further improvements to our various programmes for crisis and critical care.

HIP FRACTURE SERVICE

It is estimated that more than 2,500 cases of hip fractures occur annually in Singapore, and the number is expected to rise in tandem with an ageing population.

Hip fractures are more common in older adults because of increased frailty and age-related conditions such as osteoporosis. Such factors predispose them to falls and injuries. While any broken bone is a painful and serious affair, hip fractures in seniors are more worrying because the consequences can be dire.

Patients are assessed by the HFS consultant after admission via the ED

Yishun Health’s HFS was started in 2015 to not only address the acute issues, but to get people back on their feet and prevent future falls. Under the HFS, a transdisciplinary team — comprising ED clinicians, geriatricians, cardiologists, anaesthetists, orthopaedic surgeons, nurses, allied health professionals (physiotherapists, occupational and speech therapists, dietitians), and case managers — that operates across both KTPH and YCH work together to streamline and improve processes. Since it was started, some 900 patients have benefited from this model of care.

The integrated care experience ensures elderly hip fracture patients are cared for by a specialised team and receive the care needed in the right setting. This includes timelier access to surgery, shortened hospital stays in the acute setting, and earlier initiation of comprehensive rehabilitation in a step-down care setting. This transition of care allows patients to achieve better clinical and functional outcomes, lets them save time and money, and offers them an enhanced quality of life — even after a fall.

STAFFING THE HFS

Clinical Team

ED Consultants lead the A&E team in assessing the patient upon arrival at the A&E, and put the patient on the hip fracture care pathway.

Geriatricians front the inpatient physician team to ensure that patients are optimally cared for — pre- and post-operatively — to prevent and minimise complications. Pre-operative and geriatric assessments are performed to assess patients’ conditions and decisions are made accordingly.

Orthopaedic Surgeons communicate treatment options to the patients and their families by assessing and classifying the hip fracture and weighing the risks and benefits of surgery.

Anaesthetists work on managing pain for patients, from admission to post-operative care, enabling early mobilisation post-surgery.

Cardiologists assess and optimis cardiac conditions pre-operatively to prevent peri-operative cardiac mortality.

YCH Medical Lead receives patients into the community hospital and ensures continuity of care for patients. Conditions are monitored and serious issues that arise are brought to the attention of the acute hospital clinicians for further review and transfer back if deemed necessary.

Community Care Team ensures that our elderly hip fracture patients receive the appropriate medical management and care support after they transition home. This includes home visits by doctors, nurses, physiotherapists and occupational therapists to assess medical conditions and functional recovery.

Nursing & Allied Health Team

Inpatient Nurses (HFS Coordinators) lead the inpatient nursing team in implementing hip fracture care standards to ensure that patients receive quality care in the wards and that conditions are well managed.

Osteoporosis Nurses educate patients and their families on the importance of osteoporosis treatment, the risks associated, and treatment options that are advisable according to the patients’ conditions.

Ensuring timely access to surgery, Operations Managers facilitate the availability of the operating theatre and communication between the ward and Major Operating Theatre for a smooth flow.

Radiologists turn around scans within four hours, speeding up the process of diagnosis, providing the entire care team with critical information they need to develop care plans.

Physiotherapists assess patients before and after surgery, and facilitate early mobilisation from post-surgery Day 1 to improve functional recovery. Goal setting is performed and communicated to family and carers, allowing the smooth transition to community hospital.

YCH Occupational Therapists ensure the continuity of care, aiding in the recovery and rehabilitation of patients through optimising the environment and providing aids and appliances to patients to improve their functional outcomes.

Speech and Language Therapists train nursing staff in performing swallowing assessments, monitor patients with swallowing problems, and work closely with dietitians in the provision of appropriately textured meals for at-risk patients.

Dietitians perform nutrition assessment and develop individualised nutrition care plans to optimise recovery and rehabilitation. They also looks at energy, protein, vitamin and mineral intake, and hydration to boost functional outcomes and bone health.

Case Managers play an active role in getting to know the patient and his or her family. They conduct financial counselling and proactively start the patient’s discharge care plan to enable a smooth transition of care to the community hospitals and home as necessary.

Medical Social Workers work with patients and their families to activate financial schemes and paperwork for nursing homes where required.

Administration, Operations & Ancillary Support

Bed Management Unit takes the lead to ensure smooth admissions and discharges for patients.

Operations works on identifying gaps in workflows, coordinating improvement works among team members, tracking and analysis of data, and aiding the team in achieving set KPIs.

YCH Operations ensures continued tracking of data for patients transferred to YCH, and coordinates improvement works with the respective team members.

Porters transfer patients to all the key points of care safely and efficiently, from ED and diagnostics to the wards, operating theatres and even to YCH.

AN INTEGRATED EFFORT FOR BETTER HIP FRACTURE RECOVERY

This collaborative effort has led to improved outcomes:

The Emergency Department (ED) team streamlined processes, from sequential to parallel, in order to shorten waiting time for investigations and expedite ward admissions: 60% of these patients are now admitted within four hours of presenting at the ED, up from 40%.

Balancing the need for hip fracture surgeries with other surgical demands in the hospital, patients gained faster access to surgery. On average, 50% of hip fracture surgeries are performed within 48 hours, with some months achieving 60%.

Previously, poor pain management, lack of information on weight bearing, medical issues, and lack of coordinated care resulted in delay in mobilisation. Today, patients are encouraged to move and walk the day after surgery, aided by physiotherapists and the Acute Pain Service team. Early mobilisation has been proven to accelerate functional recovery and reduce risk of complications, resulting in earlier discharge and shorter stay in the acute setting.

KTPH and YCH collaborated to improve the flow of processes and communicate better, trimming transfer criteria and processes. The average transfer time of 3.5 days has now been cut short. More than 80% of hip fracture patients are now transferred to YCH on the same or next day.

A comprehensive prevention programme has lowered surgical site infections (SSIs) from 2.3% in 2015 to 1.4% in 2017. SSIs are an unintended and preventable complication following a hip fracture surgery. Internationally, the rate of SSI is about 9% and about 4.6% of complications are so severe that they require surgery.

OTHER PROGRAMMES COVERED IN THIS CHAPTER:

Acute Medical Unit (AMU) was launched in February 2017 to provide high-quality rapid assessment, close monitoring, and treatment for patients with acute medical conditions. Newly admitted patients are placed in a single ward instead of being scattered throughout the hospital. This allows the multidisciplinary medical team to initiate rapid diagnosis and treatment, especially in the hours when doctors are spread more thinly.

ICU Database To streamline the flow of data, enhance patient safety, and improve medical decision-making in the ICU, the Surgical ICU (SICU) established its DSRB-registered database in 2011 to record the numbers and pertinent clinical details of each patient. After 12 months of physical data entry, the system was automated to flow in from the ICU’s IntelliSpace Critical Care and Anaesthesia software programme into a computerised ICU database.

Heart Failure Clinic Yishun Health’s early post-discharge multidisciplinary heart failure clinic sees advanced practice nurses, cardiac pharmacists, and heart failure consultants review patients in a timely manner from two weeks through to six months post-discharge. This has led to a significant reduction in 30-day readmissions. There was also a significant improvement in patient’s functional status and quality of life.

Heart Attack Pathway To ensure timely diagnosis and treatment of patients suffering heart attacks, the Emergency and Cardiology departments made refinements to the heart attack pathway. This includes training and feedback in the identification of borderline electrocardiograms, and timelier referral and decision-making, all leading to an improvement in patients receiving emergency percutaneous coronary intervention. Patients now routinely receive this treatment within 90 minutes, while the median door-to-balloon time in FY2017 is now 47 minutes, down from 56 minutes — a saving of nine critical minutes.

CT Coronary Angiogram Protocol In February 2017, the ED introduced a new CT Coronary Angiogram (CTCA) Protocol for its Extended Diagnostic Treatment Unit (EDTU). Patients with a moderate HEART score, who are at higher risk of developing cardiac events such as a heart attack, are given faster access to a CTCA. This new streamlined interdisciplinary care protocol improves the patient experience, increases safety, and ensures that those at risk are assessed early to receive appropriate care.

Oncoplastic Breast Reconstruction Service is a natural extension of the current KTPH breast unit. It provides optimal coordinated patient care for the treatment of breast cancer and benign breast diseases. The goal of the reconstructive surgery is to offer surgical options to help people return to normality, and enhance emotional and physical well-being, self-esteem, quality of life and cosmetic satisfaction.

Dr Jerry Goo (left) and Dr Pek Chong Han lead the Oncoplastic Breast Reconstruction Clinic

Emergency Surgery and Trauma (ESAT) is an acute surgical unit that has a dedicated team instead of having all emergency surgeries attended to by the surgeon on call. This model of care separates acute and elective surgical workflows with the existing manpower resources to provide consultant-led, efficient, coordinated and accessible acute care for patients; it has also reduced time to surgical review and surgery, resulting in decreased length of stay and hospital costs without compromising quality and safe patient care.