Authors (including presenting author) :
Lau TW(1), Fok WMM(1), Wong CYS(2), Hung DDD(2), Fung YF(3), Chan YSA(3), Kwong WF(3), Lui CM(4), Fan TYB(5), Li MNC(6), Lau KYG(6), Wong SPV(7), Ting TK(8), Kwok YK(9), Tam WKV(10), Lam YHR(10), Shum STV(10)
Affiliation :
(1) Department of Orthopaedics and Traumatology, Queen Mary Hospital, (2) Department of Microbiology, Queen Mary Hospital, (3) Nursing division, Department of Orthopaedics and Traumatology, Queen Mary Hospital (4) Department of Prosthetics & Orthotics, Queen Mary Hospital (5) Department of Dietetics, Queen Mary Hospital, (6) Department of Community Nursing Service, Queen Mary Hospital, (7) Department of Occupational Therapy, Queen Mary Hospital, (8) Medical Social unit, Queen Mary Hospital, (9) Department of Podiatry, Queen Mary Hospital, (10) Department of Physiotherapy, Queen Mary Hospital
Introduction :
Musculoskeletal infection (MSKI) in orthopaedics is very common. This comprise a majority of workload of our daily emergency admissions and operations. In average, we have around 160 admissions per month. More than 3/4 of these patients require at least 1 surgery before discharge. They had an average hospital length of stay of around 23 days. And the 28-day readmission rate was 12%.
Although MSKI is common, the presentations can vary a lot from a simple abscess to a severe infection like necrotising fasciitis causing septicaemia shock. Yet these are mostly managed by frontline staff when the patients are admitted and the surgeries are often managed by on-call junior surgeons. Besides, there are no standard protocols to follow and this caused variations and deviations from the best management, which may cause subsequent difficulty in both diagnosis and surgical decisions. During the hospital stay, inpatient wound nursing management often lacks a consensus. There is also a common breakdown of communication between inpatient treatment and the outpatient wound care. On the other hand, whether an operated infected limb can be safely mobilised to prevent stiffness and wasting depends much on the frontline experience. Hence, delaying rehabilitation of the patient causing unnecessary prolong hospital stay is common. Moreover, these MSKI patients commonly have comorbidites like diabetes, or peripheral vascular diseases that make them prone to re-infection. Prevention become an important part of post discharge issues. which is, unfortunately, commonly neglected. Finally, difficult social issues and support to facilitate discharge may easily be missed or delayed in acute management causing a delay in discharge when the patient is ready.
In view of all these service gaps, we started our Interdisplineray team model for the MSKI patients. The aim is to provide a clinical solution resulting in quicker diagnosis, more effective in-patient and out-patient treatment, quicker recovery and better rehabilitation with an ultimate aim to prevent recurrence of a similar problem.
Objectives :
Primary Objectives:
Improve clinical outcomes: 1. Shorten length of hospital stay 2. Decrease readmission rate 3. Decrease number of avoidable surgeries.
Secondary objectives: 1. Improve communication between clinical staff and allied health 2. Efficient utilisation of Orthopaedic wound nurse (APN) for in- and out-patient treatment 3. Optimal utilisation of orthopaedic wound clinic, led by Orthopaedic wound nurse, to decrease length of hospital stay and relieve orthopaedic subspecialty clinic work load 4. Collaboration between in-patient nursing and out-patient community nurse care to provide seamless out-patient based wound and antibiotics care 5. Collaboration between physiotherapist, prosthetics and orthotics staff for amputees to optimise the rehabilitation 6. Early involvement of occupational therapist for modification and adjustment of working and home environment 7. Early involvement of medical social worker for patients with difficulty in discharge 8. Podiatrist in- and out-patient follow-up to off-load the work of general clinic and improve awareness of foot hygiene 8. Dietary advice for patients requiring special diet need, e.g post-op DM patients that require improve nutrition and yet with optimal DM control 9. With all of the above working together, to achieve best patients' outcomes.
Methodology :
MSKI team is a multidisciplinary team involving the following professions:
1. Orthopaedic surgeons
2. Microbiologist
3. Ward nurses
4. Special wound nurses
5. Physiotherapists
6. Occupational therapists
7. Prosthetic and Orthotics
8. Podiatrists
9. Dieticians
10. Community nurses
11. Medical social workers
A preliminary date collection and analysis was done in mid 2018 by the nurses to analyse the basic statistics of the patients admitted for infection. Several planning meetings with the above professions were arranged during late 2018. Finally, we decided to have a interdisciplinary grand round every Tuesday. This grand round involves all the professions. Patients with MSKI with at least 1 surgical procedure done will be recruited for discussion. The patient list is available on Monday afternoon so everyone has time to prepare the cases the next day. During the discussion, everyone has the chance to express their opinions. The management decision and progress will be recorded by the first line doctor every week. This will be written down and it will be in the form of a brief report. Each professions will update the progress of the patient at the end of the week. This will be available for the grand round next week so as to facilitate follow-up on the management and issues raised in last week.
Also, we have a summary report on each patient demographics, clinical data such as diagnosis, micro-organism, surgery performed etc, and also administration data such as length of hospital stay, discharge destination, follow-up clinics etc will all be recorded for future audit. The data will be input into the Redcap online software for future easy statistical analysis.
The MSKI grand round started in November 2018. In last year, we had 2 interim meetings for audit meetings on the logistic and running of the team. These meetings were important for the smoother running and better efficiency of the team. Unnecessary date collection were removed and missed data collection were re-introduced for collection.
Result & Outcome :
From November 2018 to October 2020, a total of 406 patients were recruited. The male to female ratio is 2:1. The average age of the patients is 46.6. After the introduction of this interdisciplinary care model, the average length of stay in acute hospital was 24.7 in 1st year and dramatically reduced to 9.3 days in 2nd year. Among these 406 patients, there was only 6 (3.0%) unplanned 28-day readmission.
171 patients (42%) were seen by our special wound nurse clinics which means nearly half of our patients were relieved from our extremely busy orthopaedic specialist clinic. The total nurse clinic attendance was 410 in last 2 years, which reflects an average of 2.4 visits per patient.
Our microbiologist gave regular reviews and first hand identification of micro-organisms, the most appropriate antibiotics could be administered as early as possible. Several protocols are set up for the management of common infections, e.g. antibiotics usage of septic arthritis, routine standard work up for infection patients. They also set up protocols for our nurses and patients to fight against multi-drug resistant bacteria.
Physiotherapists has assessed 95% of all the MSKI patients. Majority (77%) of the patients could return to their premorbid mobility status. Occupational therapist were required in 76.8% of our patients with services focusing on ADL training, cognitive assessment, splintage application to prediscarge assessment etc.
Our community nurses has also helped to give intravenous antibiotics as an out-patient basis in 8 patients (2%). This decreased the length of hospital stay and improve the quality of life for the patients. They also provides out-patient wound care in 51 (12.6%) among all indicated patients.
Medical social workers also gave a lot of help and input, especially when the patients need temporary or permanent placement upon discharge (7%) because of the early post operative states and 13% of them require financial assistance.
Dietician is crucial because many patients have diabetes and yet their nutrition were suboptimal. This delicate balance of calories control and adequate nutrition become very difficult. They managed over 80% of our patients.
Podiatrist were also involved in 98 (24.1%) in-patient and about 21 (21.4%) of them require further outpatient follow-up.
Prosthetics and Orthotics were involved in 21% of patients, mainly amputees and shoe-wear modifications. Working with physiotherapist, early training for amputees are possible in 39% of amputees with mobilisation potential.
