Pioneering Technology Reduces Length of Stay and Carbon Footprint in Value Based Procurement Pilot

BPMpathway really benefitted our patients, allowing earlier discharge and giving the clinician the reassurance patients were progressing with their rehabilitation. Patients valued the ability to see their progress in real-time giving them the motivation to achieve their goals. Overall, we saw improved patient satisfaction and outcomes with the use of the wearable sensor.

Mr Graham Walsh, Consultant Orthopaedic Surgeon, Calderdale and Huddersfield NHS Foundation Trust

Calderdale and Huddersfield NHS Foundation Trust is an NHS Acute Foundation Trust which operates across two hospital sites and in the community, employing around 6,300 staff.

The trust treated 425 patients with a knee replacement in 2019.

The current procedure pathway requires patients to attend three appointments preoperatively: an outpatient appointment, patient pre-assessment clinic, and Joint School.

The average length of stay at Calderdale and Huddersfield NHS Foundation Trust for patients following knee replacement surgery was 3.78 days before the pilot.

Following discharge from hospital, there are three Orthopaedic outpatient appointments and an average of six physiotherapy appointments per patient.

The pathway presented an opportunity to utilise technology to streamline the patient journey. The requirement to reduce patient length of stay and face-to-face appointments has been further amplified by the Covid-19 pandemic.

The aim of the project was to identify if the use of new technology could:

• Improve patient experience
• Reduce length of stay, and facilitate early discharge (<24hrs)
• Improve patient flow and release capacity
• Reduce face-to-face appointments
• Reduce carbon footprint.

Calderdale and Huddersfield NHS Foundation Trust worked alongside BBraun to successfully pilot the BPMpathway, a digital rehabilitation program providing preoperative and postoperative support to the patient.

The BPMpathway can be utilised alongside BBraun Hip and Knee implants or as a standalone offer with other suppliers Hip and Knee implants.

BPMpathway was discussed at the initial outpatient appointment and eligible patients selected. The criteria for patients to be suitable for the pilot was:

• They could provide informed consent
• They required a knee replacement
• They had a device to facilitate the use of the application
• They had access to Wi-Fi in their home.

A one-stop preoperative assessment clinic was introduced to provide physiotherapy, occupational therapy, anaesthetic assessment, preoperative/postoperative care and Joint School, which reduced the number of appointments from three to one.

Each suitable patient was provided with a BPMpathway device, which is a wearable sensor to be worn around the lower leg to measure range of motion. The device has an accompanying application and dashboard to facilitate two-way communication and enables the patient to record other factors such as pain score. Full training was provided to each patient, and they were given exercises to be completed over two to three weeks prior to surgery in order to monitor range of motion and ensure they were prepared for postoperative rehabilitation.

The pilot included 21 patients utilising the BPMpathway for knee replacement surgery.

The BPMpathway transformed the patient pathway utilising the range of motion sensor and application to provide patient education, two-way communication and remote monitoring.

Patients were contacted following discharge three times in the first 24 hours by a member of the nursing team, followed by the physiotherapist, 48 hours postoperatively. Patients were monitored remotely and kept in touch with for 6 weeks by the physiotherapy team. Face-to-face appointments were arranged when required.

• 14 out of 21 patients treated as day case had an average length of stay of 8.8 hours
• 5 out of 21 patients treated as short stay had an average length of stay of 36.33 hours
• 2 out of 21 patients treated as long stay patients had an average length of stay over 72 hours
• 212 messages were sent and received on the application which averaged at 10 per patient
• Virtual follow up appointments led to a reduction in face-to-face appointments from an average of six to four appointments
• Carbon footprint reduced due to reduced length of stay and reduced travel for appointments for BPMpathway patients*
• 80% of patients had a positive experience using the device.

Before

After

Calderdale and Huddersfield NHS Foundation Trust working with BBraun on the project aimed to release capacity and reduce length of stay from a quantitative perspective.

Efficiency benefits were achieved through length of stay and the reduction in the need for face-to-face appointments. The notional efficiency was estimated to be reduced length of stay (£1,261) and face-to-face appointments (£168) a total of £1,103.39 per patient through the utilisation of the BPMpathway, taking into account the cost of the sensor.

This is understood to be a notional efficiency as we have not reduced our bed base or our clinic capacity. What this has enabled is the ability to support the additional patient activity required to recover the NHS waiting times etc without additional investment and hence a notional efficiency or cost avoidance as opposed to a true cost out / cash benefit.

Joanne Hardcastle, Assistant Director of Finance, Calderdale and Huddersfield NHS Foundation Trust

There is the potential for wider adoption of the BBraun BPMpathway at the trust. The pilot explored a limited number of patients to establish the concept. The opportunity to implement the pathway across the trust, considering the selection criteria, would result in approximately 218 patients being suitable for the BPMpathway.

Considering the cost of the device and the case study data, this would deliver:

• A reduction in average length of stay from 3.78 days to 2.4 days
• Notional annual efficiency of £240,540 to be reinvested back into service delivery and recovery
• A projected reduction in carbon footprint of 119,381kg CO₂e ***
• Increase capacity for the trust to facilitate the NHS recovery agenda.

To discuss this case study and opportunities for your trust to explore using this technology please contact:

Please note:
This case study was carried out at Calderdale and Huddersfield NHS Foundation Trust in conjunction with BBraun. There are other comparable solutions within the market that are suitable in addressing the challenges highlighted in this report.

*Reduction in CO₂e was compiled based on reduction of face-to-face physio appointments at clinic and reduction in length of stay for pathway patients. Methodology used average Kg CO₂e for an inpatient and outpatient stay calculated as 125Kg CO₂e and 76 Kg CO₂e respectively. This is from The Lancet publication: https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30271-0/fulltext

Methodology used to calculate travel avoided uses data on average distance travelled by patients to an NHS site for an inpatient or outpatient visit (17km) from source: http://www.bristol.ac.uk/media-library/sites/cmpo/migrated/documents/wp162.pdf

Applying a weighted average Kg CO₂e emission factor from differing vehicle types (petrol, diesel, bus etc) from DVLA data source: https://www.gov.uk/government/statistical-data-sets/veh02-licensed-cars

**Single combined appointment which includes Orthopaedic Consultation, Preoperative Assessment, Joint School, and the wearable device is provided.

***The projected annual CO₂e saving is based on applying the results of the pilot (21 patients) and rolling it out to all patients assessed as suitable for the BPM in a year. In 2019, pre-pandemic, the trust conducted 425 knee replacement surgeries. CO₂e methodologies for calculation purposes are referenced above and have been applied to 218 patients to establish projections.