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Management of Hip Fractures in the Older Patient

Project Added:
21 October 2015
Last updated:
9 November 2015

Management of Hip Fractures in the Older Patient

Summary

PMBH reviewed its fractured femur care pathway, based on the Agency for Clinical Innovation’s (ACI) Minimum Standards for the Management of Hip Fractures. This resulted in a formalised orthogeriatric model of care that addressed factors including multimodal pain control, time to theatre, time to mobilisation and refracture prevention. 

Aim

To provide a coordinated and consistent pathway of care for patients admitted to PMBH with a hip fracture.

Benefits 

  • Improves patient outcomes and reduces length of stay.
  • Provides patients with a standardised fractured femur pathway of care, which is implemented on arrival.
  • Improves the rate of patients who receive surgery within 48 hours of arrival.
  • Reduces time to theatre and cancellation rates of surgery for this patient cohort.
  • Ensures patients do not fast unnecessarily prior to surgery, to maintain patient safety and optimised nutritional status.
  • Provides a collaborative and multidisciplinary approach to the management of patients with hip fractures.

Project status

Key dates

  • Start: August 2014
  • Finish: February 2015 

Status

  • Sustained - The project has been implemented and is sustained in standard business.

Background

Hip fractures as a result of a fall are a common occurrence for older Australians - around 17,000 cases present to emergency departments (EDs) across the country each year. This can result in significant medical complications, ill health and even death. Surgery to repair the fracture, rehabilitation after surgery and the patient’s discharge home from hospital can all be delayed if medical complications are not recognised and managed quickly.

Management of patients with hip fractures are complex and challenging, involving a range of professionals and clinical departments and often crossing a number of service boundaries. These patients are among the most frail to be admitted to hospital and their outcomes critically depend on how effectively their care is managed. 

In 2014, the ACI worked with expert clinicians in NSW to develop Minimum Standards for the Management of Hip Fractures. These guidelines identify best practice on the management and care of patients with hip fractures. PMBH and 36 other NSW Health facilities were invited to implement these standards.

Although the ACI hip fracture standards were in place at PMBH, there was no standardised approach to the delivery of care and very limited communication between departments. As a result, this group of patients were often seen as a low priority, with repeated theatre cancellations leading to prolonged and unnecessary fasting times. A fractured femur care pathway did exist but its use was ad hoc and often did not commence until after surgery, resulting in a fragmented patient journey which influenced patient outcomes.

Implementation

  • An orthogeriatric model of care was developed and implemented by the orthopaedic surgeon and geriatrician on arrival.
  • Patients were reviewed by orthopaedic, geriatric and pain management teams as soon as possible after arriving in the ED.
  • Suitable patients were mobilised on day one, with multimodal pain management available.
  • Specific objectives around fasting times and malnourishment screening were established, with carbohydrate drinks provided in the ED prior to surgery and high protein drinks post-surgery. Malnutrition and bowel management also commenced in the ED.
  • A ‘starving clock’ was developed to ensure patients did not fast longer than eight hours.
  • Suitable patients were scheduled to receive surgery within 48 hours of arrival and in daylight hours.
  • The mandated cut-off time for surgery was set at 1700 hours, to reduce patient fasting times. If fasting ceased, the patient was immediately given dietary supplements.

Starving clock - time to operation, actions after 5pm or 8 hours
Starving clock

Implementation sites

  • Port Macquarie Base Hospital
  • Kempsey District Hospital

Partnership

  • Agency for Clinical Innovation

Results

  • All patients with a fractured hip are followed up daily by the Acute Pain Service and data is collected and collated.
  • From August 2014 to February 2015, it was found that:
    • all patients were admitted under the orthogeriatric model of care
    • time to theatre was reduced from an average of 40 hours to 16 hours
    • cancellation of surgery was reduced from 37% to 0% 
    • all patients deemed medically fit were mobilised on day one
    • patients with delirium experienced a decrease in severity and duration, as reported by the transitional nurse practitioner
    • no patients fasted more than eight hours
    • the average length of stay for patients in this cohort was reduced by 1.8 days
    • the standards for refracture prevention and optimum pain management were met.
  • Statewide data collection is in progress and will allow for benchmarking across NSW.
  • Ongoing evaluation of this project will be undertaken every six months to ensure continued momentum and maintain current success.
  • The orthogeriatric model of care and pain management protocol will be reviewed in 12 months.
  • The patient and staff survey will be repeated in 12 months.
  • Ongoing education is provided for ED and anaesthetics staff on fascia illiaca block and implementation of the new model of care.
  • Staff feedback report from Nov-Dec 2014
  • This project was a finalist in the 2015 MNCLHD Quality Awards - Quality Improvement category.

Lessons learnt 

  • The selection of working party members was vital, to ensure that all key players were included and all departments were represented. Identification and involvement of these key players has been vital to the success of the project.
  • Regular communication between team members meant that everyone was aware of how the project was progressing and were updated on the implementation of any changes as they occurred. Any problems could be addressed immediately and members were encouraged to voice their opinions in order to improve outcomes.
  • Involvement of the Hastings Macleay Clinical Network Quality Unit was important, to ensure all mandatory standards were met. It also provided an opportunity to discuss other areas of concern such as fasting times and malnutrition.
  • Using the Surgery Redesign Program was instrumental in providing a plan and structure for the project, while the Accelerated Implementation Management program guided the team towards seamless implementation of the standards.
  • Ongoing involvement with the ACI will provide support and encouragement to partner with other programs, such as the Medicare Local Osteoporosis Program.
  • In the future, there is scope for educating staff at residential aged care facilities on the management of patients with a fascia iliaca block, should conservative or palliative management be initiated.

Related resources

Contact

Vicki Newton
Clinical Nurse Consultant
Port Macquarie Base Hospital
Mid North Coast Local Health District
Phone: 02 5524 2066
vicki.newton@ncahs.health.nsw.gov.au 

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