Enhanced hip fracture management: use of statistical methods and dataset to evaluate a fractured neck of femur fast track pathway—pilot study
View Article PDF
In New Zealand, approximately 3,500 people over the age of 50 were hospitalised with a hip fracture in 2013 with the majority being related to falls.1 The rate of hip fracture increases significantly with age with nearly half of the hip fractures occurring in those aged 85 years or older.2 Although the incidence appears to be falling, the absolute number of hip fractures is increasing with longer life expectancy.3
It appears that the fracture rate is at least 25–50% higher in Europeans than in Pacific Islanders or Māori, but this rate is predicted to equalise with the increasing life span of the Māori and Polynesian population.4 The care of these patients varies both nationally and internationally.4 Service provision was initially surgically managed, but has evolved into a shared care model with Health Care of the Elderly Physicians.5,6 In our centre we established a Fractured Neck of Femur Pathway in 2007,7 which has significantly improved the outcomes of such patients.7 Recently, guidelines have been established for both Australia and New Zealand, outlining the standard of care from admission to the emergency department, peri-operative care, operative optimisation, rehabilitation and appropriate discharge from hospital.1 Experience has shown that this model reduces length of stay and improves cost efficiency.8 Another recent improvement has been the establishment of a hip fracture registry, which will be able to identify all hip fractures in Australia and New Zealand, to accurately classify them and provide an integrated database for this complex group of patients.9 Our hospital admits the largest number of hip fractures (>500/year) for a single hospital in New Zealand10 and has been a leader in the field of innovative management of hip fracture patients. As a tertiary hospital with a large number of acute orthopaedic admissions (4,748 in 2014), evaluation of an effective treatment pathway for these patients has become important to use the finite resources efficiently.
The introduction of a weekly analytical dataset, ‘signalfromnoise’ (SFN) within our district health board is introducing a new way in which clinical staff working within the patient pathway can clearly and quickly understand the implications of any change in patient management. SFN (proprietary software from Lightfoot Solutions)11 helps to identify variations, trends and patterns, which allows the assessment of the introduction of change in clinical practice from admission to the emergency department (ED), peri-operative management, rehabilitation and discharge. Previous patient management was independently managed with some information shared between services.
This study presents the initial results of this clinically-led pilot study in the change of the clinical management of hip fracture patients.
Methods
This fast track pathway was designed to improve the patient journey throughout all phases of their hospital admission from emergency department (ED), the peri-operative process, rehabilitation and planned discharge home. This involved all departments and staff from emergency, acute orthopaedic ward staff, anaesthetic department, surgeons, orthopaedic medicine/rehabilitation service and rehabilitation wards.
The elements of this pathway were mutually agreed by all parties in the period leading up to the introduction of the pathway. Measurement of the effectiveness of this pathway was enabled through the introduction of SFN data visualisation and analysis template that enabled quick and efficient evaluation of all parts of the pathway.11
SFN uses the principles of Statistical Process Control (SPC) to analyse and disseminate information about patient flow across the whole healthcare system. It includes a web-based interface that provides users with an ‘at a glance’ understanding of processes and improvement initiatives (Lightfoot, 2015).11 SFN uses routine information collected in the district health board (DHB) patient management systems, including ED, operating theatres and inpatients wards. This new information is present in a dashboard format with weekly update and a drop down analysis feature that enables in depth analysis of elements of individual department activities across ED, inpatient wards, operating theatres and rehabilitation wards. Figure 1 shows some of the elements within ED that can be analysed on a week by week basis, giving the ability to quickly change or alter elements of the pathway.
Figure 1: SFN process analysis capabilities.
Patients with hip fracture are usually transported to the ED by ambulance where the ambulance staff often identify the possibility of hip fracture on their arrival in the ED. These patients are rapidly assessed by medical and nursing staff, comorbid conditions identified and treated, analgesia initiated, blood tests performed and x-rays requested. It was observed at an early stage that some patients arrived into a busy ED and concurrent nursing/medical responsibilities could delay care of those patients with hip fracture. The pathway empowered and enabled nursing staff to initiate care and significantly progress the ED phase of the care. Once the hip fracture is identified on x-ray, the orthopaedic team are notified, but further orthopaedic assessment of the patient is carried out once admitted directly to an orthopaedic ward bed. Education was provided early in the course of the new approach and all staff were motivated to provide care according to the pathway and expedite transfer to the orthopaedic ward bed. Fundamental to this improvement was to encourage orthopaedic assessment of the patient on the orthopaedic ward rather than in ED. On admission to the acute orthopaedic ward, every possible attempt was made for the patient to be operated on that day or the subsequent morning.
A system was put in place where the Charge Nurse on the admitting orthopaedic ward would text page the duty anaesthetist as soon as a fast track admission arrived on the ward. For those admissions before 4:00 pm an anaesthetic assessment of the patient would be made regarding suitability for operating theatre first thing the following morning. This enabled any outstanding investigations such as blood tests, chest x-ray, cardiac echocardiography or coagulation studies to be arranged, consultation referrals to be made and medications such as anticoagulants to be stopped (and possibly reversed) in a timely manner. This would then ensure the patient was ready for theatre the next morning, preventing unnecessary fasting of patients and reduced last-minute cancellations with a significant impact on theatre room utilisation. If there were problems identified that would preclude operation the next morning then this information was communicated to the acute orthopaedic team so they could adjust the operating schedule accordingly.
Anaesthesia was provided by an anaesthetic consultant or senior registrar wherever possible, with the technique chosen dependent on both patient factors and anaesthetist’s personal preference.
The patients are admitted to an orthopaedic ward that specialises in the management of neck of femur fractures and has dedicated beds for this purpose. Nursing cares are instituted in a standardised fashion.
Registrar assessment (orthopaedic, orthopaedic medicine and anaesthetic) is then undertaken. The confirmation of the diagnosis and exclusion of other injuries or active comorbidities is made, and if present, these are also dealt with at the time of initial admission. Patients are placed on the booking system, ‘Scope’, and depending on the time on the day of admission, a decision is made regarding fasting status. Generally, the patients receive their surgery in the ensuing day(s) and therefore they are not kept nil by mouth and high-carbohydrate fluids and food commenced.
Pre-operative anaesthetic review and orthopaedic medical reviews are undertaken and any peri-operative risk is identified and mitigated with proactive intervention.
Dedicated time within an acute operating theatre is utilised for neck of femur fractures and priority is given whenever possible to this patient group.
The surgical procedure involves the administration of an anaesthetic, IV antibiotics and patient positioning, and depending on the configuration of the fracture pattern the position varies. For a hemiarthroplasty or total hip replacement, patients are positioned in the lateral decubitus position and generally a lateral approach to the hip is undertaken. This approach is felt to reduce the risk of dislocation by preserving the posterior capsule and careful attention is paid to repairing the vertical incision in the capsule and the gluteal muscles.
For intertrochanteric and subcapital neck of femur fractures treated with closed reduction and internal fixation, a supine position is utilised with the use of a traction table and image-intensifier navigation. A direct lateral approach is made, preservation of the vastus lateralis is attempted and metalware is placed in a fluoroscopic-guided fashion. A drain may be placed and generally, subcuticular dissolvable sutures are used to repair the incision site. Dressings are then applied.
The patients are then transferred to the orthopaedic ward following transfer from recovery, and antibiotics (Cefazolin 2gms) are instituted for two further doses post-operatively. DVT prophylaxis is undertaken and the patients are mobilised early with the assistance of the physiotherapy team. X-rays are taken post-operatively and this is repeated at six weeks to ensure that fracture union is satisfactory and alignment remains acceptable. Patients are reviewed if problems arise in the post-operative period after discharge from hospital.
Rehabilitation
It was agreed that all patients should be suitable for rehabilitation and weight bearing at 48 hours post-operatively. This meant implicitly that these patients would be well enough both medically and surgically to be transferred to the appropriate rehabilitation facility. In Canterbury there are two rehabilitation facilities. The first is a dedicated orthopaedic rehabilitation facility, which manages most of the older people with orthopaedic conditions that require rehabilitation. This unit is situated at another hospital and is integrated within the Department of Orthopaedic Surgery (Orthopaedic Rehabilitation Unit (ORU)). The more medically and cognitively compromised are mostly transferred to another hospital because of the more complex nature of their ongoing medical and social issues and the availability of medical/nursing staff and intensive diagnostic facilities (Older Person’s Rehabilitation). The decision as to which institution they are transferred to is made pre-operatively or immediately post-operatively. The rehabilitation process is very similar to those previously described5 and involves a multi-disciplinary team, which includes nursing, medical, occupational therapists, physiotherapists and social workers. The aim is to get people as independently mobile as possible and return them to their home and facilities or to find appropriate placement should this be needed.
There is small group (<5%) of patients that, because of the complex nature of their fracture and subsequent surgery, are unable to weight bear for mechanical implant and healing reasons. These patients are transferred to another hospital (88kms from our facility) for a period of between two to six weeks when they undergo orthopaedic review and a decision made to weight bear and then transferred to ORU for rehabilitation but are not included here for analysis. Those who were not fast tracked because of medical/surgical unsuitability were not subject to this analysis but will be in future.
Fast Track study
The Fast Track pilot study began in November 2014 and continued to the end of April 2015. A similar group of patients from the previous three years were used for comparison. All patients admitted with a fracture neck of femur were included except those patients who were younger than 65 years old, had operation times longer than three hours or who ended up in convalescent care or unknown discharge facilities.
The pathway patient flow data were then compared for the following indicators: time spent in the ED, waiting time for theatre, waiting time for rehabilitation, time spent in acute service and time spent in rehabilitation as well as total length of stay. Sub-group analysis was then performed for eligible discharge and/or rehabilitation facilities. Data was also collected on discharge destination, readmissions and functional status, and compared with the pre-pilot study group Australian Rehabilitation Outcome Centre (AROC data).12 This includes the standardised use of the Functional Independence Measurement tool (FIM™). FIM™ measures 18 items of function, (13 motor and five cognitive). It is scaled from one to seven, with seven being completely independent with a specific activity and one indicating that full assistance is required. It is based on activity over a 24-hour period and guided by observations made by staff over different shifts. Some of the activities include toileting, continence and mobility, etc. The activities are scored giving a functional independence measure (FIM™), which can be used at any stage of the hospital admission to determine progress, discharge destination and goal setting.
Estimated cost per bed day using Total Absorption costing13 was assessed in the acute and rehabilitation setting. The functional status at discharge was available from AROC data set in only 403 (40%) patients before and 80 (50%) during the trial.
Statistical analysis
Data analysed using SAS 9.3. Wilcoxon Rank Sum test was carried out to assess differences between the two groups. Statistical significance was determined with p-value less than 0.05. Operation types were also compared using Chi-square test. Figures are presented using SPS, which has been adjusted for trend and cyclical variation. Projections of expected volume based on the previous 12-month trends are made from the point of the pilot intervention.
Results
The demography of the patient groups are shown in Table 2, including fracture type and operative intervention.
Table 1: Age, gender, fracture and operation type in before and after fast track patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
Eighty-four percent of patients were fast tracked from the emergency department to the acute surgical wards, 77% went to a ward designated for these injuries and another 18% were transferred to other orthopaedic beds. A small percentage were transferred to the orthopaedic trauma unit because of co-existing medical/surgical issues.
Sixteen percent were not fast tracked because they were either inter-hospital transfers, young patients with hip fractures and thus treated differently, medically unwell or had been wrongly classified and had peri-prosthetic or sub-trochanteric or pathological fractures. This group was not included in the analysis.
Anaesthetic procedure was not significantly different between pre- and post-fast track groups. General anaesthetic was performed in 68% of the fast track group and 59% of the pre-fast track group, spinal anaesthetic 21% (31% pre) and regional anaesthetic block 3% (4% pre). There were a small number of other anaesthetic procedures that did not significantly differ between groups (ie, femoral/sciatic lumbar plexus blocks).
Emergency department
As demonstrated in Figure 2, the average time in the ED compared with the previous year decreased by half an hour (p=0.0001). All facets of the ED process appeared to contribute to this time reduction.
Figure 2: Average time in emergency department pre- and post-fast track process.
The average wait for theatre decreased by 3.6 hours (p=0.044) and the average time in theatre decreased by approximately 15 minutes (p<0.0001). The comorbidities that affected the wait for theatre are listed in Table 2 and were not different from the pre-study group. The most common was the use of “anti-coagulant like agents” in 17.5% of patients. Only Clopidogrel significantly delayed the time to theatre with an average of 3.35 days. Warfarin was ceased pre-op with a delay of 1.8 days and other agents such as Dabigatran and Dipyridamole had no effect. Aspirin was continued in most patients unless post-operation bleeding was an issue.
Table 2: Co-morbidities of before and after fast track hip fracture patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
The average time to rehabilitation decreased by almost three days (p<0.0001) and was seen in both ORU 21/2 days (p<0.0001) and Older Person’s Rehabilitation 31/2 days (p<0.0001). The overall total rehabilitation time decreased by almost seven days (p<0.0001) in ORU but only three days (p=0.048) in Older Person’s Rehabilitation. The overall length of stay during the fast track pathway decreased by approximately four days (p=0.0001). Table 3 shows data on wait times and LOS.
Table 3: Comparison in pathway activities between the before intervention group (n=989, 01/12 → 11/14) and the after intervention group (n=161, 11/14 → 04/15).
P-values for comparison * <0.05 ** <0.01 *** <0.001
Average times in components of pathway—ED = Emergency Department LOS = Length of Stay, ORU = Orthopaedic Rehabilitation Unit, OPH = Older Person’s Health, with time related variable and significance.
The total readmission rate and total orthopaedic admissions remained the same over the course of the study.
Functional status pre- and post-fast track
The average FIM gain was unchanged compared with before (n=403) at 28.9% and during the trial (n=80) at 29.0% (see Figure 3). The missing data was due to incorrect coding status.
Figure 3: Functional improvement at discharge so far.
On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved (467 acute bed days and 164 rehabilitation bed days) with a projected annual bed days saving of 1,564 bed days. Using Total Absorption Costing (TAC)13 the estimated cost per bed day in the acute setting is NZD1,200 and NZD850 in the rehabilitation setting (CDHB, 2015). Therefore, over the trial period the bed days stay equate to a projected saving of NZD699,800 across the whole of care pathway.
Discussion
We have shown that by altering the clinical management of fractured neck of femur patients that present to the ED can be admitted, operated on and undergo rehabilitation prior to discharge resulting in significant reduction in length of stay without compromising the patient.
In the ED, the average time reduced from 3.46 hours to 2.9 hours and although our target was 90 minutes, this is clearly a change in the right direction. This enabled the patient to get to the ward quicker, to be assessed, rehydrated, renourished and if necessary, additional medical and surgical co-morbidities addressed prior to theatre. The average wait for theatre has changed little from 1.62 days down to 1.47 days, and although this is statistically significant, the overall distribution would indicate that this is not clinically significant. This has led to a careful examination into the wait for theatre, including operating theatre assignment and use. Eligibility for transfer to rehabilitation 48 hours after their surgery reduced the time people wait for rehabilitation from 6.27 days to 3.61 days, and of greater importance was the reduced overall rehabilitation length of stay (from 24.24 to 17.46 days) when patients undergo focused orthopaedic rehabilitation. Although time to transfer to an Older Person’s Rehabilitation institution had decreased from 7.84 days to 4.2 days, the overall length stay at this institution continued to be long at 30.43 days (previously 33.71 days p=0.048). Although this study compares a historical group with the current fast track patients, we believe that the groups were comparable as during this pilot study period there was no significant increases in readmissions (<1%), the mortality rate remained stable (6%) and there was also no significant difference in co-morbidities or fracture types, and the functional gains experienced by patients were similar.
By using a statistically-based approach to analysing, interpreting and visually presenting the data, SFN helped to quickly identify that the changes in clinical management were effective. SFN was able to be viewed by staff on a weekly basis, using quantitative clinical measures. In addition, SFN’s powerful ‘point and click’ analytics enabled the users to follow through an assessment into any aspect of the patient pathway in real time using patient data (Lightfoot, 2015).11 This analysis is a key feature that enabled cross-functional teams to explore the root causes of process issues and to agree on the actions required to improve patient outcomes, therefore creating a high level of engagement with all clinical and non-clinical staff.
The beneficial effects of integration and co-operation through all departments involved in the management of fractured neck of femur was key to the implementation of the process and the results that were obtained. We have used accepted methods of management of hip fracture patients that are laid down by the Australian and New Zealand Guidelines.1 The clinical management of the patients is not significantly different from previously published work.1,5 The surgical procedures and anaesthetic methods are not significantly different and are in line with a recent published review on the orthopaedic medical management of the frail older patient.6,13,15
To our knowledge this is the only study to have used data integration coupled with significant change in the clinical management of hip fracture patients. Our total length of stay is comparable to other models of care, but ours is a joint model of care with a management of patients that is shared between surgeons and physicians. We have shown, however, that the length of stay of the fast track neck of femur patients can be substantially reduced. We first trialled these models of care in the 1990’s5 and they have been shown by others to be effective in reducing the length of stay15,16 and post-operative complication rates.16 The approach to clinician-led hip fracture management, audit and databases has led to substantial improvements in care and survival of older people with hip fractures.17
The importance of this pilot study shows that co-operation between departments with the aim of maintaining and improving clinical care but also trying to reduce the length of stay has been beneficial. The key to this outcome has been the rapid acquisition of data via the SFN system that enables early and robust measurement of the effects of change in practice.
The strength of this pilot study shows that the changes can be driven by weekly analysis of routinely collected data, which did not require manual collection of data and did not impact upon clinical time. The acquisition of data enabled the pathway to be monitored and protocols to be changed appropriately. During this pilot study there were no negative indicators, such as increased readmissions, mortality rates, different co-morbidities or change in functional improvement post-operatively. For the patient it meant that they spent an average of 95 hours less in hospital and co-operation between the acute and the rehabilitation setting was clearly beneficial.
The limitations of this study are that it is a pilot study over a 5-month period. The pathway has yet to be tested with larger numbers of patients and the impact of winter. Our work flow is not subject to seasonal change but overall numbers of NOF patients seem to be increasing along with the complexity of fractures and co-morbidities. Our hospital is a large tertiary hospital and the demands on its theatres are considerable. We were unable to make a significant impact in the wait for theatre and this is a limitation of this pilot study. Another limitation is that just under 20% of patients who were not fast tracked have not been analysed as part of this analysis, and this may impact on the results and conclusions reached. We have not addressed in this paper the impact of community rehabilitation programmes in this group of patients.
The clinical relevance of this paper is obvious. Patients spend less time in hospital, with a reduction in bed days and subsequent financial savings. The integration of the SFN system and the ability to interpret this data quickly and modify the pathway is a significant improvement to patient management.
Of importance, focused orthopaedic rehabilitation produced the greatest reduction in the length of stay and possible benefit to patients, whereas non-orthopaedic focused rehabilitation in another hospital did not show significant reduction in the length of stay. There are many reasons for this, including frailty, co-morbidities and cognitive impairment, but this does signal that targeted orthopaedic rehabilitation should be the focus of any changes to the current system. Better understanding of the impact of frailty on hip fracture patients may help us manage these patients better by focusing our efforts on treating frailty.18 The longer waiting list and time for OPH reflected the more complex nature of patients and co-morbidities. This hospital now contributes to the Australian and New Zealand Hip Fracture Registry.
Conclusions
This study has shown with meaningful inter-departmental co-operation and modification of existing guidelines on fractured neck of femur patient treatment resulted in significant reduction in length of stay in all areas. The ED time was significantly reduced, (p<0.0001) time to theatre was not improved (p=0.044) and time patients had to wait to go the rehabilitation (p<0.0001) as well as the time in rehabilitation overall was significantly reduced (p<0.0001). Of interest, focused orthopaedic rehabilitation was far more effective than non-focused orthopaedic rehabilitation. The use of the SFN tool to acquire and analyse data has enabled significant improvements to the monitoring on a week by week basis. This is currently undergoing modifications and is an ongoing project.
Summary
Abstract
The increasing elderly population and subsequent rise in total hip fracture(s) in this group means more effective management strategies are necessary to improve efficiency. We have changed our patient care strategy from the emergency department (ED), acute orthopaedic wards, operating theatre, post-operation and rehabilitation, and called it Fracture Neck of Femur Fast Track Pathway. All clinical data and actions were captured, integrated and displayed on a weekly basis using signalfromnoise (SFN) software. The initial four months analysis of this project showed significant improvement in patient flow within the hospitals. The overall length of stay was reduced by four days. Time in ED was reduced by 30 minutes, and the wait for rehabilitation reduced by three days. Overall time in rehabilitation reduced by 3-7 days depending on facility. On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved in this period, with projected savings of NZD700,000. No adverse effects were seen in mortality, readmission and functional improvement status. Fractured neck of femur has increasing clinical demand in a busy tertiary hospital. Length of stay, co-morbidities and waiting time for theatres are seen as major barriers to treatment for these conditions. Wait for rehabilitation can significantly lengthen hospital stay; also poor communication between the individual hospital management facets of this condition has been an ongoing issue. Lack of instant and available electronic information on this patient group has also been seen as a major barrier to improvement. This paper demonstrates how integration of service components that are involved in fractured neck of femur can be achieved. It also shows how the use of electronic data capture and analysis can give a very quick and easily interpretable data trend that will enable change in practice. This paper indicates that cooperation between health professionals and practitioners can significantly improve the length of stay and the time in which patients can be returned home. Full interdisciplinary involvement was the key to this approach. The use of electronic data capture and analysis can be used in many other health pathways within the health system.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Australian and New Zealand guideline for hip fracture care: Improving outcomes in hip fracture management of adults. Sydney: Australian and New Zealand hip fracture registry steering group; 2014.
- Atlas for healthcare variation New Zealand: Health quality and safety commission; 2015.
- Boufous S, Finch CF, Lord S. Incidence of hip fracture in New South Wales: are our efforts having an effort? Medical Journal of Australia. 2004; 180:623–6.
- Barber J, Mills H, Horne G, et al. The incidence of hip fractures in Māori and non-Māori in New Zealand. NZ Med J. 1995 Sept 8; 108(1007):367–8.
- Thwaites J, Mann F, Gilchrist N, et al. Shared care between geriatricians and orthopaedic surgeons as a model for care for older patients with hip fractures. NZ Med J. 2005 May 6; 118(1214).
- Weatherall M. Case mix and outcome for patients with fracture of the proximal femur. NZ Med J. 1993;106:451-2.
- Hall K, Wilson K, Gilchrist N, et al. Fractured neck of femur pathway project – final report to ACC (CDHB internal report); 2005 Sep 29.
- Elliot, JR, Wilkinson TJ, Hanger HC, et al. The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. NZ Med J. 1996; 109:72–3.
- Australian New Zealand Hip Fracture Registry. http://www.anzhfr.org
- Atlas of Healthcare Variation; Health Quality & Safety Commission; 2016. http://www.hqsc.govt.nz
- Signalsfromnoise. Lightfoot Solutions Ltd; 2015. http://www.lightfootsolutions.com/
- What is AROC? retrieved Australasian Rehabilitation Outcomes Centre; 2012 Feb 12 from http://ahrsi.uow.edu/aroc/whatisaroc/index.html
- Marshall DH, McManus WW, Viele DF. Accounting: What the numbers mean: McGaw-Hill Higher Education; 2010.
- Sabharwal S, Wilson H. Orthogeriatrics in management of frail older patients with a fragility fracture. Osteoporosis Int. 2015; 26:2387–2399.
- Vidan M, Serra JA, Moreno C, et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005; 53:1476–1482.
- Friedman SM, Mendelson DA, Bingham KW, et al. Impact of a comanaged geriatric fracture centre on short-term hip fracture outcomes. Arch Intern Med. 2009; 169:1712–1717.
- Neuburger J, Currie C, Wakeman R, et al. Medical Care Vol 53, No: 2015 Aug, pp 686–691.
- Li G, Papaioannou A, Thabane L, et al. Frailty change and major osteoporotic fracture in the elderly: Data from the global longitudinal study of osteoporosis in women 3-year Hamilton cohort. JBMR. 2016 Apr; Vol 31, No. 4, pp 718–724.
For the PDF of this article,
contact nzmj@nzma.org.nz
Enhanced hip fracture management: use of statistical methods and dataset to evaluate a fractured neck of femur fast track pathway—pilot study
View Article PDF
In New Zealand, approximately 3,500 people over the age of 50 were hospitalised with a hip fracture in 2013 with the majority being related to falls.1 The rate of hip fracture increases significantly with age with nearly half of the hip fractures occurring in those aged 85 years or older.2 Although the incidence appears to be falling, the absolute number of hip fractures is increasing with longer life expectancy.3
It appears that the fracture rate is at least 25–50% higher in Europeans than in Pacific Islanders or Māori, but this rate is predicted to equalise with the increasing life span of the Māori and Polynesian population.4 The care of these patients varies both nationally and internationally.4 Service provision was initially surgically managed, but has evolved into a shared care model with Health Care of the Elderly Physicians.5,6 In our centre we established a Fractured Neck of Femur Pathway in 2007,7 which has significantly improved the outcomes of such patients.7 Recently, guidelines have been established for both Australia and New Zealand, outlining the standard of care from admission to the emergency department, peri-operative care, operative optimisation, rehabilitation and appropriate discharge from hospital.1 Experience has shown that this model reduces length of stay and improves cost efficiency.8 Another recent improvement has been the establishment of a hip fracture registry, which will be able to identify all hip fractures in Australia and New Zealand, to accurately classify them and provide an integrated database for this complex group of patients.9 Our hospital admits the largest number of hip fractures (>500/year) for a single hospital in New Zealand10 and has been a leader in the field of innovative management of hip fracture patients. As a tertiary hospital with a large number of acute orthopaedic admissions (4,748 in 2014), evaluation of an effective treatment pathway for these patients has become important to use the finite resources efficiently.
The introduction of a weekly analytical dataset, ‘signalfromnoise’ (SFN) within our district health board is introducing a new way in which clinical staff working within the patient pathway can clearly and quickly understand the implications of any change in patient management. SFN (proprietary software from Lightfoot Solutions)11 helps to identify variations, trends and patterns, which allows the assessment of the introduction of change in clinical practice from admission to the emergency department (ED), peri-operative management, rehabilitation and discharge. Previous patient management was independently managed with some information shared between services.
This study presents the initial results of this clinically-led pilot study in the change of the clinical management of hip fracture patients.
Methods
This fast track pathway was designed to improve the patient journey throughout all phases of their hospital admission from emergency department (ED), the peri-operative process, rehabilitation and planned discharge home. This involved all departments and staff from emergency, acute orthopaedic ward staff, anaesthetic department, surgeons, orthopaedic medicine/rehabilitation service and rehabilitation wards.
The elements of this pathway were mutually agreed by all parties in the period leading up to the introduction of the pathway. Measurement of the effectiveness of this pathway was enabled through the introduction of SFN data visualisation and analysis template that enabled quick and efficient evaluation of all parts of the pathway.11
SFN uses the principles of Statistical Process Control (SPC) to analyse and disseminate information about patient flow across the whole healthcare system. It includes a web-based interface that provides users with an ‘at a glance’ understanding of processes and improvement initiatives (Lightfoot, 2015).11 SFN uses routine information collected in the district health board (DHB) patient management systems, including ED, operating theatres and inpatients wards. This new information is present in a dashboard format with weekly update and a drop down analysis feature that enables in depth analysis of elements of individual department activities across ED, inpatient wards, operating theatres and rehabilitation wards. Figure 1 shows some of the elements within ED that can be analysed on a week by week basis, giving the ability to quickly change or alter elements of the pathway.
Figure 1: SFN process analysis capabilities.
Patients with hip fracture are usually transported to the ED by ambulance where the ambulance staff often identify the possibility of hip fracture on their arrival in the ED. These patients are rapidly assessed by medical and nursing staff, comorbid conditions identified and treated, analgesia initiated, blood tests performed and x-rays requested. It was observed at an early stage that some patients arrived into a busy ED and concurrent nursing/medical responsibilities could delay care of those patients with hip fracture. The pathway empowered and enabled nursing staff to initiate care and significantly progress the ED phase of the care. Once the hip fracture is identified on x-ray, the orthopaedic team are notified, but further orthopaedic assessment of the patient is carried out once admitted directly to an orthopaedic ward bed. Education was provided early in the course of the new approach and all staff were motivated to provide care according to the pathway and expedite transfer to the orthopaedic ward bed. Fundamental to this improvement was to encourage orthopaedic assessment of the patient on the orthopaedic ward rather than in ED. On admission to the acute orthopaedic ward, every possible attempt was made for the patient to be operated on that day or the subsequent morning.
A system was put in place where the Charge Nurse on the admitting orthopaedic ward would text page the duty anaesthetist as soon as a fast track admission arrived on the ward. For those admissions before 4:00 pm an anaesthetic assessment of the patient would be made regarding suitability for operating theatre first thing the following morning. This enabled any outstanding investigations such as blood tests, chest x-ray, cardiac echocardiography or coagulation studies to be arranged, consultation referrals to be made and medications such as anticoagulants to be stopped (and possibly reversed) in a timely manner. This would then ensure the patient was ready for theatre the next morning, preventing unnecessary fasting of patients and reduced last-minute cancellations with a significant impact on theatre room utilisation. If there were problems identified that would preclude operation the next morning then this information was communicated to the acute orthopaedic team so they could adjust the operating schedule accordingly.
Anaesthesia was provided by an anaesthetic consultant or senior registrar wherever possible, with the technique chosen dependent on both patient factors and anaesthetist’s personal preference.
The patients are admitted to an orthopaedic ward that specialises in the management of neck of femur fractures and has dedicated beds for this purpose. Nursing cares are instituted in a standardised fashion.
Registrar assessment (orthopaedic, orthopaedic medicine and anaesthetic) is then undertaken. The confirmation of the diagnosis and exclusion of other injuries or active comorbidities is made, and if present, these are also dealt with at the time of initial admission. Patients are placed on the booking system, ‘Scope’, and depending on the time on the day of admission, a decision is made regarding fasting status. Generally, the patients receive their surgery in the ensuing day(s) and therefore they are not kept nil by mouth and high-carbohydrate fluids and food commenced.
Pre-operative anaesthetic review and orthopaedic medical reviews are undertaken and any peri-operative risk is identified and mitigated with proactive intervention.
Dedicated time within an acute operating theatre is utilised for neck of femur fractures and priority is given whenever possible to this patient group.
The surgical procedure involves the administration of an anaesthetic, IV antibiotics and patient positioning, and depending on the configuration of the fracture pattern the position varies. For a hemiarthroplasty or total hip replacement, patients are positioned in the lateral decubitus position and generally a lateral approach to the hip is undertaken. This approach is felt to reduce the risk of dislocation by preserving the posterior capsule and careful attention is paid to repairing the vertical incision in the capsule and the gluteal muscles.
For intertrochanteric and subcapital neck of femur fractures treated with closed reduction and internal fixation, a supine position is utilised with the use of a traction table and image-intensifier navigation. A direct lateral approach is made, preservation of the vastus lateralis is attempted and metalware is placed in a fluoroscopic-guided fashion. A drain may be placed and generally, subcuticular dissolvable sutures are used to repair the incision site. Dressings are then applied.
The patients are then transferred to the orthopaedic ward following transfer from recovery, and antibiotics (Cefazolin 2gms) are instituted for two further doses post-operatively. DVT prophylaxis is undertaken and the patients are mobilised early with the assistance of the physiotherapy team. X-rays are taken post-operatively and this is repeated at six weeks to ensure that fracture union is satisfactory and alignment remains acceptable. Patients are reviewed if problems arise in the post-operative period after discharge from hospital.
Rehabilitation
It was agreed that all patients should be suitable for rehabilitation and weight bearing at 48 hours post-operatively. This meant implicitly that these patients would be well enough both medically and surgically to be transferred to the appropriate rehabilitation facility. In Canterbury there are two rehabilitation facilities. The first is a dedicated orthopaedic rehabilitation facility, which manages most of the older people with orthopaedic conditions that require rehabilitation. This unit is situated at another hospital and is integrated within the Department of Orthopaedic Surgery (Orthopaedic Rehabilitation Unit (ORU)). The more medically and cognitively compromised are mostly transferred to another hospital because of the more complex nature of their ongoing medical and social issues and the availability of medical/nursing staff and intensive diagnostic facilities (Older Person’s Rehabilitation). The decision as to which institution they are transferred to is made pre-operatively or immediately post-operatively. The rehabilitation process is very similar to those previously described5 and involves a multi-disciplinary team, which includes nursing, medical, occupational therapists, physiotherapists and social workers. The aim is to get people as independently mobile as possible and return them to their home and facilities or to find appropriate placement should this be needed.
There is small group (<5%) of patients that, because of the complex nature of their fracture and subsequent surgery, are unable to weight bear for mechanical implant and healing reasons. These patients are transferred to another hospital (88kms from our facility) for a period of between two to six weeks when they undergo orthopaedic review and a decision made to weight bear and then transferred to ORU for rehabilitation but are not included here for analysis. Those who were not fast tracked because of medical/surgical unsuitability were not subject to this analysis but will be in future.
Fast Track study
The Fast Track pilot study began in November 2014 and continued to the end of April 2015. A similar group of patients from the previous three years were used for comparison. All patients admitted with a fracture neck of femur were included except those patients who were younger than 65 years old, had operation times longer than three hours or who ended up in convalescent care or unknown discharge facilities.
The pathway patient flow data were then compared for the following indicators: time spent in the ED, waiting time for theatre, waiting time for rehabilitation, time spent in acute service and time spent in rehabilitation as well as total length of stay. Sub-group analysis was then performed for eligible discharge and/or rehabilitation facilities. Data was also collected on discharge destination, readmissions and functional status, and compared with the pre-pilot study group Australian Rehabilitation Outcome Centre (AROC data).12 This includes the standardised use of the Functional Independence Measurement tool (FIM™). FIM™ measures 18 items of function, (13 motor and five cognitive). It is scaled from one to seven, with seven being completely independent with a specific activity and one indicating that full assistance is required. It is based on activity over a 24-hour period and guided by observations made by staff over different shifts. Some of the activities include toileting, continence and mobility, etc. The activities are scored giving a functional independence measure (FIM™), which can be used at any stage of the hospital admission to determine progress, discharge destination and goal setting.
Estimated cost per bed day using Total Absorption costing13 was assessed in the acute and rehabilitation setting. The functional status at discharge was available from AROC data set in only 403 (40%) patients before and 80 (50%) during the trial.
Statistical analysis
Data analysed using SAS 9.3. Wilcoxon Rank Sum test was carried out to assess differences between the two groups. Statistical significance was determined with p-value less than 0.05. Operation types were also compared using Chi-square test. Figures are presented using SPS, which has been adjusted for trend and cyclical variation. Projections of expected volume based on the previous 12-month trends are made from the point of the pilot intervention.
Results
The demography of the patient groups are shown in Table 2, including fracture type and operative intervention.
Table 1: Age, gender, fracture and operation type in before and after fast track patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
Eighty-four percent of patients were fast tracked from the emergency department to the acute surgical wards, 77% went to a ward designated for these injuries and another 18% were transferred to other orthopaedic beds. A small percentage were transferred to the orthopaedic trauma unit because of co-existing medical/surgical issues.
Sixteen percent were not fast tracked because they were either inter-hospital transfers, young patients with hip fractures and thus treated differently, medically unwell or had been wrongly classified and had peri-prosthetic or sub-trochanteric or pathological fractures. This group was not included in the analysis.
Anaesthetic procedure was not significantly different between pre- and post-fast track groups. General anaesthetic was performed in 68% of the fast track group and 59% of the pre-fast track group, spinal anaesthetic 21% (31% pre) and regional anaesthetic block 3% (4% pre). There were a small number of other anaesthetic procedures that did not significantly differ between groups (ie, femoral/sciatic lumbar plexus blocks).
Emergency department
As demonstrated in Figure 2, the average time in the ED compared with the previous year decreased by half an hour (p=0.0001). All facets of the ED process appeared to contribute to this time reduction.
Figure 2: Average time in emergency department pre- and post-fast track process.
The average wait for theatre decreased by 3.6 hours (p=0.044) and the average time in theatre decreased by approximately 15 minutes (p<0.0001). The comorbidities that affected the wait for theatre are listed in Table 2 and were not different from the pre-study group. The most common was the use of “anti-coagulant like agents” in 17.5% of patients. Only Clopidogrel significantly delayed the time to theatre with an average of 3.35 days. Warfarin was ceased pre-op with a delay of 1.8 days and other agents such as Dabigatran and Dipyridamole had no effect. Aspirin was continued in most patients unless post-operation bleeding was an issue.
Table 2: Co-morbidities of before and after fast track hip fracture patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
The average time to rehabilitation decreased by almost three days (p<0.0001) and was seen in both ORU 21/2 days (p<0.0001) and Older Person’s Rehabilitation 31/2 days (p<0.0001). The overall total rehabilitation time decreased by almost seven days (p<0.0001) in ORU but only three days (p=0.048) in Older Person’s Rehabilitation. The overall length of stay during the fast track pathway decreased by approximately four days (p=0.0001). Table 3 shows data on wait times and LOS.
Table 3: Comparison in pathway activities between the before intervention group (n=989, 01/12 → 11/14) and the after intervention group (n=161, 11/14 → 04/15).
P-values for comparison * <0.05 ** <0.01 *** <0.001
Average times in components of pathway—ED = Emergency Department LOS = Length of Stay, ORU = Orthopaedic Rehabilitation Unit, OPH = Older Person’s Health, with time related variable and significance.
The total readmission rate and total orthopaedic admissions remained the same over the course of the study.
Functional status pre- and post-fast track
The average FIM gain was unchanged compared with before (n=403) at 28.9% and during the trial (n=80) at 29.0% (see Figure 3). The missing data was due to incorrect coding status.
Figure 3: Functional improvement at discharge so far.
On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved (467 acute bed days and 164 rehabilitation bed days) with a projected annual bed days saving of 1,564 bed days. Using Total Absorption Costing (TAC)13 the estimated cost per bed day in the acute setting is NZD1,200 and NZD850 in the rehabilitation setting (CDHB, 2015). Therefore, over the trial period the bed days stay equate to a projected saving of NZD699,800 across the whole of care pathway.
Discussion
We have shown that by altering the clinical management of fractured neck of femur patients that present to the ED can be admitted, operated on and undergo rehabilitation prior to discharge resulting in significant reduction in length of stay without compromising the patient.
In the ED, the average time reduced from 3.46 hours to 2.9 hours and although our target was 90 minutes, this is clearly a change in the right direction. This enabled the patient to get to the ward quicker, to be assessed, rehydrated, renourished and if necessary, additional medical and surgical co-morbidities addressed prior to theatre. The average wait for theatre has changed little from 1.62 days down to 1.47 days, and although this is statistically significant, the overall distribution would indicate that this is not clinically significant. This has led to a careful examination into the wait for theatre, including operating theatre assignment and use. Eligibility for transfer to rehabilitation 48 hours after their surgery reduced the time people wait for rehabilitation from 6.27 days to 3.61 days, and of greater importance was the reduced overall rehabilitation length of stay (from 24.24 to 17.46 days) when patients undergo focused orthopaedic rehabilitation. Although time to transfer to an Older Person’s Rehabilitation institution had decreased from 7.84 days to 4.2 days, the overall length stay at this institution continued to be long at 30.43 days (previously 33.71 days p=0.048). Although this study compares a historical group with the current fast track patients, we believe that the groups were comparable as during this pilot study period there was no significant increases in readmissions (<1%), the mortality rate remained stable (6%) and there was also no significant difference in co-morbidities or fracture types, and the functional gains experienced by patients were similar.
By using a statistically-based approach to analysing, interpreting and visually presenting the data, SFN helped to quickly identify that the changes in clinical management were effective. SFN was able to be viewed by staff on a weekly basis, using quantitative clinical measures. In addition, SFN’s powerful ‘point and click’ analytics enabled the users to follow through an assessment into any aspect of the patient pathway in real time using patient data (Lightfoot, 2015).11 This analysis is a key feature that enabled cross-functional teams to explore the root causes of process issues and to agree on the actions required to improve patient outcomes, therefore creating a high level of engagement with all clinical and non-clinical staff.
The beneficial effects of integration and co-operation through all departments involved in the management of fractured neck of femur was key to the implementation of the process and the results that were obtained. We have used accepted methods of management of hip fracture patients that are laid down by the Australian and New Zealand Guidelines.1 The clinical management of the patients is not significantly different from previously published work.1,5 The surgical procedures and anaesthetic methods are not significantly different and are in line with a recent published review on the orthopaedic medical management of the frail older patient.6,13,15
To our knowledge this is the only study to have used data integration coupled with significant change in the clinical management of hip fracture patients. Our total length of stay is comparable to other models of care, but ours is a joint model of care with a management of patients that is shared between surgeons and physicians. We have shown, however, that the length of stay of the fast track neck of femur patients can be substantially reduced. We first trialled these models of care in the 1990’s5 and they have been shown by others to be effective in reducing the length of stay15,16 and post-operative complication rates.16 The approach to clinician-led hip fracture management, audit and databases has led to substantial improvements in care and survival of older people with hip fractures.17
The importance of this pilot study shows that co-operation between departments with the aim of maintaining and improving clinical care but also trying to reduce the length of stay has been beneficial. The key to this outcome has been the rapid acquisition of data via the SFN system that enables early and robust measurement of the effects of change in practice.
The strength of this pilot study shows that the changes can be driven by weekly analysis of routinely collected data, which did not require manual collection of data and did not impact upon clinical time. The acquisition of data enabled the pathway to be monitored and protocols to be changed appropriately. During this pilot study there were no negative indicators, such as increased readmissions, mortality rates, different co-morbidities or change in functional improvement post-operatively. For the patient it meant that they spent an average of 95 hours less in hospital and co-operation between the acute and the rehabilitation setting was clearly beneficial.
The limitations of this study are that it is a pilot study over a 5-month period. The pathway has yet to be tested with larger numbers of patients and the impact of winter. Our work flow is not subject to seasonal change but overall numbers of NOF patients seem to be increasing along with the complexity of fractures and co-morbidities. Our hospital is a large tertiary hospital and the demands on its theatres are considerable. We were unable to make a significant impact in the wait for theatre and this is a limitation of this pilot study. Another limitation is that just under 20% of patients who were not fast tracked have not been analysed as part of this analysis, and this may impact on the results and conclusions reached. We have not addressed in this paper the impact of community rehabilitation programmes in this group of patients.
The clinical relevance of this paper is obvious. Patients spend less time in hospital, with a reduction in bed days and subsequent financial savings. The integration of the SFN system and the ability to interpret this data quickly and modify the pathway is a significant improvement to patient management.
Of importance, focused orthopaedic rehabilitation produced the greatest reduction in the length of stay and possible benefit to patients, whereas non-orthopaedic focused rehabilitation in another hospital did not show significant reduction in the length of stay. There are many reasons for this, including frailty, co-morbidities and cognitive impairment, but this does signal that targeted orthopaedic rehabilitation should be the focus of any changes to the current system. Better understanding of the impact of frailty on hip fracture patients may help us manage these patients better by focusing our efforts on treating frailty.18 The longer waiting list and time for OPH reflected the more complex nature of patients and co-morbidities. This hospital now contributes to the Australian and New Zealand Hip Fracture Registry.
Conclusions
This study has shown with meaningful inter-departmental co-operation and modification of existing guidelines on fractured neck of femur patient treatment resulted in significant reduction in length of stay in all areas. The ED time was significantly reduced, (p<0.0001) time to theatre was not improved (p=0.044) and time patients had to wait to go the rehabilitation (p<0.0001) as well as the time in rehabilitation overall was significantly reduced (p<0.0001). Of interest, focused orthopaedic rehabilitation was far more effective than non-focused orthopaedic rehabilitation. The use of the SFN tool to acquire and analyse data has enabled significant improvements to the monitoring on a week by week basis. This is currently undergoing modifications and is an ongoing project.
Summary
Abstract
The increasing elderly population and subsequent rise in total hip fracture(s) in this group means more effective management strategies are necessary to improve efficiency. We have changed our patient care strategy from the emergency department (ED), acute orthopaedic wards, operating theatre, post-operation and rehabilitation, and called it Fracture Neck of Femur Fast Track Pathway. All clinical data and actions were captured, integrated and displayed on a weekly basis using signalfromnoise (SFN) software. The initial four months analysis of this project showed significant improvement in patient flow within the hospitals. The overall length of stay was reduced by four days. Time in ED was reduced by 30 minutes, and the wait for rehabilitation reduced by three days. Overall time in rehabilitation reduced by 3-7 days depending on facility. On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved in this period, with projected savings of NZD700,000. No adverse effects were seen in mortality, readmission and functional improvement status. Fractured neck of femur has increasing clinical demand in a busy tertiary hospital. Length of stay, co-morbidities and waiting time for theatres are seen as major barriers to treatment for these conditions. Wait for rehabilitation can significantly lengthen hospital stay; also poor communication between the individual hospital management facets of this condition has been an ongoing issue. Lack of instant and available electronic information on this patient group has also been seen as a major barrier to improvement. This paper demonstrates how integration of service components that are involved in fractured neck of femur can be achieved. It also shows how the use of electronic data capture and analysis can give a very quick and easily interpretable data trend that will enable change in practice. This paper indicates that cooperation between health professionals and practitioners can significantly improve the length of stay and the time in which patients can be returned home. Full interdisciplinary involvement was the key to this approach. The use of electronic data capture and analysis can be used in many other health pathways within the health system.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Australian and New Zealand guideline for hip fracture care: Improving outcomes in hip fracture management of adults. Sydney: Australian and New Zealand hip fracture registry steering group; 2014.
- Atlas for healthcare variation New Zealand: Health quality and safety commission; 2015.
- Boufous S, Finch CF, Lord S. Incidence of hip fracture in New South Wales: are our efforts having an effort? Medical Journal of Australia. 2004; 180:623–6.
- Barber J, Mills H, Horne G, et al. The incidence of hip fractures in Māori and non-Māori in New Zealand. NZ Med J. 1995 Sept 8; 108(1007):367–8.
- Thwaites J, Mann F, Gilchrist N, et al. Shared care between geriatricians and orthopaedic surgeons as a model for care for older patients with hip fractures. NZ Med J. 2005 May 6; 118(1214).
- Weatherall M. Case mix and outcome for patients with fracture of the proximal femur. NZ Med J. 1993;106:451-2.
- Hall K, Wilson K, Gilchrist N, et al. Fractured neck of femur pathway project – final report to ACC (CDHB internal report); 2005 Sep 29.
- Elliot, JR, Wilkinson TJ, Hanger HC, et al. The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. NZ Med J. 1996; 109:72–3.
- Australian New Zealand Hip Fracture Registry. http://www.anzhfr.org
- Atlas of Healthcare Variation; Health Quality & Safety Commission; 2016. http://www.hqsc.govt.nz
- Signalsfromnoise. Lightfoot Solutions Ltd; 2015. http://www.lightfootsolutions.com/
- What is AROC? retrieved Australasian Rehabilitation Outcomes Centre; 2012 Feb 12 from http://ahrsi.uow.edu/aroc/whatisaroc/index.html
- Marshall DH, McManus WW, Viele DF. Accounting: What the numbers mean: McGaw-Hill Higher Education; 2010.
- Sabharwal S, Wilson H. Orthogeriatrics in management of frail older patients with a fragility fracture. Osteoporosis Int. 2015; 26:2387–2399.
- Vidan M, Serra JA, Moreno C, et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005; 53:1476–1482.
- Friedman SM, Mendelson DA, Bingham KW, et al. Impact of a comanaged geriatric fracture centre on short-term hip fracture outcomes. Arch Intern Med. 2009; 169:1712–1717.
- Neuburger J, Currie C, Wakeman R, et al. Medical Care Vol 53, No: 2015 Aug, pp 686–691.
- Li G, Papaioannou A, Thabane L, et al. Frailty change and major osteoporotic fracture in the elderly: Data from the global longitudinal study of osteoporosis in women 3-year Hamilton cohort. JBMR. 2016 Apr; Vol 31, No. 4, pp 718–724.
For the PDF of this article,
contact nzmj@nzma.org.nz
Enhanced hip fracture management: use of statistical methods and dataset to evaluate a fractured neck of femur fast track pathway—pilot study
View Article PDF
In New Zealand, approximately 3,500 people over the age of 50 were hospitalised with a hip fracture in 2013 with the majority being related to falls.1 The rate of hip fracture increases significantly with age with nearly half of the hip fractures occurring in those aged 85 years or older.2 Although the incidence appears to be falling, the absolute number of hip fractures is increasing with longer life expectancy.3
It appears that the fracture rate is at least 25–50% higher in Europeans than in Pacific Islanders or Māori, but this rate is predicted to equalise with the increasing life span of the Māori and Polynesian population.4 The care of these patients varies both nationally and internationally.4 Service provision was initially surgically managed, but has evolved into a shared care model with Health Care of the Elderly Physicians.5,6 In our centre we established a Fractured Neck of Femur Pathway in 2007,7 which has significantly improved the outcomes of such patients.7 Recently, guidelines have been established for both Australia and New Zealand, outlining the standard of care from admission to the emergency department, peri-operative care, operative optimisation, rehabilitation and appropriate discharge from hospital.1 Experience has shown that this model reduces length of stay and improves cost efficiency.8 Another recent improvement has been the establishment of a hip fracture registry, which will be able to identify all hip fractures in Australia and New Zealand, to accurately classify them and provide an integrated database for this complex group of patients.9 Our hospital admits the largest number of hip fractures (>500/year) for a single hospital in New Zealand10 and has been a leader in the field of innovative management of hip fracture patients. As a tertiary hospital with a large number of acute orthopaedic admissions (4,748 in 2014), evaluation of an effective treatment pathway for these patients has become important to use the finite resources efficiently.
The introduction of a weekly analytical dataset, ‘signalfromnoise’ (SFN) within our district health board is introducing a new way in which clinical staff working within the patient pathway can clearly and quickly understand the implications of any change in patient management. SFN (proprietary software from Lightfoot Solutions)11 helps to identify variations, trends and patterns, which allows the assessment of the introduction of change in clinical practice from admission to the emergency department (ED), peri-operative management, rehabilitation and discharge. Previous patient management was independently managed with some information shared between services.
This study presents the initial results of this clinically-led pilot study in the change of the clinical management of hip fracture patients.
Methods
This fast track pathway was designed to improve the patient journey throughout all phases of their hospital admission from emergency department (ED), the peri-operative process, rehabilitation and planned discharge home. This involved all departments and staff from emergency, acute orthopaedic ward staff, anaesthetic department, surgeons, orthopaedic medicine/rehabilitation service and rehabilitation wards.
The elements of this pathway were mutually agreed by all parties in the period leading up to the introduction of the pathway. Measurement of the effectiveness of this pathway was enabled through the introduction of SFN data visualisation and analysis template that enabled quick and efficient evaluation of all parts of the pathway.11
SFN uses the principles of Statistical Process Control (SPC) to analyse and disseminate information about patient flow across the whole healthcare system. It includes a web-based interface that provides users with an ‘at a glance’ understanding of processes and improvement initiatives (Lightfoot, 2015).11 SFN uses routine information collected in the district health board (DHB) patient management systems, including ED, operating theatres and inpatients wards. This new information is present in a dashboard format with weekly update and a drop down analysis feature that enables in depth analysis of elements of individual department activities across ED, inpatient wards, operating theatres and rehabilitation wards. Figure 1 shows some of the elements within ED that can be analysed on a week by week basis, giving the ability to quickly change or alter elements of the pathway.
Figure 1: SFN process analysis capabilities.
Patients with hip fracture are usually transported to the ED by ambulance where the ambulance staff often identify the possibility of hip fracture on their arrival in the ED. These patients are rapidly assessed by medical and nursing staff, comorbid conditions identified and treated, analgesia initiated, blood tests performed and x-rays requested. It was observed at an early stage that some patients arrived into a busy ED and concurrent nursing/medical responsibilities could delay care of those patients with hip fracture. The pathway empowered and enabled nursing staff to initiate care and significantly progress the ED phase of the care. Once the hip fracture is identified on x-ray, the orthopaedic team are notified, but further orthopaedic assessment of the patient is carried out once admitted directly to an orthopaedic ward bed. Education was provided early in the course of the new approach and all staff were motivated to provide care according to the pathway and expedite transfer to the orthopaedic ward bed. Fundamental to this improvement was to encourage orthopaedic assessment of the patient on the orthopaedic ward rather than in ED. On admission to the acute orthopaedic ward, every possible attempt was made for the patient to be operated on that day or the subsequent morning.
A system was put in place where the Charge Nurse on the admitting orthopaedic ward would text page the duty anaesthetist as soon as a fast track admission arrived on the ward. For those admissions before 4:00 pm an anaesthetic assessment of the patient would be made regarding suitability for operating theatre first thing the following morning. This enabled any outstanding investigations such as blood tests, chest x-ray, cardiac echocardiography or coagulation studies to be arranged, consultation referrals to be made and medications such as anticoagulants to be stopped (and possibly reversed) in a timely manner. This would then ensure the patient was ready for theatre the next morning, preventing unnecessary fasting of patients and reduced last-minute cancellations with a significant impact on theatre room utilisation. If there were problems identified that would preclude operation the next morning then this information was communicated to the acute orthopaedic team so they could adjust the operating schedule accordingly.
Anaesthesia was provided by an anaesthetic consultant or senior registrar wherever possible, with the technique chosen dependent on both patient factors and anaesthetist’s personal preference.
The patients are admitted to an orthopaedic ward that specialises in the management of neck of femur fractures and has dedicated beds for this purpose. Nursing cares are instituted in a standardised fashion.
Registrar assessment (orthopaedic, orthopaedic medicine and anaesthetic) is then undertaken. The confirmation of the diagnosis and exclusion of other injuries or active comorbidities is made, and if present, these are also dealt with at the time of initial admission. Patients are placed on the booking system, ‘Scope’, and depending on the time on the day of admission, a decision is made regarding fasting status. Generally, the patients receive their surgery in the ensuing day(s) and therefore they are not kept nil by mouth and high-carbohydrate fluids and food commenced.
Pre-operative anaesthetic review and orthopaedic medical reviews are undertaken and any peri-operative risk is identified and mitigated with proactive intervention.
Dedicated time within an acute operating theatre is utilised for neck of femur fractures and priority is given whenever possible to this patient group.
The surgical procedure involves the administration of an anaesthetic, IV antibiotics and patient positioning, and depending on the configuration of the fracture pattern the position varies. For a hemiarthroplasty or total hip replacement, patients are positioned in the lateral decubitus position and generally a lateral approach to the hip is undertaken. This approach is felt to reduce the risk of dislocation by preserving the posterior capsule and careful attention is paid to repairing the vertical incision in the capsule and the gluteal muscles.
For intertrochanteric and subcapital neck of femur fractures treated with closed reduction and internal fixation, a supine position is utilised with the use of a traction table and image-intensifier navigation. A direct lateral approach is made, preservation of the vastus lateralis is attempted and metalware is placed in a fluoroscopic-guided fashion. A drain may be placed and generally, subcuticular dissolvable sutures are used to repair the incision site. Dressings are then applied.
The patients are then transferred to the orthopaedic ward following transfer from recovery, and antibiotics (Cefazolin 2gms) are instituted for two further doses post-operatively. DVT prophylaxis is undertaken and the patients are mobilised early with the assistance of the physiotherapy team. X-rays are taken post-operatively and this is repeated at six weeks to ensure that fracture union is satisfactory and alignment remains acceptable. Patients are reviewed if problems arise in the post-operative period after discharge from hospital.
Rehabilitation
It was agreed that all patients should be suitable for rehabilitation and weight bearing at 48 hours post-operatively. This meant implicitly that these patients would be well enough both medically and surgically to be transferred to the appropriate rehabilitation facility. In Canterbury there are two rehabilitation facilities. The first is a dedicated orthopaedic rehabilitation facility, which manages most of the older people with orthopaedic conditions that require rehabilitation. This unit is situated at another hospital and is integrated within the Department of Orthopaedic Surgery (Orthopaedic Rehabilitation Unit (ORU)). The more medically and cognitively compromised are mostly transferred to another hospital because of the more complex nature of their ongoing medical and social issues and the availability of medical/nursing staff and intensive diagnostic facilities (Older Person’s Rehabilitation). The decision as to which institution they are transferred to is made pre-operatively or immediately post-operatively. The rehabilitation process is very similar to those previously described5 and involves a multi-disciplinary team, which includes nursing, medical, occupational therapists, physiotherapists and social workers. The aim is to get people as independently mobile as possible and return them to their home and facilities or to find appropriate placement should this be needed.
There is small group (<5%) of patients that, because of the complex nature of their fracture and subsequent surgery, are unable to weight bear for mechanical implant and healing reasons. These patients are transferred to another hospital (88kms from our facility) for a period of between two to six weeks when they undergo orthopaedic review and a decision made to weight bear and then transferred to ORU for rehabilitation but are not included here for analysis. Those who were not fast tracked because of medical/surgical unsuitability were not subject to this analysis but will be in future.
Fast Track study
The Fast Track pilot study began in November 2014 and continued to the end of April 2015. A similar group of patients from the previous three years were used for comparison. All patients admitted with a fracture neck of femur were included except those patients who were younger than 65 years old, had operation times longer than three hours or who ended up in convalescent care or unknown discharge facilities.
The pathway patient flow data were then compared for the following indicators: time spent in the ED, waiting time for theatre, waiting time for rehabilitation, time spent in acute service and time spent in rehabilitation as well as total length of stay. Sub-group analysis was then performed for eligible discharge and/or rehabilitation facilities. Data was also collected on discharge destination, readmissions and functional status, and compared with the pre-pilot study group Australian Rehabilitation Outcome Centre (AROC data).12 This includes the standardised use of the Functional Independence Measurement tool (FIM™). FIM™ measures 18 items of function, (13 motor and five cognitive). It is scaled from one to seven, with seven being completely independent with a specific activity and one indicating that full assistance is required. It is based on activity over a 24-hour period and guided by observations made by staff over different shifts. Some of the activities include toileting, continence and mobility, etc. The activities are scored giving a functional independence measure (FIM™), which can be used at any stage of the hospital admission to determine progress, discharge destination and goal setting.
Estimated cost per bed day using Total Absorption costing13 was assessed in the acute and rehabilitation setting. The functional status at discharge was available from AROC data set in only 403 (40%) patients before and 80 (50%) during the trial.
Statistical analysis
Data analysed using SAS 9.3. Wilcoxon Rank Sum test was carried out to assess differences between the two groups. Statistical significance was determined with p-value less than 0.05. Operation types were also compared using Chi-square test. Figures are presented using SPS, which has been adjusted for trend and cyclical variation. Projections of expected volume based on the previous 12-month trends are made from the point of the pilot intervention.
Results
The demography of the patient groups are shown in Table 2, including fracture type and operative intervention.
Table 1: Age, gender, fracture and operation type in before and after fast track patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
Eighty-four percent of patients were fast tracked from the emergency department to the acute surgical wards, 77% went to a ward designated for these injuries and another 18% were transferred to other orthopaedic beds. A small percentage were transferred to the orthopaedic trauma unit because of co-existing medical/surgical issues.
Sixteen percent were not fast tracked because they were either inter-hospital transfers, young patients with hip fractures and thus treated differently, medically unwell or had been wrongly classified and had peri-prosthetic or sub-trochanteric or pathological fractures. This group was not included in the analysis.
Anaesthetic procedure was not significantly different between pre- and post-fast track groups. General anaesthetic was performed in 68% of the fast track group and 59% of the pre-fast track group, spinal anaesthetic 21% (31% pre) and regional anaesthetic block 3% (4% pre). There were a small number of other anaesthetic procedures that did not significantly differ between groups (ie, femoral/sciatic lumbar plexus blocks).
Emergency department
As demonstrated in Figure 2, the average time in the ED compared with the previous year decreased by half an hour (p=0.0001). All facets of the ED process appeared to contribute to this time reduction.
Figure 2: Average time in emergency department pre- and post-fast track process.
The average wait for theatre decreased by 3.6 hours (p=0.044) and the average time in theatre decreased by approximately 15 minutes (p<0.0001). The comorbidities that affected the wait for theatre are listed in Table 2 and were not different from the pre-study group. The most common was the use of “anti-coagulant like agents” in 17.5% of patients. Only Clopidogrel significantly delayed the time to theatre with an average of 3.35 days. Warfarin was ceased pre-op with a delay of 1.8 days and other agents such as Dabigatran and Dipyridamole had no effect. Aspirin was continued in most patients unless post-operation bleeding was an issue.
Table 2: Co-morbidities of before and after fast track hip fracture patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
The average time to rehabilitation decreased by almost three days (p<0.0001) and was seen in both ORU 21/2 days (p<0.0001) and Older Person’s Rehabilitation 31/2 days (p<0.0001). The overall total rehabilitation time decreased by almost seven days (p<0.0001) in ORU but only three days (p=0.048) in Older Person’s Rehabilitation. The overall length of stay during the fast track pathway decreased by approximately four days (p=0.0001). Table 3 shows data on wait times and LOS.
Table 3: Comparison in pathway activities between the before intervention group (n=989, 01/12 → 11/14) and the after intervention group (n=161, 11/14 → 04/15).
P-values for comparison * <0.05 ** <0.01 *** <0.001
Average times in components of pathway—ED = Emergency Department LOS = Length of Stay, ORU = Orthopaedic Rehabilitation Unit, OPH = Older Person’s Health, with time related variable and significance.
The total readmission rate and total orthopaedic admissions remained the same over the course of the study.
Functional status pre- and post-fast track
The average FIM gain was unchanged compared with before (n=403) at 28.9% and during the trial (n=80) at 29.0% (see Figure 3). The missing data was due to incorrect coding status.
Figure 3: Functional improvement at discharge so far.
On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved (467 acute bed days and 164 rehabilitation bed days) with a projected annual bed days saving of 1,564 bed days. Using Total Absorption Costing (TAC)13 the estimated cost per bed day in the acute setting is NZD1,200 and NZD850 in the rehabilitation setting (CDHB, 2015). Therefore, over the trial period the bed days stay equate to a projected saving of NZD699,800 across the whole of care pathway.
Discussion
We have shown that by altering the clinical management of fractured neck of femur patients that present to the ED can be admitted, operated on and undergo rehabilitation prior to discharge resulting in significant reduction in length of stay without compromising the patient.
In the ED, the average time reduced from 3.46 hours to 2.9 hours and although our target was 90 minutes, this is clearly a change in the right direction. This enabled the patient to get to the ward quicker, to be assessed, rehydrated, renourished and if necessary, additional medical and surgical co-morbidities addressed prior to theatre. The average wait for theatre has changed little from 1.62 days down to 1.47 days, and although this is statistically significant, the overall distribution would indicate that this is not clinically significant. This has led to a careful examination into the wait for theatre, including operating theatre assignment and use. Eligibility for transfer to rehabilitation 48 hours after their surgery reduced the time people wait for rehabilitation from 6.27 days to 3.61 days, and of greater importance was the reduced overall rehabilitation length of stay (from 24.24 to 17.46 days) when patients undergo focused orthopaedic rehabilitation. Although time to transfer to an Older Person’s Rehabilitation institution had decreased from 7.84 days to 4.2 days, the overall length stay at this institution continued to be long at 30.43 days (previously 33.71 days p=0.048). Although this study compares a historical group with the current fast track patients, we believe that the groups were comparable as during this pilot study period there was no significant increases in readmissions (<1%), the mortality rate remained stable (6%) and there was also no significant difference in co-morbidities or fracture types, and the functional gains experienced by patients were similar.
By using a statistically-based approach to analysing, interpreting and visually presenting the data, SFN helped to quickly identify that the changes in clinical management were effective. SFN was able to be viewed by staff on a weekly basis, using quantitative clinical measures. In addition, SFN’s powerful ‘point and click’ analytics enabled the users to follow through an assessment into any aspect of the patient pathway in real time using patient data (Lightfoot, 2015).11 This analysis is a key feature that enabled cross-functional teams to explore the root causes of process issues and to agree on the actions required to improve patient outcomes, therefore creating a high level of engagement with all clinical and non-clinical staff.
The beneficial effects of integration and co-operation through all departments involved in the management of fractured neck of femur was key to the implementation of the process and the results that were obtained. We have used accepted methods of management of hip fracture patients that are laid down by the Australian and New Zealand Guidelines.1 The clinical management of the patients is not significantly different from previously published work.1,5 The surgical procedures and anaesthetic methods are not significantly different and are in line with a recent published review on the orthopaedic medical management of the frail older patient.6,13,15
To our knowledge this is the only study to have used data integration coupled with significant change in the clinical management of hip fracture patients. Our total length of stay is comparable to other models of care, but ours is a joint model of care with a management of patients that is shared between surgeons and physicians. We have shown, however, that the length of stay of the fast track neck of femur patients can be substantially reduced. We first trialled these models of care in the 1990’s5 and they have been shown by others to be effective in reducing the length of stay15,16 and post-operative complication rates.16 The approach to clinician-led hip fracture management, audit and databases has led to substantial improvements in care and survival of older people with hip fractures.17
The importance of this pilot study shows that co-operation between departments with the aim of maintaining and improving clinical care but also trying to reduce the length of stay has been beneficial. The key to this outcome has been the rapid acquisition of data via the SFN system that enables early and robust measurement of the effects of change in practice.
The strength of this pilot study shows that the changes can be driven by weekly analysis of routinely collected data, which did not require manual collection of data and did not impact upon clinical time. The acquisition of data enabled the pathway to be monitored and protocols to be changed appropriately. During this pilot study there were no negative indicators, such as increased readmissions, mortality rates, different co-morbidities or change in functional improvement post-operatively. For the patient it meant that they spent an average of 95 hours less in hospital and co-operation between the acute and the rehabilitation setting was clearly beneficial.
The limitations of this study are that it is a pilot study over a 5-month period. The pathway has yet to be tested with larger numbers of patients and the impact of winter. Our work flow is not subject to seasonal change but overall numbers of NOF patients seem to be increasing along with the complexity of fractures and co-morbidities. Our hospital is a large tertiary hospital and the demands on its theatres are considerable. We were unable to make a significant impact in the wait for theatre and this is a limitation of this pilot study. Another limitation is that just under 20% of patients who were not fast tracked have not been analysed as part of this analysis, and this may impact on the results and conclusions reached. We have not addressed in this paper the impact of community rehabilitation programmes in this group of patients.
The clinical relevance of this paper is obvious. Patients spend less time in hospital, with a reduction in bed days and subsequent financial savings. The integration of the SFN system and the ability to interpret this data quickly and modify the pathway is a significant improvement to patient management.
Of importance, focused orthopaedic rehabilitation produced the greatest reduction in the length of stay and possible benefit to patients, whereas non-orthopaedic focused rehabilitation in another hospital did not show significant reduction in the length of stay. There are many reasons for this, including frailty, co-morbidities and cognitive impairment, but this does signal that targeted orthopaedic rehabilitation should be the focus of any changes to the current system. Better understanding of the impact of frailty on hip fracture patients may help us manage these patients better by focusing our efforts on treating frailty.18 The longer waiting list and time for OPH reflected the more complex nature of patients and co-morbidities. This hospital now contributes to the Australian and New Zealand Hip Fracture Registry.
Conclusions
This study has shown with meaningful inter-departmental co-operation and modification of existing guidelines on fractured neck of femur patient treatment resulted in significant reduction in length of stay in all areas. The ED time was significantly reduced, (p<0.0001) time to theatre was not improved (p=0.044) and time patients had to wait to go the rehabilitation (p<0.0001) as well as the time in rehabilitation overall was significantly reduced (p<0.0001). Of interest, focused orthopaedic rehabilitation was far more effective than non-focused orthopaedic rehabilitation. The use of the SFN tool to acquire and analyse data has enabled significant improvements to the monitoring on a week by week basis. This is currently undergoing modifications and is an ongoing project.
Summary
Abstract
The increasing elderly population and subsequent rise in total hip fracture(s) in this group means more effective management strategies are necessary to improve efficiency. We have changed our patient care strategy from the emergency department (ED), acute orthopaedic wards, operating theatre, post-operation and rehabilitation, and called it Fracture Neck of Femur Fast Track Pathway. All clinical data and actions were captured, integrated and displayed on a weekly basis using signalfromnoise (SFN) software. The initial four months analysis of this project showed significant improvement in patient flow within the hospitals. The overall length of stay was reduced by four days. Time in ED was reduced by 30 minutes, and the wait for rehabilitation reduced by three days. Overall time in rehabilitation reduced by 3-7 days depending on facility. On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved in this period, with projected savings of NZD700,000. No adverse effects were seen in mortality, readmission and functional improvement status. Fractured neck of femur has increasing clinical demand in a busy tertiary hospital. Length of stay, co-morbidities and waiting time for theatres are seen as major barriers to treatment for these conditions. Wait for rehabilitation can significantly lengthen hospital stay; also poor communication between the individual hospital management facets of this condition has been an ongoing issue. Lack of instant and available electronic information on this patient group has also been seen as a major barrier to improvement. This paper demonstrates how integration of service components that are involved in fractured neck of femur can be achieved. It also shows how the use of electronic data capture and analysis can give a very quick and easily interpretable data trend that will enable change in practice. This paper indicates that cooperation between health professionals and practitioners can significantly improve the length of stay and the time in which patients can be returned home. Full interdisciplinary involvement was the key to this approach. The use of electronic data capture and analysis can be used in many other health pathways within the health system.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Australian and New Zealand guideline for hip fracture care: Improving outcomes in hip fracture management of adults. Sydney: Australian and New Zealand hip fracture registry steering group; 2014.
- Atlas for healthcare variation New Zealand: Health quality and safety commission; 2015.
- Boufous S, Finch CF, Lord S. Incidence of hip fracture in New South Wales: are our efforts having an effort? Medical Journal of Australia. 2004; 180:623–6.
- Barber J, Mills H, Horne G, et al. The incidence of hip fractures in Māori and non-Māori in New Zealand. NZ Med J. 1995 Sept 8; 108(1007):367–8.
- Thwaites J, Mann F, Gilchrist N, et al. Shared care between geriatricians and orthopaedic surgeons as a model for care for older patients with hip fractures. NZ Med J. 2005 May 6; 118(1214).
- Weatherall M. Case mix and outcome for patients with fracture of the proximal femur. NZ Med J. 1993;106:451-2.
- Hall K, Wilson K, Gilchrist N, et al. Fractured neck of femur pathway project – final report to ACC (CDHB internal report); 2005 Sep 29.
- Elliot, JR, Wilkinson TJ, Hanger HC, et al. The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. NZ Med J. 1996; 109:72–3.
- Australian New Zealand Hip Fracture Registry. http://www.anzhfr.org
- Atlas of Healthcare Variation; Health Quality & Safety Commission; 2016. http://www.hqsc.govt.nz
- Signalsfromnoise. Lightfoot Solutions Ltd; 2015. http://www.lightfootsolutions.com/
- What is AROC? retrieved Australasian Rehabilitation Outcomes Centre; 2012 Feb 12 from http://ahrsi.uow.edu/aroc/whatisaroc/index.html
- Marshall DH, McManus WW, Viele DF. Accounting: What the numbers mean: McGaw-Hill Higher Education; 2010.
- Sabharwal S, Wilson H. Orthogeriatrics in management of frail older patients with a fragility fracture. Osteoporosis Int. 2015; 26:2387–2399.
- Vidan M, Serra JA, Moreno C, et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005; 53:1476–1482.
- Friedman SM, Mendelson DA, Bingham KW, et al. Impact of a comanaged geriatric fracture centre on short-term hip fracture outcomes. Arch Intern Med. 2009; 169:1712–1717.
- Neuburger J, Currie C, Wakeman R, et al. Medical Care Vol 53, No: 2015 Aug, pp 686–691.
- Li G, Papaioannou A, Thabane L, et al. Frailty change and major osteoporotic fracture in the elderly: Data from the global longitudinal study of osteoporosis in women 3-year Hamilton cohort. JBMR. 2016 Apr; Vol 31, No. 4, pp 718–724.
Contact diana@nzma.org.nz
for the PDF of this article
Enhanced hip fracture management: use of statistical methods and dataset to evaluate a fractured neck of femur fast track pathway—pilot study
View Article PDF
In New Zealand, approximately 3,500 people over the age of 50 were hospitalised with a hip fracture in 2013 with the majority being related to falls.1 The rate of hip fracture increases significantly with age with nearly half of the hip fractures occurring in those aged 85 years or older.2 Although the incidence appears to be falling, the absolute number of hip fractures is increasing with longer life expectancy.3
It appears that the fracture rate is at least 25–50% higher in Europeans than in Pacific Islanders or Māori, but this rate is predicted to equalise with the increasing life span of the Māori and Polynesian population.4 The care of these patients varies both nationally and internationally.4 Service provision was initially surgically managed, but has evolved into a shared care model with Health Care of the Elderly Physicians.5,6 In our centre we established a Fractured Neck of Femur Pathway in 2007,7 which has significantly improved the outcomes of such patients.7 Recently, guidelines have been established for both Australia and New Zealand, outlining the standard of care from admission to the emergency department, peri-operative care, operative optimisation, rehabilitation and appropriate discharge from hospital.1 Experience has shown that this model reduces length of stay and improves cost efficiency.8 Another recent improvement has been the establishment of a hip fracture registry, which will be able to identify all hip fractures in Australia and New Zealand, to accurately classify them and provide an integrated database for this complex group of patients.9 Our hospital admits the largest number of hip fractures (>500/year) for a single hospital in New Zealand10 and has been a leader in the field of innovative management of hip fracture patients. As a tertiary hospital with a large number of acute orthopaedic admissions (4,748 in 2014), evaluation of an effective treatment pathway for these patients has become important to use the finite resources efficiently.
The introduction of a weekly analytical dataset, ‘signalfromnoise’ (SFN) within our district health board is introducing a new way in which clinical staff working within the patient pathway can clearly and quickly understand the implications of any change in patient management. SFN (proprietary software from Lightfoot Solutions)11 helps to identify variations, trends and patterns, which allows the assessment of the introduction of change in clinical practice from admission to the emergency department (ED), peri-operative management, rehabilitation and discharge. Previous patient management was independently managed with some information shared between services.
This study presents the initial results of this clinically-led pilot study in the change of the clinical management of hip fracture patients.
Methods
This fast track pathway was designed to improve the patient journey throughout all phases of their hospital admission from emergency department (ED), the peri-operative process, rehabilitation and planned discharge home. This involved all departments and staff from emergency, acute orthopaedic ward staff, anaesthetic department, surgeons, orthopaedic medicine/rehabilitation service and rehabilitation wards.
The elements of this pathway were mutually agreed by all parties in the period leading up to the introduction of the pathway. Measurement of the effectiveness of this pathway was enabled through the introduction of SFN data visualisation and analysis template that enabled quick and efficient evaluation of all parts of the pathway.11
SFN uses the principles of Statistical Process Control (SPC) to analyse and disseminate information about patient flow across the whole healthcare system. It includes a web-based interface that provides users with an ‘at a glance’ understanding of processes and improvement initiatives (Lightfoot, 2015).11 SFN uses routine information collected in the district health board (DHB) patient management systems, including ED, operating theatres and inpatients wards. This new information is present in a dashboard format with weekly update and a drop down analysis feature that enables in depth analysis of elements of individual department activities across ED, inpatient wards, operating theatres and rehabilitation wards. Figure 1 shows some of the elements within ED that can be analysed on a week by week basis, giving the ability to quickly change or alter elements of the pathway.
Figure 1: SFN process analysis capabilities.
Patients with hip fracture are usually transported to the ED by ambulance where the ambulance staff often identify the possibility of hip fracture on their arrival in the ED. These patients are rapidly assessed by medical and nursing staff, comorbid conditions identified and treated, analgesia initiated, blood tests performed and x-rays requested. It was observed at an early stage that some patients arrived into a busy ED and concurrent nursing/medical responsibilities could delay care of those patients with hip fracture. The pathway empowered and enabled nursing staff to initiate care and significantly progress the ED phase of the care. Once the hip fracture is identified on x-ray, the orthopaedic team are notified, but further orthopaedic assessment of the patient is carried out once admitted directly to an orthopaedic ward bed. Education was provided early in the course of the new approach and all staff were motivated to provide care according to the pathway and expedite transfer to the orthopaedic ward bed. Fundamental to this improvement was to encourage orthopaedic assessment of the patient on the orthopaedic ward rather than in ED. On admission to the acute orthopaedic ward, every possible attempt was made for the patient to be operated on that day or the subsequent morning.
A system was put in place where the Charge Nurse on the admitting orthopaedic ward would text page the duty anaesthetist as soon as a fast track admission arrived on the ward. For those admissions before 4:00 pm an anaesthetic assessment of the patient would be made regarding suitability for operating theatre first thing the following morning. This enabled any outstanding investigations such as blood tests, chest x-ray, cardiac echocardiography or coagulation studies to be arranged, consultation referrals to be made and medications such as anticoagulants to be stopped (and possibly reversed) in a timely manner. This would then ensure the patient was ready for theatre the next morning, preventing unnecessary fasting of patients and reduced last-minute cancellations with a significant impact on theatre room utilisation. If there were problems identified that would preclude operation the next morning then this information was communicated to the acute orthopaedic team so they could adjust the operating schedule accordingly.
Anaesthesia was provided by an anaesthetic consultant or senior registrar wherever possible, with the technique chosen dependent on both patient factors and anaesthetist’s personal preference.
The patients are admitted to an orthopaedic ward that specialises in the management of neck of femur fractures and has dedicated beds for this purpose. Nursing cares are instituted in a standardised fashion.
Registrar assessment (orthopaedic, orthopaedic medicine and anaesthetic) is then undertaken. The confirmation of the diagnosis and exclusion of other injuries or active comorbidities is made, and if present, these are also dealt with at the time of initial admission. Patients are placed on the booking system, ‘Scope’, and depending on the time on the day of admission, a decision is made regarding fasting status. Generally, the patients receive their surgery in the ensuing day(s) and therefore they are not kept nil by mouth and high-carbohydrate fluids and food commenced.
Pre-operative anaesthetic review and orthopaedic medical reviews are undertaken and any peri-operative risk is identified and mitigated with proactive intervention.
Dedicated time within an acute operating theatre is utilised for neck of femur fractures and priority is given whenever possible to this patient group.
The surgical procedure involves the administration of an anaesthetic, IV antibiotics and patient positioning, and depending on the configuration of the fracture pattern the position varies. For a hemiarthroplasty or total hip replacement, patients are positioned in the lateral decubitus position and generally a lateral approach to the hip is undertaken. This approach is felt to reduce the risk of dislocation by preserving the posterior capsule and careful attention is paid to repairing the vertical incision in the capsule and the gluteal muscles.
For intertrochanteric and subcapital neck of femur fractures treated with closed reduction and internal fixation, a supine position is utilised with the use of a traction table and image-intensifier navigation. A direct lateral approach is made, preservation of the vastus lateralis is attempted and metalware is placed in a fluoroscopic-guided fashion. A drain may be placed and generally, subcuticular dissolvable sutures are used to repair the incision site. Dressings are then applied.
The patients are then transferred to the orthopaedic ward following transfer from recovery, and antibiotics (Cefazolin 2gms) are instituted for two further doses post-operatively. DVT prophylaxis is undertaken and the patients are mobilised early with the assistance of the physiotherapy team. X-rays are taken post-operatively and this is repeated at six weeks to ensure that fracture union is satisfactory and alignment remains acceptable. Patients are reviewed if problems arise in the post-operative period after discharge from hospital.
Rehabilitation
It was agreed that all patients should be suitable for rehabilitation and weight bearing at 48 hours post-operatively. This meant implicitly that these patients would be well enough both medically and surgically to be transferred to the appropriate rehabilitation facility. In Canterbury there are two rehabilitation facilities. The first is a dedicated orthopaedic rehabilitation facility, which manages most of the older people with orthopaedic conditions that require rehabilitation. This unit is situated at another hospital and is integrated within the Department of Orthopaedic Surgery (Orthopaedic Rehabilitation Unit (ORU)). The more medically and cognitively compromised are mostly transferred to another hospital because of the more complex nature of their ongoing medical and social issues and the availability of medical/nursing staff and intensive diagnostic facilities (Older Person’s Rehabilitation). The decision as to which institution they are transferred to is made pre-operatively or immediately post-operatively. The rehabilitation process is very similar to those previously described5 and involves a multi-disciplinary team, which includes nursing, medical, occupational therapists, physiotherapists and social workers. The aim is to get people as independently mobile as possible and return them to their home and facilities or to find appropriate placement should this be needed.
There is small group (<5%) of patients that, because of the complex nature of their fracture and subsequent surgery, are unable to weight bear for mechanical implant and healing reasons. These patients are transferred to another hospital (88kms from our facility) for a period of between two to six weeks when they undergo orthopaedic review and a decision made to weight bear and then transferred to ORU for rehabilitation but are not included here for analysis. Those who were not fast tracked because of medical/surgical unsuitability were not subject to this analysis but will be in future.
Fast Track study
The Fast Track pilot study began in November 2014 and continued to the end of April 2015. A similar group of patients from the previous three years were used for comparison. All patients admitted with a fracture neck of femur were included except those patients who were younger than 65 years old, had operation times longer than three hours or who ended up in convalescent care or unknown discharge facilities.
The pathway patient flow data were then compared for the following indicators: time spent in the ED, waiting time for theatre, waiting time for rehabilitation, time spent in acute service and time spent in rehabilitation as well as total length of stay. Sub-group analysis was then performed for eligible discharge and/or rehabilitation facilities. Data was also collected on discharge destination, readmissions and functional status, and compared with the pre-pilot study group Australian Rehabilitation Outcome Centre (AROC data).12 This includes the standardised use of the Functional Independence Measurement tool (FIM™). FIM™ measures 18 items of function, (13 motor and five cognitive). It is scaled from one to seven, with seven being completely independent with a specific activity and one indicating that full assistance is required. It is based on activity over a 24-hour period and guided by observations made by staff over different shifts. Some of the activities include toileting, continence and mobility, etc. The activities are scored giving a functional independence measure (FIM™), which can be used at any stage of the hospital admission to determine progress, discharge destination and goal setting.
Estimated cost per bed day using Total Absorption costing13 was assessed in the acute and rehabilitation setting. The functional status at discharge was available from AROC data set in only 403 (40%) patients before and 80 (50%) during the trial.
Statistical analysis
Data analysed using SAS 9.3. Wilcoxon Rank Sum test was carried out to assess differences between the two groups. Statistical significance was determined with p-value less than 0.05. Operation types were also compared using Chi-square test. Figures are presented using SPS, which has been adjusted for trend and cyclical variation. Projections of expected volume based on the previous 12-month trends are made from the point of the pilot intervention.
Results
The demography of the patient groups are shown in Table 2, including fracture type and operative intervention.
Table 1: Age, gender, fracture and operation type in before and after fast track patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
Eighty-four percent of patients were fast tracked from the emergency department to the acute surgical wards, 77% went to a ward designated for these injuries and another 18% were transferred to other orthopaedic beds. A small percentage were transferred to the orthopaedic trauma unit because of co-existing medical/surgical issues.
Sixteen percent were not fast tracked because they were either inter-hospital transfers, young patients with hip fractures and thus treated differently, medically unwell or had been wrongly classified and had peri-prosthetic or sub-trochanteric or pathological fractures. This group was not included in the analysis.
Anaesthetic procedure was not significantly different between pre- and post-fast track groups. General anaesthetic was performed in 68% of the fast track group and 59% of the pre-fast track group, spinal anaesthetic 21% (31% pre) and regional anaesthetic block 3% (4% pre). There were a small number of other anaesthetic procedures that did not significantly differ between groups (ie, femoral/sciatic lumbar plexus blocks).
Emergency department
As demonstrated in Figure 2, the average time in the ED compared with the previous year decreased by half an hour (p=0.0001). All facets of the ED process appeared to contribute to this time reduction.
Figure 2: Average time in emergency department pre- and post-fast track process.
The average wait for theatre decreased by 3.6 hours (p=0.044) and the average time in theatre decreased by approximately 15 minutes (p<0.0001). The comorbidities that affected the wait for theatre are listed in Table 2 and were not different from the pre-study group. The most common was the use of “anti-coagulant like agents” in 17.5% of patients. Only Clopidogrel significantly delayed the time to theatre with an average of 3.35 days. Warfarin was ceased pre-op with a delay of 1.8 days and other agents such as Dabigatran and Dipyridamole had no effect. Aspirin was continued in most patients unless post-operation bleeding was an issue.
Table 2: Co-morbidities of before and after fast track hip fracture patients.
P-values for comparison * <0.05 ** <0.01 *** <0.001
The average time to rehabilitation decreased by almost three days (p<0.0001) and was seen in both ORU 21/2 days (p<0.0001) and Older Person’s Rehabilitation 31/2 days (p<0.0001). The overall total rehabilitation time decreased by almost seven days (p<0.0001) in ORU but only three days (p=0.048) in Older Person’s Rehabilitation. The overall length of stay during the fast track pathway decreased by approximately four days (p=0.0001). Table 3 shows data on wait times and LOS.
Table 3: Comparison in pathway activities between the before intervention group (n=989, 01/12 → 11/14) and the after intervention group (n=161, 11/14 → 04/15).
P-values for comparison * <0.05 ** <0.01 *** <0.001
Average times in components of pathway—ED = Emergency Department LOS = Length of Stay, ORU = Orthopaedic Rehabilitation Unit, OPH = Older Person’s Health, with time related variable and significance.
The total readmission rate and total orthopaedic admissions remained the same over the course of the study.
Functional status pre- and post-fast track
The average FIM gain was unchanged compared with before (n=403) at 28.9% and during the trial (n=80) at 29.0% (see Figure 3). The missing data was due to incorrect coding status.
Figure 3: Functional improvement at discharge so far.
On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved (467 acute bed days and 164 rehabilitation bed days) with a projected annual bed days saving of 1,564 bed days. Using Total Absorption Costing (TAC)13 the estimated cost per bed day in the acute setting is NZD1,200 and NZD850 in the rehabilitation setting (CDHB, 2015). Therefore, over the trial period the bed days stay equate to a projected saving of NZD699,800 across the whole of care pathway.
Discussion
We have shown that by altering the clinical management of fractured neck of femur patients that present to the ED can be admitted, operated on and undergo rehabilitation prior to discharge resulting in significant reduction in length of stay without compromising the patient.
In the ED, the average time reduced from 3.46 hours to 2.9 hours and although our target was 90 minutes, this is clearly a change in the right direction. This enabled the patient to get to the ward quicker, to be assessed, rehydrated, renourished and if necessary, additional medical and surgical co-morbidities addressed prior to theatre. The average wait for theatre has changed little from 1.62 days down to 1.47 days, and although this is statistically significant, the overall distribution would indicate that this is not clinically significant. This has led to a careful examination into the wait for theatre, including operating theatre assignment and use. Eligibility for transfer to rehabilitation 48 hours after their surgery reduced the time people wait for rehabilitation from 6.27 days to 3.61 days, and of greater importance was the reduced overall rehabilitation length of stay (from 24.24 to 17.46 days) when patients undergo focused orthopaedic rehabilitation. Although time to transfer to an Older Person’s Rehabilitation institution had decreased from 7.84 days to 4.2 days, the overall length stay at this institution continued to be long at 30.43 days (previously 33.71 days p=0.048). Although this study compares a historical group with the current fast track patients, we believe that the groups were comparable as during this pilot study period there was no significant increases in readmissions (<1%), the mortality rate remained stable (6%) and there was also no significant difference in co-morbidities or fracture types, and the functional gains experienced by patients were similar.
By using a statistically-based approach to analysing, interpreting and visually presenting the data, SFN helped to quickly identify that the changes in clinical management were effective. SFN was able to be viewed by staff on a weekly basis, using quantitative clinical measures. In addition, SFN’s powerful ‘point and click’ analytics enabled the users to follow through an assessment into any aspect of the patient pathway in real time using patient data (Lightfoot, 2015).11 This analysis is a key feature that enabled cross-functional teams to explore the root causes of process issues and to agree on the actions required to improve patient outcomes, therefore creating a high level of engagement with all clinical and non-clinical staff.
The beneficial effects of integration and co-operation through all departments involved in the management of fractured neck of femur was key to the implementation of the process and the results that were obtained. We have used accepted methods of management of hip fracture patients that are laid down by the Australian and New Zealand Guidelines.1 The clinical management of the patients is not significantly different from previously published work.1,5 The surgical procedures and anaesthetic methods are not significantly different and are in line with a recent published review on the orthopaedic medical management of the frail older patient.6,13,15
To our knowledge this is the only study to have used data integration coupled with significant change in the clinical management of hip fracture patients. Our total length of stay is comparable to other models of care, but ours is a joint model of care with a management of patients that is shared between surgeons and physicians. We have shown, however, that the length of stay of the fast track neck of femur patients can be substantially reduced. We first trialled these models of care in the 1990’s5 and they have been shown by others to be effective in reducing the length of stay15,16 and post-operative complication rates.16 The approach to clinician-led hip fracture management, audit and databases has led to substantial improvements in care and survival of older people with hip fractures.17
The importance of this pilot study shows that co-operation between departments with the aim of maintaining and improving clinical care but also trying to reduce the length of stay has been beneficial. The key to this outcome has been the rapid acquisition of data via the SFN system that enables early and robust measurement of the effects of change in practice.
The strength of this pilot study shows that the changes can be driven by weekly analysis of routinely collected data, which did not require manual collection of data and did not impact upon clinical time. The acquisition of data enabled the pathway to be monitored and protocols to be changed appropriately. During this pilot study there were no negative indicators, such as increased readmissions, mortality rates, different co-morbidities or change in functional improvement post-operatively. For the patient it meant that they spent an average of 95 hours less in hospital and co-operation between the acute and the rehabilitation setting was clearly beneficial.
The limitations of this study are that it is a pilot study over a 5-month period. The pathway has yet to be tested with larger numbers of patients and the impact of winter. Our work flow is not subject to seasonal change but overall numbers of NOF patients seem to be increasing along with the complexity of fractures and co-morbidities. Our hospital is a large tertiary hospital and the demands on its theatres are considerable. We were unable to make a significant impact in the wait for theatre and this is a limitation of this pilot study. Another limitation is that just under 20% of patients who were not fast tracked have not been analysed as part of this analysis, and this may impact on the results and conclusions reached. We have not addressed in this paper the impact of community rehabilitation programmes in this group of patients.
The clinical relevance of this paper is obvious. Patients spend less time in hospital, with a reduction in bed days and subsequent financial savings. The integration of the SFN system and the ability to interpret this data quickly and modify the pathway is a significant improvement to patient management.
Of importance, focused orthopaedic rehabilitation produced the greatest reduction in the length of stay and possible benefit to patients, whereas non-orthopaedic focused rehabilitation in another hospital did not show significant reduction in the length of stay. There are many reasons for this, including frailty, co-morbidities and cognitive impairment, but this does signal that targeted orthopaedic rehabilitation should be the focus of any changes to the current system. Better understanding of the impact of frailty on hip fracture patients may help us manage these patients better by focusing our efforts on treating frailty.18 The longer waiting list and time for OPH reflected the more complex nature of patients and co-morbidities. This hospital now contributes to the Australian and New Zealand Hip Fracture Registry.
Conclusions
This study has shown with meaningful inter-departmental co-operation and modification of existing guidelines on fractured neck of femur patient treatment resulted in significant reduction in length of stay in all areas. The ED time was significantly reduced, (p<0.0001) time to theatre was not improved (p=0.044) and time patients had to wait to go the rehabilitation (p<0.0001) as well as the time in rehabilitation overall was significantly reduced (p<0.0001). Of interest, focused orthopaedic rehabilitation was far more effective than non-focused orthopaedic rehabilitation. The use of the SFN tool to acquire and analyse data has enabled significant improvements to the monitoring on a week by week basis. This is currently undergoing modifications and is an ongoing project.
Summary
Abstract
The increasing elderly population and subsequent rise in total hip fracture(s) in this group means more effective management strategies are necessary to improve efficiency. We have changed our patient care strategy from the emergency department (ED), acute orthopaedic wards, operating theatre, post-operation and rehabilitation, and called it Fracture Neck of Femur Fast Track Pathway. All clinical data and actions were captured, integrated and displayed on a weekly basis using signalfromnoise (SFN) software. The initial four months analysis of this project showed significant improvement in patient flow within the hospitals. The overall length of stay was reduced by four days. Time in ED was reduced by 30 minutes, and the wait for rehabilitation reduced by three days. Overall time in rehabilitation reduced by 3-7 days depending on facility. On average, fast track patients spent 95 less hours in hospital, resulting in 631 bed days saved in this period, with projected savings of NZD700,000. No adverse effects were seen in mortality, readmission and functional improvement status. Fractured neck of femur has increasing clinical demand in a busy tertiary hospital. Length of stay, co-morbidities and waiting time for theatres are seen as major barriers to treatment for these conditions. Wait for rehabilitation can significantly lengthen hospital stay; also poor communication between the individual hospital management facets of this condition has been an ongoing issue. Lack of instant and available electronic information on this patient group has also been seen as a major barrier to improvement. This paper demonstrates how integration of service components that are involved in fractured neck of femur can be achieved. It also shows how the use of electronic data capture and analysis can give a very quick and easily interpretable data trend that will enable change in practice. This paper indicates that cooperation between health professionals and practitioners can significantly improve the length of stay and the time in which patients can be returned home. Full interdisciplinary involvement was the key to this approach. The use of electronic data capture and analysis can be used in many other health pathways within the health system.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Australian and New Zealand guideline for hip fracture care: Improving outcomes in hip fracture management of adults. Sydney: Australian and New Zealand hip fracture registry steering group; 2014.
- Atlas for healthcare variation New Zealand: Health quality and safety commission; 2015.
- Boufous S, Finch CF, Lord S. Incidence of hip fracture in New South Wales: are our efforts having an effort? Medical Journal of Australia. 2004; 180:623–6.
- Barber J, Mills H, Horne G, et al. The incidence of hip fractures in Māori and non-Māori in New Zealand. NZ Med J. 1995 Sept 8; 108(1007):367–8.
- Thwaites J, Mann F, Gilchrist N, et al. Shared care between geriatricians and orthopaedic surgeons as a model for care for older patients with hip fractures. NZ Med J. 2005 May 6; 118(1214).
- Weatherall M. Case mix and outcome for patients with fracture of the proximal femur. NZ Med J. 1993;106:451-2.
- Hall K, Wilson K, Gilchrist N, et al. Fractured neck of femur pathway project – final report to ACC (CDHB internal report); 2005 Sep 29.
- Elliot, JR, Wilkinson TJ, Hanger HC, et al. The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. NZ Med J. 1996; 109:72–3.
- Australian New Zealand Hip Fracture Registry. http://www.anzhfr.org
- Atlas of Healthcare Variation; Health Quality & Safety Commission; 2016. http://www.hqsc.govt.nz
- Signalsfromnoise. Lightfoot Solutions Ltd; 2015. http://www.lightfootsolutions.com/
- What is AROC? retrieved Australasian Rehabilitation Outcomes Centre; 2012 Feb 12 from http://ahrsi.uow.edu/aroc/whatisaroc/index.html
- Marshall DH, McManus WW, Viele DF. Accounting: What the numbers mean: McGaw-Hill Higher Education; 2010.
- Sabharwal S, Wilson H. Orthogeriatrics in management of frail older patients with a fragility fracture. Osteoporosis Int. 2015; 26:2387–2399.
- Vidan M, Serra JA, Moreno C, et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005; 53:1476–1482.
- Friedman SM, Mendelson DA, Bingham KW, et al. Impact of a comanaged geriatric fracture centre on short-term hip fracture outcomes. Arch Intern Med. 2009; 169:1712–1717.
- Neuburger J, Currie C, Wakeman R, et al. Medical Care Vol 53, No: 2015 Aug, pp 686–691.
- Li G, Papaioannou A, Thabane L, et al. Frailty change and major osteoporotic fracture in the elderly: Data from the global longitudinal study of osteoporosis in women 3-year Hamilton cohort. JBMR. 2016 Apr; Vol 31, No. 4, pp 718–724.
Contact diana@nzma.org.nz
for the PDF of this article
Enhanced hip fracture management: use of statistical methods and dataset to evaluate a fractured neck of femur fast track pathway—pilot study
Subscriber Content
The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.
