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ERAS: recovering faster from a broken hip

ERAS: recovering faster from a broken hip

Enhanced Recovery After Surgery (ERAS) - improving the neck of femur patient journey


What is a fractured neck of femur?

A fractured neck of femur is a broken hip – or a fracture at the top of the thigh bone (femur) just below the hip joint. Once a hip has been broken, patients are unable to get up and walk around without an operation. This is because the fractured bone at the top of the femur takes a long time to heal and often does not heal at all.

Surgery involves securing the broken bones together so that patients can heal properly without any deformity and can become mobile again. After surgery, patients need various levels of rehabilitation which can involve:

  • staying in hospital for a few days or weeks to regain strength, flexibility and general health
  • returning home with the support of community health services such as the district nursing, physiotherapy and occupational therapy
  • home support services for help around the house or with personal care

Diagram of fracture to neck of femur


Why is improving the fractured neck of femur patient journey important?

Waitemata DHB Value: Better, Best, BrilliantMore than 360 patients come to our hospitals with a fractured hip each year and this is increasing as our population ages. Older people are more at-risk of falls and fractured hips can be a serious consequence, particularly when combined with loss of mobility and independence.

Studies have shown that delaying surgery for repairing a fractured neck of femur has a huge impact on recovery and overall health outcomes. Waiting more than 48-hours has shown to more than double the risk of complications after surgery such as pneumonia, urinary tract infections, deep vein thrombosis and pulmonary embolism.

Enhanced Recovery After Surgery (ERAS)

We are part of a national improvement programme called Enhanced Recovery After Surgery (ERAS). The basic principles of ERAS are to ensure that patients:

  1. are in the best possible condition for surgery
  2. receive excellent care before, during and after their operation
  3. receive appropriate rehabilitation to help them recover as fully as possible

Our aim is to identify areas for improvement and implement changes to support these basic principles and get patients back to their normal activities as quickly as possible.


What did we find?

We compared the ERAS recommendations to our patients’ current journeys through hospital. The most significant finding was the number of different paths that patients were following. We identified improvements to provide a more consistent experience and ultimately better outcomes.

In order to deliver the best care for these patients, we needed to focus on the following key areas:

  • Better pain management:  Better access to pain relief from the Emergency Department (ED) right through to returning to the community
  • Better team work:  Creation of a single location for patients with fracture hips to better support assessment and management of multiple health risks
  • Reduced time to surgery:  Increased access to surgery within 48-hours, as well as standardised anaesthetic and surgical protocols to support early recovery after surgery
  • More focus on rehabilitation:
    • Early mobilisation within 24-hours of surgery
    • Earlier assessment by geriatric services for admission to a rehabilitation ward
    • Focus on overall health and wellness such as nutrition, nausea and vomiting, constipation and cognitive function
  • Better patient Information:  Development of information packs for patients, their family / whānau and supporters to:
    • understand what to expect as they move through the pathway
    • encourage them to be involved in the patient’s care

What have we done and has it made a difference?

We looked at each part of the patient journey through our hospital and back into the community and have made the following improvements:

1. Planning and preparation before surgery

Patient information

'Your broken hip' patient information bookletWe have developed a patient information booklet to help patients, their family / whānau and supporters to have a better understanding of:

  • their likely journey with us and the people that will be involved in their care
  • planning and preparation for surgery, the type of fracture that they have sustained and the operation they may require
  • how to reduce the stresses of surgery and enhance their recovery after surgery
  • what is involved in getting them mobile again and back to normal activities as quickly as possible

This information booklet will be provided in the Emergency Department once a fractured hip diagnosis is confirmed.


Improved care in the Emergency Departments

All patients with a suspected fractured hip are first seen in the Emergency Department. This is where the diagnosis is confirmed and the decision to admit the patient is made. We have implemented the following improvements to the patient journey in the Emergency Department:

  • faster access to Radiology where an x-ray can confirm a fractured neck of femur
  • better pain management with the use of a fascia iliac block (local anaesthetic injection), which blocks pain from the hip to the knee
  • clearer guidelines for Emergency Department staff, including a documented pathway [see Fractured Neck of Femur Pathway below] resulting in faster referrals to an orthopaedic surgeon
  • standardised medications the help manage pain, constipation, nausea and vomiting
  • guidelines for medications to help reduce confusion in patients suffering from delirium or dementia

Waitemata DHB Fractured Neck of Femur pathway


Admission to a single location (known as a ‘home ward’)

We have created a ‘home ward’ for our fractured neck of femur patients on one of our two orthopaedic wards. It was very important to get these patients into one area so that we can provide targeted support to enhance recovery after surgery.

The results of a three-month pilot show a 48% increase in the number of patients being admitted directly to the ‘home ward’ from the Emergency Department.

Fractured neck of femur patients admitted to home ward 

Having a ‘home ward’ has also allowed us to create a Fractured Neck of Femur Nursing Care Plan, which allows nursing staff to document all the important aspects on patient care in the one document. This also makes it easier for other staff members to find information they need about the patient without needing to ask other staff members.

With these solutions we have:

  • increased the visibility of these patients and the surgical teams' focus on them
  • increased nursing focus on pre-surgery nutrition, risk identification, pain management, and identification and management of delirium and dementia
  • improved patient and family / whānau experience though shared experiences on the ward

2. Reducing the stresses of surgery

Faster access to surgery

In January 2014, the orthopaedic team made changes to the way that they manage their theatre lists, resulting in a much greater focus on getting these patients into theatre as quickly as possible.

Even though we have had a 15% increase in the number of patients with fractured neck of femurs, with these changes we have seen the following improvements in time to surgery:

  • 11% increase within 24 hours
  • 4% increase within 36 hours
  • 12% increase within 48 hours

This means that we are getting 88% of patients to surgery within 48-hours and reducing the average time to theatre by nine hours, from 42 hours to 31 hours.

Fractured neck of femur time to theatre results
Fracture neck of femur time to theatre results


Standardised surgical and anaesthetic protocol

The standardised protocol provides anaesthetists and orthopaedic surgeons with guidance on best practice and promotes a more consistent approach to managing fractured neck of femur patients.

Standardised surgical and anaesthetic protocolThe standardised protocol will:

  • improve the communication between anaesthetists and orthopaedic surgeons; a dedicated Anaesthetic Trauma Phone will allow the orthopaedic team to contact an anaesthetist for advice on patient care
  • increase the focus on anaesthetic and pain medications that minimise confusion, constipation, nausea and vomiting after surgery
  • provide guidelines on surgical techniques that allow patients to mobilise as quickly as possible after surgery

3. Recover after surgery

Early mobilisation

One of the most important parts of enhancing recovery after surgery is focusing on getting patients out of bed and mobilising as quickly as possible. Our goal is to have patients out of bed and sitting up for meals within 24-hours of surgery.

In February 2014, we started nurse education on the importance of supporting patients to get out of bed for meals, and worked with them to create an Early Mobilisation Tool that focuses on patients getting more and more active every day.

The nursing team work with the physiotherapists to tailor a rehabilitation plan for the patient that includes goals like:

  • moving to the chair for all meals
  • washing and dressing at the bedside
  • walking to the shower and back

With these solutions we have seen the following improvements:

  • an increase in the number of patients mobilising within 24-hours has increased from 16% to 45% when nurses were educated on the use of the Early Mobilisation Tool
  • a further increase in the number of patients mobilising within 24-hours to 71% with the implementation of the ‘home ward’

Results for patients mobilised with 24 hours post surgery
Results of patients mobilised within 24-hours post surgery following implementing solutions for early mobilisation


Increased access to rehabilitation

Following surgery, most patients will benefit from a period of rehabilitation in our Assessment Treatment and Rehabilitation (AT&R) Ward under the specialised care of the geriatric specialists and rehabilitation teams.

Having a ‘home ward’ for the fractured neck of femur patients has streamlined screening processes for the rehabilitation (AT&R) ward and has improved access to the ward. With this solution we have seen the following results:

Area of Improvement

Before

After

Improvement

Time between surgery and going on the AT&R waiting list

103 hours

69 hours

34 hours
33% decrease

Number of patients being transferred to AT&R

59%

68%

9% increase


Where to from here?

All of the improvements that have been implemented so far will need to be monitored to make sure that they are sustained over the coming months and further improvements will be implemented so we can reach our goals:

Goal

Current Results

Next Steps

90% of patients receive surgery within 48-hours of presentation

88%

Continue current improvement

90% active weight bearing within 24-hours from the end of the operation

71%

Continue current improvement

90% managed according the an agreed anaesthetic protocol

Implement Standardised Surgical and Anaesthetic Protocol
[due to be implemented]

90% managed according the an agreed Nausea and Vomiting Protocol

90% managed according to agreed discharge based criteria

Develop and implement discharged based criteria
[due to be implemented]


There are a number of different improvements that have not yet been completed which will continue to be worked on over the coming months:

Improvement

Description

Discharge-based criteria

Discharge-based criteria means that all teams that care for patients with a fractured neck of femur are working towards an agreed goal for the patient from day one.

Whether this goal is getting them back home with a little extra support or arranging for private hospital or rest home care, it will ensure that everyone knows what the plan is and everyone is working together to achieve it.

Orthogeriatric Specialist Services

An orthogeriatric specialist has an understanding of both orthopaedic and geriatric specialties and provides specialist medical care to older orthopaedic patients.  The orthogeriatric model of care has shown to decrease the length of stay, medical complications in hospital and mortality.

We do not currently have an orthogeriatric service. We are exploring ways to of setting up this service by 2016.

Patient Experience Measurement

Understanding and improving the patient experience is an important part of the project.

We will be working with our patients to map their experiences, helping us to bring their clinical journey to life and use their experience to further improve the service, future patients' experience and our patients' outcomes.

We are planning to develop a set of Patient Reported Outcome Measures (PROM) to help us understand and improve the clinical effectiveness of the care that we provide as perceived from patients themselves.