Peri-operative care of hip fracture patients - a quality improvement project

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<span style="font-size: 10pt;"><span style="color: #4a4a4a; font-family: Lato, "Helvetica Neue", Helvetica, Arial, sans-serif; text-decoration-color: initial;">There is a large variation in the service patients with neck of femur fracture (NOFF) receive within and between hospitals [1]. These variations impact on patient experience and outcomes. Service expansion at our hospital resulted in a > 75% increase in NOFF attendance. In Phase 1, we conducted a baseline audit comparing peri-operative outcomes in NOFFs with a similar cohort of older adult patients for elective total hip replacement (THR) [2]. Cognitively intact NOFF patients with an abbreviated mental test score >= 7 had higher pain scores postoperatively, longer time to first oral intake, mobilisation and catheter removal compared to the total hip replacement group. There was also wide variation in choice of anaesthetic, intra-operative analgesia and no coherence in the perioperative analgesic regime for the NOFF group. Following this we designed a NOFF peri-operative care pathway with multidisciplinary input. In Phase 2 of our project we aimed to audit compliance with this pathway and whether it made a difference to specific short term outcomes. Methods Between May and September 2015 we followed up a cohort of NOFF patients for 48 h postoperatively. We collected data on peri-operative pain management, time to first postoperative oral intake, mobilisation and catheter removal and compared these with results from Phase 1. In Phase 1 we used a numerical reporting scale to assess pain and so had to exclude cognitively impaired patients. In Phase 2 we again used a numerical reporting scale in patients with an abbreviated mental test score >= 7 but in addition we introduced the use of the Abbey pain scale. The Abbey pain scale enabled us to assess pain in all patients, including the cognitively impaired. Results The two groups had similar demographics. There were 51 and 40 patients in Phase 1 and 2, respectively. In Phase 2, 57.5% (23/40) of patients had a fascia iliaca block at admission for analgesia and 55% (22/40) had a standardised peri-operative analgesia prescription. In Phase 1 none of the patients had either. In Phase 2 there was a structured assessment to decide if urethral catheterisation was necessary. This reduced the number of catheterised patients from 86.2% (44/51) in Phase 1 to 75% (30/40) in Phase 2. Overall duration of catheterisation also decreased. Discussion Our data showed that standardised care in the form of a peri-operative pathway improved short term outcomes for NOFF patients. However, we recognise that there may be a 'spotlight effect' at play in these results. Therefore the onus is on the team to persist with education, engagement and relentless measurement to sustain and improve these outcomes. These are our objectives for Phase 3.</span> [Conference Abstract]</span>