Hip fractures cost the NHS over £2 billion per year. Discharge planning can be met with significant delays and prolonged hospital stay resulting in bed shortages for acute care and cancelled elective admissions. Planning care for these patients involves a multi-disciplinary approach with allied healthcare providers.
Patients who sustain a fractured neck of femur are on the increase with an incidence of 75,000.1 Fracture of the proximal femur is a major cause of morbidity and mortality. The death rate being reported between 20–35% at one year and 20% needing long-term care and 30% not returning to their pre-injury state.2,3 This is associated with a significant cost to the local treating hospital and community services. Care for these patients vary across the UK as does the length of stay.2
One of the most crucial factors affecting outcomes and mortality is how long a patient has to wait for surgery, with longer wait times associated with increased mortality, length of stay and complications.4 A recent review has shown that earlier surgery leads to a 19% less chance of a patient dying, 41% less chance of developing pneumonia, and 52% reduced chance of developing pressure sores. This is also supported by a study, which has shown a delay of 24–72% to theatre may increase the risk of death to 44% at 30 days and at one year to 33%.5,6,7
There have been published guidelines by the British Orthopaedic and Geriatric Associations8 and NICE9 on the management of hip fracture patients. This involves a multi-disciplinary approach involving consultant orthopaedic surgeons, anaesthetist, orthogeriatricians, therapists and ideally a fracture neck of femur nurse to assist in co-ordination of patient centered care.8,9
Guidance from NICE recommends that surgery is performed on the day of admission or the day after and the Department of Health Best Practice Tariff recommends that all hip fracture patients have surgery within 36 hours.10
With the aim of providing more efficient and effective care a number of strategies should be in place, such as a specific referral pathway, dedicated fracture neck of femur ward, ortho-geriatrician input and access to rehabilitation services. These additional measures improve patient flow and patient care.10
In our trust, the Early Supported Discharge (ESD) service began in September 2014. It had been highlighted that the length of stay was significantly longer than the national average for the fittest neck of femur patients, those with AMT 8-10/10, mobilising independently with one stick or less and no significant medical comorbidities.3 The impact of prolonged length of stay has increased risk of complications for patients and adds to the bed occupancy pressures facing most hospital trusts.6,11
Prior to the ESD service, the average length of stay for the same fracture neck of femur population was 22.9 days.
The ESD service commenced in September 2014. We have been prospectively collecting data for length of stay, complications, readmissions, mortality, number of therapy contacts in the community and point of discharge. Patient and family feedback was also collected. All 146 patients were included in the ESD service.
During the first year, 432 patients were admitted with a proximal femoral fracture. Some 146 patients fulfilled the inclusion criteria and have been treated by the ESD service between September 2015 and September 2016. The remaining 286 patients are not considered further in this report. Of the 146 patients, 45 males (30%) and 101 females (70%)— the average age was 86 (range was 61–101).
All patients were discharged back to their own home or suitable residence with physiotherapy support at home. The average length of stay was 9.46 days (range 4–21 days) in hospital. The average number of days from hospital discharge to discharge from ESD was 7.90 days (range 1– 13 days). This involved on average 16.8 sessions from physiotherapy as an inpatient (range 4–35). In the community on average there were 12.59 physiotherapy sessions (range 5–26).
There were seven readmissions to hospital within 30 days. There was one hemiarthroplasty dislocation, one distal radius fracture following a fall, three were patients with wound problems that were treated with antibiotics and two were patients admitted under the medical team with a chest infection.
Mortality at 30 days was 8.2% (12/146 patients) and at one year 26% (38/146).
During this year, 146 patients treated by the ESD service reduced the length of stay by 9.46 days on average, which equated to a total of 1962.24 inpatient bed days saved.
Feedback from a paper questionnaire for patient and family responses was excellent (100%).
|BOX 1. WIRRAL UNIVERSITY TEACHING HOSPITALS NHS TRUST EDS SERVICE|
At our trust there are about 450 hip fractures per year, of which 150 would be suitable for ESD. The average length of stay for the fittest hip fracture patients at our trust is 22.9 days.
Length of stay was dramatically reduced from an average of 22.9 days to 9.46 days. Mortality was lower than the national average with fewer readmissions. Family feedback was excellent.
The results illustrate the benefits of using early supported discharge to improve patient care and the hospital orthopaedic service. This shows the ESD service is beneficial for reducing length of hospital stay, improving patients’ function and rehabilitation with respect to activities of daily living and maintaining independence by enabling patients to return to their previous dwelling. This had been evident in stroke services for many years.12,13
A review of a randomised control trial in ESD services for stroke rehabilitation showed a reduction in length of stay of eight days, which is comparable to our reduction of 9.46 days in patients with a fracture neck of femur. ESD services for fracture neck of femur patients are increasing. Results from a Salford Royal NHS Foundation Trust following the introduction of the ESD pathway in 2010 shows a reduced length of stay of seven days again comparable with our results however their service contained less than half the number of patients.14
Our patient group included all fracture management methods (dynamic hip screw, intramedullary nail, hemiarthroplasty and total hip arthroplasty). There was no difference in time to discharge from hospital or from the ESD service in either of these patient groups suggesting that patient selection and appropriate functional rehabilitation is important irrespective of surgical procedure.
As mentioned previously there are strict selection criteria for our ESD service, which improves effectiveness of rehabilitation and compliance to post-operative instruction. This also maintains a throughput of patients in hospital and in the community with the therapy staff being able to target physiotherapy to those patients in hospital and their functional needs as well as patients in their own home with assistance of activities of daily living.
It is deemed that 80% of hospital discharges are simple discharges and this is a key area where care needs to improve.15 Simple discharges are those where patients are being discharged back to their own home or previous place of residence and the ESD service aids this.
In practice, discharge home from hospital is often difficult due to fears about ability to cope, however, a patient remaining in hospital can have these fears reinforced. The risk of pressure sores infection and thromboembolism increase due to this relative immobility.
There can also be a gradual decline as a patient loses their independence, including simple skills, making it appear that they may not be able to manage at home.16 This may account for much of the protracted in-patient stay causing pressure on orthopaedic bed occupancy in patients medically fit for discharge awaiting social care. Our ESD service approach to this is targeted rehabilitation to return patients to their pre-morbid function. This has been greatly appreciated by patients and relatives and has been commented upon in feedback.
The relative importance of restoring function of the elderly trauma patient is well recognised with function and independence having a complex relationship. For an average 85-year-old patient, everyday ordinary activities around the house require near maximum effort. In the early phase of recovery, pain and weakness with the inevitable loss of confidence may make independence impossible for the first few weeks. Any pre-existing disability adds to this delay in recovery.
In our series a mortality rate of 8.2% is in keeping with the national average mortality at 30 days as per the National Hip Fracture database report in 2013.17
One further aspect to consider is health economics. Hospital stay has an added price tag. Our ESD service has a yearly running cost of £375,000. The cost saved based on our calculation of 1962.24 bed days at an average estimated cost of £500 is £981,120 annually. This service more than pays for itself whilst reducing bed occupancy to aid in the ever increasing bed crisis facing most hospital trusts.
Ideal rehabilitation should include a rapid return to home, with flexible physiotherapy and occupational therapy support. This can then be adapted to the patients return to normal function. Early safe discharge and home rehabilitation is suitable for many patients with a proximal femoral fracture and has substantial benefits for patients and the orthopaedic service.
In our experience the ESD service at WUTH provides this by reducing length of stay and providing patients with appropriate rehabilitation in their own home reducing the risk of complications.
Mr B Kapur, Miss P Thorpe, Mr M Ramakrishnan, Wirral University Teaching Hospitals NHS Trust, Liverpool, UK
Conflict of interests: none declared
3. National Hip Fracture Database. National Report 2012. http://www.nhfd.co.uk/20/hip-fractureR.nsf/vwcontent/2012ReportDowlnload/$File/NHFD%20National%20Report%202012.pdf?openelement (date accessed 20 October 2016).
9. National Institute for Health and Clinical Excellence. The management of hip fracture in adults. https://www.nice.org.uk/guidance/cg124/documents/hip-fracture-full-guideline2 (date last accessed 14 December 2016).
10. National Hip Fracture Database. Best Practice Tariff (BPT) for Fragility Hip Fracture Care User Guide. http://www.nhfd.co.uk/20/hipfractureR.nsf/0/9b0c5ea2e986ff56802577af0046b1df/$FILE/Best%20Practice%20Tariff%20User%20Guide.pdf (date last accessed 14 December 2016).
12. Health Service Journal. Why early discharge in stroke care can be vital for recovery. https://www.hsj.co.uk/topics/service-design/why-early-discharge-in-stroke-care-can-bevital-for-recovery/5038502.article (date last accessed 14 December 2016)
14. National hip Fracture Database. Introduction of Early Supported Discharge to Intermediate Care Pathway for Hip Fracture. http://www.nhfd.co.uk/20/hipfractureR.nsf/0/cfff82c891eb3c0280257b2f0044be05/$FILE/ATTQS2Z8.pdf/5.%20%20Neil%20Pendleton%20-%20Introduction%20of%20Early%20Supported%20Discharge%20to%20Intermediate%20Care%20final.pdf (date last accessed 14 December 2016)
17. National Hip Fracture Database. National Report 2013. http://www.nhfd.co.uk/20/hipfractureR.nsf/luMenuDefinitions/F29405CD131D1F36802579C900553994/$file/NHFD%20Summary%20Report%202013.pdf (date last accessed 14 December 2016)