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For older people, hip fracture is the commonest serious injury; the commonest reason for them to need emergency anaesthesia and surgery; and the commonest cause of accidental death. As a result, hip fracture is associated with a total cost to health and social services of over £1 billion per year. This one injury carries a total cost equivalent to about 1% of the whole NHS budget.1
- Further reading: Imaging and opportunistic identification of fractures
These statistics highlight the personal and national impact of sustaining a hip fracture. This is potentiated in the elderly population with pre-existing comorbidities that may lead to serious consequences if managed incorrectly. Orthogeriatrics was created to improve the poor outcomes of patients over the age of 60 years suffering a hip fracture. Orthogeriatricians work with orthopaedic teams and the wider multidisciplinary team (MDT) to address the patient’s medical and social issues.2
The Best Practice Tariff (BPT) was created as a financial incentive to improve the care of these patients. It set out essential pre-operative and postoperative criteria to ensure appropriate patient management. Criteria include time-frames for assessment and operative management alongside other requirements.3
As many orthogeriatric patients suffer with co-existing medical and social problems, good handover to primary care physicians facilitates good community care. This handover is usually provided through an electronic transfer of care document (discharge summary). At the Nottingham University Hospitals (NUH), electronic discharge summaries (e-DS) are generated using the hospitalwide, generic template. Summaries for patients over 60 treated for a hip fracture are written by junior doctors who are in foundation year 1 or year 2 and in a four-month rotation in Trauma and Orthopaedics. However, the quality of these summaries vary from minimalistic to extensive depending on what the junior doctor perceives as important information to include. These discrepancies in content were noted both in the weekly orthogeriatric MDT meetings and through feedback from local GP surgeries. It was evident that guidance from community teams could help professionals in completing these documents.
This study aims to define the relevant information that ensures a good quality transfer of care document, in order to help primary care physicians (GPs) offer a high level of care after the patient is discharged to the community.4,5,6,7,8
Data collection of hip fracture patients
A list of contacts was created through established community links to local GP surgeries via the orthogeriatric specialist nurses. These surgeries were chosen by their experience with orthogeriatric patients and their proximity to NUH.
A simple online survey was then created for distribution. The survey questions were centred on the information collated in orthogeriatric assessments.
Results
Twenty seven GP surgeries were contacted and sent the survey. The results are presented in Figures 1-2 and presented in full in part one of this article in December 2016.
Discussion
The two items that all respondents to the survey classed as being important to include in the transfer of care documents related to medications. It is clear that knowing details of the medications the patient is taking or has stopped is key to continuing care.
This may be influenced by the Quality Outcome Framework (QOF) indicators for ‘osteoporosis and secondary prevention of fragility fractures’.
These indicators reward primary care practices for providing ‘quality care’. These indicators include: the percentage of patients aged 75 or over with a fragility fracture on or after 1 April 2012, who are currently treated with an appropriate bone-sparing agent.9 Other factors that may relate to QOF targets include: details of osteoporosis follow up and postural blood pressure.
Other information of importance to respondents included functional outcomes. For example, 96% believed the discharge destination was important to include and 92% requested that information on further community support at discharge should be included. This was also emphasised in some of the comments from the survey’s open questions. The most likely reasons for requesting such information would be that the patient who has suffered a hip fracture may be at a lesser functional status than before the event. This will impact the community care of the patient and be important information for GPs.
However, this information is not always included in the e-DS, possibly because the junior doctors who complete these documents, may not be involved in physiotherapy and social care. As a result, their knowledge of these areas may be limited and their importance overlooked.
In addition, time constraints can also affect what information is included in an e-DS. The results also suggest respondents would generally prefer more succinct information. This point was also noted in the information regarding the falls assessment, where 91% felt it should be included, but the details were not essential to include.
One comment further emphasised this: “It would be helpful to know if a falls assessment has been completed, and the outcome, but it would not be necessary to include the assessment in the transfer documentation”.
This is a reflection of the time pressures under which the GPs also operate. With the results, a proforma was generated. This is in use by the orthogeriatric team and is inserted in the e-DS in the section: “clinical summary, progress in hospital, and specialist teams’ opinion”. Items included were those where 50% or more respondents felt that they were necessary to include. Of these items three are not included in the proforma: medication commenced, altered or stopped; surgery performed and input from other specialties. These three items are already documented in other specific parts of the e-DS and are therefore not in the proforma.
Monitoring quality of transfer of care documentation
Following the implementation of the proforma, a survey has shown significant improvement in the uniformity and quality of the e-DS. The survey reviewed 70 randomly selected patients discharged from the acute orthopaedic ward prior to the introduction of the proforma, and 179 after its introduction. The dates were selected to avoid bias from the authors of this project, who were in orthogeriatric junior doctor positions from December 2014 to March 2015. Of these, 39 patients were excluded due to a lack of e-DS.
Reasons for this include patients transfer with medical notes rather than an e-DS and a community geriatrician providing summaries for a particular residential rehabilitation unit. As a result, a total of 48 e-DSs written before the proforma was introduced, were compared to 162 after. The results show all but four sections of the proforma are being completed in more than 50% of e-DSs compared to only one section prior to the introduction of the proforma.
| ADDITIONAL COMMENTS FROM THE PARTICIPANTS OF THE SURVEY | |
|---|---|
| Question 1: is there any further information you feel should be included in a transfer of care document? | Question 2: Do you have any further comments? |
| Clear details of follow-up arrangements with whom.
Input from other agencies eg. social worker It would be great if the information could be shared and its transfer could be relied upon in a timely manner. Details of the agencies involved in transfer of care with contact details, eg. Community Services, Lings Bar, social care etc and relatives. It would be helpful to know if a falls assessment has been completed, and the outcome, but it would not be necessary to include the assessment in the transfer documentation. Whether or not they had iv bisphosphonate. Info on whether DEXA done/ordered and osteoporosis plan. Safety of mobilisation at discharge. Carers/care package on discharge. Clear out-patient follow-up arrangements if arranged. Clear confirmation that abnormal tests ordered by the hospital service will be followed-up by them, not passed back to primary care. |
Don’t need results of CXR, ECG or blood unless abnormal.
Discharge letters that included the points you have suggested would be gratefully received. One of the most useful pieces of information in where patients are discharged to. Any improvement on current discharge information— particularly medications stopped and reasons why would be hugely appreciated. This would be facilitated by having one clinical system for primary and secondary care (SystemOne) or the ability to share a patient’s care record between primary/secondary/ primary care. The discharge would become less relevant but data sharing would be complete. Remember we can access all hospital lab results directly so not essential to include them. Also remember we probably know pre fall levels of mobility and activity. |
Poorly recorded sections include: continence, mobility on discharge and rehabilitation on discharge. This is likely due to the summaries being completed when much of this information is not available, often soon after the orthogeriatric MDT meetings. Postural blood pressure was also poorly reported, likely due to time pressure on nursing staff who used to be entrusted with this task. The results of the survey are outlined in Figure 3.
There were several recommendations following this survey. Firstly, to increase awareness of the proforma in the induction of professionals working with the orthogeriatric team. Secondly, the day before a patient is discharged, the discharge coordinator should make the junior doctor aware of them, allowing time to complete the proforma. Thirdly, physiotherapists now measure patients’ postural blood pressures and record this prior to MDT meetings. Finally, a further survey is planned to ensure monitoring, maintenance and improvement of the quality of transfer of care documentation within orthogeriatrics.
Limitations
One of the main limitations was time. Most GP surgeries only open during normal working hours and so the majority of data had to be collected over breaks or off-days so as not to impact ward work. More people involved in collecting data would have increased the number of GP surgeries participating.
Another limiting factor was the reliance on a named contact at the GP surgeries to distribute the survey. If there was more direct contact with all possible respondents, more data may have been collected. However, a transfer of care document has to cater to the requirements of the person receiving it. From this perspective, a sizeable sample of primary care practices has been reached and their needs identified.
This information has then been used to design a more meaningful document to the primary care provider when transferring a patient from the acute hospital following treatment of a hip fracture. This has been possible through the generation of a proforma and staff education.
Conclusion
Through this project, we were able to define what information in a transfer of care document is helpful for community care providers. The resulting proforma ensures efficiency is maximised for hospital and community physicians. It has the potential to be used by orthogeriatric teams in other hospitals and across other specialties. The positive impact of this proforma is demonstrated in a follow up survey and this quality will continue to be monitored in future surveys.
Acknowledgments
We would like to acknowledge Catherine Neighbour (Nurse Practitioner) for her invaluable support during the project.
Dr Sarah Fitch, Paediatric ST1, Derby Children’s Hospital, Derby
Dr Michael Cheah, Paediatric ST2, St Peters Hospital Guilford, UK
Dr Kateryna Arlachova, Core Medical Trainee 1, Nottingham University Hospitals
Dr Namal Weerasuriya, Consultant Orthogeriatric Medicine, Nottingham University Hospitals
Conflict of interest: none declared
References
- Royal College of Physicians Falls and Fragility Fracture Programme Audit. National Hip Fracture Database Annual Report 2016 [internet]. London: Royal College of Physicians; 2016. Available from: http://web1.crownaudit.org/Report2016/NHFD2016Report.pdf (Accessed December 2017)
- Hudson H, Hepherd R, Ruckledge A, Ajaj A. Orthogeriatrics. GM [internet]. 2013. Available from: https://www.gmjournal.co.uk/orthogeriatrics_79995.aspx (Accessed December 2017)
- NHS England. 2016/17 National Tariff Payment System [internet]. London: Monitor; 2016. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/509697/2016-17_National_Tariff_Payment_System.pdf (Accessed December 2017)
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- Williams C, Voytas J, Lewis-Hengy K, Evoe S. A quality audit on the effectiveness of continence care documentation during care transitions. 2010 Annual Scientific Meeting of the American Geriatrics Society. Orlando, FL United States. Embase Journal of the American Geriatrics Society; 2010
- Soong C, Kurabi B, Exconde K, Tajammal F, Bell C. Design of an orthopaedic-specific discharge summary. BMC Health Serv Res 2016; 16(1): 545
- National Institute for Health and Care Excellence. Osteoporosis: secondary prevention of fragility fracture [Internet]. London: NICE Quality and Outcomes Framework indicator; 2011 [cited 2017 February 17]. Available from: https://www.nice.org.uk/Standards-and-Indicators/QOFIndicators?categories=3905&page=1 (Accessed December 2017)