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In an aging population the number of hip fracture cases is on the rise. With over 16 000 cases annually, the human and system costs are becoming an increasing issue. In the lead-up to the 2nd annual Hip Fracture Management conference, we had the chance to ask some of our speakers what they consider key obstacles to improving time to surgery for hip fracture patients and what initiatives their organisation has put in place to improve this element of patient flow.
“The main strategy to improve time to surgery is the implementation of an Orthogeriatrics service. This service which is coordinated between orthopaedics and geriatrics, involves a joint admission between these two specialties. Any patient admitted with a femoral fracture is assessed by both advanced trainees and a preoperative assessment is performed within 12 hours after admission. Our hospital has significantly reduced the time to surgery since the implementation of this program in 2006.”
Gustavo Duque, Professor of Medicine, Head, Division of Geriatric Medicine, Department of Medicine & Director, Ageing Bone Research Program, Nepean Hospital
“I think that one of the biggest obstacles is the perception among many people involved that hip fractures are not particularly urgent, not particularly important. Convincing everyone that this is not the case leads to a gradual chipping away of the multiple barriers to prompt and effective treatment.“
Alasdair Sutherland, Orthopaedic Surgeon, Director of Orthopaedic Services, South West Healthcare
“Mainly time limitations at the moment. We are a small hospital servicing over 400 000 people with more than double that in the holiday season. In the last 12 months we looked after more than 200 #NOF’s with patients attending theatres within 48hr in more than 95% of the cases. In the remaining patients it is mainly due to unreadiness to proceed due to medical issues.
One initiative is the introduction of a dedicated orthopaedic trauma list on the weekends with usually the first place is dedicated to any NOF patients on the unit. The ortho team met every morning (including a reduced team on the weekends) to discuss the management of trauma and emergency cases for the day, all of our consultants are very eager to proceeding with our NOF patients first off the list with great support from our anaesthetic team. Our main issue is if there is a life threatening admission obviously they have priority to any theatres open. We also give priority to paediatric cases.
Our patients are medically optimised with the assistance of the ortho-geriatrician and her team who work hard to optimise patients early rather than later to ensure prompt surgical intervention.
Another initiative is the introduction of my role. I tend to coordinate the different stages but most of the times the teams have already done what is needed and the patient is ready for theatre.
Last week we started a NOF planning team that will be looking into best practice models from around the world and locally to formulate a comprehensive clinical pathway to ensure optimum care throughout the patient journey. I am blessed with a wonderful team who make me look good.”
Tracey Finigan, Acting Clinical Nurse, Neck of Femur Patient Flow, Gold Coast Hospital
“Key obstacles in improving time to surgery are as follows
- Minimise time for diagnosis in ED
- Prevent access block to inpatient bed in orthogeriatric unit by admitting patients by dedicated ortho-geriatric team- i.e. medical and surgical admission
- Medical optimisation of patients prior to surgery (limit investigations to unstable patients), management of anticoagulation issues etc.
- Extensive discussion with patients and Enduring Power of Attorney on capacity to give consent for procedure, Acute Resuscitation plans
- Dedicated Hip Fracture OT Theatre lists
- Multidisciplinary team approach- Surgeons, Anaethetists, Geriatricians, Nursing and Allied Health Team”
Chrys Pulle, Geriatrician Hip Fracture Unit, The Prince Charles Hospital Brisbane
“We have found the key obstacles to improving time to surgery for this cohort of patients to be multi-factorial. The biggest area for improvement we identified was ensuring shared expectations and communication. We achieved this through stakeholder meetings, analysis of data and open discussions. Once we had agreed on the priorities and expectations around hip fracture surgery the rest came together and the team was able to redesign the existing process to ensure timely and safe surgery for these patients.”
Gillian Puckeridge, Orthopaedic Clinical Nurse Consultant, Nambour General Hospital
“There is a HNELHD guideline currently being developed to ensure best practice for management of hip fractures in ED. There is currently no LHD requirement or adherence to an orthogeriatric approach, however at Armidale Rural Referral Hospital there is an expectation that the orthopaedic team will refer all hip fracture patients for review by the physician on call. This is to ensure the timely identification and treatment of any conditions that might otherwise delay surgery due to anaesthetic risk.”
Narelle Marshall, Acute to Aged Related Care – AARCS Nurse, Hunter New England Local Health District, NSW Health
Darlene Saladine, Acting Health Service Educator, Hunter New England Local Health District, NSW Health
Visit the event website to view the full agenda and to register for the 2nd annual Hip Fracture Management Conference, to be held on the 2-3 December 2013 in Melbourne.