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UK hip fracture program at six hospitals seeks to save lives
The program's multidisciplinary pathway approach includes improvements in nutrition, pain management, imaging, surgery, physiotherapy and patient experience.
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The Northumbria Healthcare NHS Foundation Trust in Northumbria, United Kingdom, which has had a successful hip fracture quality improvement program called HIP QIP for 5 years, has teamed with five other acute NHS Trust hospitals to collaborate and share best practice and to help improve the safety and quality of care following a hip fracture.
The Health Foundation, an independent charity dedicated to bringing better health and health care to people in the United Kingdom, selected the HIP QIP fracture quality improvement project as one the projects in its £3.5 million Scaling Up Improvement initiative. Currently, HIP QIP is the only orthopaedic project in Scaling Up Improvement, according to Mike R. Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), clinical lead for Quality, Northumbria Healthcare NHS Foundation Trust, who is leading the HIP QIP project as part of Scaling Up Improvement. Expertise in the technical skills of service improvement and redesign is provided by Annie Laverty, BMedSc, Msc, PGCE, director of patient experience and quality improvement for Northumbria Healthcare NHS Foundation Trust. She will provide the team with executive leadership support throughout the course of the program.
The British Orthopaedic Association (BOA) and Academic Health Science Network for the North East and Cumbria are partners on the project, and the Royal College of Physicians (RCP) will perform the evaluations for it. The RCP will also provide monthly updates to each Trust detailing how they are doing on each aspect of the improvement.
Change that leads to improvement
The goal of this expanded adoption of HIP QIP is to share and spread the successes in continuity of care for hip fracture patients. The initiative picks up the best practice in each of the participating Trusts and helps the others implement it.
“We made a wide variety of changes and improvements which have led to faster access to information and imaging and surgery, better pain management, [and] earlier physio, which we have 7 days a week. What this has meant, as a bottom line, is patients are more likely to survive now having had a hip fracture and there is also wide improvement in their care,” Reed told Orthopaedics Today Europe.
On the heels of the HIP QIP programs’ initial successes, some of which are now published including a recently published study by Sprowson and colleagues on the effect of antibiotic-laden bone cement on hip fracture infections following hemi-arthroplasty, Reed and colleagues wanted to continue to improve their results with hip fracture treatment. They decided to collaborate with other Trusts “to see if we could help them and to see where they could help us to get better,” Reed said.
Collaborative training, meetings
The Northumbria group underwent training at the Institute for Healthcare Improvement in Cambridge, Mass., USA, on how to lead a collaborative and submitted to The Health Foundation what ended up being a successful bid for funding to run the HIP QIP as a collaborative at the six hospital Trusts. The collaboration, which includes physicians, nurses, physiotherapists and data staff at the participating Trusts, has completed two of five learning events planned to be held through March 2018.
“Northumbria is the host Trust which has a role in bringing all the organizations together,” Laverty told Orthopaedics Today Europe. “Together, we have supported the early development of a learning collaborative, building relationships and trust, teaching skills around service improvement and coaching the other Trusts so they can launch and run the own local improvement programs. As the collaborative develops, there will be more direct influence from the other Trusts, telling us about their own great ideas and improvement plans so we can begin to copy those ideas essentially, and spread best practice.”
Nutrition program, emergency care
As there is an increasing number of patients with hip fractures, Reed and colleagues recognized when they started their hip fracture outcome improvement program that these patients were frail and needed extra attention. Therefore, among other things, the program “is based around timely pain relief in the emergency department (ED),” Reed said, which involves giving a patient a nerve block, sometimes even before imaging is done, if the diagnosis is clear.
“We have a metric which says, ‘The patients have to have their X-ray within an hour of arrival in the ED,’ because previously they may have faced long delays. But now, the patients are fast-tracked through,” he said.
According to Reed, the cost of running Scaling Up HIP QIP includes providing each site with a nutrition assistant for 1 year, which he said has been shown in a randomized trial to reduce mortality.
Involvement
Surgery, which includes more consultant involvement than in the past, is now performed as early as possible because the patients are high-risk and about 7% of them will die within 30 days, according to Reed. From the outset, the attending surgeon now scrubs for higher risk cases. Also, should there be a delay in progression of surgery for any reason, “the attending surgeon will scrub, which means the patients do not have an unnecessarily lengthy operation,” he said. “That is a shift from where we were 6 years ago, certainly.”
Unless major exceptions must be made, every patient with a hip fracture receives all the components of HIP QIP, including a 7-day physiotherapy program that involves mobilizing patients the day of surgery.
“This has led to a reduction in their mortality,” Reed said.
As independent evaluators for the program, the RCP will compare outcomes for the six Trusts involved in HIP QIP to the hip fracture outcomes in the National Hip Fracture Database for non-collaborating Trusts.
“The idea is we will outperform the mortality by 100 lives,” Reed said.
The BOA Trauma group is tasked with organizing multidisciplinary teams to visit all involved Trusts help guide areas to focus on for their HIP QIP project. The visits took place after the first meeting and before the second meeting of the collaborative on Dec. 1, 2016, which involved multidisciplinary representatives visiting each site to determine how hip fractures results could be improved.
“The role of the BOA is to help with spread what was learned in the program throughout British orthopaedics,” said Reed, who noted time is already allotted for HIP QIP updates on the program for the BOA Annual Congresses in 2017 and 2018. – by Susan M. Rapp
- References:
- Duncan DG, et al. Age and Ageing. 2006;doi:10.1093/ageing/afj011.
- http://www.health.org.uk/news/seven-teams-selected-scale-health-care-improvement
- Sprowson AP, et al. Bone Joint J. 2016;98-B:1534–1541.
- For more information:
- Annie Laverty, BMedSc, Msc, PGCE, can be reached at; email: annie.laverty@nhct.nhs.uk.
- Mike R. Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), can be reached at Northumbria Healthcare NHS Foundation Trust; email: mike.reed@nhs.net.
Disclosure: Laverty reports she is a Gen Q fellow and has a funded role to support improvement from The Health Foundation. Reed reports he is on the speaker’s bureau for Heraeus Medical. The HIP QIP grant was supported by The Health Foundation.