SHFA

Page last updated: 27-JUL-2010

SHFA

Statistical Publication Notice

26 May 2009

The patient journey post hip fracture: What constitutes rehabilitation?
A Report from the Scottish Hip Fracture Audit

INTRODUCTION

'The patient journey post hip fracture: What constitutes rehabilitation?' is a report from the Scottish Hip Fracture Audit, a clinician-led and ISD-administered audit focusing on hip fracture patients. It presents data summarising investigation and management practice for hip fracture patients across Scotland over six months in 2008.

As our population ages, we expect the number and age of hip fracture patients to increase, giving hospitals and rehabilitation units an increasingly important opportunity to positively intervene in the recovery period of hip fracture patients and in their secondary preventative care. This report identifies many areas of good practice, as well as identifying differences from unit to unit. It is hoped that individual units will find the report useful to reflect on current practice and, where necessary, implement changes to practice.

In recent years, a number of publications and initiatives have recognised the importance of multiple interventions in the assessment and management of hip fracture patients (e.g. publication of the revised 'Blue Book' on the Care of Fragility Fractures in 2007, the first BOA Standard for Trauma, Hip Fracture in the Older Person in 2008, and the updated SIGN 56 Prevention and Management of Hip Fracture in Older People expected in 2009). Evidence of benefit is strongest in areas such as falls and osteoporosis assessment, but there is also a growing body of support for good practice in nutritional and cognitive assessment of this complex cohort of patients aimed at both maximising recovery and reducing the risk of future falls and fractures.

From April to September 2008 we collected information on the following rehabilitation topics from all hip fracture patients admitted to all but one of the 21 mainland orthopaedic units which carry out hip fracture surgery in Scotland:

Falls - cause and context
Actions during inpatient (acute orthopaedic and rehabilitation ward) stay - ECGs, COE and medical specialty inpatient reviews, specialist and other clinic referrals
Falls assessments and careplans
Cognition assessment, patient confusion and actions for confusion
Medication for bone health
Nutrition assessments, dietician referrals and dietary actions (supplements, special diets and advice)
Physiotherapy and occupational therapy input
Environmental visits, home visits and supported discharge

We also summarise additional general rehabilitation practices across Scotland as scoped from clinical staff/managers in each hospital at the time of the sprint audit.

KEY POINTS

2708 hip fractures (97% of the total from participating hospitals) were audited between April and September 2008. 93% of hip fracture patients were known to have fallen and although many of these were recorded as simple/mechanical falls, 16% had diagnosed or suspected medical causes.

67% of patients were on prescribed bone health medication at 120 days post-admission.

31% of surgical patients were authorised for surgery using the Adults With Incapacity (Scotland) Act 2000. Although impaired cognition is known to influence falls risk, rehabilitation potential and outcome, only 53% of patients had their cognition assessed during their inpatient stay.

69% of patients had their nutritional status assessed.

96% of patients are assessed and treated by physiotherapy services during their inpatient stay, and 73% by occupational therapists. 39% of patients discharged home from orthopaedics or rehabilitation were discharged with the assistance of a supported discharge team.

INTERPRETATION

Participation and completeness

We report on data from 2708 patients, representing 97% of all hip fractures admitted to participating hospitals in Scotland during the six-month period from April to September 2008. Patients under 50 years old were excluded from audit. Aberdeen Royal Infirmary did not participate in the Rehabilitation audit. Perth Royal Infirmary began sprint audit data collection on 1st May and Queen Margaret Hospital, Dunfermline in mid-June. July to September Glasgow Royal Infirmary and Victoria Infirmary, Glasgow data was collected retrospectively and could not always be sourced.

Trained SHFA Local Audit Co-ordinators (LACs) collected the data from casenotes. In units that discharged patients to multiple off-site rehabilitation units, resources did not always allow collection of all rehabilitation data. In these circumstances, LACs focused on gathering complete data from the sites which accommodated most of their hip fracture patients. Some LACs were supplied with data from remote off-site rehabilitation units through collaboration with a link nurse who provided the requested data. In hospitals where we were unable to collect all rehabilitation data, the overall proportion of care given may have been slightly underestimated as described in the report.

For rehabilitation patients, we report on the first rehabilitation stay after they leave acute orthopaedic care. A small proportion (5%) of rehabilitation patients were subsequently transferred to another rehabilitation facility for further rehabilitation care.

In addition to patient-specific data, we collected general information 'profiles' for all 20 contributing operating units, and sixty-four regular rehabilitation units.

DETAILED FINDINGS

As our population ages and the hip fracture incidence is correspondingly expected to rise, we have an increasingly important opportunity to positively intervene in the recovery period of our patients and in their secondary preventative care. This report identifies many areas of good practice, as well as identifying differences from unit to unit. It is hoped that individual units will find the report useful to reflect on current practice and, where necessary, implement changes to practice.

Falls

93% of patients were known to have presented with a fall
57% of falls were recorded as simple or mechanical falls, but 16% had diagnosed or suspected medical causes
54% of patients had falls assessment carried out, and this fell to 33% of those returned/discharged to a care home
34% of rehabilitation patients had their lying/standing blood pressure recorded

It is important that we remain aware that many patients admitted to hospital with a hip fracture will have multi-factorial causes for their falls. However, the fall is often attributed to a simple or mechanical cause and, as a result, opportunities to assess, properly investigate and modify underlying falls risk factors may be overlooked.

Bone health

41% of patients who had a history of previous fragility fracture were on medication for bone health at presentation; 15% were on bisphosphonate and calcium/vitamin D
At 120 days 67% of patients were on prescribed bone health medication; 27% were on bisphosphonate and calcium/vitamin D

Many clinicians will make the conscious decision not to prescribe bone health medication until at least six weeks after hip fracture. Reviewing patients at 120 days (rather than at 42 days as in the previous rehabilitation audit) is likely to have provided us with a more accurate impact of services provided after hospital discharge.

Speciality review

56% of patients had a Care of the Elderly review while an inpatient
31% had a medical speciality review while an inpatient
13% of rehabilitation facilities caring for hip fracture patients had orthopaedic clinicians providing routine input

The data does not separate routine reviews from those carried out for acute episodes but certainly we must be aware of the opportunity to assess and modify any multi-factorial issues which may have contributed to the patient?s admission.

Cognitive assessment

69% of patients who went onto a rehabilitation facility had their cognition assessed during their inpatient stay
31% of surgical patients were authorised for surgery using Adults With Incapacity
Only 38% of patients authorised using Adults With Incapacity had their cognition assessed in acute orthopaedic care

Early recognition and assessment of cognitive impairment is important in tailoring all aspects of rehabilitation and discharge planning to the needs of each patient. It is disappointing that even in patients whose surgery required to be authorised using Adults with Incapacity only slightly more than a third had their cognition assessed in acute orthopaedic care.

Nutritional assessment

69% of patients had a nutritional assessment
24% of patients were referred to a dietician

Appropriate nutrition is important in maximising a patient?s recovery from a hip fracture and subsequent surgery.

Physiotherapy/occupational therapy

96% of hip fracture patients were assessed and treated by physiotherapy services during their inpatient stay
73% of hip fracture patients were assessed and treated by occupational therapists during their inpatient stay

Loss or partial loss of mobility is a common and serious complication of hip fracture and it is obvious that physiotherapy and occupational services play a large part in optimising timely discharge of patients.

Supported discharge teams

36% of patients who were discharged home from orthopaedics and 41% of those discharged home from rehabilitation were discharged with the assistance of a supported discharge team

Supported discharge teams are multi/interdisciplinary teams who provide short-term care post-discharge ? commonly for up to six weeks. By continuing the rehabilitation process within the patient?s own environment, supported discharge teams can improve the quality and safety of discharges. In addition, they often reduce length of stay in hospital, and can provide valuable links between primary and secondary care services.

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MAIN CONTACTS:

Rik Smith
Senior Information Analyst for SHFA
0131 275 7040
Rik.Smith@isd.csa.scot.nhs.uk

Kathleen Duncan
Clinical Co-ordinator for SHFA
01355 585306
Kathleen.Duncan@isd.csa.scot.nhs.uk

Damien Reid
Consultant COE/Chairman SHFA & Rehab subgroup
01355 585511
Damien.Reid@lanarkshire.scot.nhs.uk

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PRE-RELEASE ACCESS

Under terms of the ?Pre-Release Access to Official Statistics (Scotland) Order 2008?, ISD are obliged to publish information on those receiving Pre-Release Access (?Pre-Release Access? refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre-Release Access and, separately, those receiving extended Pre-Release Access.

Standard (five day) Pre-Release Access:

Scottish Government Health Department (Analytical Services Division)
NHS Board Chief Executives
NHS Board Communication leads

Extended Pre-Release Access:

Scottish Government Health Department (Analytical Services Division)
This extended Pre-Release Access is given to a small number of named individuals in the Scottish Government Health Department (Analytical Services Division). This Pre-Release Access is for the sole purpose of enabling that department to gain an understanding of the statistics prior to briefing others in Scottish Government (during the period of standard Pre-Release Access).

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