“The fall and fall of the
femoral empire”
A/Prof Lyn MARCH
Victorian Quality Council Sustainability Symposium
Melbourne, 2007
Institute of Bone and Joint Research, University of Sydney Dept of Rheumatology, Royal North Shore Hospital
Treatment of Hip Fracture:
Treatment of Hip Fracture:
Can Evidence
Can Evidence
-
-
Based Clinical
Based Clinical
Pathways make a Difference?
Pathways make a Difference?
A/Prof Lyn MARCH& Northern Sydney Fractured Neck of Femur Health Outcomes Project Team
Northern Sydney Public Health Unit & University of Sydney Dept of Rheumatology, Royal North Shore Hospital
AIM
AIM
To evaluate the impact of
evidence-based clinical pathways for acute
management of hip fracture on
☺ patient care
☺ mortality
METHODS
METHODS
METHODS
METHODS
☺ Systematic literature review
☺ Formulation of guidelines
☺ Implementation of clinical pathways in 2 hospitals
☺ Retrospective & prospective audit of medical
records in 2 “pathway” & 4 “non-pathway” hospitals
☺ Systematic literature review
☺ Formulation of guidelines & development of pathways
☺ Implementation of clinical pathways in 2 hospitals
☺ Retrospective & prospective audit of medical records
☺ Audit and feedback
☺ Academic detailing and presentation of the evidence
☺ Involvement in pathway development
☺ Continuing education to support pathway
☺ Patient Brochures
☺ Project staff to measure outcomes
IMPLEMENTATION Strategies
ANALYSIS
ANALYSIS
☺ ‘Before & after’ comparison within pathway hospitals ☺ Prospective comparison between “pathway” and
“non-pathway” hospitals concurrently
☺ Logistic regression adjusting for confounders for
main outcome measures
4 month mortality
RESULTS
Table 1:
Table 1:
Pathway Guidelines
Pathway Guidelines
☺ no routine pre-operative traction (Level 2)(Level 2) ☺ pressure relieving mattresses (Level 1)(Level 1) ☺ prophylactic anticoagulation (Level 1)(Level 1) ☺ operate within 24-36 hours (Level 3)(Level 3) ☺ regional anaesthesia (Level 1)(Level 1) ☺ prophylactic antibiotics (Level 1)(Level 1) ☺ surgical fixation (Level 1)(Level 1) ☺ no routine in-dwelling catheters (Level 2)(Level 2) ☺ oxygen saturation monitoring (Level 2)(Level 2) ☺ nutritional assessment & protein supplements (Level 2)(Level 2) ☺ remove drains early (Level 2)(Level 2) ☺ mobilise within 48 hrs post-surgery (Level 3)(Level 3) ☺ early & active rehabilitation (Level 1)(Level 1)
Table 2:
Table 2:
Pre
Pre
-
-
admission characteristics of patients
admission characteristics of patients
at 2 “pathway” & 4 “non
at 2 “pathway” & 4 “non
-
-
pathway” hospitals
pathway” hospitals
Non-pathway PathwayPathway
(n=286) (n =195)(n =195)
% male
% male 22.6 17.417.4
% female
% female 77.4 82.682.6
% from nursing homes
% from nursing homes 36.4 21.521.5 ******
% confused &/or demented
% confused &/or demented 42.1 29.7 29.7 ****
age (mean years)
age (mean years) 82.5 84.4 84.4 **
co
Table 3:
Table 3: Performance in “pathway” hospitals Performance in “pathway” hospitals before & after pathway implementation
before & after pathway implementation
Hospital A Hospital B
Pre PostPost Pre PostPost
(n=256) (n=114)(n=114) (n=199) (n=81)(n=81) % no traction % no traction 42.9 71.9 71.9 ****** 40.3 84.684.6****** % pressure mattress % pressure mattress < 5 97.997.9****** < 5 85.985.9****** % anticoagulants % anticoagulants 81.6 94.594.5**** 88.6 100100**** % surgery in 36 hrs % surgery in 36 hrs 86.9 90.290.2 61.7 81.381.3**** % regional anaesthesia % regional anaesthesia 73.1 56.356.3**** 17.2 21.321.3 % antibiotics % antibiotics 98.8 98.298.2 97.2 98.798.7 % no urinary catheter % no urinary catheter 9.5 29.729.7****** 36.0 43.643.6 % oximetry & O % oximetry & O22 < 5 35.135.1**** < 5 98.798.7****** % nutrition % nutrition < 10 67.667.6 < 10 43.643.6 % no drains % no drains 0.8 8.08.0 1.4 21.821.8 % mobilise by day 3 % mobilise by day 3 53.7 76.076.0****** 61.0 85.085.0****
median acute stay (days)
Table 4:
Table 4: Performance in Performance in ““pathwaypathway”” & & ““nonnon-
-pathway
pathway”” hospitals after pathway implementationhospitals after pathway implementation
Non-pathway PathwayPathway (n=286) (n=195)(n=195) % no traction % no traction 66.0 77.177.1** % pressure mattress % pressure mattress 38.3 92.592.5****** % anticoagulants % anticoagulants 93.6 96.896.8 % surgery in 36 hrs % surgery in 36 hrs 72.3 86.786.7****** % regional anaesthesia % regional anaesthesia 53.0 42.5 42.5 ** % antibiotics % antibiotics 97.9 98.498.4 % no urinary catheter % no urinary catheter 52.4 37.0 37.0 ****** % oximetry & O % oximetry & O22 30.2 77.577.5****** % nutrition % nutrition 44.8 57.757.7**** % no drains % no drains 9.2 13.713.7 % mobilise by day 3 % mobilise by day 3 66.7 79.579.5****
median acute stay (days)
median acute stay (days) -- non NHnon NH 10 99
median acute stay (days)
median acute stay (days) -- NHNH 6 5 5 **
median rehab stay (days)
Table 5:
Table 5: Outcomes at 4 months for “pathway”Outcomes at 4 months for “pathway” & “non
& “non--pathway” hospitalspathway” hospitals
Non-pathway PathwayPathway
(n=286) (n=195)(n=195) % 4 month mortality % 4 month mortality NH at entry NH at entry 22.1 28.628.6 non NH at entry non NH at entry 13.8 14.614.6 OVERALL OVERALL 16.8 17.617.6
% new nursing home admission
% new nursing home admission
non NH at entry
Table 6: Logistic regression results for
Table 6: Logistic regression results for
predictors of death by 4 months
predictors of death by 4 months
Predictors
Predictors Odds RatioOdds Ratio (95% CI)(95% CI) p valuep value
Age
Age >> 8585 4.4 (1.3-14.9) 0.0190.019
Nursing home resident
Nursing home resident 2.2 (1.2-40.7) 0.0090.009
> 3 post
> 3 post--op complicationsop complications 3.0 (1.7-5.2) 0.00010.0001
Urinary catheter
Urinary catheter 2.7 (1.4-5.0) 0.0020.002
Sliding screw/plate surgery
Sliding screw/plate surgery 2.2 (1.2-4.0) 0.0140.014
Pathway hospital
Table 7: Predictors of new nursing home
Table 7: Predictors of new nursing home
admission by 4 months
admission by 4 months
Predictors
Predictors Odds RatioOdds Ratio (95% CI)(95% CI) p valuep value
Confusion/Dementia Confusion/Dementia 4.9 (2.2-10.9) 0.00020.0002 Hostel resident Hostel resident 2.4 (1.0-5.3) 0.0440.044 Rehab stay Rehab stay 1.03 (1.01-1.05) 0.0010.001 Pathway hospital Pathway hospital 0.5 (0.3-1.1) 0.0920.092
CONCLUSIONS
CONCLUSIONS
Evidence
Evidence
-
-
based clinical pathways for
based clinical pathways for
acute treatment of hip fracture:
acute treatment of hip fracture:
-
-☺
☺ increased use of “best practice”increased use of “best practice”
☺
☺ reduced acute hospital stayreduced acute hospital stay
☺
☺ reduced rate of new nursing home admissionreduced rate of new nursing home admission
☺
☺ had no impact on 4 month mortalityhad no impact on 4 month mortality
☺
☺ were resource intensive to develop & maintainwere resource intensive to develop & maintain
☺
BARRIERS
BARRIERS
Implementation & Sustainability barriers:
Implementation & Sustainability barriers:-
-☺
☺ Level of evidenceLevel of evidence -- sometimes lackingsometimes lacking
☺
☺ Patient factorsPatient factors -- lack of awarenesslack of awareness
-- cant stick up for themselvescant stick up for themselves
☺
☺ Clinician factorsClinician factors -- timetime--honoured practiceshonoured practices
-- lack of awarenesslack of awareness
-- lack of timelack of time
-- lack of lack of numbenumbersrs
☺
☺ System factorsSystem factors -- emotional support lackingemotional support lacking
-- lack of integrationlack of integration
ACKNOWLEDGEMENTS
ACKNOWLEDGEMENTS
NSW Health
NSW Health
Northern Sydney Area Health Service
Northern Sydney Area Health Service
Staff from orthopaedics,emergency, anaesthetics, theatres,
Staff from orthopaedics,emergency, anaesthetics, theatres,
physiotherapy, rehab, dietetics, social work, occupational
physiotherapy, rehab, dietetics, social work, occupational
therapy, medical records, clinical process management &
therapy, medical records, clinical process management &
quality assurance
quality assurance
I Cameron, R Cumming, A Chamberlain, J Schwarz, A
I Cameron, R Cumming, A Chamberlain, J Schwarz, A BrnabicBrnabic,, P O’Meara, T Taylor, S Riley, T Finnegan, S
P O’Meara, T Taylor, S Riley, T Finnegan, S KurrleKurrle, J Skinner,, J Skinner, B
