The fall and fall of the femoral empire

(1)

“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

(2)

Treatment of Hip Fracture:

Can Evidence

-

Based Clinical

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

(3)

AIM

To evaluate the impact of

evidence-based clinical pathways for acute

management of hip fracture on

☺ patient care

☺ mortality

(4)

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

(5)

☺ 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

(6)

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

(7)

RESULTS

(8)

Table 1:

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)

(9)

Table 2:

Table 2:

Pre

-

admission characteristics of patients

at 2 “pathway” & 4 “non

-

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

(10)

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)

(11)

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) -- non NHnon NH 10 99

median acute stay (days) -- NHNH 6 5 5 **

median rehab stay (days)

(12)

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

non NH at entry

(13)

Table 6: Logistic regression results for

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

(14)

Table 7: Predictors of new nursing home

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

(15)

CONCLUSIONS

Evidence

-

based clinical pathways for

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

☺

(16)

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

(17)

ACKNOWLEDGEMENTS

NSW Health

NSW Health

Northern Sydney Area Health Service

Staff from orthopaedics,emergency, anaesthetics, theatres,

physiotherapy, rehab, dietetics, social work, occupational

therapy, medical records, clinical process management &

therapy, medical records, clinical process management &

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