Hip rehab: joining up a fractured service

CSP's standards for physio-led hip fracture rehab could improve care

Hip Rehab: Joining up a fractured service

Alice Price was a frail but relatively independent 88-year-old when she fell and broke her hip in the care home she had recently moved to. But sadly that was the start of a downward cycle that led to her death less than a year later. 

Alice’s daughter Iona explains that after the operation her mother’s rehab had to be delayed because she was suffering from delirium. But the problems really began on discharge to a nursing home where she was supposed to receive intensive therapy to get her back on her feet.

The reality was that ‘she disappeared off the rehab radar’, says Iona. She became a new referral and didn’t receive any further intervention for three months. Once she was working with a physio she made excellent progress and her mood lifted, but sadly she then contracted a chest infection – a high risk with hip fractures – and died shortly afterwards.

Iona can’t help wondering whether her mother might still be alive if she’d had rehab earlier. ‘At the least I wonder how much better her last few months would have been had she received the rehab when she was better able to undertake it.’

Her plea now is for ‘better joined-up care so that you can have the rehab when you need it wherever you are. Care should be continuous. It’s just not fair on people like my mum who were basically in the wrong place at the wrong time.’

Hip fractures are the most common serious injury in older people and the commonest cause of death in this group following an accident. They account for 1.5 million hospital beds days a year and cost the NHS an estimated £1 billion a year.  

Hip fracture accounts for 1.5 m hospital bed days a year

They can also be devastating for the individuals, many of whom never recover their previous mobility and sometimes have to move to institutional care. Their health may deteriorate and they can also become depressed and withdrawn.  

Physio rehab pays

Yet all the evidence suggests that with good, physio-led rehabilitation from the start many of the worst effects – and much of the cost – could be avoided. The CSP’s chief executive Karen Middleton suggests just 20 minutes’ therapy a day could free up 1,000 hospital beds a year.

The CSP recently launched the first national standards for the entire rehabilitation pathway. Its seven-point plan says patients should be assessed within a day of hip surgery, should receive at least two hours of physiotherapy in the following week and should be seen by their next provider within 72 hours of discharge.

The standards put patients at their heart, says CSP professional adviser Pip White. They also stress physios’ centrality if good, seamless rehab is to be delivered. Physios have to be involved from the very start of planning. They should also be part of the hip fracture governance team that oversees the entire pathway.

The standards follow a nationwide audit, the ‘Hip Sprint’ by the Royal College of Physicians on behalf of the CSP which exposed a very different reality. The average wait for community physiotherapy, for example, was four weeks and the longest 80 days. Only 20% of providers successfully maintained rehab continuity and 10% of community providers received no handover information at all. 

Hip fracture rehab is still subject to a postcode lottery, says White. One of the biggest problems is the barrier that exists between different sectors of care, particularly between hospital and community.

‘What surprised me most from this audit was that organisation and delivery of care are still in these silos,’ she says. ‘When you’re a patient you probably don’t care which organisation delivers your care. All you care about is that you get that rehab.’

The fragmentation is reflected in the complicated network of community-based rehab services. ‘With acute trust services it’s fairly easy to find the NHS co-ordinator. But when you ask where patients go next there could be myriad pathways and structures out there.’ 

The audit showed that in many cases information was not getting through or was not being acted upon quickly enough. One problem could be that physios are worried about breaching confidentiality if they share information. ‘But that has to be balanced with the obligation to share information with other professionals directly involved in the care of that named patient.’

Staff shortages also play a part. Some hospitals do not operate a 7-day physiotherapy service which inevitably means interruptions to rehab. And resources are already stretched to the limit in the community.

Good practice

Despite this, there are many examples of good practice. The Royal Cornwall Hospitals Trust has a fully integrated rehab service covering acute and community services which uses the pathway to ensure patients return home quickly and safely. Pippa Ellery, the physiotherapy team and clinical lead on the rehab wards, sees many patients needing further support. She liaises with community re-ablement services to ensure all patients continue to receive rehab at home.

The last two years have seen significant progress, she says. Hip fracture patients are now being discharged more quickly and there is a renewed focus on mobilising all patients within 24 hours of the operation. ‘Most patients really want to go home again and be as mobile as possible and that is what we’re focusing on.’ 

One of the keys has been making rehab everybody’s business. ‘We say rehab is 24 hours a day. Right from the acute side to the community.’  There is still room for improvement, Ellery admits, with some delays in restarting rehab once patients are discharged. ‘Our community colleagues do have a waiting list but they are trying to prioritise those who most need to be seen.’ 

Pip White, the CSP professional advice service lead, says the standards can be used to identify gaps in practice. Equally important is taking a multidisciplinary approach. ‘It can be difficult for one physio to call for a change. But if the organisation recognises it everyone pulls in the same direction.’

Details of the new standards

Case study: Creating a safe pathway 

All the evidence shows that patients recover more quickly from broken hips in their own home than in hospital. At St George’s Hospital in Tooting, South London, the recovery and rehabilitation team is dedicated to ensuring that happens as rapidly as possible, with most patients now back home within 10 days.

Consultant physiotherapist Louise McGregor plays a critical role in this, liaising with the different teams and following a number of patients with more complex needs through the system and back into the community. 

Her particular expertise is with fragile elderly patients, especially those with cognitive issues, so she will often be called in if patients are having problems mobilising because of delirium or dementia.

It is vital to address these problems immediately, says McGregor. 

‘We want to make sure that if someone starts to deviate from the normal pattern they get a senior review very quickly. What you don’t want is that they get that review two weeks after surgery when it’s too late.’

She also works closely with those patients who transfer to the community hospital for further rehab before – in most cases – being discharged home. ‘One of the advantages of that is I get to know the patient and their family and then can help them with that transition,’ she says. She can also feedback on patients’ progress to the acute staff.

McGregor also plays an important role liaising with community re-ablement services. ‘Discussing things through emails and electronic notes is essential for sharing information but there is nothing like knowing the person you’re dealing with and talking face to face about the patient.’

She doesn’t under-estimate the challenges. But, she says, the key to much of this is knowing the team you are referring into. ‘We’re part of a pathway and we need to understand each other.’

The CSP’s new standards should spur physios to help make rehab an uninterrupted process, she believes. ‘Too often patients start their rehab and are doing well and then have to stop and then restart. We need to have conversations with commissioners to show why this is so important and to persuade them to provide this type of service.’

Author: Andrew Cole 

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