Nicole Nielsen

The trauma and orthopaedic physio talks to Mark Gould about her team’s successful approach to hip fracture rehabilitation

Nicole Neilson (Photos: David Harrison)

It’s feel good Friday in the trauma and orthopaedic physiotherapy department at the Princess Royal University Hospital – known as the PRUH – in Orpington, where the sprawl of suburban south London meets the greenery of Kent. There are home-made chocolate chip cookies for a team catch-up, as part of a range of staff well being activities started by Nicole Nielsen, physiotherapy team lead.

Nielsen is half Swedish and half Danish which perhaps explains her emphasis on nurturing the feel-good factor at work – an extension of the Danish concept of hygge – a not totally translatable sense of cosiness and contentment gained from enjoying the simple pleasures of life – and the Swedish fika – shared time with colleagues and friends – often involving coffee and cakes, or chocolate chip cookies.

She qualified from the University of Brighton in 2009 and completing her band 5 rotations convinced her that she wanted to work in an acute setting. ‘Trauma and orthopaedics uses a whole range of physiotherapy skills,’ Nielsen says. ‘We often see patients who have sustained a fracture or another musculoskeletal injury but we get to use our entire toolbox of skills as they

Between January and March 2019 82.6% of patients were mobilised the day after surgery

might also be suffering from a stroke or spinal cord injury or have respiratory problems. Most certainly the best care is provided if we can see them holistically and manage their mental health as well as their physical health.’

For Nielsen, effective rehabilitation is crucial to this holistic approach. Alongside her clinical lead physiotherapist Jane Sykes, she has led the PRUH team in implementing the CSP’s hip fracture rehab standards, and auditing the impact the standards have had among their hip fracture patients. 

They have seen impressive results that – arguably – would exceed those of larger, more specialist, medical institutions, and they have shared these with the CSP as part of the Hip Sprint Local project to aid wider use of the standards among other physiotherapy teams.

Impressive results

In the original Hip Sprint audit (run by the Royal College of Physicians in 2017), of the 50 patients their data represented, 74 per cent were mobilised by the day after surgery, on average they received 118 minutes of therapy in the first week after surgery, 93.6 per cent received therapy on the first day post op – putting the PRUH in the top five nationwide. 

Following the publication of the CSP’s hip fracture standards, the team looked at their data and how they might improve, specifically around getting people out of bed after hip fracture surgery. During the period January to March 2019, 86 patients were re-audited locally and this time 82.6 per cent of patients were mobilised the day after surgery – well above the national average as reported by the NHFD.

The Hip Sprint standards give us a benchmark of care to aspire to, and having those profession-wide targets helps us to keep motivated and excited. When we started out, we had no idea that our results would lead to such wide recognition. We’re a district hospital, and while we’re part of the larger King’s College Hospital NHS Foundation Trust it was nice that the PRUH was recognised on its own merits, Nielsen says. 

Following the RCP audit, the team was invited to give a best practice presentation at the Royal College of Physicians’ Hip Sprint Audit Report launch in London, and Nielsen took on the challenge, even though it took her out of her ‘comfort zone’. She explains: ‘I was proud of our achievement and wanted to get more involved in the fantastic hip sprint work on a more national level so I decided this was the perfect way to do it.’  

Nielsen acknowledges that there is always room for improvement, and that the team’s progress against some standards is better than others: ‘For various reasons, we don’t see all our patients every day within the first seven days post-operation, but we might achieve five days per week. But then we scored high on standard four – the two hours physio per week – and 100 on attendance at clinical governance meetings (standard 6).’
As insightful as the standards have been in showing how the team stand in relation to other organisations, they have also been invaluable to the team members themselves, illustrating their progress and success, and, as Nielsen explains, providing ‘a useful tool for us to highlight to the trust the need for more resources to provide a seven-day rehab service.’

Many of the PRUH patients are older people and a high proportion of them experience dementia, which all adds to the complexity of delivering good rehab. Nielsen says, ‘We recognise that for all patients it’s essential that we address their pain relief and get them back into a routine, getting into a chair, using the toilet - we are keen to treat them holistically and help them on their journey to recovery.’

Supporting patients in their recovery is one of the most rewarding elements of the role for Nielsen. In considering her professional development, she was clear she did not want a move into management: ‘I wanted to stay clinical, not be the boss, but a team lead position came up three and a half years ago and I love it. It has given me the opportunity to change and influence things more than I could as a band six, and empower other people - patients and staff. 

‘My job is so rewarding, it’s great to work with such a good team and we try to give them as much autonomy as possible and invest in their learning and development.’

    Hip fracture standards

    The seven CSP standards for hip fracture physiotherapy rehabilitation are:
    1    A physiotherapist assesses all patients on the day of, or day following, hip fracture surgery 
    2    All patients are mobilised on the day of, or day following, hip fracture surgery. 
    3    All patients receive daily physiotherapy that should total at least two hours in the first seven days post-surgery
    4    All patients receive at least two hours of rehabilitation in subsequent weeks post-surgery until they have achieved their goals. 
    5    All patients moving from hospital to the next phase of rehabilitation are seen by their new rehabilitation provider within 72 hours. 
    6    A physiotherapist is part of every hip fracture programme’s monthly clinical governance meeting. 
    7   Physiotherapists share their assessment findings and rehabilitation plans with all rehabilitation providers to enable clear communication with the MDT.

    CSP professional adviser Pip White, who leads on the Hip Sprint:

    Nicole and the PRUH team have really demonstrated what can be achieved by all working together to make improvements to hip fracture rehabilitation. What has struck me is that the whole team, including support workers, physiotherapists and managers, all understand their own role in creating an effective environment for allowing quality improvement to occur. They were one of the first hospitals to really look at the CSP hip fracture standards and see where changes to how they delivered rehab could be made, and I’m delighted to see the results of their hard work pay off.

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