Improving Day One Mobilisation Following Hip Fracture

Purpose

Hip fracture is a serious, life changing injury, which typically occurs in people in their eighties with pre-existing medical conditions and subsequent complex post-operative rehabilitation needs. The Hip Sprint Audit in 2017, run by the CSP in conjunction with the NHFD (National Hip Fracture Database), provided for the first time a detailed national understanding of the wide variation in the physiotherapy management of patients following a hip fracture. Participation in this audit demonstrated the hospital was significantly below the national average for achieving day 1 mobilisation following surgery. Aim:

· To increase the number of patients mobilising by day 1 post-operatively to at least the national average on the NHFD

Objectives:

· To establish a detailed understanding of our physio service, specifically in the mobilisation of patients day 1 post operatively

· To understand the team’s perception of ‘mobilisation’ post-operatively, mobilisation strategies currently employed and factors limiting success

· To address any deficiencies to improve our performance

In 2017
61% patients were mobilising day 1
By 2019
80% achieved day 1 mobilisation

Approach

Using the NHS Model for Improvement this project was conducted in a ‘Plan Do Study Act’ (PDSA) format. A three-month retrospective audit of hip fracture patients’ notes was undertaken in 2018, recording reasons for not achieving day 1 mobilisation. An action plan was developed to address deficiencies and implemented in January 2019. This included new guidance from the anaesthetists and ortho-geriatricians to remove emphasis on figures and focus on symptoms in regards to Hb and blood pressure. Pain relief was offered routinely before all sessions, second treatment sessions offered for patients failing to mobilise during the first session, and a lower threshold to using a hoist if it allowed the patient to achieve their goals. The physio team was educated on the importance of day 1 mobilisation and a root-cause analysis sheet developed for all patients who failed to mobilise by day 1. A re-audit was conducted for one-month in September 2019 in conjunction with Hip Sprint 2.

Outcomes

Results: The 2017 Sprint Audit showed 44 of the 72 patients (61%) were mobilising day 1, compared to a national average of 68%. In 2018 the hospital had improved by 14% (to 75%), but nationally the average was 80.5%. The retrospective 2018 audit highlighted pain, low Hb and low blood pressure as the most common reasons for not mobilising. The 2019 Sprint Audit included 50 patients, of which 40 (80%) achieved day 1 mobilisation. The 2019 yearly NHFD figures showed the hospital had a 31% improvement from 2017 to 92% (2019 national average 81%).

Conclusion(s): The use of the PDSA cycle on one aspect of care allowed a multi-disciplinary approach to significantly improve the mobilisation of patients’ day 1 post-hip fracture, without increasing funding or staffing, and sustaining this improvement. Further work is now planned to explore the rehabilitation patients receive throughout their inpatient stay. Environmental constraints of being in a new build hospital with 75% single rooms and 5+2 service is compounding the issue.

Cost and savings

There was no funding for this project.

Implications

By PDSA testing the physiotherapy service on the hip fracture ward it has demonstrated effective changes can be implemented into practice.

Top three learning points

No further information. 

Funding acknowledgements

Nil funding was received for this project.