Improving early mobilisation following femoral fracture using a therapy led education programme

Purpose

Early mobilisation following a femoral fracture is a key hip fracture metric¹ ² and is associated with improved outcomes related to acute length of stay, morbidity and mortality³ During 2018 2019 the percentage of patients mobilised by day one at the JPUH was substantially lower than the national average⁴ and we were also a mortality outlier.

Our key objective was to improve the percentage of patients who were successfully mobilised by post operation day one following femoral fracture surgery.

Our secondary objective was to increase the ward staff confidence in attempting early mobilisation of patients by day one following femoral fracture surgery.

 

Approach

Method
Using a Model for Improvement method the orthopaedic therapy team provided education to the ward Healthcare Assistants (HCAs) and Trainee Nurse Associates (TNAs) to:
• Successfully mobilise ‘less complex’ patients by POD 1 prior to physiotherapy assessment
• Identify issues preventing mobilisation by HCAs and begin to modify these to increase the chance that the Physiotherapist would be able to mobilise the patient later that day e.g. HCA identifying pain on moving to wash prompting nurse to provide additional analgesia or low blood pressure in the morning then focusing on increasing oral fluids to improve this

We used the NHFD data, collected monthly, to provide us with the percentage of patients mobilised before and after the intervention.

A confidence questionnaire, measured out of 100%, was completed before and after training as part of the PDSA cycle of improvement.

Outcomes

Results

Primary outcome was percentage of patients mobilised from bed by post operation day one.

Prior to therapy led education programme:

During the periods of 2018, 2019 and January to June 2020 the percentage mobilised was 60%.

Following the therapy led edcuation programme:

During the period of July to December 2020 the percentage mobilised was 76.5%

Secondary outcome was ward staff confidence to provide early mobilisation.

20 questionnaires were given out, 7 lost to attrition, therefore a total of 13 responding to both questionnaires were included.

The confidence score improved from 62% prior to the therapy led education programme to 92% following the therapy led education programme.

Conclusion

Therapy led ward based education has been demonstrated to improve the percentage of patients mobilised and also improved staff confidence to mobilise patients by post operation day one. This can have the potential to improve patient experience, reduce demand on acute therapists, allow therapists to focus on rehabilitation specific progression, reduce care needs on discharge and reduce acute length of stay.

Due to staff attrition, this therapy led education programme should be considered as an integral part of ward staff induction training with yearly updates to maintain the improvements seen.

Cost and savings

No additional staff were employed to complete this project. Therapy time was the only cost associated with this and this is estimated to have been around 20 hours over one month to provide training.

We have estimated that the therapy time required to develop and implement this training will be outweighed by the reduced demand on therapy time to be the first health care professional mobilising patients. This is an important task but can be particular time consuming. Therapy time can therefore be more effectively utilised if a patient is already sitting out in their chair. 

We did not measure the impact on LOS, functional improvement or morbidity in this period but literature exists to suggest early mobility improves morbidity and reduces complications associated with prolonged length of stay.

Implications

This therapy led education programme demonstrates the important role that therapists can play in increasing the confidence, confidence and engagement of all ward staff in early mobilisation of femoral fracture patients.

This approach could be adapted to other specialist areas to improve early mobility and prevent de-conditioning in the acute setting.

Following the success of this programme in orthopaedics we are commencing an Occupational Therapy led delirium education programme within orthopaedics, providing a refresher training session to the trauma ward staff and adapting the education programme to other ward areas within the Trust.

Top three learning points

Therapists are well placed to instigate, lead and develop projects that improve our patients experience and national metrics.

Engagement and support from the wider MDT is essential - We have had excellent buy-in and support from our Lead orthopaedic Consultant, Matron and ward nurses and healthcare assistants.

It is important for us as therapists to collect our data, look at where we can improve and use service improvement methodology to try and improve.

Funding acknowledgements

This work was unfunded.

Additional notes

This submission combines the VPUK poster submissions 128 and 294 as they use the same methodology and service improvement project.

Out Of Bed Project success (jpaget.nhs.uk)

References:
1. Royal College of Physicians (2018) Recovering After Hip Fracture. Physiotherapy ‘ HipSprint ’ Audit Report. London.
2. Chartered Society of Physiotherapy. Hip Fracture Standards (2018) www.csp.org.uk
3. Siu, A. et al. (2006) Early ambulation after hip fracture Effects on function and mortality . Archives of Internal Medicine 166 (7): 766 771
4. Royal College of Physicians (2021) The challenge of the next decade: are hip fracture services ready? A review of data from the National Hip Fracture Database (Jan Dec 2019). London .

Attachment