Improving Hip Fracture Rehabilitation against CSP standards using an Integrated Physiotherapy and Occupational Therapy Team Approach

Purpose

We delivered a new model of care utilising our existing workforce in a more efficient way to deliver the CSP rehabilitation standards following hip fracture. By integrating Physiotherapy and Occupational Therapy rehabilitation using shared goals we are better able to meet increasing demand.

Purpose: The 2017 RCP HipSprint audit showed a wide variation in provision of rehabilitation across the country and the CSP published Hip Fracture Rehabilitation Standards in 2018. Our baseline HipSprint audit identified we were delivering significantly less than the recommended 2 hours rehabilitation per week. On reviewing our service we identified a lack of joint Physiotherapy and Occupational Therapy working, patient goals were not the focus of the MDT, and there was a delayed start to Occupational Therapy delaying provision of equipment and onward care leading to delayed discharge.

Rehabilitation provided per patient in the first 7 days after surgery
Increased from 64 minutes a week to 168 minutes a week.

Approach

All patients over 60 admitted to JPUH for surgical management of primary fractured neck of femur were included in the audit. Physiotherapy care provided was measured against CSP Hip Fracture Standards 1, 2, 3 and 4, using CSP audit tool. We used the PDSA Quality Improvement cycle method. In August 2018 we introduced integrated working combining: · Early OT initial assessment in line with PT POD 0/1 assessment, where possible (POD 3 at the latest) · Early combined integrated PT/OT therapy rehabilitation sessions · Key elements for therapy led discharge including a clinical decision point on day 7, clinical criteria for discharge and an estimated day of discharge using a central ward-board. Data was collected between 1-31 December 2019 inclusive and results compared with our baseline data from July 2017.

Outcomes

Results: 26 patients were included in the audit. We increased the amount of rehabilitation provided per patient in the first 7 days after surgery from 64 minutes a week to 168 minutes a week. We increased the amount of rehabilitation provided per patient in week two from 57.5 minutes to 97 minutes a week. We experienced a reduction in patients mobilised out of bed D0/1 mainly due to hypotension or agitation/confusion. Our LOS in August 2018 was 15.1 days Our LOS in December 2019 was 13.5 days

Conclusion(s): Integrated OT and PT provision using criteria led discharge and a clinical decision point for the whole MDT can have a positive impact on how hip fracture services can be delivered. The increased value provided to patients by better utilising our team includes reducing duplicate assessments, better skills mix across the caseload, providing meaningful engagement in therapy sessions and ensuring the whole MDT are working to the same goals. This has allowed us to deliver the recommended amount of rehab per patient in the first 7 days post-surgery and significantly increase the amount of rehabilitation received in the second week. We were also able to reduce the LOS by 1.6 day. Our future QI project will look to increase understanding of delirium and dementia and provide training to our healthcare assistants to increase confidence and competence to mobilise patients out of bed by POD 1 with an aim to improve percentage of patients mobilising out of bed POD 0/1.

Cost and savings

The service improvement and results achieved were made within existing staffing levels. The increased rehabilitation time achieved in week 1 and week 2 post surgery was gained by changing how the Physiotherapists, Occupational Therapists and Therapy Assistant Practitioners worked from time of patient admission to discharge from our Trust. We moved from a predominantly Physiotherapy led process where patients achieved a particular level of function before our Occupational Therapists provided their initial assessment and began discharge planning to an approach where our Occupational Therapists aimed to complete their initial assessments in line with Physiotherapists completing or by 72 hours post surgery at the latest. This ensured a greater MDT understanding of each patient at an earlier stage of patient journey. By having earlier details of patients home environment, functional requirements to return home and identification of specific barriers to returning home the whole Physiotherapy, Occupational Therapy and Therapy Assistant Practitioner workforce were better able to provide effective rehabilitation in a meaningful way to achieve timely discharge home. We were also able to maximise our clinical skill sets and skills mix by offering more joint rehabilitation sessions between Physiotherapists and Occupational Therapists which allowed the same number of Physiotherapists to effectively double the number of patients they could see each day. This greater efficiency increased the amount of rehabilitation time each patient received. Others benefits of a greater integrated approach to rehabilitation for this patient group was the shared knowledge and learning between Physiotherapists and Occupational Therapists which increased confidence in the cognitive and physical aspects of rehabilitation respectively. Finally, we embraced a new electronic central ward board, setting estimated discharge dates (EDD) by day 3 post surgery and also by creating a "decision point" at post operation day 7 to establish the "next steps" in each patients journey e.g. slow stream rehabilitation bed or bed to be moved downstairs or package of care etc. Ultimately this approach has resulted in a reduction in the acute length of stay for patients following a fractured neck of femur by 1.6 days over a 16 month period. This represents a cost saving of £180, 480 in reduced acute bed days

Implications

There was a reduction in bed days of 1.6 day for each patient with a hip fracture over the audit period. If sustained this equates to savings of £180,480 per year (£300 bed cost x 1.6 x 376 patients

Top three learning points

No further data 

Funding acknowledgements

This work was not funded and utilised existing resources.