The fall and fall of the femoral empire

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1 The fall and fall of the femoral empire A/Prof Lyn MARCH Victorian Quality Council Sustainability Symposium Melbourne, 2007 Institute of Bone and Joint Research, University of Sydney Dept of Rheumatology, Royal North Shore Hospital

2 Treatment of Hip Fracture: Can Evidence-Based Clinical Pathways make a Difference? A/Prof Lyn MARCH & Northern Sydney Fractured Neck of Femur Health Outcomes Project Team Northern Sydney Public Health Unit & University of Sydney Dept of Rheumatology, Royal North Shore Hospital

3 AIM To evaluate the impact of evidencebased clinical pathways for acute management of hip fracture on patient care mortality nursing home admission

4 METHODS Systematic literature review Formulation of guidelines & development of pathways Implementation of clinical pathways in 2 hospitals Retrospective & prospective audit of medical records records in 2 pathway & 4 non-pathway hospitals Telephone follow-up 4 months post discharge

5 IMPLEMENTATION Strategies Audit and feedback Academic detailing and presentation of the evidence Involvement in pathway development Continuing education to support pathway Patient Brochures Project staff to measure outcomes

6 ANALYSIS Before & after comparison within pathway hospitals Prospective comparison between pathway and non-pathway hospitals concurrently Logistic regression adjusting for confounders for main outcome measures 4 month mortality 4 month nursing-home admission

7 RESULTS

8 Table 1: Pathway Guidelines no routine pre-operative traction (Level 2) pressure relieving mattresses (Level 1) prophylactic anticoagulation (Level 1) operate within hours (Level 3) regional anaesthesia (Level 1) prophylactic antibiotics (Level 1) surgical fixation (Level 1) no routine in-dwelling catheters (Level 2) oxygen saturation monitoring (Level 2) nutritional assessment & protein supplements (Level 2) remove drains early (Level 2) mobilise within 48 hrs post-surgery (Level 3) early & active rehabilitation (Level 1)

9 Pre-admission characteristics of patients at 2 pathway & 4 non-pathway hospitals Table 2: Pre Non-pathway Pathway (n=286) (n =195) % male % female % from nursing homes *** % confused &/or demented ** age (mean years) * co-morbidities (mean) ***

10 Table 3: Performance in pathway hospitals before & after pathway implementation Hospital A Hospital B Pre Post Pre Post (n=256) (n=114) (n=199) (n=81) % no traction *** *** % pressure mattress < *** < *** % anticoagulants ** ** % surgery in 36 hrs ** % regional anaesthesia ** % antibiotics % no urinary catheter *** % oximetry & O 2 < ** < *** % nutrition < < % no drains % mobilise by day *** ** median acute stay (days) - non NH *** **

11 Table 4: Performance in pathway & non- pathway hospitals after pathway implementation Non-pathway Pathway (n=286) (n=195) % no traction * % pressure mattress *** % anticoagulants % surgery in 36 hrs *** % regional anaesthesia * % antibiotics % no urinary catheter *** % oximetry & O *** % nutrition ** % no drains % mobilise by day ** median acute stay (days) - non NH 10 9 median acute stay (days) - NH 6 5 * median rehab stay (days) *

12 Table 5: Outcomes at 4 months for pathway & non-pathway hospitals Non-pathway (n=286) Pathway (n=195) % 4 month mortality NH at entry non NH at entry OVERALL % new nursing home admission non NH at entry

13 Table 6: Logistic regression results for predictors of death by 4 months Predictors Odds Ratio (95% CI) p value Age > ( ) Nursing home resident 2.2 ( ) > 3 post-op op complications 3.0 ( ) Urinary catheter 2.7 ( ) Sliding screw/plate surgery 2.2 ( ) Pathway hospital 0.8 ( ) 0.505

14 Table 7: Predictors of new nursing home admission by 4 months Predictors Odds Ratio (95% CI) p value Confusion/Dementia 4.9 ( ) Hostel resident 2.4 ( ) Rehab stay 1.03 ( ) Pathway hospital 0.5 ( ) 0.092

15 CONCLUSIONS Evidence-based clinical pathways for acute treatment of hip fracture:- increased use of best practice reduced acute hospital stay reduced rate of new nursing home admission had no impact on 4 month mortality were resource intensive to develop & maintain were not sustainable without research support

16 BARRIERS Implementation & Sustainability barriers:- Level of evidence Patient factors Clinician factors System factors - sometimes lacking - lack of awareness - cant stick up for themselves - time-honoured practices - lack of awareness - lack of time - lack of numbers - emotional support lacking - lack of integration - lack of resources

17 ACKNOWLEDGEMENTS NSW Health Northern Sydney Area Health Service Staff from orthopaedics,emergency, anaesthetics, theatres, physiotherapy, rehab, dietetics, social work, occupational therapy, medical records, clinical process management & quality assurance I Cameron, R Cumming, A Chamberlain, J Schwarz, A Brnabic, P O Meara, T Taylor, S Riley, T Finnegan, S Kurrle,, J Skinner, B Carfrae,, B Christiansen, J Makaroff, P Sambrook

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