The effect of early mobilization on functional outcomes after hip surgery in the Chinese population - A multicenter prospective cohort study

Early mobilisation after hip fracture surgery is associated with improved patient outcomes: A systematic review and meta-analysis

INTRODUCTION

The aims of this systematic review and meta-analysis were to determine if after hip fracture surgery (1) early mobilisation is associated with improved clinical outcomes, and if so (2) are benefits directly proportional to how soon after surgery the patient mobilises.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review was conducted using four databases to identify all studies that compared postoperative early mobilisation with delayed mobilisation, in patients after hip fracture surgery. The Critical Appraisal Skills Programme checklist was employed for critical appraisal and evaluation of all studies that met the inclusion criteria.

RESULTS

A total of 13 studies, including 297,435 patients were identified, of which 235,275 patients were mobilised early and 62,160 were mobilised late. Six studies assessed 30-day mortality, of which two also investigated 30-day complication rates. Pooled meta-analysis demonstrated that there were significantly lower 30-day mortality rates (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.31-0.41, p < 0.001) and complication rates (OR 0.43, 95% CI 0.36-0.51, p < 0.001) in patients mobilising early after hip fracture surgery. Five studies investigated length of stay (LOS) and meta-analysis revealed no difference between groups (mean difference -0.57 days, 95% CI -1.89-0.74, p = 0.39).

CONCLUSION

Early mobilisation in hip fracture patients is associated with a reduction in 30-day mortality and complication rates compared to delayed mobilisation, but no difference in LOS. These findings illustrate that early mobilisation is associated with superior post operative outcomes. However, a direct casual effect remains to be demonstrated, and further work on the factors underlying delayed mobilisation is required.

What factors affect early mobilisation following hip fracture surgery: a scoping review

OBJECTIVES

Identify and evaluate factors affecting early mobilisation on the day following hip fracture surgery.

DESIGN

Mixed methods, scoping review.

DATA SOURCES

MEDLINE, AMED, CINAHL, APA PsycINFO, APA PsycArticles, ISRCTN, Clinical Trials registry and grey literature accessed in November 2022 with publication dates between 2001 and November 2022.

ELIGIBILITY CRITERIA

English language publications that:1. Include patient populations who sustain a fragility hip fracture managed surgically2. Include patient populations who are mobilised out of bed on the day following their hip fracture surgery3. Report factors which influence the ability to undergo early mobility postsurgery DATA EXTRACTION AND SYNTHESIS: One reviewer screened all titles and abstracts for inclusion. Two reviewers performed data extraction and quality assessments using the relevant Critical Appraisal Skills Programme tools and the Mixed Methods Appraisal Tool.

RESULTS

3337 papers were identified, of which 23 studies were eligible for review, representing 210 811 patients. The heterogeneity in the types of study included, the definition of early mobilisation and the outcome measures used precluded meta-analysis. 13 factors were identified as having an effect on whether people were mobilised on day 1 post-hip fracture surgery, grouped into 5 principal themes: (1) healthcare setting or worker-related factors, (2) patient psychological factors, (3) acute patient health factors, (4) non-acute patient health factors and (5) surgical factors.

CONCLUSIONS

There was a paucity of robust research investigating day 1 mobilisation post-hip fracture surgery.Each of the five factors identified is potentially modifiable through service improvement change and innovation strategies. There is an opportunity to explore how service provision change could be implemented to improve outcomes for all patients following hip fracture surgery demonstrating the clinical and cost benefits of these changes against the cost of delivering the change.

A short length of hospital stay is not associated with risk of readmission among hip fracture patients - a Swedish national register-based cohort study

BACKGROUND

Hospital length of stay (LoS) after a hip fracture likely mirrors health status; however, a too short hospitalization might increase the risk of readmission. In this national register-based study, we investigated the association between LoS after a hip fracture and the risk of readmissions.

METHODS

73,551 patients with a first hip fracture between 2012 and 2019 were followed for 4 months after discharge. LoS was categorized by cubic splines and the association with readmissions was analyzed with Cox regression models.

RESULTS

The mean LoS was 11 ± 6 days and 25% of the study population had at least one readmission. Compared to the mean LoS of 9-12 days, there was a 18% decreased risk of readmission for LoS of 2-4 days (HR 0.82 [95% CI 0.77-0.87]) and 13% decrease for 5-8 days (HR 0.87 [95% CI 0.83-0.91]), when adjusting for sex, age, walking ability, ASA score, CCI, complications during hospitalization and living arrangements. For longer LoS, risk of readmission increased (13-23 days: HR 1.09 [95% CI 1.05-1.13] and 24 + days: HR 1.19 [95% CI 1.11-1.28]). The results were robust across sex, age, and living arrangements. The most common specific reasons for readmission were trauma/injury, cardiovascular and complications, and the proportions did not differ considerably between short and long LoS-categories.

CONCLUSIONS

While a long LoS can be explained by the care need of the patient, a short LoS - compared to the average stay - does not increase the risk of readmission regardless of health status and hospital complications in a Swedish setting.

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Orthopaedic Out of Bed Project (OOBP): improving early mobilisation following femoral fracture using a therapy-led education programme

Delayed mobilisation following hip fracture surgery is detrimental to patients and health systems. Prolonged hospital stay additionally results in decreased function and increased mortality. Our hospital was underperforming against the national metric for mobilisation by the day after surgery and physiotherapists were the primary healthcare professionals expected to do this. The therapy team therefore undertook a service improvement to increase the number of patients mobilised by the day after their femoral fracture surgery. This was through a ward-based education programme aimed at increasing confidence and competence of the trauma ward healthcare assistants (HCAs) to complete this task when appropriate instead of physiotherapists.The model for improvement was used, with two Plan-Do-See-Act cycles completed between 2020 and 2022. On completion of the therapy-led intervention, the percentage of patients mobilised by the day after surgery was shown to have increased from a mean average of 60% in 2019 to 79% in 2022. The number of patients mobilised by HCAs prior to physiotherapy assessment increased from 2% prior to and 30% following the intervention.The programme improved HCA confidence and competence using a rehabilitation ethos to mobilise patients following hip fracture surgery. It also showed a clinically significant improvement in the percentage of patients with hip fracture mobilising by the day after surgery and a large increase in the number of patients mobilised by our trauma ward HCAs prior to an initial physiotherapy assessment. This work has demonstrated implications for orthopaedic trauma services and the patients who receive them. It reduces the single point of failure of relying on a physiotherapist to mobilise a patient through increasing multidisciplinary confidence and capability on the ward to perform the task. In turn, this increases physiotherapy capacity to provide acute rehabilitation, which is another important part of femoral fracture recovery.