Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery

BACKGROUND

Hip fractures are devastating injuries, with high health and social care costs. Despite national standards and guidelines, substantial variation persists in hospital delivery of hip fracture care and patient outcomes. This qualitative study aimed to identify organisational processes that can be targeted to reduce variation in service provision and improve patient care.

METHODS

Interviews were conducted with 40 staff delivering hip fracture care in four UK hospitals. Twenty-three anonymised British Orthopaedic Association reports addressing under-performing hip fracture services were analysed. Following Thematic Analysis of both data sources, themes were transposed onto domains both along and across the hip fracture care pathway.

RESULTS

Effective pre-operative care required early alert of patient admission and the availability of staff in emergency departments to undertake assessments, investigations and administer analgesia. Coordinated decision-making between medical and surgical teams regarding surgery was key, with strategies to ensure flexible but efficient trauma lists. Orthogeriatric services were central to effective service delivery, with collaborative working and supervision of junior doctors, specialist nurses and therapists. Information sharing via multidisciplinary meetings was facilitated by joined up information and technology systems. Service provision was improved by embedding hip fracture pathway documents in induction and training and ensuring their consistent use by the whole team. Hospital executive leadership was important in prioritising hip fracture care and advocating service improvement. Nominated specialty leads, who jointly owned the pathway and met regularly, actively steered services and regularly monitored performance, investigating lapses and consistently feeding back to the multidisciplinary team.

CONCLUSION

Findings highlight the importance of representation from all teams and departments involved in the multidisciplinary care pathway, to deliver integrated hip fracture care. Complex, potentially modifiable, barriers and facilitators to care delivery were identified, informing recommendations to improve effective hip fracture care delivery, and assist hospital services when re-designing and implementing service improvements.

Open tibial fractures in major trauma centres: A national prospective cohort study of current practice

AIMS

To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network.

MATERIALS AND METHODS

Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016.

RESULTS

Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates.

CONCLUSIONS

Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.

The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications

AIMS

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications.

PATIENTS AND METHODS

We reviewed the case notes and radiographs of 50 patients treated with an anterior pelvic internal fixator between April 2010 and December 2015 at a major trauma centre in the United Kingdom. The median follow-up time was 38 months (interquartile range 24 to 51).

RESULTS

Three patients were excluded from the analysis leaving 47 patients with complete follow-up data. Of the 47 patients, 46 achieved radiological union and one progressed to an asymptomatic nonunion. Of the remaining patients, 45 required supplementary posterior fixation with percutaneous iliosacral screws, 2 of which required sacral plating. The incidence of injury to the lateral femoral cutaneous nerve (LFCN) was 34%. The rate of infection was 2%. There were no other significant complications. Without this treatment, 44 patients (94%) would have needed unilateral or bilateral open reduction and plate fixation extending laterally to the hip joint.

CONCLUSION

The anterior pelvic internal fixator reduces the need for extensive open surgery and is a useful addition to the armamentarium for the treatment of anterior pelvic injuries. It is associated with injury to the LFCN in a third of patients. Cite this article: Bone Joint J 2017;99-B.1232-6.

The administration of intermittent parathyroid hormone affects functional recovery from trochanteric fractured neck of femur: a randomised prospective mixed method pilot study

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

Patients and Methods

We undertook a pilot study comparing the functional recovery after trochanteric hip fracture in patients 60 years or older, admitted with a trochanteric hip fracture, and potentially eligible to be randomised to either standard care or the administration of subcutaneous PTH for six weeks. Our desired outcomes were functional testing and measures to assess the feasibility and acceptability of the study.

Results

A total of 724 patients were screened, of whom 143 (20%) were eligible for recruitment. Of these, 123 were approached and 29 (4%) elected to take part. However, seven patients did not complete the study. Compliance with the injections was 11 out of 15 (73%) showing the intervention to be acceptable and feasible in this patient population.

Take home message: Only 4% of patients who met the inclusion criteria were both eligible and willing to consent to a study involving injections of PTH, so delivering this study on a large scale would carry challenges in recruitment and retention. Methodological and sample size planning would have to take this into account. PTH administration to patients to enhance fracture healing should still be considered experimental.

Cite this article: Bone Joint J 2016;98-B:840–5.

Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle

AIMS

This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery.

METHODS

We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively.

RESULTS

The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%.

DISCUSSION

Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union.

TAKE HOME MESSAGE

Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion.

The Pattern of Injury and Workload Associated with Managing Patients After Suicide Attempt by Jumping from a Height

PURPOSE

The aim of this study is to examine the pattern of injuries sustained and the hospital workload generated by patients who deliberately jump from height.

METHOD

One regional trauma centre's admissions were scrutinized to find all patients who jumped, or were suspected of jumping from one storey or greater over a four year period. Patients who died prior to admission were excluded.

RESULTS

41 patients were included. Each patient suffered a mean of 3 injuries. The probability of calcaneal fracture was 0.32, of ankle injury 0.2, tibial fracture 0.2, femoral fracture 0.17, pelvic fracture 0.34, spinal injury 0.51, upper limb injury 0.26, head injury 0.2 and trunk injury 0.32. The mean length of inpatient stay was 7.9 days, rising to 17.9 for the 11 patients requiring intensive care. The average number of operations per patient was 1.5.

CONCLUSION

Patients who jump from height generate large volumes of operative and inpatient workloads. Our data show that there may be a protective effect of limb trauma against lethal head, chest or pelvic injury. Injury to the upper limb is associated with a 4 times greater risk of head injury. The incidence of pelvic injury in this series is higher than in previous work. There was a high incidence of spinal fracture. Patients generated 64 surgical procedures and consumed a mean of 17.9 inpatient days, including prolonged stay in intensive care.

Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri‐operative period 1, 2. The advice presented is based on previously published advice and clinical studies.

Hip precautions after hemiarthroplasty: what is happening in the UK and at what cost?

INTRODUCTION

The aim of this study was to observe current practice of the use of hip precautions following hemiarthroplasty for hip fractures in England and to audit the cost of hip precautions in this patient group.

METHODS

A telephone review was undertaken of all units identified by the National Hip Fracture Database as receiving centres for hip fractures across England to ascertain current practice in the use of hip precautions. A prospective audit of occupational therapy (OT) practice including the cost of equipment provision and OT time was carried out locally.

RESULTS

All 174 units in England were successfully contacted. Practice varied between centres but hip precautions were in use at 78% of centres. Prior to stopping hip precautions at the local hospital, we audited the costs associated with their use. Mean equipment costs per patient decreased by £12 (from £49 to £37, range: £0–£83) and mean OT time per patient decreased by 1.5 hours (from 8 hours to 6.5 hours, range: 1–22 hours) following removal of hip precaution guidelines. A mean of 0.25 days' discharge delay (range: 0–4 days) due to equipment provision was identified prior to removing hip precautions with no discharge delay following.

CONCLUSIONS

This study has highlighted the variation in practice across the country and inconsistency with the advice published by the British Orthopaedic Association and British Geriatrics Society in the ‘Blue Book’ (The Care of Patients with Fragility Fracture). Hip precautions are unnecessary after hemiarthroplasty, cost money both in therapist time and equipment provision and increase the length of hospital stay. Nevertheless, they continue to be used by three-quarters of trauma hospitals in England.

Survival of ceramic bearings in total hip replacement after high-energy trauma and periprosthetic acetabular fracture

Surgeons remain concerned that ceramic hip prostheses may fail catastrophically if either the head or the liner is fractured. We report two patients, each with a ceramic-on-ceramic total hip replacement who sustained high-energy trauma sufficient to cause a displaced periprosthetic acetabular fracture in whom the ceramic bearings survived intact. Simultaneous fixation of the acetabular fracture, revision of the cementless acetabular prosthesis and exchange of the ceramic bearings were performed successfully in both patients. Improved methods of manufacture of new types of alumina ceramic with a smaller grain size, and lower porosity, have produced much stronger bearings. Whether patients should be advised to restrict high-impact activities in order to protect these modern ceramic bearings from fracture remains controversial.

The use of LISS femoral locking plates and cabling in the treatment of periprosthetic fractures around stable proximal femoral implants in elderly patients

A retrospective review was performed of Vancouver type C periprosthetic femoral fractures treated using the Less Invasive Stabilisation System (LISS) femoral locking plate system. Five patients with stable hip prostheses (only one of which was an uncomplicated primary arthroplasty) were treated with the LISS plating system in combination with bone grafting and cables. The average age at the time of fixation was 87 years (range 83-93). All fractures united and all but one of the patients was able to mobilise independently. One case was complicated by superficial wound infection, but there were no other significant complications. One patient is still alive 50 months after surgery; the remaining four died a mean of 27 months postoperatively. Our results indicate that the LISS system is effective in the management of Type C periprosthetic fractures around well-fixed proximal femoral implants in the elderly, even in complex cases.

Determination of pelvic ring stability: A new technique using a composite hemi-pelvis

Traumatic disruption of the pelvic ring caused by high-energy impact is associated with significant mortality and morbidity. A variety of fixation techniques have been developed for treating these injuries with the main aims of restoring the stability of the pelvic ring and promoting recovery of normal function. The stability of fixation of these techniques is often analysed by cadaveric studies, which can introduce high variability into the results and have small sample numbers. This study presents a new method that uses a composite hemi-pelvis to enable stabilization of the pelvic ring to be accurately determined. The pelvis was loaded cyclically to simulate walking conditions and to assess the stability of the fixation, which was measured using a displacement transducer that monitors the motion of the pelvis in six degrees of freedom. The motions measured showed comparable results with previously published cadaveric studies. This reproducible method of testing with a hemi-pelvis composite model and rig allows valid analysis of pubic symphysis implants, obviating the difficulties of performing a cadaveric study.

The use of the long gamma nail in proximal femoral fractures

The results of 100 'Long Gamma Nails' (LGN) inserted in 97 patients, for the treatment of complex proximal femoral fractures and pathological lesions, are reported. The mean patient age was 74 (16-98). Seven significant complications occurred; four lag screws cut out, one broken nail, one infected non-union and one peri-prosthetic fracture. Five patients underwent revision either to total hip arthroplasty or exchange nailing. Seventy patients had follow-up of greater than 2 months (mean 10.8 months). Success was defined as stability of the fracture until union or death; this was achieved in 85% of cases. The mortality was 10% at 30 days and 25% at 1 year. The complication rate fell with increasing experience. Complex proximal femoral fractures are difficult to treat with all implants demonstrating high complication rates. The long gamma nail allowed early weight bearing and was effective in 85% of cases. Malpositioning of the implant should be avoided, as this was the leading cause of failure. Surgeon experience is an important factor but training of surgeons does not adversely affect outcome.

Does changing the configuration of a motor racing circuit make it safer?

OBJECTIVES

To assess the pattern of injuries presenting to a racing circuit medical centre in two three-year periods before and after two chicanes were built into the track.

METHODS

Medical centre records were used to identify all patients assessed during the two time periods. Those referred to hospital were categorised by injury severity into three groups.

RESULTS

The proportions of those attending the medical centre that were referred and admitted to hospital were the same in both periods (12-13% and 3% respectively). During the two study periods, the risk of a severe injury for a car driver decreased from 0.1% to 0.03% (p<0.05). For a motorcyclist, similar values were 0% and 0.2% (not significant).

CONCLUSIONS

Chicanes have improved the safety of the racing circuit for car drivers, reducing the risk of injury.

Complications of temporary and definitive external fixation of pelvic ring injuries

OBJECTIVES

To determine the incidence of complications of external fixation in pelvic ring injuries, comparing fixator use for temporary and definitive treatment.

DESIGN

Retrospective case-note review.

SETTING

A regional centre for pelvic trauma in the UK.

PATIENTS

100 consecutive patients.

INTERVENTION

All patients were treated with pelvic external fixation for a pelvic ring injury.

RESULTS

In 52 patients, external fixation was intended for use as the definitive treatment of the pelvic ring injury and was maintained for a mean duration of 60 days (17-113). In 48 patients, it was used temporarily for a mean duration of 8 days (1-20) before internal fixation of the pelvic ring. The complication rate for definitive and temporary fixators was 62 and 21%, respectively. Pin-site infection occurred in 50% of definitive fixators and 13% of temporary fixators but rarely led to more serious complications. In five patients, the definitive management was changed as a result of a complication of the external fixator. The commonest cause for revision of either fixator was aseptic pin loosening. Revision for loose pins in eight patients was associated with the use of two pins in each iliac crest rather than three.

CONCLUSIONS

The temporary use of external fixation is safe and effective, but use for definitive treatment is associated with a high rate of infection and aseptic pin loosening.