Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis.

BACKGROUND: Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery. OBJECTIVE: Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture. METHODS: Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis. RESULTS: Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements. CONCLUSIONS: Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

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.

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.