Introduction of enhanced weekend physiotherapy for patients with hip fracture is associated with improved early mobility outcomes.

OBJECTIVE: To assess whether enhanced daily weekend physiotherapy (EWP) for patients with hip fracture was associated with improved clinical outcomes. METHODS: We retrospectively analysed all previously ambulatory adults admitted with hip fracture to our tertiary hospital, comparing 'usual' ('control') care (09/19-03/20) to EWP (09/20-03/21). Outcomes included Day-7 mobility ≥20 m (primary), additional mobility measures, specified postoperative complications, new residential facility placement, acute length-of-stay (LOS) and 30-day death. RESULTS: Amongst 235 eligible patients (128 control, 107 EWP), 66% were female, mean age was 80.4 years (SD 10.5), 20% from residential care and 49% (114/235) were mobilising without aid at baseline (no between-group differences; all p ≥ .20). Median acute LOS was 10 days (IQR 6-15), total hospital LOS was 21 days (IQR 12-37) and 3% (n = 6) died by Day 30. Median Day-7 distance mobilised was 25 m (IQR 7-50) with EWP versus 10 m (3-40) (p = .06). No EWP patients developed pressure injury (0 vs. 6, p = .02); other outcomes were similar between groups. Adjusting for age, residence, baseline cognitive impairment, American Society of Anesthesiologist score and preadmission mobilisation without aids, EWP was independently associated with increased likelihood of mobilising ≥20 m at Day 7 (aOR 1.83, 95% CI 1.04-3.23, p = .03). CONCLUSIONS: Enhanced daily weekend physiotherapy was associated with improvement in early mobility, but not other outcomes assessed. These data would be strengthened by randomised controlled trial data exploring more intense physiotherapy, cost-benefit analysis and patient experience measures.

Poorer outcomes in patients with early postoperative delirium: 120-day follow-up of the Delirium Reduction by Analgesia Management in Hip Fracture (DRAM-HF) study.

OBJECTIVES: The Delirium Reduction by Analgesia Management-Hip Fracture (DRAM-HF) model of care, which incorporated a multicomponent intervention focussing on perioperative analgesia and medication optimisation, was associated with reduced Day 3 postoperative delirium (POD) amongst hip fracture patients. We investigated whether this effect was seen at 120 days postoperatively. METHODS: We assessed 120-day outcomes in all patients who were included in the DRAM-HF study, by telephone, supplemented by electronic medical records, to include death (primary outcome), residential aged care facility (RACF) residence, patient/carer-reported frailty, hospital readmission and new dementia diagnosis. RESULTS: Amongst 300 patients (mean age 81.1, 70% female, none lost to follow-up), by 120 days, 8% (n = 24) had died; 25% of survivors (n = 68/276) were RACF residents. Twenty-two per cent were readmitted (n = 61/281). A new dementia diagnosis was reported by 6% (n = 17/281). Intervention status in the DRAM-HF trial (intervention/control) was not associated with death by 120 days (OR 0.83, 95% CI 0.36-1.93, p = 0.67) or other outcomes assessed. POD was independently associated with 120-day death (aOR 3.3, 95% CI 1.2-9.2, p = 0.02), RACF residence (aOR 2.2, 95% CI 1.1-4.7, p = 0.03) and patient/carer-reported frailty (aOR 5.6, 95% CI 1.0-30.7, p = 0.05), but not readmission (p = 0.21) or new diagnosis of dementia (p = 0.08). CONCLUSIONS: In this cohort, while the DRAM-HF bundle of care did not influence 120-day outcomes, patients who experienced POD had poorer clinical outcomes 120-day postfracture. Given that delirium was associated with death, RACF residence and frailty, models of care which have the potential to reduce POD may have benefits beyond the acute admission, and further investigation is needed.

Frailty among older surgical patients and risk of hospital acquired adverse events: The South-Western Sydney frailty and nurse sensitive indicators study.

BACKGROUND: While advances in healthcare mean people are living longer, increasing frailty is a potential consequence of this. The relationship between frailty among older surgical patients and hospital acquired adverse events has not been extensively explored. We sought to describe the relationship between increasing frailty among older surgical patients and the risk of hospital acquired adverse events. METHODS: We included consecutive surgical admissions among patients aged 70 years or more across the SWSLHD between January 2010 and December 2020. This study used routinely collected ICD-10-AM data, obtained from the government maintained Admitted Patient Data Collection. The relationships between cumulative frailty deficit items and risk of hospital acquired adverse events were assessed using Poisson regression modelling. This study followed the RECORD/STROBE guidelines. RESULTS: During the study period, 44,721 (57% women) older adults were admitted, and 41% (25,306) were planned surgical admissions. The risk of all adverse events increased with increasing number of frailty deficit items, the highest deficit items group (4-12 deficit items) compared with the lowest deficit items group (0 or 1 deficit item): falls adjusted rate ratio (adj RR) = 15.3, (95% confidence interval (CI) 12.1, 19.42); pressure injury adj RR = 21.3 (95% CI 12.53, 36.16); delirium adj RR = 40.9 (95% CI 31.21, 53.55); pneumonia adj RR = 16.5 (95% CI 12.74, 21.27); thromboembolism adj RR = 17.3 (95% CI 4.4, 11.92); and hospital mortality adj RR = 6.2 (95% CI 5.18, 7.37). CONCLUSION: The increase in number of cumulative frailty deficit items among older surgical patients was associated with a higher risk of adverse hospital events. The link offers an opportunity to clinical nursing professionals in the surgical setting, to develop and implement targeted models of care and ensure the best outcomes for frail older adults and their families.

Delirium Reduction by Analgesia Management in Hip Fracture surgery (DRAM-HF): Exploration of perceived facilitators and barriers.

OBJECTIVES: In tandem with the implementation of a multidisciplinary protocol which was successful in reducing delirium after hip fracture surgery (DRAM-HF), we sought to investigate enablers and barriers to same. METHODS: Single-centre, prospective, before-and-after questionnaire targeted at health-care professionals involved in DRAM-HF. We assessed respondent-reported enablers and barriers to the multidisciplinary protocol, using 0-100 agreement scales and free-text responses. RESULTS: A total of 134 preintervention and 124 postintervention responses were collated (out of 200, response rates 67% and 62%, respectively). Preintervention support for DRAM-HF was 100% (n = 130) and postintervention 95.9% (n = 116). Study design was well received with a mean score of 76.7 (SD 19.7) for being easy to understand. Support for additional computer alert systems was also high (mean 73.6, SD 23.9). Free-text responses emphasised the need for integration of ward pharmacists into medication optimisation (n = 31) and upskilling nurse practitioners (n = 23). CONCLUSION: Whilst generally supported, DRAM-HF implementation may be streamlined by optimising electronic delivery, offering targeted education and expanding roles.

Is discharge knee range of motion a useful and relevant clinical indicator after total knee replacement? Part 2.

OBJECTIVE: Knee range of motion (ROM) at discharge from acute care is used as a clinical indicator following total knee replacement (TKR) surgery. This study aimed to assess the clinical relevance of this indicator by determining whether discharge knee ROM predicts longer-term knee ROM and patient-reported knee pain and function. METHODS: A total of 176 TKR recipients were prospectively followed after discharge from acute care. Outcomes assessed included knee ROM and Oxford knee score post rehabilitation and 1 year post surgery. Discharge ROM and other patient factors were identified a priori as potential predictors in multiple linear regression modelling. RESULTS: A total of 133 (76%) and 141 (80%) patients were available for follow-up post rehabilitation [mean postoperative week 8.1 (SD 2.7)] and at 1 year [mean postoperative month 12.1 (SD 1.4)], respectively. Greater discharge knee flexion was a significant (P < 0.001) predictor of greater post-rehabilitation flexion but not 1-year knee flexion (P < 0.083). Better discharge knee extension was a significant predictor of better post-rehabilitation (P = 0.001) and 1-year knee extension (P = 0.013). Preoperative Oxford score and post-rehabilitation knee flexion independently predicted post-rehabilitation Oxford score, and gender predicted 1-year Oxford score. Discharge ROM did not significantly predict Oxford score in either model. CONCLUSION: The finding that early knee range predicts longer-term range provides clinical evidence favouring the relevance of discharge knee ROM as a clinical indicator. Although longer-term patient-reported knee pain and function were not directly associated with discharge knee ROM, they were associated with ROM when measured concurrently in the sub-acute phase. No causal effect has been demonstrated, but the findings suggest it may be important for physiotherapists to maximize range in the early and sub-acute periods.

A prospective study of the effect of nursing home residency on mortality following hip fracture.

BACKGROUND: The strength of nursing home residence as a prognostic indicator of outcome following hip fracture has not previously been examined in Australia. The aim of the study was to examine the influence of nursing home residency on mortality after sustaining an acute hip fracture. METHODS: A prospective study of all adults aged 65 years and over presenting to a single tertiary referral hospital for management of a proximal femoral fracture between July 2003 and September 2006. Residential status was obtained at admission. Patients were followed up to September 2007 (minimum 12 months). Relative risk values for mortality were calculated comparing nursing home residents with non-nursing home residents. Survival analysis was performed. RESULTS: Relative risk of death was higher in nursing home patients compared with non-nursing home patients. The difference was greater in the immediate period (30 days) post-injury (relative risk 1.9, 95% confidence interval 1.0-3.6, P= 0.04) than after 12 months (relative risk 1.5, 95% confidence interval 1.2-1.8, P= 0.001). Survival analysis showed that 25% of patients in the nursing home group died by 96 days post-injury, compared with 435 days in the non-nursing home group. CONCLUSIONS: Nursing home residence confers an increased risk of death following hip fracture; this difference is greater in the immediate post-injury period. The relative risk of death decreases over time to equal previously reported comparative mortality rates between nursing home residents and community dwellers without hip fracture.

Non-emergency management of hip fractures in older patients.

PURPOSE: To evaluate the effects of a policy change from emergency to scheduled management of hip fractures in older patients. METHODS: 91 and 107 patients aged 50 years or older with hip fractures were scheduled for operation on the emergency and orthopaedic lists, respectively. Cancellation rates, consultant supervision rates, after-hour operation rates, 30-day mortality, and preoperative and total length of hospital stay were compared. RESULTS: When older patients with hip fractures were scheduled on orthopaedic lists rather than emergency lists, the cancellation rates owing to lack of theatre time (4% vs 54%, p<0.001), the supervision rates (45% vs 24%, p=0.002), and after-hour operation rates (1% vs 25%, p<0.001) were significantly better. The 30-day mortality rates decreased from 4.4% to 1.9% (p=0.3). The median preoperative length of hospital stay significantly increased from 2 to 4 days (p=0.046), but the increase in total length of hospital stay was non-significant (6 to 10 days, p=0.14). CONCLUSIONS: Non-emergency management of hip fractures in older patients resulted in fewer cancellations and after-hour operations, and increased consultant supervision. Nonetheless, extra time slots for operating theatres are required to avoid an associated increase in preoperative and total length of hospital stay.