A pilot model of care to achieve next-day discharge in patients undergoing hip and knee arthroplasty in an Australian public hospital setting.

Objectives Internationally, hip or knee arthroplasty (TJA) with a 1-day hospital length of stay (LOS) is common and demonstrates improved patient and health service outcomes. This study aimed to develop and pilot an enhanced recovery program (ERP) for patients undergoing TJA to achieve a next-day discharge in an Australian public hospital setting. Methods A project lead and six perioperative clinical craft group leads developed an ERP protocol based on enhanced recovery after surgery (ERAS) principles. Strict patient eligibility criteria were developed. Quality improvement methodology was used to implement the ERP. A patient navigator was put in place as a single contact point for patients. Results A total of 825 patients were screened for the ERP and 47 patients completed the protocol. The mean ± standard deviation (s.d.) of the LOS was 34.7 (± 7.2) h with 41 patients (87%) achieving next-day discharge, the remaining six (13%) discharged on Day 2. Compliance with ERAS was high (96%) with mobilisation within 12 h occurring on 87% of occasions. There were no adverse events. Patient experience was positive. Conclusion Next-day discharge was achieved with a selected cohort of patients with no adverse events and positive patient experience, using a multidisciplinary approach and an improvement framework. Broadening inclusion criteria will make ERP available to more patients.

Recumbent cycling to improve outcomes in people with hip fracture: a feasibility randomized trial.

BACKGROUND: Early mobilization after surgery is a key recommendation for people with hip fracture, however this is achieved by only 50% of people. Recumbent bike riding has been used in other populations with limited mobility and has potential to allow early exercise in people post hip fracture. The primary aim of this pilot trial was to demonstrate the feasibility of a trial protocol designed to determine the effect of early post-operative cycling in bed on outcomes in people with hip fracture. METHODS: Single-blinded, multi-site randomized controlled pilot trial. Fifty-one people with hip fracture were recruited within 4 days of surgery from two sites in Victoria. Participants were randomly allocated to receive either usual care (n = 25) or usual care plus active cycling in bed (n = 26). The cycling intervention was delivered on weekdays until the participant could walk 15 m with assistance of one person. The primary outcomes were trial feasibility and safety. Clinical outcomes, including mobility (Modified Iowa Level of Assistance Scale) and delirium were measured at day seven post-operatively and at hospital discharge by an assessor blinded to group. Additional outcomes at discharge included gait speed, cognition and quality of life. RESULTS: The intervention was safe, feasible and acceptable to patients and staff. Delivery of the intervention was ceased on (median) day 9.5 (IQR 7, 12); 73% of scheduled sessions were delivered; (median) 4 sessions (IQR 2.0, 5.5) were delivered per participant with (median) 9 min 34 s (IQR 04:39, 17:34) of active cycling per session. The trial protocol was feasible, however at day seven 75% of participants had not met the criterion (able to walk 15 m with assistance of one person) to cease the cycling intervention.. CONCLUSION: In bed cycling is feasible post-operatively following hip fracture, however seven days post-operatively is too early to evaluate the impact of the cycling intervention as many participants were still receiving the intervention. A fully powered RCT to explore the effectiveness and cost efficiency of this novel intervention is warranted. TRIAL REGISTRATION: The trial was prospectively registered (25/09/2017) with the Australian New Zealand Clinical Trials Registry ACTR N12617001345370 .

Factors Impacting Early Mobilization Following Hip Fracture: An Observational Study.

BACKGROUND AND PURPOSE: Hip fracture guidelines emphasize mobilization within 48 hours of surgery. The aims of this audit were to determine the proportion of patients with hip fracture who mobilize within 48 hours, identify factors associated with delayed mobilization, and identify barriers to mobilization. METHODS: Single-site prospective audit of 100 consecutive patients (age 82 ± 9 years) admitted for surgical management of hip fracture. Data collected included time to mobilization, factors that may impact mobilization (age, weight-bearing status, additional injuries, premorbid mobility status, time to surgery, dementia, delirium, and postoperative complications), and barriers to mobilization as identified by the physical therapist. RESULTS AND DISCUSSION: Mobilization within 48 hours of surgery was achieved by 43% of patients. Multivariate logistic regression demonstrated odds of mobilizing early increased with higher New Mobility Scores, representing better premorbid mobility (odds ratio [OR] = 1.30; 95% confidence interval [CI], 1.06-1.60); odds reduced if delirium was present on day 1 or 2 (OR = 0.25; 95% CI, 0.08-0.79). New Mobility Scores 5 or more, which indicate independent premorbid mobility inside and outside the house, best predicted early mobilization in patients who did not develop delirium. No cutoff score was identified for those with delirium. Identified barriers to mobilization included patient confusion, manual handling risk, patient declined, and hypotension. CONCLUSIONS: Less than half of this cohort achieved the guideline of mobilization within 48 hours of surgery. Patients who develop delirium within the first 2 days of surgery or who had premorbid mobility limitation were less likely to mobilize. Identification of patients likely to have delayed mobilization will assist physical therapists with delivering appropriate management to patients with hip fracture during their acute hospital stay.