|
Delays In Discharge Following
Hemiarthroplasty: Is There A Solution?
Elahi MM, Kwong FC, Spaine LA
Department of
Orthopaedic Surgery, Glenfield Hospital, Leicester, LE3 9QP,
United Kingdom.
Address for Correspondence
Mr Maqsood M Elahi,
Room 22, Leicester General Hospital,
Gwendolen Road, LE5 4PW, United Kingdom.
Tel/ Fax: +44 (0) 792-901-0164
The
increasing number of hip fractures as a result of ageing
population, has markedly increased the need for hip fracture
beds. 1,2 The care of patients with hip fracture is a good
indicator of the quality of hospital services for elderly people
in general because their recovery requires a wide range of
services. There is a large variation in the mean length of stay
of patients between different hospitals.3 The length of
hospital stay is partly dependent on patient characteristics
such as age, the presence of cognitive impairment, implant
complications and type of operations. 4 The implementation of
hospital strategies, such as joint orthopaedic-geriatric
rehabilitation 5 and ‘hospital at home’ teams 6 can also
significantly reduce the length of hospital stay. Those
patients with poor mobility before the hip fractures are the
ones that utilize most of the cost in rehabilitation. Although
experienced clinicians are often able to make an accurate
prediction, little information is available about the factors
that allow early determination of whether a patient may return
to the community. We prospectively studied 95 consecutive
patients > 70 years admitted with fractures of the neck of femur
and treated with a hemiarthroplasty between January 2001 to
March 2001 in a busy tertiary centre. 61.1% of them had their
operation within 48 hrs of admission compared to the rest
(36.8%) who had their operation > 48 hrs. The overall mortality
was 7.4%. At the time of their injury, 38.9% were resident in a
nursing home, a residential home or a warden controlled flat.
The rest were living independently either on their own or with
their spouse. Prior to sustaining their injury, 3% of patients
were immobile, 63% were mobile with use of aids and 34% were
independently mobile without aids. When functional ability was
considered, 42% were independent while the majority (53%) were
either house bound and/or depended on meals on wheels delivered
to their residence. 88% of the patients had established,
significant medical problems on admission. 38% of patients
developed a post-operative complication such as deep vein
thrombosis and chest infection. 47% of patients were discharged
within 10 days following surgery. The main causes of delays in
discharge were delay in provision of social services (5%), delay
in obtaining placement in a suitable place after discharge
(11%), waiting for occupational therapist assessment (9%),
arranging a care package (17%) and medical problems (10%)
(Figure 1).
It is
now recognised that the rising incidence of hip fractures in the
elderly is a disturbing trend with significant health and
socio-economic consequences, including increased morbidity, loss
of function, long term institutionalisation and mortality. 7
Moreover, delay in the treatment of these patients leads to
increased morbidity, mortality; length of hospital stay and
overall cost as well 8 but there are no published guidelines on
how to possibly avoid a reasonable delay between admission and
discharge by the accurate assessment of the patients admitted
with fracture of the proximal femur. With the view of fast tract
referral system and the avoidance of possible delays a new
initiative at our centre was developed called Post Acute Care
Team (PACT). The service is available to patients from
Leicestershire, who are able to satisfy specific pre-determined
criteria such as cognitive function, pre-injury mobility and
functional abilities. During their inpatient stay and following
surgery, the patients receive intensive physiotherapy in order
to achieve independent mobility with a mobility aid and a full
activity of daily living assessment is taken by the occupational
therapist. Continued care and rehabilitation is provided in the
community by the team on a daily basis, aiming to discharge the
patient within ten days following their admission.
We
conclude that monitoring at the time of admission by the
provision of designated staff and appropriate treatment package
by early recognition of potential factors may result in a
significant reduction in both morbidity and mortality together
with significant savings in patient bed days. Para-medical
services involved in rehabilitation should be improved. This
would enable more patients to be treated with the same number of
hospital beds and lower direct costs of rehabilitative care.
With the increasing number of hip fractures over time, this
study highlights the need to expand rehabilitation services
perhaps more than was previously thought.
References:
1.
Beech R, Withey C, Morris R. Understanding variations in lengths
of stay between hospitals for fractured neck of femur patients
and the potential consequences of reduced stay targets. J Public
Health Med. 1995; 17: 77-84.
2. Clague JE, Craddock E, Andrew G,
Horan MA, Pendleton N. Predictors of outcome following hip
fracture. Admission time predicts length of stay and in-hospital
mortality. Injury. 2002; 33: 1-6.
3. Lau EM, Cooper C, Fung H< Lam D,
Tsang KK. Hip fracture in Hong Kong over the last decade- a
comparison with the UK. J Public Health Med 1999; 21(3):
249-50.
4. Melton LJ 3rd. Epidemiology of hip
fractures; implications of the exponential increase with age.
Bone (Suppl 3) 1996; 18:121-5.
5. Murphy PJ, Rai GS, Lowy M,
Bielawaska C. The beneficial effects of joint
orthopaedic-geriatric rehabilitation. Age Ageing 1987; 16:
273-8.
6. Pryor GA, Myles JW, Williams DRR,
Anand JK. Team management of the elderly patient with hip
fracture. Lancet 1988; 1 (8582): 401-3.
7. Ethens, KD., MacKnight, C. (1998)
Hip fracture in the elderly. An interdisciplinary team approach
towards rehabilitation. Postgrad Med; 103: 157-8, 163-4, 167-70.
8. Lancaster, BJ., Paterson, Medical
Practice., Capon, G., Belcher, J. (2000) Delays in orthopaedic
trauma treatment: setting standards in time interval between
admission and operation. Ann R Coll Surg Engl; 82: 322-6
|
