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Dr Colin Currie, Chair, Hip Fracture Audit Database Special Interest Group, Fragility Fracture Network; Clinical Lead (Geriatric Medicine), 2007-2013, UK National Hip Fracture Database, joined us recently to discuss the importance of hip fracture management and audit.
You are presenting the International Keynote Address and facilitating an inclusive interactive workshop at the 2014 Hip Fracture Management Conference on the subject of ‘Hip Fracture Audit’.
Without giving too much away, can you briefly explain the importance of hip fracture audit, and what impact data collection has on the provision of care?
Colin: Hip fracture audit matters, because hip fracture care is a huge challenge and hip fracture audit is quite simply the best way of improving it.
Better care leads to better outcomes, and the good news is it costs less than bad care. So it’s worth doing for economic as well as humane reasons and – since case numbers are rising worldwide with mass ageing – we have got to get on with it.
But I don’t want to make it sound like a grim duty – people who get involved often get quite fired up: far more aware of the care they provide, able to improve it, and seeing measurable improvements in quality and patient satisfaction, and in cost effectiveness too.
And the better the data you’re working with, the better placed you are to do all that. Good acute care data will spot problems and often suggest solutions; and good follow-up data (which is harder to collect) will tell you whether your solutions are effective or not. Has mortality gone down? Are more people getting home earlier and more mobile? So good data collection matters hugely. All a bit obvious, really.
With over 35 years of experience working in hip fracture care, are you able to expand on the predictors of good and bad outcomes after hip fracture?
Colin: There’s a fair amount of science now about patient characteristics associated with good and bad outcomes – the Nottingham Hip Fracture Score is a good example, and it can provide casemix-adjusted outcomes, which make for fairer inter-hospital comparisons.
And – to state the obvious again – bad care is a pretty good predictor of bad outcomes.
Michael Devas, a great pioneer in the surgical care of older patients was also a great phrase-maker. One of his war-cries was ‘Bed rest is rehabilitation… for the coffin.’ For various bad reasons, too many patients still get too much bed rest and too little early mobilisation.
But what I’ve learned in the course of a fair few ward rounds over the years is that patient-level bedside prediction is full of surprises. In practical terms, that means that only the near-moribund or the grossly cognitively impaired should be denied the opportunity of at least some rehabilitation.
From your experience, what are some of the best rehabilitation approaches for hip fracture patients?
Colin: In structural terms, ideally almost all hip fracture patients – with the exclusions above – would benefit from a system that provided:
1. Early and vigorous rehabilitation in the acute ward, backed up by community rehabilitation provisions that would allow many of them to go straight home. Organising all that is a challenge, but more than justified in the patient satisfaction and cost-effectiveness it delivers.
2. And people too frail for that would, ideally, have a second chance in the care of a geriatrician-led multidisciplinary unit specialising in fracture rehabilitation. Even if that took time and cost a bit, the benefits – again in humane and economic terms – of the resulting avoidance of unnecessary permanent institutionalisation can be more than justified.
How important is multidisciplinary care in the prevention and management of hip fracture patients?
Colin: Primary prevention isn’t really my thing, but – again ideally – a multidisciplinary Fracture Liaison Service can reduce – cost effectively, again – the incidence of hip fracture, as reports from the West Glasgow service have shown. Secondary prevention clearly involves multidisciplinary falls assessment – physiotherapy and OT being integral to that.
Managing hip fracture patients is of course hugely multidisciplinary, if the whole journey of care – from fall through pre-hospital care, emergency room care, preoperative assessment, anaesthesia, surgery, pressure area care, the management of medical complications in people who often have prior multiple pathology, and the various rehabilitation options thereafter – is taken into account.
Trying to get all that right is not for the faint-hearted. But some of the most dramatic improvements documented in NHFD National Reports began with a meticulous scrutiny of the journey of care, from start to finish. Seeing it as the patient sees it might be seen as the beginning of wisdom.
And in the longer term – and this has happens in many units using audit successfully – cultural change results. People just think differently about hip fracture. If there is information to discuss, real collective responsibility for joined-up care can emerge; and clinicians and managers can discuss service problems and improvements with regular, credible and up-to-date data (rather than just the usual complaints and the occasional atrocity – and at the very least enjoy a better class of argument as a result).
Yes, a lot of it is detail, but together all that can amount to a cultural change: the creation of ‘a critical mass of enthusiasm and expertise in hip fracture care’ that simply did not exist in the bad old days – when ‘hip fracture’ and ‘heart-sink’ were more or less synonymous.
How can healthcare professionals effectively engage with hip fracture patients and their families and carers to support a safe recovery?
Colin: By being accessible, interested, honest, and by listening a lot – which is much easier where the multidisciplinary culture described above exists. Above all, remembering that patients are individuals often in distress; people with a past, a present and – we hope – a future. Nobody is just ‘the left hip in the first bed on the right in Room 3’. Patients, their families and carers would be appalled by that.
Are there any presentations from the 2014 Hip Fracture Management Conference that you are particularly looking forward to?
Colin: Great programme! So it is hard to choose. However, if forced to, I’d probably prefer talks about what people have done to make things better for patients – rather than talks about what people just know about (and might know about in excessive detail…).