A joined-up approach to rehabilitation

Physiotherapists at the Royal Derby Hospital (RDH) are using targeted measures based on CSP standards, and working closely with occupational therapists, nursing staff, doctors, the discharge team and a newly-appointed hip fracture patient advocate, to follow an audited set patient rehabilitation pathway. 

It delivers shared assessment sheets on the progress of fractured neck of femur (NOF) patients and includes individualised rehabilitation plans plus supported discharge and follow-up, as part of a concerted effort to improve recovery from the most common serious injury in older people, which costs the NHS and social care £1 billion per year.

Delays in starting physiotherapy after hip fracture surgery can prevent someone from regaining the strength and mobility they need to avoid later complications and immediate post-op complications and future falls and fractures. Delays in sourcing ongoing rehabilitation facilities and implementing a care package and therapy follow up can also halt their discharge, even if they’re medically fit, blocking much-needed beds.  

Kerry Harrison, clinical lead physiotherapist, said: ‘Working together, having a clear patient-focussed plan and a discharge pathway to work towards has definitely helped on the ward. Each patient’s progress is a lot clearer to everyone including the discharge team, with whom we now have a much-improved working relationship.’

Although there are still problems bridging the gap between inpatient rehabilitation and continued support after discharge, the new hip fracture patient advocate, Kim Dokic, has made great strides in this area. In 2018, 27 per cent of patients were back to their base line mobility 120 days post-op. A year after Dokic’s appointment to the seconded position, the latest figures show that number is now 47 per cent. 

Finding a solution together

The new way of working was prompted by the introduction of the Discharge to Assess model, coupled with the closure of local community hospitals and no increase in community services. This meant some patients were being discharged before they could live independently, with minimal community support and rehabilitation.  

Harrison worked with Helen Cliff, RDH’s clinical lead occupational therapist in trauma and orthopaedics, to devise a proposed inpatient pathway that followed the multidisciplinary working practices and early input suggested by Hip Sprint and NICE, as well as the CSP recommended standards. After a successful month-long trial in summer 2018, which included a 12 weeks post-discharge review, they tweaked the pathway and continued with it. 

The post-operative plan (right) includes set point assessments that record completion by registered professionals and continually measures patients’ progress against best practice targets.

Harrison says the collaboration and sharing of information has made a huge difference to patients’ progress through to a managed discharge: ‘For example, we were aware that even though as physios we recorded our patient progress/plans on our own systems, it wasn’t as clear as it could be to others. So we’ve helped implement an MDT-focussed e-handover that clearly documents patient progress from all members of the team daily. Improved communication has really been the key, along with the fact everyone has been willing to pull together to achieve the best outcome for the patient.’

She and Cliff liaised with the trust’s audit team, who had previously found it hard to interpret patients’ notes, to establish clear assessment sheets. A tick box system (with room for observations) was devised, meaning auditors could collect specific data on each patient and their progress, noting the reasons for any change of pathway. If, for example, a patient is unable to get up on day one, the reasons are recorded on the sheet and fed back to medical teams via the audit as an ongoing improvement. 

Cliff says OTs have also seen the benefits of earlier involvement: ‘OTs used to delay their intervention on the wards as previously most patients were sent from the acute hospital to community hospital settings so we were only involved if a patient was being discharged straight home from the ward. Now we see them from day one and we complete the initial assessment to give us a clear idea of how they will manage when they leave hospital. As a result we practise different transfer techniques, assess and educate them differently, to establish a clear discharge pathway from the acute hospital, working closely with the physiotherapists and the MDT.

‘The nurses changed the way they worked as well, removing catheters earlier and starting diaries of care, so that when we came to do our day five assessment we can establish together what patients’ needs are.’

Teams pulling together

NICE recommends that hip fracture programmes in acute trusts should have responsibility for all stages of the pathway of care and rehabilitation, and the CSP standards state that therapists should ensure their patients are able to continue uninterrupted rehabilitation when they return home. Dokic’s role as hip fracture patient advocate is helping to identify gaps in this process by collecting audit data on patient progress from admission to a year after discharge. She feeds back all the data to the governance team, as well as liaising with all patient-facing staff 
to promote a joined-up approach to care.

Dokic said the inpatient assessment sheets had proved crucial in pulling the different specialties together: ‘It was time-consuming to go through the notes but Kerry [Harrison] came up with this great idea for simplifying the assessment process. It’s making everyone more aware of what’s best practice and what is necessary to achieve this for the patient.’

She added: ‘I can see the whole picture as I assess post-discharge, too, and try to iron out any problems at that stage. 
The increase in baseline mobility figures reflect that there is a need for additional staff to bridge the gap between acute discharge and community services to ensure continued care.’

All the audited findings are fed into bi-monthly governance meetings, led by consultant surgeon Steve Milner. 
He said: ‘Before this new way of working we didn’t feel fully in control of the rehabilitation pathway of some of our patients, even though colleagues from community physio are represented at the hip fracture clinical governance group. 

‘Kerry’s measures have improved our compliance with NICE guidance and best practice tariff criteria. The latter, as a package of measures, have been shown to be associated with a better outcome, but some factors may be more important than others. Time to theatre is perhaps the most important, but early mobilisation is also helpful in preventing pneumonia, DVTs, pressure sores etc.’

He added: ‘Patients sometimes struggle to navigate the rehabilitation services available, and our evidence shows 120-day mobility outcomes have improved as a result of Kim [Dokic]’s input. This in turn reduces social dependence and may reduce the risk of further falls in the future.

‘We believe that the post of hip fracture patient advocate is unique, or at least very uncommon, in UK hospitals that treat hip fractures. The data that Kim has collected as part of the year-long pilot demonstrates significant unmet need as patients struggle to navigate the rehabilitation services available.’ 

‘They’ve been very, very good. They got me up and walking across to the door and back again, and the next day I did that a couple of times. Then I went down the corridor. I’ve been climbing stairs this morning. They explain to me what I have to do and as long as I’m okay I’ll do it. I’m very impressed with the service. I just want to go home now and be back on my feet.’ 

By Claire White.