Development of an Early Activation Hip Fracture Care Bundle and Implementation Strategy to Improve Adherence to the National Hip Fracture Clinical Care Standard

Abstract Background Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a ‘clinical care bundle’ for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the “E-MOTIVE” bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice. Methods We will use behavior change and implementation science frameworks [e.g. capability, opportunity, motivation and behavior (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative interviews; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops. Discussion This formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective. Trial registration: ClinicalTrials.gov: NCT04341662

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Prior Admissions as a Risk Factor for Readmission in Patients Surgically Treated for Femur Fractures: Implications for a Potential Hip Fracture Bundle

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321996169 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199616

Author(s):

Robert Erlichman ◽

Nicholas Kolodychuk ◽

Joseph N. Gabra ◽

Harshitha Dudipala ◽

Brook Maxhimer ◽

...

Keyword(s):

Logistic Regression ◽

Regression Analysis ◽

Hip Fracture ◽

Logistic Regression Analysis ◽

Hip Fractures ◽

Surgical Procedure ◽

Hospital Admissions ◽

Fracture Care ◽

Increased Risk ◽

Payment Models

Introduction: Hip fractures are a significant economic burden to our healthcare system. As there have been efforts made to create an alternative payment model for hip fracture care, it will be imperative to risk-stratify reimbursement for these medically comorbid patients. We hypothesized that patients readmitted to the hospital within 90 days would be more likely to have a recent previous hospital admission, prior to their injury. Patients with a recent prior admission could therefore be considered higher risk for readmission and increased cost. Methods: A retrospective chart review identified 598 patients who underwent surgical fixation of a hip or femur fracture. Data on readmissions within 90 days of surgical procedure and previous admissions in the year prior to injury resulting in surgical procedure were collected. Logistic regression analysis was used to determine if recent prior admission had increased risk of 90-day readmission. A subgroup analysis of geriatric hip fractures and of readmitted patients were also performed. Results: Having a prior admission within one year was significantly associated (p < 0.0001) for 90-day readmission. Specifically, logistic regression analysis revealed that a prior admission was significantly associated with 90-day readmission with an odds ratio of 7.2 (95% CI: 4.8-10.9). Discussion: This patient population has a high rate of prior hospital admissions, and these prior admissions were predictive of 90-day readmission. Alternative payment models that include penalties for readmissions or fail to apply robust risk stratification may unjustly penalize hospital systems which care for more medically complex patients. Conclusions: Hip fracture patients with a recent prior admission to the hospital are at an increased risk for 90-day readmission. This information should be considered as alternative payment models are developed for hip fracture care.

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Protocol-based interdisciplinary co-management for hip fracture care: 3 years of experience at an academic medical center

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-020-03699-7 ◽

2021 ◽

Author(s):

Heather J. Roberts ◽

Stephanie E. Rogers ◽

Derek T. Ward ◽

Utku Kandemir

Keyword(s):

Hip Fracture ◽

Medical Center ◽

Academic Medical Center ◽

Years Of Experience ◽

Fracture Care ◽

Academic Medical

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Too Cool? Hip Fracture Care and Maintaining Body Temperature

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459320949478 ◽

2020 ◽

Vol 11 ◽

pp. 215145932094947

Author(s):

James Arkley ◽

Suhib Taher ◽

Ján Dixon ◽

Gemma Dietz-Collin ◽

Stacey Wales ◽

...

Keyword(s):

Hip Fracture ◽

Temperature Control ◽

Functional Outcomes ◽

Surgical Site Infections ◽

Fragility Fractures ◽

Perioperative Period ◽

Readmission Rates ◽

Comprehensive Review ◽

Fracture Care ◽

Increase Risk

Introduction: Patients with hip fractures can become cold during the perioperative period despite measures applied to maintain warmth. Poor temperature control is linked with increasing complications and poorer functional outcomes. There is generic evidence for the benefits of maintaining normothermia, however this is sparse where specifically concerning hip fracture. We provide the first comprehensive review in this population. Significance: Large studies have revealed dramatic impact on wound infection, transfusion rates, increased morbidity and mortality. With very few studies relating to hip fracture patients, this review aimed to capture an overview of available literature regarding hypothermia and its impact on outcomes. Results: Increased mortality, readmission rates and surgical site infections are all associated with poor temperature control. This is more profound, and more common, in older frail patients. Increasing age and lower BMI were recognized as demographic factors that increase risk of hypothermia, which was routinely identified within modern day practice despite the use of active warming. Conclusion: There is a gap in research related to fragility fractures and how hypothermia impacts outcomes. Inadvertent intraoperative hypothermia still occurs routinely, even when active warming and cotton blankets are applied. No studies documented temperature readings postoperatively once patients had been returned to the ward. This is a point in the timeline where patients could be hypothermic. More studies need to be performed relating to this area of surgery.

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Orthogeriatrics and Hip Fracture Care in the UK: Factors Driving Change to More Integrated Models of Care

Geriatrics ◽

10.3390/geriatrics3030055 ◽

2018 ◽

Vol 3 (3) ◽

pp. 55 ◽

Cited By ~ 2

Author(s):

Mark Middleton

Keyword(s):

Hip Fracture ◽

Financial Incentives ◽

Models Of Care ◽

Social Needs ◽

Medical Rehabilitation ◽

Integrated Models ◽

National Guidelines ◽

Fracture Care ◽

The Uk ◽

The Impact

In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex medical, rehabilitation, and social needs of this patient group. Mounting evidence suggests that more integrated models of orthogeriatric care result in superior quality of care indicators and clinical outcomes. Clinical governance through national guidelines, audit through the National Hip Fracture Database (NHFD), and financial incentives through the Best Practice Tariff (providing a £1335 bonus for each patient) have driven hip fracture care in the UK forward. The demanded improvement in quality indicators has increased the popularity of collaborative care models and particularly integrated orthogeriatric services. A significant fall in 30-day mortality has resulted nationally. Ongoing data collection by the NHFD will lead to greater understanding of the impact of all elements of hip fracture care including models of orthogeriatrics.

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HipMod: Development of a Multi-Agent Audit-Based Computer Simulation of Hip Fracture Care

Health Informatics Journal ◽

10.1177/14604582030093005 ◽

2003 ◽

Vol 9 (3) ◽

pp. 183-197 ◽

Cited By ~ 2

Author(s):

C. T. Currie ◽

D. Hoy ◽

A. J. Tierney ◽

J. Bryan-Jones ◽

I. Lapsley

Keyword(s):

Computer Simulation ◽

Hip Fracture ◽

Fracture Care ◽

Multi Agent

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REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study

BMJ Open ◽

10.1136/bmjopen-2021-049763 ◽

2021 ◽

Vol 11 (5) ◽

pp. e049763

Author(s):

Rita Patel ◽

Sarah Drew ◽

Antony Johansen ◽

Tim Chesser ◽

Muhammad K Javaid ◽

...

Keyword(s):

Mixed Methods ◽

Hip Fracture ◽

Patient Outcomes ◽

Ethics Committee ◽

High Quality ◽

England And Wales ◽

Fracture Care ◽

Unwarranted Variation ◽

Organisational Factors ◽

Organisational Level

IntroductionSubstantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients’ outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care.Methods and analysisQuantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016–2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an ‘Implementation Toolkit’ to inform and improve commissioning and delivery of hip fracture services.Ethics and disseminationThis study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops.

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