A hip fracture pathway in an emergency department, supported by associate practitioners, has resulted in the timely care of patients and a reduced mortality rate
In 2016, Medway Maritime Hospital changed the way hip fracture patients are managed in the emergency department to improve their experience and get them into the care of the orthopaedic team more quickly. At the centre of the hospital’s new hip fracture pathway were associate practitioners, trained to complement registered nurses in looking after patients – often frail, older people – arriving in hospital. One year after implementation, the results are promising: the time between initial assessment by paramedics and transfer to a specialist ward has been reduced from 379 to 81 minutes and the mortality rate has decreased from 11.2% to 5.7%. This article explains what led to the changes, how the new pathway works, the role of associate practitioners and what outcomes have been achieved so far.
Citation: Evans C et al (2018) Involving associate practitioners in a hip fracture pathway. Nursing Times [online]; 114: 1, 22-25.
Authors: Cliff Evans is consultant nurse in emergency medicine; John Ferguson is general manager for acute and continuing care; Tracey Croft is lead emergency nurse practitioner and practice development nurse; all at Medway Foundation Trust.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
Since 2016, associate practitioners (APs) complement the nursing workforce at the emergency department (ED) of Medway Maritime Hospital in Kent, where they support a redesigned hip fracture pathway. This new pathway was implemented to improve the safety and experience – and potentially outcomes – of patients on their journey through the ED into the care of the orthopaedic team. The project was undertaken at a time of unprecedented nursing vacancies and saw APs undergo a comprehensive development programme to enable them to take on new tasks. This article describes the project, its background and outcomes.
A life-changing event
In England, Wales and Northern Ireland, approximately 65,000 hip fractures occur each year and 4,000 hospital beds are occupied by a patient with a fractured hip at any one time. The average age of people who sustain a hip fracture is 84 years and hip fractures often occur in people who have become increasingly frail (Royal College of Physicians [RCP], 2016).
For older people, a sudden fall can result in significant injury (Trauma Audit and Research Network [TARN], 2017). If they fell while on their own, patients may not be able to get up, and may develop illnesses such as pneumonia, which further complicate the presentation. A hip fracture is a life-changing event and may result in increased dependency and reduced mobility. Associated mortality rates are high – a quarter of patients will require long-term care and only a minority will completely regain their previous abilities (RCP, 2014).
The diagnosis and management of hip fractures is a complex journey and there is evidence that having patients seen by orthopaedic and orthogeriatric specialists more quickly improves their outcomes and their chances of regaining previous levels of health (Larsson et al, 2016).
Before the new pathway, patients at Medway Maritime Hospital underwent surgery within acceptable timeframes and the orthogeriatrician played a leading role in their care; however, the mortality rate was well above average. In 2013, it reached a historic high of 11.2%, while the national average was 8.4% (RCP, 2016).
In January 2016, senior staff from the ED, quality improvement team and local ambulance service got together to discuss the existing pathway at the hospital. The existing pathway was initiated by the ambulance crew, who alerted the orthopaedic ward on the way to the hospital. An orthopaedic nurse then instigated a series of actions to speed up patients’ journey through the ED.
However, due to ongoing problems with nursing recruitment across the hospital, the pathway was only available Monday to Friday between 8am and 4.30pm. The ambulance service had noted that it was unreliable and they had stopped using it.
In November 2015, the nursing vacancy rate in the ED had been as high as 65%, compromising the provision of even essential nursing care. Inspections by the Care Quality Commission had confirmed that overcrowding, insufficient nursing staff and poor processes were resulting in unsafe and undignified care (CQC, 2016). The ED was the only area of the hospital that failed to be classified as ‘good’ in the ‘caring’ category.
An internal retrospective audit undertaken in September 2016 identified that 80% of patients with a hip fracture arrived at the hospital at a time when the hip fracture pathway was not available. Patients frequently had to wait for long periods of time to be transferred from the ambulance to the ED, and then on a trolley in the ED with insufficient nurse numbers to meet their needs.
On average, in July/August 2016, it had taken 379 minutes for patients to go through the pathway – that is, to be assessed by the paramedics at the scene, undergo investigations at the ED, have their hip fracture diagnosed and be transferred to the orthopaedic ward.
An improvement plan and strategy for workforce development were implemented at the ED during 2016, with one of the priorities being to improve older patients’ experience and outcomes. One element of the plan was the creation of a patient-centred, accelerated hip fracture pathway (Fig 1), which was introduced in October 2016.
A literature review was conducted to inform that pathway. The senior ED team examined innovative projects and practices designed to speed up and improve patients’ journeys, and combined the findings with recommendations from national guidance and professional bodies (RCP, 2016; NHS Evidence, 2013). The target time set for patients to complete the new pathway, based on anecdotal evidence, was 90 minutes between arrival at the hospital and admittance on the orthopaedic ward.
One theme from the literature was the need to rule out time-critical conditions such as myocardial infarction, stroke or sepsis before referral to orthopaedics (TARN 2017; NHS Evidence, 2013). In older people, there are often precipitating factors resulting in falls that causes the hip fracture (Aronsson et al, 2014).
Another theme was the role of paramedics in hip fracture pathways, with McRae et al (2015) endorsing their ability to make a correct diagnosis at first assessment.
To ensure the early treatment of time-critical conditions (Evans et al, 2017), the new pathway starts with an immediate and comprehensive assessment of patients, by the ambulance team, in the location where patients have sustained their injury. Paramedics are empowered to make a diagnosis based on clinical signs at the scene, and then activate the pathway if appropriate.
Pauyo et al (2014) argue that hip fracture patients below the age of 60 should be managed separately due to differences in physiology, injury characteristics and care requirements. This 60-years age limit is endorsed by the RCP (2016).
There is extensive evidence supporting early corrective surgical intervention (RCP, 2016; NHS Evidence, 2013). Eriksson et al (2012) discuss ways of circumventing the ED and fast-tracking patients into orthopaedic care. Singh et al (2016) recommend that this should be combined with an initial assessment, to ensure that seriously unwell patients are not prematurely referred to the orthopaedic surgeon.
The inclusion criteria chosen for our new pathway are:
- The patient is 60 years of age or older;
- The ambulance crew has identified all of the following signs of hip fracture: trauma, shortened and externally rotated leg, pain in hip, inability to bear weight;
- There are no time-critical findings.
If, upon arrival at the hospital, there are no specialist beds available, patients are removed from the pathway and are treated by an ED clinician before they can be referred on for specialist care.
The literature supports a staggered approach to pain management and the initial use of intravenous (IV) paracetamol. Schug et al (2015) have shown that one-gram dose of IV paracetamol can reduce subsequent doses of opioids by 30%. The efficacy of IV paracetamol is similar to that of opioids, without many of the side-effects that opioids commonly cause in older patients (Clinical Pharmacist, 2011).
NHS Evidence (2013) recommends femoral or fascia-iliaca nerve blocks as part of the hip fracture programme. These blocks can be administered, with training, by non-medical staff (Callear and Shah, 2016), however, their administration early during patients’ admission is not without problems: if the block is administered before confirmation of the fracture, patients may be unnecessarily admitted.
Pain management in the new pathway therefore follows a three-step approach:
- IV paracetamol;
- Low-dose morphine if required;
- Administration of a nerve block once the patient is on the orthopaedic ward and the hip fracture is confirmed.
Paramedics administer IV paracetamol at the scene and the effectiveness of pain relief is evaluated on arrival at the ED.
It became apparent that the new pathway would require one person to be responsible for it, to ensure all steps were completed, improve interdisciplinary communication and provide continuity of care (Stenqvist et al, 2016). However, previous pathways had failed due to the inability to provide a dedicated nurse role available 24/7, so we decided to look at employing APs.
APs are seen as having knowledge and skills beyond those of traditional healthcare support workers. They are accountable to their employers and the public, which enables them to undertake clinical tasks previously only done by registered professionals (Skills for Health (SFH), 2009). A structured AP development plan with specific learning outcomes and competencies is considered sufficient to safeguard patient safety (SFH, 2016).
There are almost 70 different types of training and no consensus on what training should entail and the skills and knowledge of APs after completing foundation-level degrees have been found to be variable (Ripley and Hoad, 2016).
Developing the role
In November 2015, the ED staff included only one AP but several experienced support workers who had shown an ability to progress and take more responsibilities. A local recruitment campaign was launched to increase the number of APs to complement – but not replace – the existing nursing workforce and improve capacity. A comprehensive AP training programme – which included supervised clinical practice – was introduced. Table 1 summarises the key components and objectives of the AP development programme.
Policy documents supporting tasks already undertaken by APs were examined and new policies developed where needed. Changes to traditional boundaries of practice were accompanied by a robust clinical governance framework (Smith and Baltruks, 2015). Regular audits were conducted, which showed that APs were having a positive impact on the ED. This made them feel valued and created a sense of belonging.
Place of APs today
Today, there are 15 APs working in the ED and the pathway is available 24/7. Their role in the new hip fracture pathway is shown in Fig 1 and detailed in Box 1. Decision-making by APs is supported by the senior ED team and a dedicated pro forma acts as an aide-mémoire and helps to ensure effective interdisciplinary communication.
One of the pathway’s defining features is its safety. The initial assessment by paramedics is highly effective in identifying actual or potential serious illness. While patients are in the ED, APs check that their venous blood gases and electrocardiograms are within normal limits and that their NEWS is ≤4. Routine pre-operative blood tests performed in the ED are later reviewed by the orthopaedic doctor. This provides an excellent safety net.
Box 1. Role of APs in hip fracture pathway
- The AP receives early notification from ambulance crew at the patient’s home
- The AP notifies the wider MDT and requests a specialist bed
- The AP greets the patient, makes them feel welcome, informs and reassures them
- The AP provides continuity of care for the patient
- The AP conducts diagnostic investigations (VBG, ECG, bloods)
- The AP conducts NEWS assessments
- The AP evaluates patient’s pain and coordinates pain medication
- The AP records audit information
AP = assistant practitioner; ECG = electroencephalogram; MDT = multidisciplinary team; NEWS = National Early Warning Score; VBG = venous blood gases
Outcomes so far
The time taken by patients to complete the pathway – that is, time between initial assessment at the scene and transfer to a specialist ward – has been dramatically reduced. On average, in July/August 2016, it was 379 minutes. In October/November 2016 (the first month of implementation of the new pathway), the figure had gone down to 81 minutes and in December 2016/January 2017 is was 75 minutes.
However, not all patients admitted to the ED with a hip fracture complete the pathway: only 18% of them did so in October/November 2016, rising to 24% in December 2016/January 2017, the main issue being the lack of specialist beds.
At the end of 2016, the pathway was peer-reviewed by a panel of experts, who highlighted several best practices including: multidisciplinary team working; APs ensuring continuity of care and improved initial management of the patient; including, the use of a safety criteria at initial assessment to safely accelerate the pathway and bypass the ED.
In February 2017, the CQC acknowledged the positive impact that APs were having on patients’ experiences in the ED, which received a rating of ‘good’ for ‘caring’ (CQC, 2017). Between March and June 2017, 49% of patients completed the pathway in an average time of 81 minutes; only 22% were removed from the pathway because of the lack of specialist beds; the remaining 29% were removed due to safety concerns identified during the initial assessment.
Since the introduction of the new pathway, the mortality rate among hip fracture patients at Medway Maritime Hospital has decreased month by month. It currently is 5.7%, which is below the national average of 6.5% and nearly half the historic high of 11.2% (RCP, 2017).
The acute trust and local clinical commissioning group are now working together to speed up the transition of post-operative patients from the hospital to a rehabilitation bed, in order to free up specialist beds for new patients. The success of the new pathway is in part due to different professional groups within and outside the hospital forming close working relationships.
This project demonstrates that the patient experience can be improved by reviewing existing pathways and linking workforce development with patient-centred care. It shows the benefits of empowering nurse leaders to challenge the effectiveness of traditional care practices from the patient’s perspective.
- Patients who have sustained a hip fracture, often frail older people, have to go through a complex journey
- Reducing the time it takes for hip fracture patients to be seen by orthopaedic specialists improves their outcomes
- Involving associate practitioners in the care of hip fracture patients can improve the patient experience
- With the right training and safeguards in place, they can safely care for patients in the emergency department
- Empowering nurse leaders to challenge the effectiveness of traditional care practices can benefit patients
Aronsson K et al (2014) Prehospital emergency care for patients with suspected hip fractures after falling – Older patients’ experiences. Journal of Clinical Nursing; 23: 21-22, 3115-3123.
Callear J, Shah K (2016) Analgesia in hip fractures. Do fascia-iliaca blocks make any difference? British Medical Journal; 5: 1: 210130.
Care Quality Commission (2017) Medway NHS Foundation Trust. Medway Maritime Hospital. Quality Report. Newcastle-upon-Tyne: CQC.
Care Quality Commission (2016) Medway NHS Foundation Trust. Quality Report. Newcastle-upon-Tyne: CQC.
Clinical Pharmacist (2011) What is the evidence supporting the use of intravenous paracetamol? The Pharmaceutical Journal; 1 January 2011.
Eriksson M et al (2012) ‘Straight to bed’ for hip-fracture patients: a prospective observational cohort study of two fast-track systems in 415 hips. Injury; 43: 12, 2126-2131.
Evans C et al (2017) Improving patient safety through the introduction of a formal triage process. Emergency Nurse; 24: 9, 19-25.
Larsson G et al (2016) Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury; 47: 4, 881-886.
McRae PJ et al (2015) Paramedic-performed fascia iliaca compartment block for femoral fractures: a controlled trial. Journal of Emergency Medicine; 48: 5, 581-589.
NHS Evidence (2013) Hip Fracture: Evidence Update March 2013. NICE: London.
Pauyo T et al (2014) Management of femoral neck fractures in the young patient – A critical analysis review. World Journal of Orthopaedics; 5: 3, 204-217.
Ripley K, Hoad B (2016) Supporting assistant practitioners during their training. Nursing Standard; 30: 48, 45-52.
Royal College of Physicians (2017) National Hip Fracture Database Annual Report 2016. London: RCP.
Royal College of Physicians (2016) National Hip Fracture Database Annual Report 2016. London: RCP.
Royal College of Physicians (2014) Falls and Fragility Fracture Audit Programme National Hip Fracture Database Anaesthesia Sprint Audit of Practice. London: RCP.
Schug SA et al (2015) Acute Pain Management – Scientific Evidence, 4th edn. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine.
Singh S et al (2016) Hip Fractures. Complications of the Surgical Management of Hip Fractures. Orthopaedics and Trauma; 30: 2, 137-144.
Skills for Health (2016) Skills for Health Working Paper 2: How we can act now to create a high quality support workforce in the UK’s health sector. Bristol: SFH.
Skills for Health (2009) Core Standards for Assistant Practitioners. Bristol: Skills for Health.
Smith C, Baltruks D (2015) The Nursing Journey: Recruitment and Retention. East Sussex: Good Governance Institute.
Stenqvist C et al (2016) Orthogeriatric service reduces mortality in patients with hip fracture. Geriatric Orthopaedic Surgery and Rehabilitation; 7: 2, 67-73.
Trauma Audit and Research Network (2017) England & Wales: Major Trauma in Older People. Salford: TARN.