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Exclusive: New A&E nursing role helps boost hip fracture survival


The introduction of an advanced nursing support role has contributed to a dramatic fall in mortality rates among the most vulnerable, older patients at an acute trust in Kent, say senior nursing staff.

Brought in as part of a new clinical pathway, the associate practitioner role in accident and emergency care has resulted in what the trust’s nursing staff describe as a “dramatic” shift in survival rates.

“The associate practitioner knows them by name on arrival – the caring side is just huge”

Cliff Evans

The 30-day death rate for hip fracture patients at Medway Maritime Hospital hovered at around 10% for several years, consistently exceeding the national average and hitting an all-time high of 11.2% in 2013.

But it has virtually halved to 5.7% since the launch of an “accelerated hip fracture pathway” – in which the associate practitioners play an integral role – show latest figures from the National Hip Fracture Database.

Medway Foundation NHS Trust started training associate practitioners two years ago, as part of efforts to improve patient experience and safety, with 15 now working in emergency care, said Cliff Evans, consultant nurse in emergency medicine.

The advanced support role sees healthcare workers undergo an extensive training programme to enable them to take on extra responsibility. This includes taking the lead in the new hip fracture pathway, which was launched in October last year.

“I have been a senior nurse in A&E for about 30 years and I was really quite gobsmacked with the results”

Cliff Evans

The pathway – a collaboration between the local ambulance service, emergency department and orthopaedics – is triggered as soon as ambulance workers arrive at the home of someone with a suspected hip fracture.

They contact one of the associate practitioners on duty who ensures everything is in place to assess and care for the patient, and facilitate a swift transfer to orthopaedics.

Mr Evans said: “Prior to the pathway starting, it took a prolonged period of time for patients to get to the orthopaedic ward and that might have been one of the reasons why the outcomes aren’t so good.

“Since we introduced the pathway, on average, from arrival in A&E it takes 70 minutes to get them into an orthopaedic bed on a ward,” he told Nursing Times.

“In that time, they’ve had blood tests, an ECG and a whole series of X-rays and safety checks,” he said. “You really have to go at it full pelt to do that.”

Two associate practitioners have responsibility for the pathway at any one time round the clock, seven days a week.

Mr Evans said it had improved patients’ experience of care and sense of feeling valued, as well as ensuring key factors such as adequate and safe pain relief.

“This role was introduced to complement nursing, not replace it and we made that very clear”

Cliff Evans

“Particularly in this age group, patients [used to] come to the emergency department with this injury, they wait around for tests for hours, they wait to see different professionals for hours – that was the traditional route,” he said.

“They must have felt like they are not really cared about,” he said. “Now they are actually met at the door and the associate practitioner knows them by name on arrival – the caring side is just huge.

“I believe that if patients feel they are being looked after and cared for, then their outcomes have got to improve,” Mr Evans told Nursing Times.

However, he admitted staff had been surprised by the very tangible drop in mortality rate, which is now below the national average of 6.5% and lower than many other comparable trusts .

“I have been a senior nurse in A&E for about 30 years and I was really quite gobsmacked with the results,” he said.

“We knew we had improved the patient pathway and were quite happy about that, but the updated statistics on hip fracture outcomes were quite startling,” he said. “When the pathway started in October you can see the death rate dropping month by month.”

Mr Evans said ensuring a swift transfer onto the wards was key to improved outcomes, as it meant patients were able to get nerve block injections administered by an anaesthetist, which allowed them to sit up – thus reducing the risks of life-threatening complications like pneumonia.

The pathway also meant serious illness was identified and treated early on, which was another important factor in boosting survival rates, he added.

When the role was first introduced, the trust had one of the highest nurse vacancy rates in the country, at 65%, but this was now at 12% after a concerted recruitment campaign.

Mr Evans admitted staff were initially concerned that the new advanced practitioner role would be used as a substitute for employing qualified nurses.

“This role was introduced to complement nursing, not replace it and we made that very clear,” said Mr Evans. “But initially I would imagine that my nurses thought I was trying to replace them with a less qualified workforce.

Medway hospital

182Medway hospital

Medway Maritime Hospital

“As time has progressed, everybody can see they do a very different, distinct role from nurses,” he told Nursing Times.

He said the role was now a “key aspect of the infrastructure” in his department, and was helping free up nurses to concentrate on core nursing tasks.

“The nurses are now able to focus on areas of practice that take more specialist knowledge and input, and I think that is really important for an emergency department where demand can often exceed capacity,” he said.

Other roles undertaken by the trust’s A&E associate practitioners include the assessment of patients with minor injuries, assisting with all ambulance handovers and with the triage process.

Most recently – following extra training – associate practitioners have been deployed in the resuscitation room to support specialist clinicians

“Now they are dealing with the most critically ill patients in a supporting role as well,” said Mr Evans.

The role has proved so successful that it is currently being introduced to acute medical areas at the trust, which is also now helping train associate practitioners to work at other organisations.

“All trusts are struggling to achieve good practice on this and quite a few have double the national mortality rate, so it is really good to be able to share what we have done,” said Mr Evans.

He added: “Associate practitioners provide a level of stability and allow nurses to be able to concentrate on more specialist roles, so it is incredibly beneficial and I think a lot of hospitals could learn from that.

“You have to look at how you do things and think ‘Right – does that really need a nurse? Could that be done just as effectively or even more effectively by someone else with adequate training’,” he said.

Medway NHS Foundation Trust

Exclusive: New A&E nursing role helps boost hip fracture survival

Source: Royal College of Physicians

National Hip Fracture Database chart for Medway Maritime Hospital showing improved survival rate


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Readers' comments (3)

  • Well it is lovely that the outcomes of one of our most vulnerable groups are improving, however a cynical person might see this as treating the group as second class, putting their care in the hands of " a less qualified, (and no doubt less well paid) workforce" !

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  • Doremouse

    My Mum didnt die because of the fracture. She died of neglect, a grade 4 pressure sore and massive infection.
    The staff that did give Mum care were care assistants, the RNs never left the desk except to do meds.
    The nursing care needs to be drastically improved, if it is only HCAs doing the work then there needs to be more of them & they need to be better trained.

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  • Well done to Medway & the teams around them. So important to see this in this vulnerable group of patients. With the progress of ,Model Hospital, & further work with ,GIRFT' hopefully we will see more coordinated care like this for other patients.

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