Hip Fracture Redesign Project
Summary – Dr Pierre Guy (Orthopedic Trauma Surgeon at Vancouver Acute) and Dr Ken Hughes (Orthopedic Surgeon at Richmond General Hospital) successfully applied for funding from the joint BCMA – MoHS Specialists Services Committee as part of a one-time competition to undertake a project aimed at improving care for hip fracture patients. The project specifically aims to i) review hip fracture care across the care continuum, ii) implement simple proven best practice measures in a pilot setting iii) measure the system’s performance at baseline and following implementation of best practices, and iv) assess the feasibility of expansion of these best practices on a Provincial scale.
Background - Hip fractures from simple falls in the elderly represent a significant public health burden due to their frequency (3,866 admissions in BC in 2010/11; 3,885 in 2011/2012) and the expected growth of the aging segment of BC’s population. The societal impact affects resource utilization and management in both acute and long term health care sectors. Hip fracture events also affect individuals, with up to 30% dying in the year that follows and 50% losing one level of mobility and independence and they also impact funding as many require supervised housing. Estimates of first year cost of care range between $26,000 - $47,000 per fracture depending on the level of support required.
Looking elsewhere, population-level initiatives such as the UK National Hip Fracture Database and the Swedish Hip Fracture Register have informed best practices guiding care decisions. From these groups, simple measures such as early access to operative care and the involvement of ortho-geriatricians / internists as part of the multi-disciplinary team have proven effective in decreasing not only complications and mortality but have affected length of hospital stay and the need for Long Term Care. Supported by policy and health administrative changes, implementation of best practices can result in significant financial and quality of care impacts for the health system. Specifically, results from the UK experience indicate that of the first 200,000 patients tracked in the hip fracture database there was:
· A 15% reduction in mortality
· A 5% reduction in hospital stay
Placed in the context of hip fracture care in BC, where In-Hopsital LOS represents 66300 bed-days annually, one could expect an efficiency gain of 3300 bed-days to be saved or committed to other growing needs, along with the improved level of care and communication reported by jurisdictions which have committed to a best practice redesign.
Best Practices - A Canadian best practices document, A National Hip Fracture Model of Care Toolkit, was developed in collaboration with BC clinicians and researchers in 2010-2011. Implementation has unfortunately not automatically followed. Provincially, BC already benefits from a network of individuals –The Hip Fracture Collaborative, who, as change agents on local projects, come together to share experiences and exchange strategies. While aspects of care have improved and awareness has risen, there are still wide variations in care (LOS range 10.8-18.5) and significant gaps and barriers to best practice care for patients with hip fractures. To address this, our 18-month project includes four sub-projects:
1. A scoping / snapshot review of hip fracture care in BC
2. Identification of key indicators and creation of a data set for tracking /monitoring purposes
3. A pilot project at selected sites –
4. Development of a change management strategy for Province-wide roll out
The intended goals and outcomes include:
• Implementation of innovative, evidence-based clinical practices in care of hip fractures
• Improved access to surgery (e.g. within 24-48 hours of admission)
• Expected lower mortality rates and lower post-operative complications (e.g. infections, pressure sores)
• Improved patient flow, particularly at point of entry to the system and at discharge
• Reduced length of stay, improved turnover and access for others
• Improved collaborative practice and transfer of care between health care providers involved at various stages in the care continuum
• Improved patient engagement and involvement in the care pathway
• A database of performance and feasibility indicators to inform practice change and requirements of roll-out or spread across the Province. The data base will link Ministry of Health and PHSA (BCAS) data ( aka passive data) to real-time data actively collected thru a web-process (GRP-Global Research Platform) developed and used by the Rick Hansen’s Institute for its National Spinal Cord Injury Registry (active data). The GRP is owned by the Rick Hansen Institute and is being made available for use for the project on a contracted basis. System administration (data release, data linkage, troubleshooting) and data storage will be provided by the Rick Hansen Institute, as a service provider to Vancouver Coastal Health. The BC Hip Fracture Registry, will be responsible for paying the costs related to the provided service.
Growth –Initially aimed as a small pilot project of sites caring for hip fracture patients, interest in this project from other Health Authorities has grown, where additional sites now wish to participate. A welcomed development in considering a future Provincial roll-out.
In summary, predictable problems with hip fracture patients delay recovery from surgery and result in added morbidity, mortality and functional decline. Further, post-operative adverse events are often foreseeable, preventable and linked to delayed surgery. The experience of the UK and Sweden suggest that there are significant financial and quality of care gains to be made in BC by a coordinated initiative of introducing best practice care.
Thank you in advance for your commitment and support of this important work. Please contact Dr. Pierre Guy () or Laura Reeves ( or 250-655-8961) if we can provide further information or clarify any areas of concern.
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February 1, 2013