Hip fractures are one of the most serious and costly injuries suffered by older people globally.
Every year, an average of 180 patients present to the Mater Emergency Department with fractured hips, many of them frail older persons.
90% of these patients ending up having surgery. The team at The Mater were concerned because:
- 45% were waiting up to 63 hours before undergoing surgery
- Only 7.5% received nerve block to effectively relieve pain pre-operatively
- Only 1% getting to a ward or theatre within four hours of presentation
Analysis of the problem using Lean Six Sigma methodology highlighted the potential value of front loading the decision making process, which in turn helped significantly improve wait times.
The team also engaged stakeholders across the multidisciplinary team to agree on the changes, and formulated a robust control plan to ensure they were maintained.
In 2020, of the older patients that presented to the Mater Emergency Department with a hip fracture:
- 85% underwent surgery within 48 hours
- 60% received a nerve block pre-operatively to manage pain
- 30% were admitted to a ward or theatre within 4 hours of presentation
The Green Belt multidisciplinary team supported by the Mater Lean Academy included an Orthogeriatric doctor, an advanced nurse practitioner from the Emergency Department, an advanced practice physiotherapist and a cancer data coordinator. They extensively mapped the process and carried out critical data collection to understand pain points for all.
Through discussions with stakeholders and working collaboratively across all disciplines, they found that in most circumstances, the team in the Emergency Department could diagnose the hip fracture straight away, meaning that the process for admission and scheduling a patient for surgery could start before the Orthopaedic team had seen the patient.
The development of this pathway meant increased early referrals to the Orthogeriatric service, whose specialist knowledge helped to ensure that these older and often frail patients were optimally prepared for their surgery. Additionally, anaesthetists and the advanced nurse practitioners in the Emergency Department worked together to train other advanced nurse practitioners to administer the iliac nerve block, relieving the patient’s pain and making their journey more comfortable.
The team used a rigorous control plan which included monthly data monitoring of performance, to measure against the best practice standard.
“Fantastic and enjoyable opportunity to lead improvement and collaborate on a Patient Pathway for Hip Fractures, resulting in meaningful improvements and better outcomes for our patients – i.e., Increased % of patients operated on <48hrs and standardised approach to early
Eithne Mullen, Director of Strategy, Transformation & Improvement | Ireland East Hospital Group.