IMPROVED SAFETY AND QUALITY OF CARE FOR PATIENTS WITH A HIP FRACTURE Intervention Audited by the National Quality Register RIKSHÖFT

Sammanfattning: Aim: Hip fractures are common and costly. The overall aim of this thesis was to explore how different clinical pathways influence safety and quality of care among patients with a hip fracture and to test the usefulness of the national quality register RIKSHÖFT as a working tool. The aim in paper I was to improve the outcome of patients with a hip fracture through optimized preoperative pain relief, to diminish the time from admission to operation and to reduce the occurrence of pressure ulcers. Furthermore, in paper II-V a new evidence based clinical pathway was introduced and evaluated to improve the quality of care and patient safety in patients with a hip fracture. In paper II prevention and development of hospital acquired pressure ulcers is described. In paper III investigates the effects of the improved care intervention in relation to nutritional status and pressure ulcers development. Paper IV the delays to operation as well as the length of stay in the acute hospital and the total institutional days up to one year after the hip fracture, the reoperations of the patients and their mortality are analysed. Differences in complications and length of stay between patients with a hip fracture treated at the Orthopaedic department compared to patients with a hip fracture admitted to other departments within the hospital due to limited availability of beds were investigated in paper V. Design: In paper I a retrospective study of all medical records from the last four months of 1998 was compared with prospective registration during the same period in 1999 and 2000 after the introduction of the internal audit programme focusing on pain relief within one hour, time to operation and risk assessment for developing pressure ulcers. A quasi experimental design was used in paper II-V. These patients were consecutively included from April 1st 2003 to March 31st 2004. Results: In paper I the number of patients who had to wait for pain relief more than one hour was decreased as well as the number of patients who had to wait for more than 24 hours to surgery. Pressure ulcers were decreased from 19% in 1998 to 4.4% in 2000. In paper II the focus on prevention of hospital acquired pressure ulcers gave a reduction from 19% to 9% (p = 0.007). Co-morbidity was higher in the intervention group as well as more patients had signs of under nutrition at admission to hospital compared to patients in the control group as shown in paper III. Early surgery (within 24 hours) was significantly associated with reduced length of stay (p<0.001). There was a significant difference in 4 months mortality between patients operated with no delay compared to the group with administrative delay, (p<0.001) (Paper IV). Before discharge from hospital significantly more patients (p<0.02) treated at other departments were affected by any complication compared to patients treated at the Orthopaedic department. Also length of stay at the acute hospital was prolonged (p<0.001) (Paper V). Conclusion: Patients with a hip fracture ought to be treated at an Orthopaedic department, or at departments with combined orthopaedic, geriatric and rehabilitation knowledge. The patients should follow an evidence based clinical pathway like the one described in this thesis. Despite that many of the patients with a hip fracture have signs of under-nutrition it is possible to reduce development of hospital acquired pressure ulcers in patients with a hip fracture. Early surgery, within 24 hours, was significantly associated with reduced length of stay. Healthy patients with administrative delay for surgery have higher mortality at 4 months follow-up compared to healthy patients operated without delay. RIKSHÖFT was found very sufficient as working tool for this quality project of health care.