An audit of integrated care pathway completion in 2007 for fractured neck of femur admissions - Mr Amir Sadri, Mr Hani Basil Abdul-Jabar November 2008

An audit of integrated care pathway completion in 2007 for fractured neck of femur admissions

Department of Trauma and Orthopaedics,
Chelsea and Westminster Hospital, London, UK.

Mr Amir Sadri. Foundation Year 1 (FY1), Department of Trauma & Orthopaedic, Chelsea & Westminster Hospital, Fulham Road, London

Mr Hani Basil Abdul-Jabar Specialist Trainee Year 2 (ST2), Department of Trauma & Orthopaedics, Hillingdon Hospital, Pield Heath Road, Uxbridge

Introduction

Fractured neck of femur (NOF) is a common problem encountered by the majority of orthopaedic departments in the UK.   Most hospitals within the UK have an integrated care pathway for the management of such cases, with some pathways more comprehensive than others.

Most fractured NOF pathways incorporate a multidisciplinary approach to the management of patients to help patients move progressively through a clinical experience with a positive outcome ⁽¹⁾ .

Studies have shown that a multidisciplinary integrated care pathway (ICP) for patients with fracture NOF improve outcome with respect to mean length stay, 30 day mortality and the number of patients operated within 24 hours ^(2,3) .

Although the evidence supports the use of ICPs in the management of patients with fractured NOF; problems can arise during implementation.   This usually begins at the time of admission.  

The admitting A&E staff, junior orthopaedic doctor on-call or the trauma nurse (in certain hospitals) may forget to fill-in the ICP form within the admission clerking notes.   The ICP usually involves a substantial amount of paper work which is time consuming during a busy shift.   Lack of awareness by medical staff on the ward, and finally inadequate senior encouraging for use of the pathway are other obstacles for ICP implementation.

We audited the implementation of the fractured NOF pathway at Chelsea and Westminster Hospital, London, UK, to evaluate compliance of medical staff to the pathway.

Method

We retrospectively analysed the case notes of all patients admitted with NOF fracture during 2007.   We collected data on lengths of admission, the presence of the ICP in the case notes, and whether the pathway was completed fully or left incomplete in the notes.

All data was exported to Microsoft Excel for analysis.

Results

During 2007 there were 113 admissions with a diagnosis of fractured neck of femur.   There were 75 female and 38 males with an average age of 78.8 and an average length of stay for all fractured NOFs being 21 days.

Of the 113 cases, 67 patients had no pathway documentation within the notes.   46 cases had ICP documents within the notes, but only 19 of these were filled in completely with entries on all sheets.

Comparing the average length of admission with respect to completion of the ICP; we found that the 19 patients who had a complete ICP in the notes had an average length of stay of 18.6 days (range 6-43, median 13 and mode 6).    27 patients had an incomplete ICP and their average length of stay was 17.8 days (range 3-88, median 17.6 and mode 12).   For the 67 patients who had no ICP documentation in the notes the average length of stay was 22.3 days (range 3-71, median 16.5 and mode 12). See table below.

Conclusion

Our results show that a large proportion (59.2%) of patients had no ICP documentation in their case notes.   For these patients the average length of stay was 3.7 days longer compared to patients who had a completed ICP, and 4.5 days longer compared to those patients who had an incomplete pathway.

The causes for these differences in the lengths of stay are multifactorial.   Patients without a pathway may have had less streamlined input with regards to occupational and physiotherapy. Also without daily prompting from the ICP, the implementation of social care and discharge planning may have been delayed.   The care pathway allows clear and precise documentation of a patient’s progress, and anticipates the need for further input, thus allowing a smoother transition of patients through their clinical experience.  

Recommendations

1. Senior clinicians, nursing staff and allied health workers (physiotherapist and occupational therapist) must encourage the use of the ICP by all health care professionals involved in the care of the fractured NOF patient.
2. The education of new and current staff on the importance of the implementation of the ICP. This can be done at hospital induction of new staff and at departmental meetings.
3. More frequent auditing of the ICP implementation to ensure progressive improvement.   This can be done at the monthly “morbidity and mortality” departmental meetings.

Plan

Re-audit with the above recommendations for patients admitted during the year 2008.

References

1. Middleton S, Roberts A, Reeves D (2000) What is an ICP? www.evidence-based-medicine.co.uk
2. Gholve P, Kosygan K, Sturdee S, Faraj A.   Multidisciplinary integrated care pathway for fractured neck of femur: A prospective trial with improve. Injury 2005 36(1):93-98.
3. Onslow L, Roberts H, Steiner A, Roberts A, Powell J, Pickering R.   An integrated care pathway for fractured neck of femur patients. Prof Nurse 2003 18(5):265-68.