Summary
Delirium is a common complication following hip fracture surgery. We introduced a peri‐operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p = 0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1–4.4) (p = 0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30 days postoperatively) including: all‐cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p < 0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p < 0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p = 0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.
Older women seem to have lower GP follow-up rates after an emergency department (ED) discharge than men. This qualitative study investigated how older women seek GP follow up after an ED visit. In 2018, women aged ≥65 years were recruited from an ED in a suburban hospital in south-western Sydney, Australia, and then contacted 1 week later for a telephone interview exploring factors associated with their follow-up behaviour. Grounded theory was used to construct a potential explanatory model of follow-up behaviours. Of the 100 women recruited, 64% had attended a GP follow up by Day 7, as instructed. The balance of perceived cost and benefit of GP follow up emerged as a useful model to understand the factors affecting follow-up behaviour. Perceived costs included inconvenience caused to self and others, access to transport options and the availability of a patient’s GP. Perceived benefits included previous experiences with the healthcare system, pre-existing health-seeking behaviours and ED messaging. Our findings suggest that follow-up rates could be improved by strengthening the perceived benefit of GP follow up at the point of ED discharge, in addition to addressing perceived costs. Approaches may include ensuring discharge instructions are purposeful and given in the company of an older woman’s social supports.
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