Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study

Abstract

BackgroundDelay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients.MethodsThis study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data.ResultsThe improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47 % to 83 %, with performance predictably ranging between 67 % and 98 % if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation.ConclusionsTimeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

Operational strategies to manage non-elective orthopaedic surgical flows: a simulation modelling study

“… 26 The effects of OR planning and scheduling strategies were measured by waiting time to surgery and the percentage of patients undergoing surgery within 24 hours, a common improvement target for patients with hip fracture. 7 The study has been granted ethical approval by the Regional Ethics Committee in Stockholm (ref no. 2009/1657-31).…”

“…2–5 Despite the positive effects of improvement efforts to reduce waiting time to surgery, the management of OR resources still represents a challenge for the timely delivery of surgical services for this vulnerable patient group. 6 7 Waiting time to surgery is consequently still one of the most important performance variables for managing non-elective patient flows in order to prevent unnecessary patient suffering.…”

Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study

“…Initially, there were fears that with focus on fast tracking hip-fracture patients this would negatively affect other fracture patients. These fears, however, proved to be unfounded, as the results of a concurrent study investigating the effects of process change was able to show 145 . There were knock-on effects that possibly benefited other patient groups, as there was a heightened awareness and vigilance among staff to actively reduce waiting time to surgery for fracture patients.…”

“…In recent years, acute care facilities have introduced dedicated processes such as integrated care pathways 149 and fast-track systems 59 to streamline and co-ordinate the management of the care of hip-fracture patients. Reducing waiting time to surgery can be achieved by staff involvement in improvement measures and by active management of acute surgical procedures 145,150 . The use of a multidisciplinary team approach has proved effective in the care of hip-fracture patients, in areas such as reducing waiting time to surgery and lowering the complication rate post-operatively 134,151 Nurses, as members of an inter-professional team and by virtue of their close proximity to patients, have an important role to play in the co-ordination 152 of the pre-operative patient care and preparation of hip-fracture patients for surgery.…”

Mortality effects of timing alternatives for hip fracture surgery

“…Some have argued that understanding the effects of policy change should guide reorganization of operating room resources 26 and prioritization in the presence of competing demand. 7,[27][28][29] In this paper, we offer 2 new estimates: the effect of possible changes in surgical timing policy in the same popula tion of patients, and the proportion of inhospital deaths attrib utable to surgical delays.…”