Project Mission:
Improvement in the clinical care of elderly patients admitted to CGH with a hip fracture through the establishment of a formal orthopaedic-geriatric team.

Team:
Dr Helen Thomas, Nurse Clinician Faezah Kadir, Dr Lee Haw Chau, Senior Staff Nurse Raudhah Haji Mohammed, Dr David Yong, Dr Low Shou Lin

Hip fractures - a unique challenge

Hip fractures are common among the elderly and proper care of these patients presents a unique challenge to health care services. Elderly patients often have several medical conditions and social issues that require multidisciplinary care if they are to achieve functional recovery and return to their status before the fracture.

A clear set of objectives

The objectives of this programme were to:

Significant achievements

Since 2004, we started an orthogeriatric service to improve standards of care for hip fracture patients aged above 70 years. Initially, a geriatrician and orthopaedic doctor conducted regular ward rounds and multidisciplinary meetings on two orthopaedic wards. A comprehensive assessment of physical, psychological and functional status of hip fracture patients over 70 years old was conducted.

In 2007, we received funding from Ministry of Health’s Healthcare Quality Improvement Fund (HQIF), which enabled the employment of a full time nurse clinician for the service. Her core responsibilities are to reduce the incidence of common complications experienced by elderly people in the hospital, improve communication with family members, and manage early discharge planning.

The CPIP methodology was used to establish a collaborative project with St Andrew’s Community Hospital (SACH) to improve the referral and transfer process for patients going to SACH for rehabilitation. This project has helped to ensure the “right siting” of patients and their seamless transfer between the hospitals.

Other initiatives include the re-design of hip fracture pathway, collection of comprehensive data for audit of hip fracture care, development of a separate ‘hip fracture’ referral form to SACH, and a revised information brochure for patients and their families.

Noteworthy results

The number of conservatively managed patients, the waiting time to surgery, as well as the mortality rate have been reduced.

The length of hospital stay has decreased from an average of 18.6 to 14.9 days. Earlier postoperative mobilisation has improved the functional status of patients' upon transfer to the community hospital - 72% of patients were able to stand with a walking frame compared to 57% before the initiative.

The appointment of a nurse clinician has improved discharge planning and enhanced liaison with community hospitals. Importantly, this has resulted in the seamless and timely transfer of patients to community hospitals with no increase in the rate of readmission.

Project Mission:
Compliance in the correct, timely and adequate prophylactic antibiotics administration for hip fracture surgeries.

Team:
Dr Lee Haw Chou, Dr Tan Su Meng, Nurse Clinician Loh Siw Eng, Nurse Manager Ho Geok Lay, Nurse Clinician Rubavathy, Nurse Clinician Chong Siew Heng, Ms Nuri Ng (Clinical Services), Ms Sarina (Research Coordinator)

Reduction of Surgical Site Infection (SSI)

With this objective, we initiated a project to address the compliance issues of proper, timely and adequate prophylactic antibiotics administration in all hip fracture surgeries in an orthopaedic ward over a period of 11 months. Proper antibiotic administration is one of the most important factors in the reduction of SSI. The rate of SSI averages between 2 to 3% for clean cases. Of these, an estimated 40 to 60% of these infections are preventable.

Teamwork matters

We recognised that group responsibility is often overlooked in our efforts to reduce prolonged hospital stay, and there is excessive resource consumption due to SSI. Everyone involved in the treatment process, from the nurse, junior doctors, anaesthetist to the surgeons, must be educated to pay close attention to achieving good outcomes and assume collective responsibilities.

We aim to instil a cultural change towards group responsibilities in patient treatment outcomes so that good practice guidelines can be implemented successfully throughout the hospital.

The interventions

We actively encouraged the idea of group responsibilities and “buy-in” from all the staff involved. Close door discussions on SSI were held to raise awareness and critique of our practice. Other measures included education for nurses, junior anaesthetists and house officers through posters and presentations.

Positive results attained

We collected data pre- and post-intervention and noted significant improvements in timely and adequate antibiotics administration in our hip fracture surgeries.

From pre-intervention rates of 65% for timely administration and 30% for appropriate antibiotics administration, the figures improved to 100% and 70% respectively at the end of the study. Although not statistically significant, SSI rate has also decreased.

The established principles and methods of intervention in this successful project can be extended to other types of orthopaedic surgery and other surgical units such as cardiac surgery and neurosurgery.