IMPACT OF ORGANIZATIONAL CHANGES ON NECK OF FEMUR FRACTURE MORTALITY RATE

Abstract

Delay in operative fixation of neck of femur fracture is associated with increased morbidity and mortality, and has reduced chance of successful internal fixation and rehabilitation. Apart from medical reasons, inadequate facilities or poor organization has also shown to delay neck of femur fracture patients going to theatre.

In the year 2005, the Orthopaedic Directorate of University Hospitals of Leicester formed a #NOF project group to look at achieving a mean 24 hour wait (from clinical fitness to surgery) for this group to get to theatre. This group identified the areas of deficiencies and suggested organizational changes to overcome these.

The salient changes effected by the group are as follows.

1. Assigning a dedicated #NOF ward where patients can be fast tracked from A & E, promptly assessed and pre operative management instituted.

2. A dedicated half-day theatre hip list 7 days a week, staffed by senior anaesthetist and surgeons.

3. Senior anaesthetic cover on weekends from 8 am to 8 pm.

4. Ortho geriatricians and consultant anaesthetist designated for each day to pre operatively assess #NOF patients and optimize their medical condition.

5. Increasing the number of Trauma coordinators to provide 7 days a week cover. They attend post take ward rounds to obtain information from consultants detailing type of surgery, anaesthetic skill requirement and if medical input is required. They are then required to co ordinate with theatres to list the patient and make appropriate pre operative arrangements.

6. Appointing Clinical Aides to ensure pre operative preparation of patients by carrying out pre op bloods and other formalities. This also supports a reduction in the junior Doctors working hours.

7. Appointment of specialist discharge coordinators for early assessment and triage to appropriate rehabilitation services post operatively.

These measures were implemented in total from June 2006.

As a result of these measures the mean time to theatre of fit #NOF patients increased from 35% in 2005 to 75% in 2007 and 90% for the first 6 months of 2008. The mortality decreased from 18.5% in 2005 to 13.2% in 2007 and 11.3% for first 6 months of 2008. Relative risk of death decreased from 123 in 2005 to 107.9 in 2007 and 79.8 for Jan – June 2008. Also percentage of patients staying longer in hospital decreased from 30.5% in 2005 to 19.3% in 2007 and 13.4% in 2008.

In conclusion, identifying deficiencies and re organization to over come them has resulted in a better service provision and decreased mortality rate in #NOF patients. This is also a model for other hospitals to follow to improve on their care of #NOF patients.