Care Pathway for Sub-acute Hip Rehabilitation

Integrated Care Pathway for Hip Fractures in a Subacute Rehabilitation Setting

The effectiveness of integrated care pathways for hip fractures in sub-acute rehabilitation settings is not known. The study objective was to assess if a hip fracture integrated care pathway at a sub-acute rehabilitation facility would result in better functional outcomes, shorter length of stay and fewer institutionalisations. A randomised controlled trial on an integrated care pathway was conducted for hip fracture patients in a sub-acute rehabilitation setting. The study supports the use of integrated care pathways in sub-acute rehabilitation settings to reduce length of stay whilst achieving the same functional gains.

Study Overview

• Status: Completed
• Conditions: Hip Fractures
• Intervention / Treatment: Other: Care Pathway

Detailed Description

All patients admitted to St Luke's Hospital, a 185-bed hospital in Singapore providing multidisciplinary stepdown care, from 8 September 2004 to 14 June 2006 for the purpose of rehabilitation after a new hip fracture were included. Patients were excluded if any of the following criteria were present: (i) Pre-morbid non-ambulatory status, (ii) nursing home residents, (iii) palliative care patients, and (iv) patients previously enlisted for the trial. Administrative staff allocated patients to either ICP or usual care according to the last digit of their National Registration Identity Card (NRIC) numbers, odd numbers to the intervention group and even numbers to the control group. Patients were then admitted to 1 of 2 intervention wards or 1 of 3 control wards. Patients were enrolled by the principal investigators only after moving into their respective wards because of work flow limitations. Those who refused consent or were excluded remained in their assigned wards and received usual care. Both intervention and control groups were under the care of multidisciplinary teams but the intervention group had structured assessments and checklists in addition to usual care while the control group had usual care alone.

• Study Type: Interventional
• Enrollment (Actual): 162
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Singapore
  • Singapore, Singapore, 659674
    • St Luke's Hospital, Singapore

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients admitted to St Luke's Hospital for the purpose of rehabilitation after a new hip fracture.

Exclusion Criteria:

• Patients were excluded if any of the following criteria were present: (i) Pre-morbid non-ambulatory status, (ii) nursing home residents, (iii) palliative care patients, and (iv) patients previously enlisted for the trial.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control group; Usual care consisted of 2 half hourly therapy sessions per day from Monday to Friday and medical ward rounds 3 times a week. Multidisciplinary rounds were conducted every 2 weeks. Any specific goals or interventions were at the discretion of the managing team.
Experimental: Intervention group; Intervention group had structured assessments and checklists (as part of the integrated care pathway) in addition to usual care.	Other: Care Pathway; The intervention group had the following as part of the integrated care pathway: Medical assessment on admission for risk factors for falls.; A weekly assessment of complications including pain, deep venous thrombosis, anaemia, wounds and pressure ulcers, etc. The Confusion Assessment Method and the Geriatric Depression Scale were utilized.; Physiotherapy and occupational therapy guidelines with recommended milestones (set for the full, partial and non-weight bearing groups); Physiotherapy Clinical Outcome Variables Scale (PTCOVS)16 was used by the physiotherapists in the intervention group to assess the baseline mobility, to define outcome goals and to direct treatment plans.; A postoperative hip precaution handout (containing information on avoiding hip prosthesis dislocation in patients with total hip replacement or hemiarthroplasty) was given to patients and their caregivers.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Montebello Rehabilitation Factor Score (MRFS)	MRFS is a recognised measure of hip fracture patients' functional outcome, calculated with the following formula, using the Modified Barthel Index (MBI) scores (which scores the degree of independence of a subject from any assistance up to a maximum score of 100)	1 day At discharge
Montebello Rehabilitation Factor Score (MRFS)	MRFS is a recognised measure of hip fracture patients' functional outcome, calculated with the following formula, using the Modified Barthel Index (MBI) scores (which scores the degree of independence of a subject from any assistance up to a maximum score of 100)	At 6 months
Montebello Rehabilitation Factor Score (MRFS)	MRFS is a recognised measure of hip fracture patients' functional outcome, calculated with the following formula, using the Modified Barthel Index (MBI) scores (which scores the degree of independence of a subject from any assistance up to a maximum score of 100)	At 1 year
Proportions of patients achieving pre-morbid ambulatory status	Pre-morbid ambulatory status is a predictor for post-operative mobility	1 day At discharge
Proportions of patients achieving pre-morbid ambulatory status	Pre-morbid ambulatory status is a predictor for post-operative mobility	At 6 months
Proportions of patients achieving pre-morbid ambulatory status	Pre-morbid ambulatory status is a predictor for post-operative mobility	At 1 year
Length of stay in hospital	Refers to the average number of days that patients spend in hospital	1 day At discharge
Percentage of patients admitted to nursing home	A form of institutional care	Up to 1 year after discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Readmissions to an acute hospital for any reason	An episode when a patient who had been discharged from a hospital is admitted again within a specified time interval	up to 1-year post-discharge
Cumulated mortality	Probability or risk of individuals dying from the disease during a specified period	1 year
Quality of life scale-Short form 12 quality of life	Scale for short form 12 quality of life 0-100 Scale for Physical Component Summary (PCS) and Scale for Mental Component Summary (MCS), a multipurpose, generic measure of health status 0-100 Interpretation of the score : The higher score, the better	6 months and 1 year

Collaborators and Investigators

• Sponsor: St Luke's Hospital, Singapore
• Collaborators: National University, Singapore
• Investigators: Study Chair: Tze Pin Ng, FAMS, PhD, National University, Singapore

Publications and helpful links

General Publications

• Handoll HH, Cameron ID, Mak JC, Panagoda CE, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev. 2021 Nov 12;11(11):CD007125. doi: 10.1002/14651858.CD007125.pub3.

Study record dates

Study Major Dates

• Study Start (Actual): September 8, 2004
• Primary Completion (Actual): June 14, 2006
• Study Completion (Actual): December 26, 2012

Study Registration Dates

• First Submitted: September 16, 2018
• First Submitted That Met QC Criteria: April 5, 2019
• First Posted (Actual): April 8, 2019

Study Record Updates

• Last Update Posted (Actual): April 8, 2019
• Last Update Submitted That Met QC Criteria: April 5, 2019
• Last Verified: April 1, 2019

More Information

Terms related to this study

• Keywords: Critical pathway, length of stay, recovery of function, subacute care
• Additional Relevant MeSH Terms: Fractures, Bone; Wounds and Injuries; Leg Injuries; Femoral Fractures; Hip Injuries; Hip Fractures
• Other Study ID Numbers: slhdoc01; 65 68953250 (Other Identifier: St Luke's Hospital)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Study Data/Documents

1. Publication

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No