The development of a comprehensive multidisciplinary care pathway for patients with a hip fracture: design and results of a clinical trial

Elvira R Flikweert, Gerbrand J Izaks, Bas A S Knobben, Martin Stevens, Klaus Wendt, Elvira R Flikweert, Gerbrand J Izaks, Bas A S Knobben, Martin Stevens, Klaus Wendt

Abstract

Background: Hip fractures frequently occur in older persons and severely decrease life expectancy and independence. Several care pathways have been developed to lower the risk of negative outcomes but most pathways are limited to only one aspect of care. The aim of this study was therefore to develop a comprehensive care pathway for older persons with a hip fracture and to conduct a preliminary analysis of its effect.

Methods: A comprehensive multidisciplinary care pathway for patients aged 60 years or older with a hip fracture was developed by a multidisciplinary team. The new care pathway was evaluated in a clinical trial with historical controls. The data of the intervention group were collected prospectively. The intervention group included all patients with a hip fracture who were admitted to University Medical Center Groningen between 1 July 2009 and 1 July 2011. The data of the control group were collected retrospectively. The control group comprised all patients with a hip fracture who were admitted between 1 January 2006 and 1 January 2008. The groups were compared with the independent sample t-test, the Mann-Whitney U-test or the Chi-squared test (Phi test). The effect of the intervention on fasting time and length of stay was adjusted by linear regression analysis for differences between the intervention and control group.

Results: The intervention group included 256 persons (women, 68%; mean age (SD), 78 (9) years) and the control group 145 persons (women, 72%; mean age (SD), 80 (10) years). Median preoperative fasting time and median length of hospital stay were significantly lower in the intervention group: 9 vs. 17 hours (p < 0.001), and 7 vs. 11 days (p < 0.001), respectively. A similar result was found after adjustment for age, gender, living condition and American Society of Anesthesiologists (ASA) classification. In-hospital mortality was also lower in the intervention group: 2% vs. 6% (p < 0.05). There were no statistically significant differences in other outcome measures.

Conclusions: The new comprehensive care pathway was associated with a significant decrease in preoperative fasting time and length of hospital stay.

Figures

Figure 1
Figure 1
Flow chart of the treatment in both groups. Schematic representation of the differences between the treatment in the intervention group (comprehensive care pathway) and the historical control group (standard care). For details, see text. ER: emergency room, OR: operating room.
Figure 2
Figure 2
Delirium protocol. The delirium protocol that was part of the comprehensive care pathway and was applied upon arrival at the emergency room.

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