Quality improvement report•

Orthopaedic Out of Bed Project (OOBP): improving early mobilisation following femoral fracture using a therapy-led education programme

Abstract

Delayed mobilisation following hip fracture surgery is detrimental to patients and health systems. Prolonged hospital stay additionally results in decreased function and increased mortality. Our hospital was underperforming against the national metric for mobilisation by the day after surgery and physiotherapists were the primary healthcare professionals expected to do this. The therapy team therefore undertook a service improvement to increase the number of patients mobilised by the day after their femoral fracture surgery. This was through a ward-based education programme aimed at increasing confidence and competence of the trauma ward healthcare assistants (HCAs) to complete this task when appropriate instead of physiotherapists.

The model for improvement was used, with two Plan-Do-See-Act cycles completed between 2020 and 2022. On completion of the therapy-led intervention, the percentage of patients mobilised by the day after surgery was shown to have increased from a mean average of 60% in 2019 to 79% in 2022. The number of patients mobilised by HCAs prior to physiotherapy assessment increased from 2% prior to and 30% following the intervention.

The programme improved HCA confidence and competence using a rehabilitation ethos to mobilise patients following hip fracture surgery. It also showed a clinically significant improvement in the percentage of patients with hip fracture mobilising by the day after surgery and a large increase in the number of patients mobilised by our trauma ward HCAs prior to an initial physiotherapy assessment. This work has demonstrated implications for orthopaedic trauma services and the patients who receive them. It reduces the single point of failure of relying on a physiotherapist to mobilise a patient through increasing multidisciplinary confidence and capability on the ward to perform the task. In turn, this increases physiotherapy capacity to provide acute rehabilitation, which is another important part of femoral fracture recovery.

What is already known on this topic

  • Delayed mobilisation following hip fracture surgery prolongs hospital stay and leads to decreased function and increased mortality. There is wide variation in achieving this important metric across hospitals in the UK.

What this study adds

  • This study demonstrates that a clinically significant improvement in the percentage of patients with hip fracture mobilising by the day after surgery can be achieved through a therapy-led education programme to the wider ward team.

How this study might affect research, practice or policy

  • This project has influenced service change within our organisation and has the potential to be replicated across other ward areas and departments outside of orthopaedics, as well as further afield across other health and care establishments nationally.

Background

Delayed mobilisation following hip fracture surgery is detrimental to patients and health systems with prolonged hospital stay,1 decreased function2 and increased mortality.3–6 There are established national guidelines from the Royal College of Physicians7 and the National Institute for Health and Care Excellence8 promoting early mobilisation (day 1 postoperatively) which aim to improve survival rate and reduce the negative sequelae of prolonged bed rest.7 8

The Physiotherapy Hip Fracture Sprint Audit in 2017,9 more commonly referred to as ‘Hip Sprint’, found a significant variation in performance in relation to mobilisation out of bed by the day after surgery. Our Trust was underperforming on this metric between the years 2017 and 2020 and as a Trust we were also an outlier for 30-day mortality.10 Our underachievement in relation to early mobilisation may be a contributory factor to our outlier mortality status.3–6

Patients not assessed by a physiotherapist were three times less likely to mobilise than those who were assessed by day 1.11 Our own Hip Sprint reaudit in 2019 found that in the absence of a physiotherapy assessment only one patient (1.7%) was mobilised by day 1 after surgery by the ward. Volkmer et al12 found that postoperative mobilisation may be seen as a single profession activity by professions other than physiotherapists, rather than a ‘care delivery’ approach. This potential lack of wider MDT, defined as ward nurses and healthcare assistants, engagement can negatively impact on early mobilisation in the absence of the physiotherapist.11 Volkmer et al12 reported examples of joint working with occupational therapists and that physiotherapists had identified the need to provide training and collective action to engage the wider MDT in early mobilisation. This approach could help overcome some perceived medical barriers that prevented nurses from considering early mobilisation.12

The James Paget University Hospitals NHS Foundation Trust is a district general hospital located in the East of England. It serves a population of over 250 000 and admitted over 450 patients last year with a femoral fracture.10 A large number of this population are living in deprivation, with a growing number of older adults.13

The dedicated trauma ward has 35 beds and the orthopaedic therapy team cover both the trauma and elective wards and outpatient clinics. There are 14 inpatient therapists consisting of physiotherapists, occupational therapists and therapy assistant practitioners who cover a 7-day service. This paper will describe the development of a service improvement project focused on improving early mobilisation after femoral fracture and surgical repair, the consequent results and the recommendations for future research.

Problem

Previous large-scale programmes aimed at increasing mobilisation in acute patients14 have failed to demonstrate improvements in the percentage of patients mobilised after hip fracture surgery at our Trust. The demand from increasing numbers of patients with femoral fracture, together with other fragility fractures and growing elective waiting lists, means that the responsibility for ensuring patients are mobilised after surgery cannot be the sole domain of one profession.

The service improvement project aimed to develop and deliver a therapy-led training and education programme to the trauma ward healthcare assistants (HCAs). We called the project ‘The Out of Bed Project (OOBP)’ to provide local branding and awareness. The purpose of the project was to improve the percentage of patients mobilised out of bed by the day after femoral fracture surgery from 60% to at least the national average for the UK, which is currently 81%.10 We theorised that this project would provide other staff with the ability to support the achievement of this metric. Furthermore, we hypothesised that common barriers to getting out of bed, such as postural hypotension and pain, could be identified and addressed prior to physiotherapy assessment. This approach would then offer two opportunities to mobilise by the day after surgery, once by the HCA and once by the therapist, and could potentially allow therapists more time to engage in other rehabilitation activities.

Measurement

The primary outcome measure was the percentage of patients mobilised by the day after surgery. The therapy and nursing teams were familiar with this outcome measure, and baseline data were available to use as these were routinely collected on a monthly basis as part of the National Hip Fracture Database (NHFD) data set. Demographic information was also collected from this existing NHFD data. Hip Sprint audit data were used which were collected in 2019 prior to commencing the project, in addition to a Trust-specific audit completed in 2022. This followed the end of the second intervention period and looked solely at patient mobilisation out of bed by day after surgery. These data also provided more detailed information on which staff group mobilised each patient during this period of time.

We used a newly developed hip fracture sticker (online supplemental file 1) to easily document if a patient was mobilised either before or during the physiotherapy assessment and which also allowed the hip fracture key worker to better identify this information for their records. The NHFD definition was used and advises: ‘the patient is mobilised (standing or hoisted) out of bed by the day following surgery’.

The secondary outcome measure was the percentage of patients mobilised by HCAs prior to physiotherapy assessment. For our baseline data we used the Hip Sprint data from 1 to 31 September and 1 to 31 December 2019 to retrospectively identify if HCAs had mobilised patients prior to physiotherapy assessment. These data were collected prospectively as part of the second Plan-Do-See-Act (PDSA) cycle between 22 August and 10 October 2022.

Design

The project team consisted of orthopaedic physiotherapists, occupational therapists and therapy assistant practitioners, based on the trauma ward, who worked collaboratively throughout the two PDSA cycles (online supplemental file 2) to develop and provide the education programme. The trauma ward sisters, matron and the lead consultant, were key stakeholders in the project. They provided access to staff meetings to engage the ward team, prioritised HCA attendance at training within shift patterns and raised the profile of the project within the Trust.

We engaged with the trauma HCAs at the start of the project to ensure the planned teaching programme was appropriate for their learning needs and to ensure buy-in from our key stakeholders in the project. The concept of the project was to develop a comprehensive training resource deliverable by the orthopaedic therapy team on the ward. This would consist of both theoretical and practical components and would provide guidance to improve consistency of patient care for the metric of early mobilisation by the day after surgery. We hope to develop this project into a sustainable model that can be used on a rolling basis to ensure compliance and improvement in achieving mobilisation out of bed by the day after surgery.

Ethical approval was not required for this quality improvement project; however, ethical behaviours were considered and applied throughout.15

Strategy

PDSA cycle 1

The orthopaedic therapy team developed the teaching programme content and structure based on input from trauma HCAs (online supplemental file 3). Training was delivered as a 2:1 training model with one physiotherapist providing a 1-hour, face-to-face session to two HCAs. Following completion of the theoretical topics, the physiotherapist only signed off HCAs once they had been observed successfully mobilising a day 1 patient with femoral fracture. A risk assessment was completed to mitigate for the potential increased risk of falls due to the predicted increase in numbers of patients mobilised by HCAs prior to physiotherapy assessment (online supplemental file 4).

To ensure staff were aware of the project, a poster was displayed on the ward outlining the aims (online supplemental file 5). We also took part in a Trust media campaign to raise the profile and momentum of the project and further posters were created to launch the second PDSA cycle. Both can be found in online supplemental file 5. Finally, we used our monthly hip fracture governance meeting to explain the project and gain direct support from key clinical stakeholders within this forum.

PDSA cycle 2

The second PDSA cycle was undertaken in 2022 with the aim of identifying how much of the improvement seen in the first cycle was due to HCAs mobilising patients prior to physiotherapy assessment. A prospective audit was completed following the training programme rollout to measure how many patients were mobilised prior to physiotherapy assessment. In order to provide a comparison of how many patients were mobilised by HCAs prior to physiotherapy assessment before and after the two PDSA cycles, data were collected retrospectively from existing James Paget University Hospital 2019 Hip Sprint audit data by the orthopaedic therapy team. Data collection at this stage also included information on mobilisation by day 1 after surgery and by whom.

Results

Between 1 June and 31 July 2020, twenty-three out of 30 HCAs completed the training programme. The percentage of patients mobilised in the 6 months prior to the intervention was a mean average of 60%. The percentage of patients mobilised in the 6 months following the intervention was a mean average of 78%.

Between 27 June and 12 August 2022, nineteen out of 29 HCAs completed the training programme. Eight of the 19 were part of PDSA cycle 1, leaving 11 new HCAs experiencing the programme for the first time.

The improvements seen in the first PDSA cycle diminished and plateaued in 2021 to a mean average of 71.8%. Following completion of the second PDSA cycle, the percentage of patients mobilised increased to a mean average of 79.2%.

Overall results from NHFD baseline data show an 18.5% increase in the number of patients mobilised by the day after surgery between 2019 and 2022 (figure 1).

Figure 1
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Figure 1

Comparison of the number of patients mobilised at the James Paget University Hospital (JPUH) and the whole UK by the day after femoral fracture surgery using the National Hip Fracture Database (%).

We compared the number of patients mobilised by HCAs at baseline and following our interventions to measure how many patients were mobilised by HCAs prior to physiotherapy assessment. Table 1 provides a comparison of the two cohorts in terms of demographics, other related metric assessments and the number of patients mobilised by HCAs prior to physiotherapy assessment.

Table 1
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Comparison between baseline (2019) and postintervention (2022) patient cohorts

Although we saw an increase in the percentage of patients mobilised in the first PDSA cycle we were not able to specifically say if this was due to more patients being mobilised by HCAs prior to physiotherapy assessment. For the second cycle we compared the number of patients mobilised by HCAs prior to physiotherapy assessment. This was collected prospectively in 2022 and compared against retrospective data from baseline in 2019. The number of patients mobilised by HCAs prior to physiotherapy assessment was 1.7% in 2019 and had increased to 30% in 2022. Of those seen by HCAs prior to physiotherapy assessment, seven were not successfully mobilised. The reasons were: postural hypotension (n=3), postoperative delirium (n=2), uncontrolled pain (n=1) and being acutely unwell (n=1). Following physiotherapy assessment later that day, all but one of these patients were then mobilised successfully.

Unanticipated results

As well as results directly linking to our project aims, we noted some unanticipated results. Within 1 month of the first PDSA cycle being completed, the improvement in the number of patients mobilised by the day after surgery was noticeable, increasing from 60% to 70%. This helped keep momentum among the MDT and also garnered attention from key stakeholders who could easily see the benefits of the project. The consequent impact of the second PDSA cycle was further increased support from original and new stakeholders.

There is also encouragement to replicate this project in clinical areas outside of orthopaedics. Within orthopaedics there is now buy-in to incorporate the OOBP work into trauma HCA and nurse induction and we have a rolling ward update programme delivered by the therapy team.

This project has been presented to the Trust board, clinical leaders and governors to ensure that the project is on the Trust agenda. This strategy has successfully ensured that the OOBP has been referenced within several Trust work streams and discussed in wider system forums.

Financial calculations and impact were not part of the remit of this particular project; however, indirect benefits come from improving staff well-being, improving achievements against national metrics, increasing therapy capacity to complete acute rehabilitation and reducing the complications related to delayed mobilisation such as chest infection, deep vein thrombosis and delirium which may increase acute length of stay.1–6 A follow-up project could retrospectively investigate length of stay and the financial impact from a cost savings perspective.

Although we are unable to determine causality, we have seen a reduction in our 30-day mortality rate from 10.1% to 7% in 2019–2022. This aligns with the existing literature on the benefits of early mobilisation.3–6

Lessons and limitations

Four strengths and lessons learnt are highlighted throughout this work and specifically include:

  • The positive impact of the therapy team on national hip fracture metrics.

  • The impact of working collaboratively across the MDT and communicating continuously with stakeholders.

  • Outside of project development and delivery time, no additional resource or workforce is required for the OOBP to be successful.

  • The positive and proven reproducibility of this work with new staff and teams supports future replication of the project locally and more widely across other organisations.

The impact of trauma ward staff turnover among HCAs, which increased throughout the pandemic, negatively impacted the rate of early mobilisation. This was shown through a plateau of the positive impact from PDSA cycle 1. As a result of this, it was important to complete PDSA cycle 2; however, due to COVID-19 implications we were required to reduce the audit period after intervention.

Following completion of the first PDSA cycle we reflected and modified one element of data collection. In the first cycle the reasons for not mobilising were collected retrospectively and we did not directly ask the HCAs. The second cycle changed this to prospectively identify the reasons why patients were not mobilised by HCAs and also prompted HCAs to mobilise prior to physiotherapy assessment. This has improved our understanding of this aspect of the project but does reduce the ability to directly compare this outcome between the two cycles.

One possible bias or confounder to account for the improvements seen in this project could be from the therapy team becoming more proactive with attempts to mobilise patients rather than HCAs being more empowered and increasing the number of patients they mobilise out of bed. However, the percentage mobilised by the HCAs in the second PDSA cycle shows a marked increase in the HCA contribution to this metric and suggests this is not the case. Equally, as part of the audit in the second PDSA cycle, prompts by therapists to the HCAs were given which may have increased the numbers mobilised. Conversely, the sustained improvement outside of the audit period would suggest this was not the case. Increasing therapy team engagement may be one positive side effect of the project and could be seen as part of the wider MDT improvement in this metric.

Despite the limitations acknowledged, the patterns of improvement were positive for all project aims, and unanticipated positive outcomes arose from the widening of those involved in the project. Although reduced in the following year, gains that were made in cycle 1 subsequently remained, which suggests an element of positive culture change.

Generalisability

This service improvement project took place within a femoral fracture ward with a workforce including orthogeriatricians, surgeons, hip fracture ke workers (co-ordinators), nurses, HCAs, occupational therapists, physiotherapists and therapy assistant practitioners.

When replicating this work, other health and care organisations would need to consider potential differences and challenges of organisational support, existing composition of the MDT and the embedded nature of the therapy team within the surgical division.

The orthopaedic therapists at our Trust are part of the hip fracture governance meeting with physiotherapy and occupational therapy representation, which goes beyond the minimum recommendations of the hip fracture standards.8 The therapy team have good working relationships with members of the MDT ensuring the therapy team voice is heard and support is given with projects such as this. An example includes ensuring sufficient HCA cover on the trauma ward during the training phase of the project and highlighting the project at Trust meetings across all levels. The orthopaedic therapy team have worked in a supportive environment to encourage development in audit and service improvement as part of an embedded research programme16 17 which has empowered a team-wide approach to building capacity, capability and confidence in delivering quality improvement, service evaluation and research activities. This relationship and therapy support may not always be present at other Trusts and so it may be harder to implement this type of project without a greater resource and time requirement.

In undertaking this project again and to support other organisations who wish to replicate this project, there are two aspects we would approach differently:

  • Complete a prospective data collection from baseline for the reasons HCAs were not able to mobilise patients on day 1 postoperatively. This would assist us in better targeting training, education and more effective definition of patients who are not suitable for HCA mobilisation.

  • We would consider creating some recorded educational material. This could reduce therapy staff resource requirement to implement the project and ensure consistency of content. This approach would need to be implemented with caution and evaluated to ensure it maintained a positive impact on culture development and collaborative working. The face-to-face aspect of this throughout the project has contributed to increasingly positive working relationships across the MDT, which could be lost through video-based training.

Conclusion

The OOBP, which focused on an educational training programme supporting HCAs, was successful in improving mobilisation by day 1 after femoral fracture surgery from 60% in 2019 to 79% in 2022, which is an important national metric for best practice in this population group. The project has also positively impacted the number of patients mobilised by our HCA colleagues prior to physiotherapy assessment. Although we cannot determine causality, we have also seen an improvement in our 30-day mortality rate which supports the existing literature in relation to early mobilisation and mortality. This project has influenced service change within our organisation and has the potential to be replicated in other orthopaedic trauma wards, across other ward areas and departments outside of orthopaedics, as well as further afield across other health and care establishments nationally.

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