Hip Fracture

Management Conference

Managing rehabilitation and

discharge planning

• Eastern Suburbs•Total population 162,446•55.1% live in flats or apartments compared to national average of 13.65%•Most densely populated area in Australia with up to 8,600 people per sq km•Great disparity of wealth and opportunity in a small geographical area-•23.3% earn over $3000 – national average is 11.2% •But 17.9% earn less than $600 which compares to national average of 23.7%•All stats from ABS website

War Memorial HospitalServices the entire eastern suburbs

It has been a Geriatric specialist centre for over 20yrs

It is the only publicly funded age care specific rehab facility in our area

It combines inpatient, outpatient and community services

“ one stop geriatric shop”

Nursing home s and hostels can be very expensive often only cater for wealthy

Very few concessional beds

Hip fractures at WMH

•580 admissions - July 2011 – June 2012

•74 hip fractures = 12.75% of total admissions

•49 female 25 male

•Average age 83.69 yrs

•All have extensive co-morbidities

•Most are cognitively impaired

•Average LOS is 26.38 days Vs 21.2 days for all others

•Rate of transfer to nursing home is 14.86% , 18.9% transferred to hostel accommodation

5% of all other admissions are transferred to nursing homes

almost 35% do not return home

Referral process

Post –op

•assessed by geriatrician at referring hospitals

• deemed suitable referred to WMH

•Referral should include clear identifications of goals for rehab

•We have an average of 4 days wait from referral to admission

•Anything from 4 days onwards post op

Clinical pathway

Once admitted all pts have full multi disciplinary assessment over 3 days

All have –PhysiotherapyOccupational TherapyMedical and NursingSocial Work

If required-Speech pathDieticianClinical psychologyPodiatry

Multi disciplinary teams at the War Memorial

Each team comprises of

•Patient and family•Geriatrician•Resident medical officer•Pharmacist•Nurses•Physiotherapist•Occupational therapist•Social worker

There are 4 teams average of 9 patients on each team, 2 teams on each floorThe team expands to accommodate other disciplines as required and each presents weekly at Case Conference

Team Communication

Treatment plans are organised into a series of goals

Goals are set by whole teamTeam meets weekly to discuss, establish and plan how to achieve goals

Daily ‘whiteboard ‘ meeting are held on each floor to discuss changes and communicate progress

Clinical handover is given to nursing staff each day to ensure both patients and staff are aware of goals and plans of care

Discharge planning

Discharge dates are set early in admission

Revised up or down as goals met or revised

No such thing as a straightforward discharge in this group

Intensive involvement from all members of MDT

100% are referred on for further therapy post discharge

Pat

• Pat 89yrs,

• Lives with daughter and son-in-law who both work full-time

as teachers

• Was (I) with ADL’s, very mild cog impairment, functioning well

• Fell at daughters in Wollongong -> # R NOF, transferred to

SVH- surgery delayed due to CRF

• Op open reduction and external fixation cannulated screws

06/09

• t/f WMH 13/09

• PMHx: Fe anaemia,

• Cerebro vascular Disease

• Coronary artery disease

• Chronic renal failure

• Mobilised FASF x 1 A

• Continent

• Nausea secondary to opiods – controlled with antiemetics

• Very slow to progress – discussions with family re d/c

destination, decision made to continue rehab

• 17/10 – sudden increase in pain new x-ray revealed

cannulated screws displaced- decision made to proceed to

THR performed 22/10

• Returned to WMH29/10

Week 1

Mon

29/10

Admit

WMH

Tues

30/10

FASF x2

A

X2 25

min gym

sessions

+ 2

walks

Wed

31/10

X 2 P/T

sessions

+ 1 walk

session

Thurs

1/11

X 2 gym

+ 1 walk

still FASF

Fri 2/11

X 2 gym

+ S&D

assess’

Sat 3/11

X 1 P/T

session

on ward

Sun 4/11

Week 2

Mon

5/11

X 1 gym

session

Tues

6/11

X 2 gym

sessions

X1 Group

Lite and

Easy

Wed

7/11

X 2 P/T

Gym

sessions

+

podiatry

for

routine

nail care

Thurs

8/11

OT

session –

bed

t/fers

X 1 gym

session

X1 group

Lite &

Easy

Fri 9/11

c/o feel

ing

“down”

referred

clin

psych-

seen that

day CBT

X 1 gym

Sat

10/11

X1 Pt

session

on ward

Sun

11/12

Week 3

Mon

12/11

Gym x 2

Tues

13/11

Gym x1

Move

and

groove

class

14/11

Wed

OT home

visit

X1 gym

session

in am

15/11

Thurs

X 1 gym

session

Tai Chi

Haircut

16/11 Fri

X 1 gym

session-

feeling

tired

Sat

17/11

X 1 ward

based PT

session

Sun

18/11

Week 4

Mon

19/11

X1 gym

session

commenc

ed RF

walks

120 m no

rests

Group

Lite &

Easy

Tues

20/11

X 2 gym

sessions

Started

Wii

For

standing

balance

Loved it

Wed

21/11

X 1 Wii

session

Group –

dance

Also 90th

birthday

Home

with

family

Thurs

22/11

ACAT

assess for

TACP

Gym and

Wii

Group

Tai Chi

Fri 23/11

X1 gym

X1

outdoor

mobility

Group

Art

therapy

Sat 24/11

FAB

group

Sun

25/11

• Discharged 26/ 11 home with family supported by TACP

• All mobility exclusive of ward mobility to bathroom and dining room

• By D/C minimal (A) S&D, mobilising freely with RF, TACP will progress to

4WW

• h/v 2/52 post admission recommendations for minor b’room mods hhsh

ota, hi chair to be hired, rails in b’rom,

• Progressed well

• Discharged home with TACP who will progress Pat to a 4WW