EMPIRICAL STUDIES
doi: 10.1111/scs.12157
Power to the patient: care tracks and empowerment a recipe for improving rehabilitation for hip fracture patients € fgren PT, PhD (Researcher)1, Margareta Hedstro € m MD, PhD (Associate Professor)2, Susanne Lo € m MD, PhD (Senior Consultant Orthopaedics)3, Lene Lindberg PhD (Associate Professor)4, Wilhelmina Ekstro Lena Flodin MD (PhD Student)2 and Leif Ryd MD, PhD (Professor)1 1
Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Center, Karolinska Institutet, Stockholm, Sweden, 2Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden, 3Division of Orthopedics and Technology, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska Institutet, Stockholm, Sweden and 4Department of Public Health Science, Karolinska Institutet, Stockholm, Sweden
Scand J Caring Sci; 2015; 29; 462–469 Power to the patient: care tracks and empowerment a recipe for improving rehabilitation for hip fracture patients
Background/Aim: New surgical procedures, early operation and medical optimisation in patients with hip fracture have shown positive results on length of hospital stay. Our aims were to investigate whether patient empowerment along with an individually designed, postoperative rehabilitation programme could reduce length of hospital stay and whether the patients would have better chances to return to their previous living. Design/Method: Patients were recruited during a 12-month period 2009–2010, with an intervention group treated with an individually designed, postoperative rehabilitation programme and a control group treated in a traditional way according to the hospitals routines. Final assessment was performed 4 month after surgery. The postoperative programme for the intervention group consisted of four standardised care tracks adapted individually for the patients. Assessments of Activity of Daily Living, American Society of Anesthesiologists classification of medical disease status and Short Portable Mental
Introduction In recent years, there has been an increased focus on the medical status of hip fracture patients, in part because of the effect this patient group has on the healthcare system Correspondence to: Susanne L€ ofgren, PhD, Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Center, Karolinska Institutet, SE-171 77 Stockholm, Sweden. E-mail: [email protected]
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Status Questionnaire and living conditions were used to determine which care track was most appropriate. The patients were cared for with focus of empowerment in their rehabilitation. Results: The study involved 503 hip fracture patients, 285 patients in the intervention group and 218 patients in the control group. The mean length of stay was 4 days shorter in the intervention group than in the control group (p = 0.04). Varied only to a small extent between the age groups in the intervention group and was greater between the age groups in the control. Patients in the intervention group returned to their previous living in 90% compared with 80% in the control group (p < 0.05). There were no significant differences between the age groups. Conclusion: Patient empowerment administrated by specially trained nursing staff and with specialised, tailormade rehabilitation programme may be of benefit in helping patients to a shorter hospital stay and to return to their previous living. Keywords: nursing, hip fracture, care tracks, empowerment, length of hospital stay, return to previous living. Submitted 27 February 2014, Accepted 19 May 2014
with respect to length of hospital stay (LOS). Other aspects are that the hip fracture patient group is a fragile group of old people with significant postfracture disability, morbidity and mortality (1–3). Previous studies have shown an increased need to focus on the resources of patients in planning rehabilitation programmes and follow-up (4) especially for patients with reduced cognitive function or dementia (5). In addition to a long LOS, multiple comorbidities in patients suggest that ‘hospitalisation’ is a significant problem in health care (6). Different approaches to reduce LOS have © 2014 Nordic College of Caring Science
Power to the patient shown dramatic results in many countries (7, 8). These approaches include the development of new surgical procedures (9), early operations (10) and medical optimisation (11). One of the most important short-term outcome measures is the patients’ return to their previous living conditions (12). Several studies which have discussed the potential of patient empowerment (13–16) suggest that clinical research may result in new avenues that strengthen the autonomy of patients (14). To experience powerlessness is a significant health risk factor but to have the opportunities to experience power and control in one’s life contribute to health and wellness (17). Empowerment is a process of helping people to assert control over factors that affect their lives (18) and sufficiently empowered individuals have the capacity to influence the behaviour of those around them (19). In a broad sense, empowerment is a process by which persons gain mastery over their lives (20, 21). Davis et al. (22) have in a randomised study demonstrated the usefulness of empowerment in rehabilitation and treatment for osteoporosis after sustaining a hip fracture. It has also been suggested by Johansson et al. (23) to consider empowerment as a way of shortening the LOS. St-Cyr Tribble et al. (15) concluded that it is a challenge to teach healthcare professionals to be experts in promoting self-care initiatives that support patient autonomy. To our knowledge, the impact of empowerment on LOS and the capability to return to previous living has not been studied before in rehabilitation of hip fracture patients.
The study Aims The aim of this study was to evaluate the effect on LOS of an empowerment approach together with standardised care tracks adapted individually for the patients. Secondary aims were to assess the patients’ ability to return to previous living after the hospital stay and also to evaluate whether mortality was affected.
Design Sample and data collection. Included were hip fracture patients, ≥65 years of age, admitted to a university hospital in Stockholm between February 2009 and January 2010. The following patients were excluded: with pathologic fractures; with comorbidities that prohibited surgical treatment; and those who died before surgery. The hospital had two sites (site 1 and site 2), which were 30 km apart. At site 1, patients were treated according to the new, special individually designed rehabilitation programme with empowerment at a geriatric ward © 2014 Nordic College of Caring Science
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(the intervention group). At site 2 (the control group), patients were first treated at the orthopaedic ward, thereafter transferred to a geriatric ward or a rehabilitation ward at another location, following the standard regime for the hospital. From an orthopaedic perspective, hip fracture patients were treated identically at the two sites as identical surgery algorithms were used. Cervical fractures were surgically treated with two pins (Garden I–II) or hip replacement (total or uni-polar [Garden III–IV]). Trochanteric fractures were operated on with a sliding hip screw (DHS) or a short intramedullary nail (Gamma 3). Subtrochanteric fractures were operated on with a long intramedullary nail (Gamma 3). The new, specially designed rehabilitation programme consisted of four standardised care tracks adapted individually for the patient, and an information package for the patients and their relatives were given. The patients were treated by a nursing staff, this includes Registered Nurses, RN and licensed practitioner nurses, LPN, all trained in empowering the patients. The eight guidelines of the World Health Organization (WHO) for good interaction (24, 25) were taught in the empowerment training. The WHO guidelines are designed to support the autonomy of the patient and to counteract the negative feelings, such as fatigue and weakness. The empowerment programme also trained the nursing staff to be more observant to the capabilities and needs of the patients to be able to act with a coaching behaviour. The nursing staff in the geriatric ward received empowerment training, coaching, and supervision to feel capable and confident in using the new approach. On admission an occupational therapist (OT) screened the patient to evaluate the pre-hip fracture status. The screening was based on an activity for daily living (ADL) taxonomy (26) for OT in clinical situations. The in-charge geriatrician evaluated the medical status of the patient based on the American Society of Anesthesiologists (ASA) classification (27). The geriatrician and the OT also made a clinical assessment of the patient’s cognitive function according to the Short Portable Mental Status Questionnaire (SPMSQ) (28, 29). Based on ADL, cognitive function, ASA grade and living condition, the patient/relatives, the geriatrician and the OT together decided which care track was most appropriate. At that point, the rehabilitation plan was presented to the patient as a contract (Table 1). An information package was distributed to the patients and their relatives in the emergency ward, and it described the type of fracture, the intended surgery and the four postoperative care tracks in detail. If the patient had cognitive problems, the information was presented in a suitable way, and more detailed information was given to the patient’s relatives.
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Table 1 Assessment base at site 1 for care tracks of rehabilitation and planned discharge Care track
ASA (medical status)
Cognition SPMSQ (10-item test)
In from
Out to
Planned discharge after surgery
1 2 3 4
1–2 3–4 1–4 1–4
≥7 ≥7 Any function Any function
Own home Own home Institutional living Own home
Own home Own home Institutional livinga Institutional livinga
5 days 9 days 4 days Indeterminate
a
With continuing rehabilitation.
The primary outcome, which was LOS, was defined as ‘the time in the emergency hospital and rehabilitation in direct connection to the hip fracture.’ Patients in the intervention group received postoperative care and rehabilitation at the geriatric ward in the emergency hospital and were thereafter discharged directly to their final living. In the control group, patients received postoperative care at the emergency hospital and a rehabilitation period was routinely included at a geriatric or rehabilitation unit outside of the emergency hospital and the total length was registered. Mortality during hospital stay and after 3 months was recorded, as well as returns to previous living. Ethical considerations. The study was a part of a larger study that has been granted approval by the regional ethical committee, Stockholm Ethical Review Board (decision 2008/1676-31/4). All patients/relatives at the two sites received information, both written and oral, about the purpose of the study at the enrolment. No written approval was presented to the patient in the acute traumatic condition. Later, the patient agreement was documented in the journal. This study was conducted in agreement with the Helsinki Declaration. Data analysis/Statistical methods. The statistical analysis was performed using SPSS 21.0 for Windows software (SPSS, Inc., Chicago, IL, USA) with Peat and Barton as a guide (30). Nominal variables were tested by a chisquared test and ordinal variables by a chi-squared for trend. An independent t-test was employed to compare LOS at the two sites. Levine’s test was used to test the assumption that each group had the same variance, and the Mann–Whitney U-test was performed when violated. All tests were two-sided. A logistic regression analysis was made to examine the relationship between death as an outcome variable and age, gender and site as the explanatory variables.
Results There were 503 patients included in this observational study. There were 285 patients in the intervention group and 218 patients in the control group. Baseline data are
shown in Table 2. No significant differences were found between the two sites regarding gender, age and fracture types. During the study, there was no loss of patients. Number of patients at the two sites and distribution between the four care tracks at site 1 are showed in Fig. 1. The distribution of patients at site 1 by age group and in the four care tracks is shown in Fig. 2. The LOS was significantly shorter in the intervention group, by approximately 4 days (p = 0.04, Table 3). Differences in the LOS among the four care tracks were observed in the intervention group, especially for patients in care tracks 2 and 3, in which a mean of 7 days was found. The LOS varied only to a small extent between the age groups. In the control group, the difference in the LOS was greater between the age groups. The largest difference (8.6 days) was seen between the 75–84 year and ≥95 year age groups. Ninety percentage of the patients in the intervention group and 80% of the patients in the control group returned to their pre-hip fracture living; the difference between the groups was significant (v2 = 3.9, p < 0.05) (Fig. 3). No significant differences were found between the two sites regarding gender, age and fracture types. The mortality rates during the hospital stay and within 3 months differed between the two sites as follows: intervention group, 43 (15.1%); and control group, 49 (22.4%). A logistic regression analysis showed a significant age effect on mortality during the in-hospital time and a significant age and gender effect on mortality within 120 days after the fracture. The difference between the sites was then no longer significant (Tables 4 and 5).
Discussion The mean length of stay was 4 days shorter in the intervention group than in the control group. Patients with an individually designed, empowerment rehabilitation programme returned to their previous living in 90% compared with 80% in the control group. The two groups in the study were consecutively recruited to the two different sites of the hospital. The patients were drawn from different areas of the county © 2014 Nordic College of Caring Science
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Table 2 Descriptive and bivariate analysis of gender, age and fracture types at the two sites (n 503) Site 1 (n = 285)
Variables Gender Female Male Age, years Age, mean (SD)
196 89
Site 2 (n = 218)
68.8% 31.1%
148 70
v2a
df
P-value
67.6% 32.1%
0.1
1
0.76
0.58a
83.4 (8.6) 17.9%
38
83.2 (8.4) 17.4%
100
35.3%
61
28%
105
36.8%
104
47.7%
29
10.1%
15
6.9%
34 106 6 49 62 28
11.9% 37.1% 2.1% 17.1% 21.7% 9.8%
30 81 1 51 41 14
13.7% 37.1% 0.5% 23.3% 18.7% 6.4%
51
0.45
Age group 65–74 years Age group 75–84 years Age group 85–94 years Age group 95-years Fracture type Cervical undislocated (Garden I–II) Cervical dislocated (Garden III–IV) Basocervical Trochanteric two fragment Trochanteric multifragment Subtrochanteric
7.69
5
0.17
a
Chi-squared for trend.
Site 1 Intervention group N 285 Geriatric ward
Track 1 n 56
Track 2 n 123
Track 3 n 77
Site 2 Control group N = 218 Ortopaedic ward
Track 4 n 21
Unallocated n8
Ortopaedic ward n = 218
Figure 1 Included patients and the distribution between the different care tracks at site 1.
without any appreciable difference in average socio-economic status. There was no ‘care-track analysis’ at site 2, as this procedure was an explicit part of the intervention at site 1. However, there were no reasons to assign any overall difference regarding cognition or any other significant factor between the two groups. Our interpretation is that ‘rehabilitation’ was better at site 1 due to the customisation brought about by the care-track assignment in combination with the empowerment programme. In the current study, the content of the change was a new rehabilitation programme. This was the intervention, and it consisted of a package of three distinct entities: an individually designed postoperative rehabilitation care tracks, an information package and finally, support of nursing staff trained in care behaviour to enable empowerment. The eight guidelines from the WHO programme (24), which were trained by the nursing staff and tested on a group of patients > 65 years of age, were found to be © 2014 Nordic College of Caring Science
well suited for interactions between the nursing staff and their patients. Given the design, which was controlled to the highest degree that was practically achievable, we hold the intervention to be the main cause of the results. The process was the application of the new programme for rehabilitation postoperatively together with the coaching of the patients. In the coaching, the nursing staff showed interest and empathy which generally make patients feel secure (31) as nurses always are in a position to influence patients and their care (32). The rehabilitation programme in the present study was intended to empower patients by giving them greater responsibility. Patients were encouraged to take command of their own mobilisation according to their ability as a response to the ‘task’ they had agreed on. It has been shown that patient empowerment can support patient’s ability to make decision of one’s care (33); however, it has not been shown in elderly patients after a fracture before. The effect of the programme was most evident for the patients in care tracks 1 and 2 who had a good cognitive function and well-organised living. We realised that less good cognitive status bears heavily on frailty, but it does not hamper the outcomes of genuine rehabilitative efforts in geriatrics (34). In accordance with this, Moncada et al. (35) showed that cognitively impaired patients achieved short-term outcomes comparable to those of their unimpaired counterparts. The outcomes showed a reduction in the LOS by 4 days for the intervention group as compared to the
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Figure 2 Patients in the intervention group by age group, care track and those not allocated to any track.
Table 3 Length of hospital stay for the intervention and the control groups
Meana Site 1 Intervention group (n = 285) Site 2 Control group (n = 218)
SD
Median
25th percentile
75th percentile
13.0
6.4
12
8.7
16.0
16.9
12.3
14
7.0
22.0
a
Levine’s test of the whole care episode at site 1 and site 2 was significant and the p-value for unequal variance was 0.04.
Figure 3 Distribution of patients returning to prefracture living and to changed living.
control group; however, the number of in-hospital days did not decline to the intended and ‘contracted’ length of hospital stay. Our assumption was that patients in care track 1 would resemble patients with osteoarthritis (OA) admitted for elective hip replacement surgery with respect to the LOS (5). For patients undergoing hip surgery for OA, the mean LOS is 5 days in Sweden (36); however, the hip fracture patients in care track 1 were discharged 10.5 days after surgery. One explanation may be that previously healthy individuals who sustain a hip fracture are mentally unprepared for such an event and therefore could have difficulties to cope with the traumatic situation. Hip OA patients who have elective surgery receive preoperative planning and physiotherapy training; obviously, such planning and training are not provided to hip fracture patients who do not anticipate their injury. In summary, hip fracture patients cannot easily be compared with OA patients who have elective surgery, even though their surgical procedures are quite similar. Compared with the average LOS (17.6 days) for hip fracture patients at the seven emergency hospitals in Stockholm in 2005 (8), a change has been demonstrated. In the intervention group, it appears that the empowerment programme together with the standardised care tacks helped to decrease the LOS by 4 days compared with the control group and historical data. A variety of studies have shown the importance of well educated and experienced nurses in geriatric care (37, 38), factors that could have influenced our results. However, we could not find any differences with regard to education or experience of the nurses between the sites. The nurses at site 1 and 2 were equal in number, and they had similar education and experience level. Many have found that when a geriatrician instead of an orthopaedic surgeon oversees the care of an elderly patient, there is a greater possibility that other medical conditions may be identified (39, 40). This may be explained by the different roles of the geriatrician and the orthopaedic surgeon in medical treatment for elderly patients. For example, geriatricians may be more interested in the general health of elderly patients. The benefits resulting from this interest with respect to the LOS
Table 4 Logistic regression analysis of mortality in hip fracture patients during hospital stay Variable Gender Site Age Intercept
Regression coefficient 0.480 0.365 0.056 6.504
Standard error
Wald v2
df
P-value
Odds ratio
95% CI
0.274 0.260 0.017 1.479
3.064 1.964 10.919 19.338
1 1 1 1
0.080 0.161 0.001 0.000
1.616 0.694 1.057 0.001
0.944–2.764 0.417–1.156 1.027–1.093
Gender: 1 male, 2 female. Hospital: 1 = site 1, 2 = site 2.
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Table 5 Results of logistic regression analysis of mortality in hip fracture patients within 120 days after fracture Variable Gender Site Age Intercept
Regression coefficient 1.211 0.661 0.106 12.551
Standard error
Wald v2
df
P-value
Odds ratio
95% CI
0.490 0.0483 0.036 3.208
6.096 0.870 8.907 15.304
1 1 1 1
0.014 0.171 0.003 0.000
3.357 0.516 1.112 0.000
1.284–8.777 0.200–1.332 1.037–1.192
may, however, be offset by the decisions of orthopaedic surgeons at the site 2 who are thought to be more ‘discharge oriented.’ How these opposing roles affect individual patients is unclear. We conclude that a coordinated treatment in a geriatric ward was beneficial and may explain some of the differences in the LOS between sites 1 and 2. Another reason for having a coordinated care at a geriatric ward may be that early discharge to a rehabilitation institution (i.e. the transfer itself) can be associated with an increase in the hospital stay (41), as well as to the adjustment to new conditions that may delay the rehabilitation (42). It may be argued that the decrease of LOS is a variable sensitive to subjective assessment. This does not mean that our results are irrelevant rather that patient and professionals have worked towards the same goal. The programme in our study was intended to restore patients, as close as possible, to the same level of daily activities after rehabilitation as before the fracture. One measure of this success was the ability to return to previous living. Returning ‘back home’ is a robust variable and also a beneficial one, both for the individual and for society. It is well known that patients with an independent living have a better quality of life compared with those living in an institution after a hip fracture (43). The forms of living differ in all age groups and we chose the criterion ‘return to previous living’ as the outcome measure. It is important to point out that we wanted to see whether the intervention after the hip fracture could prevent a change of living and help the patients to return to the same living as they had before the fracture or not. The empowered patients in the rehabilitation programme could return to their previous living to a significant higher extent than the control group despite the fact that they also had a shorter LOS. We perceive this finding as the programme was effective. Our results showed that the programme gave good results, but our opinion is that it required a positive commitment from patients, medical, nursing and rehabilitation staff. Additional studies to develop the programme and to refine the care tracks can be of interest in future research but also to investigate to which extent the patients feel that the programme affects the health-related quality of life. © 2014 Nordic College of Caring Science
Limitations One limitation of this research was that we did not include rehabilitation in long-term or residential care. In Sweden, those forms of care are the responsibility of local authorities and are not registered in a comprehensive way. An alternative and a better design of the study would have been a randomised controlled trial (RCT). However, the context did not allow for a RCT, and it was not possible to make a random study of the treatment both with and without the empowerment training administered by the professionals at the same site. Therefore, our only option was to use site 2 as the control group. Contextual aspects were regarded as the differences between the two sites. Empowerment programmes, such as this, cannot be fully isolated or held constant. Little evidence has been found in RCT comparative and observational studies in which treatment results differ (44, 45). Because of the variation in context, any programme is likely to have mixed outcome patterns (46, 47). A generalisation of our findings to other settings requires consideration. We suggest that further studies are needed to increase our understanding of successful strategies for improving autonomy in the rehabilitation stages of hip fracture patients.
Conclusions Patient empowerment administrated by specially trained nursing staff and with standardised rehabilitation programme may be of benefit in helping patients to a shorter hospital stay and return to their previous living.
Acknowledgements We gratefully acknowledge the dedicated work in the study provided by the research nurses, Asa Norling and Luigi Belcastro, by their assistant, Angela la Terra, and by the occupational therapist, Iwona Olsson. We thank Mesfin Kassaye Tessma for his advice and assistance with statistical calculations.
Conflicts of interest No conflict of interest has been declared by the authors.
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Author contributions
31/4). This study was conducted in agreement with the Helsinki Declaration.
Susanne L€ ofgren analysed the data and have conceived and designed the study together with Leif Ryd. All authors performed the study, wrote the paper, revised, read and approved the final manuscript.
Funding
Ethical approval The study was a part in a larger study that has been granted approval by the regional ethical committee, Stockholm Ethical Review Board (decision 2008/1676-
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of randomised controlled trials. BMJ 2010; 340: c1718. Chong CP, Savige J, Lim WK. Orthopaedic-geriatric models of care and their effectiveness. Australas J Ageing 2009; 28: 171–6. Logters T, Hakimi M, Linhart W, Kaiser T, Briem D, Rueger J, Windolf J. Early interdisciplinary geriatric rehabilitation after hip fracture: effective concept or just transfer of costs? Unfallchirurg 2008; 111: 719–26. Tha HS, Armstrong D, Broad J, Paul S, Wood P. Hip fracture in Auckland: contrasting models of care in two major hospitals. Intern Med J 2009; 39: 89–94. Tidermark J, Zethraeus N, Svensson O, Tornkvist H, Ponzer S. Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol. Qual Life Res 2002; 11: 473–81. Benson K, Hartz AJ. A comparison of observational studies and randomized, controlled trials. N Engl J Med 2000; 342: 1878–86. Concato J, Shah N, Horwitz RI. Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 2000; 342: 1887–92. Pawson R, Tilley N. Realistic Evaluation. 1997, Sage, London, Thousand Oaks, CA. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review–a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005; 10(Suppl 1): 21–34.
doi: 10.1111/scs.12157
Power to the patient: care tracks and empowerment a recipe for improving rehabilitation for hip fracture patients € fgren PT, PhD (Researcher)1, Margareta Hedstro € m MD, PhD (Associate Professor)2, Susanne Lo € m MD, PhD (Senior Consultant Orthopaedics)3, Lene Lindberg PhD (Associate Professor)4, Wilhelmina Ekstro Lena Flodin MD (PhD Student)2 and Leif Ryd MD, PhD (Professor)1 1
Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Center, Karolinska Institutet, Stockholm, Sweden, 2Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden, 3Division of Orthopedics and Technology, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska Institutet, Stockholm, Sweden and 4Department of Public Health Science, Karolinska Institutet, Stockholm, Sweden
Scand J Caring Sci; 2015; 29; 462–469 Power to the patient: care tracks and empowerment a recipe for improving rehabilitation for hip fracture patients
Background/Aim: New surgical procedures, early operation and medical optimisation in patients with hip fracture have shown positive results on length of hospital stay. Our aims were to investigate whether patient empowerment along with an individually designed, postoperative rehabilitation programme could reduce length of hospital stay and whether the patients would have better chances to return to their previous living. Design/Method: Patients were recruited during a 12-month period 2009–2010, with an intervention group treated with an individually designed, postoperative rehabilitation programme and a control group treated in a traditional way according to the hospitals routines. Final assessment was performed 4 month after surgery. The postoperative programme for the intervention group consisted of four standardised care tracks adapted individually for the patients. Assessments of Activity of Daily Living, American Society of Anesthesiologists classification of medical disease status and Short Portable Mental
Introduction In recent years, there has been an increased focus on the medical status of hip fracture patients, in part because of the effect this patient group has on the healthcare system Correspondence to: Susanne L€ ofgren, PhD, Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Center, Karolinska Institutet, SE-171 77 Stockholm, Sweden. E-mail: [email protected]
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Status Questionnaire and living conditions were used to determine which care track was most appropriate. The patients were cared for with focus of empowerment in their rehabilitation. Results: The study involved 503 hip fracture patients, 285 patients in the intervention group and 218 patients in the control group. The mean length of stay was 4 days shorter in the intervention group than in the control group (p = 0.04). Varied only to a small extent between the age groups in the intervention group and was greater between the age groups in the control. Patients in the intervention group returned to their previous living in 90% compared with 80% in the control group (p < 0.05). There were no significant differences between the age groups. Conclusion: Patient empowerment administrated by specially trained nursing staff and with specialised, tailormade rehabilitation programme may be of benefit in helping patients to a shorter hospital stay and to return to their previous living. Keywords: nursing, hip fracture, care tracks, empowerment, length of hospital stay, return to previous living. Submitted 27 February 2014, Accepted 19 May 2014
with respect to length of hospital stay (LOS). Other aspects are that the hip fracture patient group is a fragile group of old people with significant postfracture disability, morbidity and mortality (1–3). Previous studies have shown an increased need to focus on the resources of patients in planning rehabilitation programmes and follow-up (4) especially for patients with reduced cognitive function or dementia (5). In addition to a long LOS, multiple comorbidities in patients suggest that ‘hospitalisation’ is a significant problem in health care (6). Different approaches to reduce LOS have © 2014 Nordic College of Caring Science
Power to the patient shown dramatic results in many countries (7, 8). These approaches include the development of new surgical procedures (9), early operations (10) and medical optimisation (11). One of the most important short-term outcome measures is the patients’ return to their previous living conditions (12). Several studies which have discussed the potential of patient empowerment (13–16) suggest that clinical research may result in new avenues that strengthen the autonomy of patients (14). To experience powerlessness is a significant health risk factor but to have the opportunities to experience power and control in one’s life contribute to health and wellness (17). Empowerment is a process of helping people to assert control over factors that affect their lives (18) and sufficiently empowered individuals have the capacity to influence the behaviour of those around them (19). In a broad sense, empowerment is a process by which persons gain mastery over their lives (20, 21). Davis et al. (22) have in a randomised study demonstrated the usefulness of empowerment in rehabilitation and treatment for osteoporosis after sustaining a hip fracture. It has also been suggested by Johansson et al. (23) to consider empowerment as a way of shortening the LOS. St-Cyr Tribble et al. (15) concluded that it is a challenge to teach healthcare professionals to be experts in promoting self-care initiatives that support patient autonomy. To our knowledge, the impact of empowerment on LOS and the capability to return to previous living has not been studied before in rehabilitation of hip fracture patients.
The study Aims The aim of this study was to evaluate the effect on LOS of an empowerment approach together with standardised care tracks adapted individually for the patients. Secondary aims were to assess the patients’ ability to return to previous living after the hospital stay and also to evaluate whether mortality was affected.
Design Sample and data collection. Included were hip fracture patients, ≥65 years of age, admitted to a university hospital in Stockholm between February 2009 and January 2010. The following patients were excluded: with pathologic fractures; with comorbidities that prohibited surgical treatment; and those who died before surgery. The hospital had two sites (site 1 and site 2), which were 30 km apart. At site 1, patients were treated according to the new, special individually designed rehabilitation programme with empowerment at a geriatric ward © 2014 Nordic College of Caring Science
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(the intervention group). At site 2 (the control group), patients were first treated at the orthopaedic ward, thereafter transferred to a geriatric ward or a rehabilitation ward at another location, following the standard regime for the hospital. From an orthopaedic perspective, hip fracture patients were treated identically at the two sites as identical surgery algorithms were used. Cervical fractures were surgically treated with two pins (Garden I–II) or hip replacement (total or uni-polar [Garden III–IV]). Trochanteric fractures were operated on with a sliding hip screw (DHS) or a short intramedullary nail (Gamma 3). Subtrochanteric fractures were operated on with a long intramedullary nail (Gamma 3). The new, specially designed rehabilitation programme consisted of four standardised care tracks adapted individually for the patient, and an information package for the patients and their relatives were given. The patients were treated by a nursing staff, this includes Registered Nurses, RN and licensed practitioner nurses, LPN, all trained in empowering the patients. The eight guidelines of the World Health Organization (WHO) for good interaction (24, 25) were taught in the empowerment training. The WHO guidelines are designed to support the autonomy of the patient and to counteract the negative feelings, such as fatigue and weakness. The empowerment programme also trained the nursing staff to be more observant to the capabilities and needs of the patients to be able to act with a coaching behaviour. The nursing staff in the geriatric ward received empowerment training, coaching, and supervision to feel capable and confident in using the new approach. On admission an occupational therapist (OT) screened the patient to evaluate the pre-hip fracture status. The screening was based on an activity for daily living (ADL) taxonomy (26) for OT in clinical situations. The in-charge geriatrician evaluated the medical status of the patient based on the American Society of Anesthesiologists (ASA) classification (27). The geriatrician and the OT also made a clinical assessment of the patient’s cognitive function according to the Short Portable Mental Status Questionnaire (SPMSQ) (28, 29). Based on ADL, cognitive function, ASA grade and living condition, the patient/relatives, the geriatrician and the OT together decided which care track was most appropriate. At that point, the rehabilitation plan was presented to the patient as a contract (Table 1). An information package was distributed to the patients and their relatives in the emergency ward, and it described the type of fracture, the intended surgery and the four postoperative care tracks in detail. If the patient had cognitive problems, the information was presented in a suitable way, and more detailed information was given to the patient’s relatives.
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Table 1 Assessment base at site 1 for care tracks of rehabilitation and planned discharge Care track
ASA (medical status)
Cognition SPMSQ (10-item test)
In from
Out to
Planned discharge after surgery
1 2 3 4
1–2 3–4 1–4 1–4
≥7 ≥7 Any function Any function
Own home Own home Institutional living Own home
Own home Own home Institutional livinga Institutional livinga
5 days 9 days 4 days Indeterminate
a
With continuing rehabilitation.
The primary outcome, which was LOS, was defined as ‘the time in the emergency hospital and rehabilitation in direct connection to the hip fracture.’ Patients in the intervention group received postoperative care and rehabilitation at the geriatric ward in the emergency hospital and were thereafter discharged directly to their final living. In the control group, patients received postoperative care at the emergency hospital and a rehabilitation period was routinely included at a geriatric or rehabilitation unit outside of the emergency hospital and the total length was registered. Mortality during hospital stay and after 3 months was recorded, as well as returns to previous living. Ethical considerations. The study was a part of a larger study that has been granted approval by the regional ethical committee, Stockholm Ethical Review Board (decision 2008/1676-31/4). All patients/relatives at the two sites received information, both written and oral, about the purpose of the study at the enrolment. No written approval was presented to the patient in the acute traumatic condition. Later, the patient agreement was documented in the journal. This study was conducted in agreement with the Helsinki Declaration. Data analysis/Statistical methods. The statistical analysis was performed using SPSS 21.0 for Windows software (SPSS, Inc., Chicago, IL, USA) with Peat and Barton as a guide (30). Nominal variables were tested by a chisquared test and ordinal variables by a chi-squared for trend. An independent t-test was employed to compare LOS at the two sites. Levine’s test was used to test the assumption that each group had the same variance, and the Mann–Whitney U-test was performed when violated. All tests were two-sided. A logistic regression analysis was made to examine the relationship between death as an outcome variable and age, gender and site as the explanatory variables.
Results There were 503 patients included in this observational study. There were 285 patients in the intervention group and 218 patients in the control group. Baseline data are
shown in Table 2. No significant differences were found between the two sites regarding gender, age and fracture types. During the study, there was no loss of patients. Number of patients at the two sites and distribution between the four care tracks at site 1 are showed in Fig. 1. The distribution of patients at site 1 by age group and in the four care tracks is shown in Fig. 2. The LOS was significantly shorter in the intervention group, by approximately 4 days (p = 0.04, Table 3). Differences in the LOS among the four care tracks were observed in the intervention group, especially for patients in care tracks 2 and 3, in which a mean of 7 days was found. The LOS varied only to a small extent between the age groups. In the control group, the difference in the LOS was greater between the age groups. The largest difference (8.6 days) was seen between the 75–84 year and ≥95 year age groups. Ninety percentage of the patients in the intervention group and 80% of the patients in the control group returned to their pre-hip fracture living; the difference between the groups was significant (v2 = 3.9, p < 0.05) (Fig. 3). No significant differences were found between the two sites regarding gender, age and fracture types. The mortality rates during the hospital stay and within 3 months differed between the two sites as follows: intervention group, 43 (15.1%); and control group, 49 (22.4%). A logistic regression analysis showed a significant age effect on mortality during the in-hospital time and a significant age and gender effect on mortality within 120 days after the fracture. The difference between the sites was then no longer significant (Tables 4 and 5).
Discussion The mean length of stay was 4 days shorter in the intervention group than in the control group. Patients with an individually designed, empowerment rehabilitation programme returned to their previous living in 90% compared with 80% in the control group. The two groups in the study were consecutively recruited to the two different sites of the hospital. The patients were drawn from different areas of the county © 2014 Nordic College of Caring Science
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Table 2 Descriptive and bivariate analysis of gender, age and fracture types at the two sites (n 503) Site 1 (n = 285)
Variables Gender Female Male Age, years Age, mean (SD)
196 89
Site 2 (n = 218)
68.8% 31.1%
148 70
v2a
df
P-value
67.6% 32.1%
0.1
1
0.76
0.58a
83.4 (8.6) 17.9%
38
83.2 (8.4) 17.4%
100
35.3%
61
28%
105
36.8%
104
47.7%
29
10.1%
15
6.9%
34 106 6 49 62 28
11.9% 37.1% 2.1% 17.1% 21.7% 9.8%
30 81 1 51 41 14
13.7% 37.1% 0.5% 23.3% 18.7% 6.4%
51
0.45
Age group 65–74 years Age group 75–84 years Age group 85–94 years Age group 95-years Fracture type Cervical undislocated (Garden I–II) Cervical dislocated (Garden III–IV) Basocervical Trochanteric two fragment Trochanteric multifragment Subtrochanteric
7.69
5
0.17
a
Chi-squared for trend.
Site 1 Intervention group N 285 Geriatric ward
Track 1 n 56
Track 2 n 123
Track 3 n 77
Site 2 Control group N = 218 Ortopaedic ward
Track 4 n 21
Unallocated n8
Ortopaedic ward n = 218
Figure 1 Included patients and the distribution between the different care tracks at site 1.
without any appreciable difference in average socio-economic status. There was no ‘care-track analysis’ at site 2, as this procedure was an explicit part of the intervention at site 1. However, there were no reasons to assign any overall difference regarding cognition or any other significant factor between the two groups. Our interpretation is that ‘rehabilitation’ was better at site 1 due to the customisation brought about by the care-track assignment in combination with the empowerment programme. In the current study, the content of the change was a new rehabilitation programme. This was the intervention, and it consisted of a package of three distinct entities: an individually designed postoperative rehabilitation care tracks, an information package and finally, support of nursing staff trained in care behaviour to enable empowerment. The eight guidelines from the WHO programme (24), which were trained by the nursing staff and tested on a group of patients > 65 years of age, were found to be © 2014 Nordic College of Caring Science
well suited for interactions between the nursing staff and their patients. Given the design, which was controlled to the highest degree that was practically achievable, we hold the intervention to be the main cause of the results. The process was the application of the new programme for rehabilitation postoperatively together with the coaching of the patients. In the coaching, the nursing staff showed interest and empathy which generally make patients feel secure (31) as nurses always are in a position to influence patients and their care (32). The rehabilitation programme in the present study was intended to empower patients by giving them greater responsibility. Patients were encouraged to take command of their own mobilisation according to their ability as a response to the ‘task’ they had agreed on. It has been shown that patient empowerment can support patient’s ability to make decision of one’s care (33); however, it has not been shown in elderly patients after a fracture before. The effect of the programme was most evident for the patients in care tracks 1 and 2 who had a good cognitive function and well-organised living. We realised that less good cognitive status bears heavily on frailty, but it does not hamper the outcomes of genuine rehabilitative efforts in geriatrics (34). In accordance with this, Moncada et al. (35) showed that cognitively impaired patients achieved short-term outcomes comparable to those of their unimpaired counterparts. The outcomes showed a reduction in the LOS by 4 days for the intervention group as compared to the
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Figure 2 Patients in the intervention group by age group, care track and those not allocated to any track.
Table 3 Length of hospital stay for the intervention and the control groups
Meana Site 1 Intervention group (n = 285) Site 2 Control group (n = 218)
SD
Median
25th percentile
75th percentile
13.0
6.4
12
8.7
16.0
16.9
12.3
14
7.0
22.0
a
Levine’s test of the whole care episode at site 1 and site 2 was significant and the p-value for unequal variance was 0.04.
Figure 3 Distribution of patients returning to prefracture living and to changed living.
control group; however, the number of in-hospital days did not decline to the intended and ‘contracted’ length of hospital stay. Our assumption was that patients in care track 1 would resemble patients with osteoarthritis (OA) admitted for elective hip replacement surgery with respect to the LOS (5). For patients undergoing hip surgery for OA, the mean LOS is 5 days in Sweden (36); however, the hip fracture patients in care track 1 were discharged 10.5 days after surgery. One explanation may be that previously healthy individuals who sustain a hip fracture are mentally unprepared for such an event and therefore could have difficulties to cope with the traumatic situation. Hip OA patients who have elective surgery receive preoperative planning and physiotherapy training; obviously, such planning and training are not provided to hip fracture patients who do not anticipate their injury. In summary, hip fracture patients cannot easily be compared with OA patients who have elective surgery, even though their surgical procedures are quite similar. Compared with the average LOS (17.6 days) for hip fracture patients at the seven emergency hospitals in Stockholm in 2005 (8), a change has been demonstrated. In the intervention group, it appears that the empowerment programme together with the standardised care tacks helped to decrease the LOS by 4 days compared with the control group and historical data. A variety of studies have shown the importance of well educated and experienced nurses in geriatric care (37, 38), factors that could have influenced our results. However, we could not find any differences with regard to education or experience of the nurses between the sites. The nurses at site 1 and 2 were equal in number, and they had similar education and experience level. Many have found that when a geriatrician instead of an orthopaedic surgeon oversees the care of an elderly patient, there is a greater possibility that other medical conditions may be identified (39, 40). This may be explained by the different roles of the geriatrician and the orthopaedic surgeon in medical treatment for elderly patients. For example, geriatricians may be more interested in the general health of elderly patients. The benefits resulting from this interest with respect to the LOS
Table 4 Logistic regression analysis of mortality in hip fracture patients during hospital stay Variable Gender Site Age Intercept
Regression coefficient 0.480 0.365 0.056 6.504
Standard error
Wald v2
df
P-value
Odds ratio
95% CI
0.274 0.260 0.017 1.479
3.064 1.964 10.919 19.338
1 1 1 1
0.080 0.161 0.001 0.000
1.616 0.694 1.057 0.001
0.944–2.764 0.417–1.156 1.027–1.093
Gender: 1 male, 2 female. Hospital: 1 = site 1, 2 = site 2.
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Table 5 Results of logistic regression analysis of mortality in hip fracture patients within 120 days after fracture Variable Gender Site Age Intercept
Regression coefficient 1.211 0.661 0.106 12.551
Standard error
Wald v2
df
P-value
Odds ratio
95% CI
0.490 0.0483 0.036 3.208
6.096 0.870 8.907 15.304
1 1 1 1
0.014 0.171 0.003 0.000
3.357 0.516 1.112 0.000
1.284–8.777 0.200–1.332 1.037–1.192
may, however, be offset by the decisions of orthopaedic surgeons at the site 2 who are thought to be more ‘discharge oriented.’ How these opposing roles affect individual patients is unclear. We conclude that a coordinated treatment in a geriatric ward was beneficial and may explain some of the differences in the LOS between sites 1 and 2. Another reason for having a coordinated care at a geriatric ward may be that early discharge to a rehabilitation institution (i.e. the transfer itself) can be associated with an increase in the hospital stay (41), as well as to the adjustment to new conditions that may delay the rehabilitation (42). It may be argued that the decrease of LOS is a variable sensitive to subjective assessment. This does not mean that our results are irrelevant rather that patient and professionals have worked towards the same goal. The programme in our study was intended to restore patients, as close as possible, to the same level of daily activities after rehabilitation as before the fracture. One measure of this success was the ability to return to previous living. Returning ‘back home’ is a robust variable and also a beneficial one, both for the individual and for society. It is well known that patients with an independent living have a better quality of life compared with those living in an institution after a hip fracture (43). The forms of living differ in all age groups and we chose the criterion ‘return to previous living’ as the outcome measure. It is important to point out that we wanted to see whether the intervention after the hip fracture could prevent a change of living and help the patients to return to the same living as they had before the fracture or not. The empowered patients in the rehabilitation programme could return to their previous living to a significant higher extent than the control group despite the fact that they also had a shorter LOS. We perceive this finding as the programme was effective. Our results showed that the programme gave good results, but our opinion is that it required a positive commitment from patients, medical, nursing and rehabilitation staff. Additional studies to develop the programme and to refine the care tracks can be of interest in future research but also to investigate to which extent the patients feel that the programme affects the health-related quality of life. © 2014 Nordic College of Caring Science
Limitations One limitation of this research was that we did not include rehabilitation in long-term or residential care. In Sweden, those forms of care are the responsibility of local authorities and are not registered in a comprehensive way. An alternative and a better design of the study would have been a randomised controlled trial (RCT). However, the context did not allow for a RCT, and it was not possible to make a random study of the treatment both with and without the empowerment training administered by the professionals at the same site. Therefore, our only option was to use site 2 as the control group. Contextual aspects were regarded as the differences between the two sites. Empowerment programmes, such as this, cannot be fully isolated or held constant. Little evidence has been found in RCT comparative and observational studies in which treatment results differ (44, 45). Because of the variation in context, any programme is likely to have mixed outcome patterns (46, 47). A generalisation of our findings to other settings requires consideration. We suggest that further studies are needed to increase our understanding of successful strategies for improving autonomy in the rehabilitation stages of hip fracture patients.
Conclusions Patient empowerment administrated by specially trained nursing staff and with standardised rehabilitation programme may be of benefit in helping patients to a shorter hospital stay and return to their previous living.
Acknowledgements We gratefully acknowledge the dedicated work in the study provided by the research nurses, Asa Norling and Luigi Belcastro, by their assistant, Angela la Terra, and by the occupational therapist, Iwona Olsson. We thank Mesfin Kassaye Tessma for his advice and assistance with statistical calculations.
Conflicts of interest No conflict of interest has been declared by the authors.
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Author contributions
31/4). This study was conducted in agreement with the Helsinki Declaration.
Susanne L€ ofgren analysed the data and have conceived and designed the study together with Leif Ryd. All authors performed the study, wrote the paper, revised, read and approved the final manuscript.
Funding
Ethical approval The study was a part in a larger study that has been granted approval by the regional ethical committee, Stockholm Ethical Review Board (decision 2008/1676-
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