Retrospective analysis of administrative data examining the feasibility of quality statements for the management of patients with hip fractures in the emergency department

Highlights

• Patients who sustain a hip fracture tend to be older and female.

• Many of these patients spend a significant amount of time in the emergency department.

• Emergency nurses play a pivotal role in delivery of care impacting patient outcomes.

• Assigned triage scores influence the quality of care received.

• Establishing nurse-sensitive quality statements helps improve healthcare quality.

Introduction

Internationally, hip fractures have been described as one of the most serious osteoporotic fractures and musculoskeletal injuries, with the incidence of this injury increasing exponentially with age [1], [2], [3], [4]. Older adults who have sustained a hip fracture are at higher risk for experiencing adverse events and poorer long-term outcomes, such as loss of independence, institutionalization, and mortality [5], [6], [7]. Such outcomes increase costs not only for patients and their families but also the healthcare system [7], [8], [9]. Measures to improve outcomes for these patients need to be initiated during the pre-operative period because there is convincing evidence to support that care received prior to surgery impacts long-term recovery [9], [10], [11], [12], [13], [14]. The care received in the emergency department (ED) deserves particular attention because this is the point of entry into the healthcare system for most of these patients [8], [9], [10], [11], and where many may spend a large portion of the pre-operative period. However, few studies have focused on quality of ED care for patients with hip fractures [15], [16].

A first step in improving the quality of care is the establishment of explicit statements of what constitutes best practice within a specific healthcare context (i.e., quality statements). These statements provide a basis for identifying measurable aspects of care that can be used to evaluate practice performance. Quality statements are ideally derived from the recommendations contained within high-quality clinical practice guidelines that are based on the best available evidence [17], [18]. An evidence synthesis (i.e., umbrella review) of current clinical practice guidelines for the management of patients with hip fractures was conducted to synthesize and group recommendations addressing aspects of the pre-operative management of these patients [19]. These recommendations were grouped into six categories: timely surgery, expedited patient management, multidisciplinary approach to care, identification and treatment of correctable co-morbidities, pain management, and implementation of measures to prevent common complications. Additional information on this review and synthesis of recommendations can be found in Filiatreault et al. (2018; [19]). The synthesized recommendations provided an evidence-based foundation for the creation of a set of quality statements for the management of patients with hip fracture in the ED. In addition, existing organizational databases (the National Quality Measure Clearinghouse, the Australian Institute of Health and Welfare, and the National Institute of Health and Care Excellence) were examined to identify existing quality statements and measures, for the pre-operative management of patients with a hip fracture. This work resulted in the development of seven quality statements addressing the management of patients with hip fracture in the ED that are sensitive to nursing intervention (see Table 1). Two quality statements were developed to address the categories of pain management and measures to prevent common complications. A quality statement for expedited patient management (e.g., time to specialist consult or time to patient transfer) was not developed due to lack of recommendations sensitive to nursing intervention and increased emphasis on a comprehensive approach to care [11], [20], [21], [22]. A more detailed description of the process used to develop the quality statements can be found in Filiatreault (2019; [23]). To examine how others have investigated the quality of ED care for patients with hip fractures, a structured search of the CINAHL and PubMed bibliographic databases was conducted. Only 5 studies were found examining quality statements relevant to the ED [15], [16], [24], [25], [26]. Two of these studies examined predictors of attainment, however, only in terms of a target for timely surgery [24], [25].

Although time to surgery is not directly affected by nursing interventions, it is a widely accepted standard of care for patients with hip fractures. Historically, a reason to delay surgery has been the presence of co-morbidities [11]. Such delays are now viewed as unnecessary and as contributing to a higher incidence of post-operative complications [11], [20], [21], [22]. Rather than delaying surgery, the emphasis has shifted to the early identification and treatment of correctable co-morbidities [11]. Emergency nurses can be instrumental not only in the early identification of patients with suspected hip fractures but also those with potentially correctable co-morbidities. The basis for such identification is a skilled assessment conducted by a clinically experienced registered nurse on the patient’s arrival to the ED, which includes the documentation of a focused history and physical assessment, a complete set of vital signs, blood glucose value, cognitive status, and assignment of a triage score [15], [20], [21], [22], [27]. The assigned triage score sets the stage for the care trajectory in the ED as it prioritizes patients based on their acuity and risk [28]. The Canadian Triage and Acuity Scale (CTAS) system is used in the majority of Canadian EDs and is a 5-point scale with lower scores indicating the need for more rapid intervention (i.e., CTAS 1 classified as requiring immediate intervention/resuscitation and CTAS 5 as non-urgent) [28].

A retrospective analysis of electronically-available clinical data from one ED for the 2016–2017 fiscal year was conducted to examine the feasibility of using a set of evidence-based quality statements to evaluate current practices in the management of patients with hip fractures in the ED. The specific objectives were to:

• Determine the proportion of cases in which the quality statements were met, individually and as a set.

• Examine differences in attainment of the quality statements by patients’ age and sex, triage score, as well as timing of presentation.