Introduction
Methods
Recruitment and randomization
Intervention (n = 102) | Control (n = 97) | p value | |
---|---|---|---|
Sociodemographic | |||
Age, mean±SD | 82.3 ± 6.6 | 82.0 ± 5.9 | 0.724 |
Females | 74 | 74 | 0.546 |
Independent living before the fracture | 66 | 60 | 0.677 |
Health and medical problems | |||
Stroke (n = 102/93) | 29 | 20 | 0.265 |
Dementia | 28 | 36 | 0.145 |
Previous hip fracture (n = 102/96)a
| 16 | 14 | 0.829 |
Depression (n = 102/95) | 33 | 45 | 0.031 |
Diabetes (n = 102/95) | 23 | 17 | 0.417 |
Cardiovascular disease (n = 101/93) | 57 | 53 | 0.938 |
Medications on admission | |||
Number of drugs, mean±SD | 5.8 ± 3.8 | 5.9 ± 3.6 | 0.867 |
Antidepressants | 29 | 45 | 0.009 |
Sensory impairments | |||
Impaired hearing (n = 94/82) | 42 | 34 | 0.667 |
Impaired vision (n = 91/74) | 37 | 27 | 0.584 |
Functional performance before fracture | |||
Use of roller walker (n = 101/93) | 56 | 52 | 0.948 |
Use of wheelchair (n = 101/93) | 23 | 16 | 0.334 |
Previous falls, last month (n = 99/90)b
| 24 | 25 | 0.580 |
Walking independently, at least indoors (n = 101/94) | 85 | 85 | 0.191 |
Staircase of ADL, median (Q1,Q3) (n = 92/88) | 5 (1–7.75) | 5 (0.25–7) | 0.859 |
Assessments during hospitalization | |||
Mini Mental State Examination, mean±SD (n = 93/90) | 17.4 ± 8.2 | 15.7 ± 9.1 | 0.191 |
Organic Brain Syndrome Scale, mean±SD (n = 94/90) | 10.1 ± 10.8 | 12.5 ± 11.4 | 0.148 |
Geriatric Depression Scale, mean±SD (n = 81/68) | 5.2 ± 3.6 | 4.5 ± 3.5 | 0.271 |
Intervention
Intervention group | Control group | |
---|---|---|
Ward layout | Single and double rooms | Single, double, and four-bed rooms |
24-bed ward, extra beds when needed | 27-bed ward, extra beds when needed | |
The geriatric control ward was similar to the intervention ward | ||
Staffing | 1.07 nurses/aides per bed | 1.01 nurses per bed |
Two full-time physiotherapists | Two full-time physiotherapists | |
Two full-time occupational therapists | 0.5 occupational therapist | |
0.2 dietician | No dietician | |
The geriatric control ward had staffing similar to the intervention ward | ||
Staff education | A 4-day course in caring, rehabilitation, teamwork, and medical knowledge including sessions about how to prevent, detect, and treat various postoperative complications such as postoperative delirium and falls | No specific education before or during the project |
Teamwork | Team included registered nurses (RN), licensed practical nurses (LPN), physiotherapists (PT), occupational therapists (OT), dietician, and geriatricians | No corresponding teamwork at the orthopedic unit |
Close cooperation between orthopedic surgeons and geriatricians in the medical care of the patients | The geriatric ward, where some of the control group patients were cared for, used teamwork similar to that in the intervention ward | |
Individual care planning | All team members assessed each patient as soon as possible, usually within 24 h, to be able to start the individual care planning | Individual care planning was used in the orthopedic unit but not routinely as in the intervention ward |
Team planning of the patients’ individual rehabilitation process and goals twice a week | At the geriatric rehabilitation unit there was weekly individual care planning | |
Prevention and treatment of complications | Investigation as far as possible regarding how and why they sustained the hip fracture, through analyzing external and internal fall risk factors | No routine analysis of why the patients had fractured their hips |
An action to prevent new falls and fractures was implemented including global ratings of the patients’ fall risk every week during team meetings | No attempt was made to systematically prevent further falls | |
Calcium and vitamin D and other pharmacological treatments for osteoporosis were used when indicated | No routine prescription of calcium and vitamin D | |
Active prevention, detection, and treatment of postoperative complications such as delirium, pain, and decubitus ulcers was systematic | Assessments for postoperative complications were made with check-ups for, i.e., saturation, hemoglobin, nutrition, bladder and bowel function, home situation etc., but these check-ups were not carried out systematically as in the intervention group | |
Oxygen-enriched air during the 1st postoperative day and longer if necessary until the measured oxygen saturation was stable | ||
Urinary tract infections and other infections were screened for and treated | ||
If a urinary catheter was used it should be discontinued within 24 h postoperatively | ||
Regular screening for urinary retention, and prevention and treatment of constipation | ||
Blood transfusion was prescribed if B-hemoglobin <100 g/l and <110 for those at risk of delirium or those already delirious | ||
If the patient slept badly, the reason was investigated and the aim was then to treat the cause | ||
Nutrition | Food and liquid registration was systematically performed and protein-enriched meals were served to all patients during the first 4 postoperative days and longer if necessary | A dietician was not available at the orthopedic unit |
Nutritional and protein drinks were served every day | No routine nutrition registration or protein-enriched meals were available for the patients | |
Rehabilitation | Mobilization within the first 24 h after surgery | Mobilization usually within the first 24 h |
The training included both specific exercise and other rehabilitation procedures delivered by a PT and OT, as well as basic daily ADL performance training, by caring staff. The patients should always do as much as they could by themselves before they were helped | The PT on the ward mobilized the patients together with the caring staff. The PT aimed to meet the lucid patients every day. Functional retraining in ADL situations was not always given. The OT at the orthopedic unit only met the patients for consultation | |
The rehabilitation was based on functional retraining with special focus on fall risk factors | The geriatric control ward had both specific exercise and other rehabilitation procedures delivered by a PT and OT, similar to the intervention ward but did not systematically focus on fall risk factors | |
Home visit by an OT and/or a PT | No home visits were made by staff from the orthopedic unit |
Data collection
Statistical analysis
Results
Intervention (n = 102) | Control (n = 97) | p value | |
---|---|---|---|
Number of falls | 18 | 60 | |
Postoperative in-hospital days | 2,860 | 3,685 | |
Crude fall incidence rate (number of falls/1,000 days) | 6.29 | 16.28 | |
IRR (95% CI) | 0.38 (0.20–0.76)a
| 1.00 (Ref.) | 0.006 |
Number of fallers | 12 | 26 | 0.007 |
Number of fallers with injuries due to falls | 3 | 15 | 0.002 |
Number of fallers with fractures due to falls | 0 | 4 | 0.055 |
Number of falls among people with dementia | 1 | 34 | |
IRR (95% CI) among people with dementia | 0.07 (0.01–0.57)a
| 1.00 (Ref.) | 0.013 |
Number of fallers among people with dementia (n = 28/36) | 1 | 11 | 0.006 |
Discussion
Conclusion
Acknowledgements
Conflict of Interest
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Michael Stenvall, none, Birgitta Olofsson, none, Maria Lundström, none, Undis Englund, none, Bengt Borssén, none, Olle Svensson, none, Lars Nyberg, none, Yngve Gustafson, none.
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Michael Stenvall, study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparing of the manuscript.
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Birgitta Olofsson, acquisition of subjects and data, analysis and interpretation of data, and preparing of the manuscript.
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Maria Lundström, study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparing of the manuscript.
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Undis Englund, study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparing of the manuscript.
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Bengt Borssén, study concept and design, interpretation of data, and preparing of the manuscript.
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Olle Svensson, interpretation of data, and preparing of the manuscript.
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Lars Nyberg, study concept and design, analysis and interpretation of data, and preparing of the manuscript.
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Yngve Gustafson, study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of the manuscript, and study supervision.
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Providing financial support but nothing else.