Alternative Workforce Boosts Hip Fracture Recovery
One of the many challenges that can face those who wish to implement research evidence into routine clinical practice is securing enough staff to undertake and sustain the new intervention.
Senior physiotherapist at Western Sydney Local Health District (WSLHD), Dr Marie March, was interested in the evidence from a clinical trial in Victoria which had shown that providing hip fracture patients with more frequent physiotherapy sessions was effective in improving their mobility and reducing the length of their hospital stay. But there simply weren’t enough physios to make it happen.
It’s a practical problem that inspired March and fellow principal investigator, Associate Professor Alison Harmer, to propose and test a novel solution.
“We wanted to replicate the findings of the Victorian study, accounting for local differences in physio service provision, but our physiotherapist workforces have been stretched for a very long time,” said March. “The volume of patients we have to deal with in our hospitals is growing but the funding to support more workers on the ground is not. And at the same time, the clinical complexity of the patients we are seeing is increasing.”
March and Harmer’s proposed solution was to explore whether an alternative workforce of pre-registration physiotherapy students and allied health assistants could, with supervision, provide hip fracture patients with physiotherapy exercises several times on weekdays, plus opportunistic intervention on the weekends.
Supported by an implementation science pilot grant from Sydney Health Partners, the BOOST pilot trial evaluated whether such high frequency physiotherapy using the alternative workforce was safe, acceptable, feasible, effective and cost effective.
“Hip fracture patients are a clinically challenging group,” said March. “They are usually older and frail and may have been on the cusp of needing nursing home placement at the time of their injury. The fracture is often the straw that breaks the camel's back of their frailty.”
March says the high frequency physio model of care addresses the barriers to the discharge of these patients from hospital.
“The factors which typically limit their discharge are regaining sufficient strength, balance and the ability to walk. But these patients fatigue very quickly, so we found that a ‘little and often’ approach to physiotherapy exercises works better for them.”
The researchers interviewed patients and carers to learn what they thought of the high frequency treatment.
“As part of a patient-centred approach, we wanted understand the acceptability of high frequency physio from their perspective, not just from the point of view of the staff implementing it,” said March.
“In WSLHD, we have over 150 languages spoken and the idea that you should increase exercise while you're recovering from surgery, rather than rest in bed, is often in contrast to common cultural practices.
“But hip fracture patients told us that they see regaining mobility as synonymous with recovery more broadly, and that high frequency physio met their goal of going home as soon as possible.”
The intervention met health system goals as well. When trialled at Northern Sydney Local Health District’s Hornsby Hospital and at WSLHD’s Blacktown hospital, the BOOST model reduced the length of hospital stay in the acute ward from an average of eleven days to eight days.
“It was an important result because in the acute setting every bed day counts,” said March. “When someone is an inpatient for a long time, it's someone else's grandma that's stuck in ED with their hip fracture and can't come up to the ward because there's no bed.
“And so that was an amazing result and it’s a credit to my colleagues across all the sites who worked hard to accomplish the clinical trial, despite some very difficult circumstances during the COVID-19 pandemic.”
March and her colleagues are now looking at ways the BOOST model of care can be spread to rural and remote areas of NSW and whether other workforce types - including nursing students, wardspeople or volunteers - can supervise the physio exercises.
“Hip fracture care is a team sport and it's not just what the physio can do, it's actually what the whole team can do.”