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Clinical pathways are proposed as a means of providing high quality care in a timely and cost-effective manner. These pathways consist of treatment protocols that aim to streamline and standardise management with multidisciplinary input from medical, nursing, paramedical and administrative staff. They have been used successfully to improve outcomes after elective hip and knee joint replacement.³ This led us to examine the impact of such a coordinated approach on acute and unpredictable admissions such as in patients with femoral-neck fractures. However, surgery for acute hip fracture differs significantly from hip joint replacement as it is non-elective and patient needs and clinical course are more variable.

We conducted a prospective, controlled study to assess the effectiveness of clinical pathways for improving outcomes of patients undergoing surgery for acute fracture of the neck of femur. Specifically, we examined time to mobilisation, length of hospital stay, and complication and readmission rates as indices of outcome.

In this period, 126 patients were admitted with a diagnosis of fractured neck of femur. Fifteen were excluded from the study, five because they were transferred to another institution for treatment, eight because of associated medical conditions that precluded surgical intervention, and two because of a decision to undertake non-standard surgery.

One hundred and eleven patients were allocated to one of two groups (control or clinical pathway) by an administrative clerk, who was independent of the study and unaware of the study hypothesis. Patients were allocated on the basis of their unit record number -- even numbers to the control group (56 patients), and odd numbers to the clinical pathway group (55 patients).

A retrospective analysis of a historical treatment group (n = 118) showed a mean length of stay of 11.8 days (range, 2.6-40.0 days; SD, 7.3). To detect a reduction in length of stay of a third at a significance level of 0.05 with a power of 0.8 would require two groups, each with a minimum of 55 participants.

Patients who were not expected to regain their prefracture functional level, were not expected to achieve this level in less than two months or were expected to need a higher level of care than before the fracture were referred to the Aged-Care Assessment Service (ACAS) for placement in slow-stream rehabilitation, nursing home, hostel or special accommodation, depending on patient medical conditions and limitations. This service was mediated by a social worker who, together with a medical registrar, prepared the patient for thrice-weekly assessment by a consultant geriatrician which could take place on three occasions per week.

To surgery: time between admission and theatre;

To mobilisation: time between surgery and the patient first walking with the use of aids;

To ACAS assessment: time between submission of the referral to ACAS and first assessment by the geriatrician; and

Total length of stay: time from admission to discharge from hospital.

Inpatient complications: Patients were assessed daily for confusion (disorientation in time, place or person). Wound infection was defined as all wound erythema lasting longer than 24 hours. Deep vein thrombosis was diagnosed clinically and confirmed by ultrasonography, and urinary tract infection was confirmed microbiologically.

Postdischarge complications and readmissions: All patients' medical records were examined 28 days after discharge to identify postdischarge complications or readmissions related to the fracture. This time was chosen as we expected the patient to have recovered significantly from their surgery by then.

Durations of stay
Durations at various stages of the admission for pathway and control patients are compared in Box 2. No significant differences were found between the groups in mean time in the emergency department or mean time from admission to surgery. Pathway patients walked significantly earlier than control patients, but the difference (1.6 versus 2.0 days) was not clinically important.

However, the pathway group had a significantly shorter total length of stay than the control group (mean, 6.6 versus 8.0 days; P = 0.03). This meant that control patients stayed 21% longer than pathway patients. After adjusting the log-transformed length-of-stay values for the possible confounding variables of age, sex, aged-care assessment and premorbid status with multiple linear regression, we found that none of these variables produced significant between-group interactions. Group (pathway versus control) remained the most significant factor influencing total length of stay.

Referral for aged-care assessment
Fifteen of the 55 pathway patients and 18 of the 56 control patients were referred for ACAS assessment. This referral was preoperative for three pathway and two control patients. Time from referral to first assessment by a geriatrician differed only slightly between pathway and control patients: mean times were 2.5 days for pathway patients (range, 1-8 days) and 2.8 days for control patients (range, 0-8 days).

Patients who were referred to ACAS had significantly longer total stays than those who were not referred (11.7 versus 6.5 days; P < 0.001; difference, 5.2 days; 95% CI, 3.0-7.5 days). This difference remained significant when the control and pathway groups were analysed separately.

However, mean length of stay was significantly shorter for pathway patients referred to ACAS than for control patients referred to ACAS (9.5 versus 13.6 days; Box 2). We explored the possibility of confounding variables for patients referred to ACAS and found that there were none, suggesting that group membership (pathway or control) was the most influential factor affecting length of stay. Postdischarge destinations were similar in pathway and control groups referred to ACAS: 12/15 pathway patients and 16/18 control patients proceeded to slow-stream rehabilitation.

Discharge destinations
Discharge destinations are shown in Box 2. Patients in each group were most often discharged into fast-stream rehabilitation, followed in frequency by slow-stream rehabilitation or nursing homes.

Complications and readmissions
There were no significant differences between pathway and control patients in numbers who were confused postoperatively (23/55 versus 31/56) and in rates of other inpatient complications (10/55 versus 14/56 patients), postdischarge complications (3/55 versus 6/56), or readmission rates (2/55 versus 6/56).

To date, only a few studies^5-7 have reported results of a coordinated, multidisciplinary approach to management of fractured neck of femur in Australia. They found, similarly to our study, that these early-intervention programs reduced the length of stay of elderly patients with this condition compared with standard care.^5-7 However, actual length of stay varied greatly between studies (from 11.3⁸ days to 32.5⁵ days). This variation highlights the limitations in management inherent in individual institutions because of variation in local factors such as availability of ACAS and support services and patient characteristics. Length of stay in the pathway group at our hospital, which was two to four times shorter than at other hospitals,^5-7 may have benefited from our on-site rehabilitation unit.

Although we found that use of a clinical pathway reduced total length of stay, the change (1.4 days) was not dramatic. This may be because the strong culture of continued refinement of care in our orthopaedic department had already reduced length of stay for many classes of orthopaedic conditions, including fractured neck of femur. Nevertheless, the reduction of 1.4 days in the clinical pathway group was encouraging.

Unlike a previous study,⁵ our study included patients with language and cognitive difficulties. This choice was made to minimise any selection bias, as patients susceptible to osteoporotic fractures are in an age group which commonly has cognitive difficulties and as our patient population includes a large proportion of non-English-speaking people. We believed that their inclusion would test the efficacy of clinical pathways in the delivery of multidisciplinary care. We observed no difficulties applying the pathway to patients who had cognitive difficulties or did not speak English.

Importantly, while use of clinical pathways reduced total length of stay, we found no significant clinical difference in time to mobilisation or complication or readmission rates between the two groups. This contrasted with our earlier findings on the effect of clinical pathways in elective joint replacement surgery.³ Possible explanations for the difference include the frequent existence of unstable and often untreated premorbid conditions in patients with fractured neck of femur, which require attention during their acute admission. In contrast, patients undergoing elective joint replacement have the benefit of preadmission assessment clinics which may resolve expected medical, allied health or discharge issues before admission.

Up to a third of our patients with fractured neck of femur were referred for ACAS assessment for placement. Patients who required this assessment stayed significantly longer than patients who did not, possibly reflecting their respective comorbidities and the shortage of aged-care beds in the community.

While the time between ACAS referral and consultation was similar for pathway and control patients, total length of stay was four days shorter for pathway than for control patients. It is likely that the daily review of patients' health status promoted by the clinical pathway optimised their readiness for discharge and prompted more regular reviews of discharge plans by the ACAS team. Interestingly, time between ACAS referral and consultation ranged up to eight days in both pathway and control groups. Reasons for this large range were not recorded and warrant further investigation.

Some authors have identified that acute care, convalescence, rehabilitation and surgery accounted for more than 90% of total costs for fractured neck of femur, and that the main factors explaining cost variation were the number of days spent in acute care and convalescence or rehabilitation.^9,10 However, our study was not designed to evaluate cost-effectiveness of clinical pathways, and, although use of the clinical pathway reduced length of stay by 1.4 days, we did not quantify costs involved in administering the pathway compared with control care. The net cost-effectiveness of our pathway is therefore unknown.

Despite the weakness of a limited study, we showed that a multidisciplinary approach using clinical pathways for fractured neck of femur can reduce length of stay without increasing patient morbidity.

1. Sanders KM, Nicholson GC, Ugoni AM, et al. Health burden of hip and other fractures in Australia beyond 2000. Med J Aust 1999; 170: 467-470.
2. Day RO, Henry DA, Muirden KD, et al. Non-steroidal anti-inflammatory drug induced upper gastrointestinal haemorrhage and bleeding. Med J Aust 1992; 157: 810-812.
3. Dowsey MM, Kilgour ML, Santamaria NM, Choong PF. Clinical pathways in hip and knee arthroplasty: a prospective, randomised controlled study. Med J Aust 1999; 170: 59-62.
4. SPSS Inc. SPSS Base 8.0 for Windows. Chicago, (Ill): SPSS Inc, 1998.
5. Swanson CE, Day GA, Yelland CE, et al. The management of elderly patients with femoral fractures. A randomised controlled trial of early intervention versus standard care. Med J Aust 1998; 169: 515-518.
6. Tallis G, Balla JI. Critical path analysis for the management of fractured neck of femur. Aust J Public Health 1995; 19: 155-159.
7. Cameron I, Lyle D, Quine S. Accelerated rehabilitation after proximal femoral fracture: a randomised controlled trial. Disabil Rehabil 1993; 15: 29-34.
8. Lavernia CJ. Hemiarthroplasty in hip fracture care: effects of surgical volume on short-term outcome. J Arthroplasty 1998; 13: 774-778.
9. French FH, Torgerson DJ, Porter RW. Cost analysis of fracture of the neck of femur. Age Ageing 1995; 24: 185-189.
10. Hollingworth W, Todd C, Parker M, et al. Cost analysis of early discharge after hip fracture. BMJ 1993; 307: 903-906.

University of Melbourne, Melbourne, VIC.
Nick M Santamaria, MEdSt, PhD, Senior Research Fellow.

Reprints: Professor P F M Choong, Department of Orthopaedics, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065.
PeterChoongATc031.aone.net.au

©MJA 2000
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