Benefits of an advanced nurse practitioner led hip fracture clinic in an Irish Orthopaedic Trauma Service

Abstract

Summary

Ireland has high hip fracture rates, stressing services for older adults. An ANP-led clinic was introduced to improve post-discharge care. Among 87 patients, significant gains in pain, mobility, and bone health management were seen. The clinic proved a safe, effective model addressing critical gaps in hip fracture follow-up care.

Purpose

Ireland has one of the highest rates of hip fracture in the world. With a rapidly aging and increasing population, more stress will be put on services for hip fracture patients. Furthermore, accurate data collection with regard to Irish Hip Fracture Data standards needs to be collected to ensure optimal care for this vulnerable patient cohort. To address this, our unit has begun an advanced nurse practitioner (ANP) led hip fracture clinic. The purpose of this study is to assess the benefit of an ANP led hip fracture clinic in a single orthopaedic trauma unit.

Methods

Prospectively, over an 8-month period, all patients from a single Irish trauma hospital aged 60 years or older who suffered a hip fracture were seen post discharge at 30 days and again, but virtually, at 120 days in an ANP led clinic. X-rays, wound reviews, and hip exam are assessed initially while residential status, recent hospital re-admission, unplanned return to theatre, bone health, mobility assessment, and health questionnaire are assessed during both sessions. We wanted to assess the impact of our new clinic in terms of service provision and measuring outcomes.

Results

Then, 87 patients were seen in clinic at 30 days. Then, 64 had 120-day follow-up. Significant improvements were made with regard to patients pain scores, mobility, and wellbeing. All patients followed up had been prescribed bone protection by 120-day follow-up. Data were also collected with regard to surgical complications, patient residential status, and functional outcomes.

Conclusions

ANP led hip fracture clinic provide safe, holistic hip fracture care. It addresses an urgent care gap in bone health management post hip fracture.

Introduction

Over the last few years nurses have begun to perform roles which traditionally have been undertaken by doctors. These changes are partly due to the European working time directive, reducing working hours for junior doctors, but also due to increasing clinical load. Ireland has one of the highest rates of hip fracture in the world [1].Over 3700 adults 60 or older suffer a hip fracture every year in Ireland [2]. There were 3983 reported hip fractures last year [3]. With a rapidly aging and increasing population, this number will increase placing more stress will be put on acute services for hip fracture patients. The Irish Hip Fracture Database (IHFD) audit records acute hospital data up until patient discharge from the acute hospital setting but does not follow longer term outcomes.

In 2022, the international Fragility Fracture Network (FFN) recommended a common dataset for audit of hip fracture patient to facilitate international comparisons. It includes the long-term outcomes of mortality, unplanned return to theatre, mobility, residential status, and bone protection medication [4]. They recommended that while 120 days post-fracture is the ideal time to collect these outcomes to give patients a chance to make a meaningful recovery, 30 days after fracture may be more feasible for many healthcare systems. These outcomes were decided upon using a systematically developed core outcome set for hip fracture trials, which additionally includes quality of life using the EQ-5D patient reported outcome measure (PROM) [5, 6]. National hip fracture audits in the UK, Australia, New Zealand, Germany and Norway have adopted the EQ-5D at 120 days, although, similar to here in Ireland, completeness of data collection has been an ongoing challenge [7, 8].

As high-quality and internationally comparable data is needed to inform decision-making, it is vital that this data collection receives adequate support. Traditionally, this burden has been informally assigned, often to trainee junior doctors who often only spend six months to one year in a post. This inconsistency leads to poor quality data. To help address this clinical need, our unit has begun an advanced nurse practitioner (ANP) led hip fracture clinic. A literature review investigating nurse led hip fracture clinic shows that there is expanding interest in defining and expanding their role [9]. There is already evidence that ANP led hip fracture clinics improve one year mortality [10, 11]. However, there is no research assessing their impact with regard to bone health management post-hip fracture.

Aims

We wanted to evaluate the introduction of an ANP led hip fracture clinic in a single Irish orthopaedic trauma unit. The secondary aim of this study was to compare our unit’s performance with those internationally using the FFNs common dataset audit.

Methods

Prospectively, from 01/01/2024 to 31/08/2024, data were collected for all patients with a hip fracture who were discharged from a single Irish orthopaedic trauma hospital. Inclusion criteria included patients aged 60 or greater with a proximal femur fracture. Exclusion criteria included midshaft and distal femur fractures.

Patients were seen in person in clinic approximately 30 days post-discharge. Patients were followed up with a phone call at 120 days. Standard assessment protocols were used in both clinic appointments. These protocols were guided by the FFNs common dataset for hip fracture audit. In the clinic patients had a 6-week check X-ray, a wound review and a hip examination. At both the clinic review and again at 120 days post-discharge, patients underwent a review of their current residential status, an assessment to check if there was a recent hip related hospital re-admission or unplanned return to theatre, a review of their bone health work-up, a mobility assessment using the New Mobility Score (NMS), and a general health questionnaire (EQ-5D-SL). The NMS is a validated questionnaire that uses patient mobility at 30 days to predict one year mortality [12]. The Eq-5D-5L health questionnaire is a validated questionnaire in which patients rate their own “overall health” and perceived quality of life. It includes 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [6].

Orthopaedic clinician backup was provided to the ANP if there were any concerns regarding any of the areas assessed.

The outcomes at 30 days were given as means. A paired two tail T test was used for comparison. A p-value of < 0.05 was considered to be statistically significant. All calculations were performed with Microsoft excel software.

Ethical review and approval was not required for the study in accordance with the local institutional requirements (Table 1).

Table 1.

Comparison of 30-day and 120-day clinic standardised protocols

30 days (face-to-face)	120 day s(virtual appointment)
6 week check x-ray	N/a
Wound review	N/a
Hip examination	N/a
Review of their current residential status	Review of their current residential status
Assess if there has been a recent hip related hospital admission	Assess if there has been a recent hip related hospital admission
Review of bone health (assess need for DEXA)	Review of bone health (assess need for DEXA)
Mobility assessment (new mobility score)	Mobility assessment (New mobility score)
Health Questionnaire EQ-5D-5L	Health Questionnaire EQ-5D-5L

Results

Then, 118 patients were offered 30-day clinic appointments. Four patients (3.6%) had passed away within 30 days of discharge. Then, 77 patients attended (69%) their appointment in-person, 13 patients (12%) had virtual reviews for their 30-day appointment resulting in 78% of patients having 30-day follow-up. Then, 24 patients (22%) either refused or were not able to attend their 30-day follow-up.

Then, 114 patients were offered 120-day virtual follow-up. No further patients had passed away in the interim period. Then, 83 (73%) had virtual appointments. 11 (10%) had in person 120-day reviews meaning 94 patients (83%) offered, and had 120-day virtual follow up.

Residential status at 30 and 120 days were analysed, see Table 2.

Table 2.

Breakdown of residential status at 30 days and 120 days

Residence	30 days (n = 90)	120 days (n = 94)
Home	50	56
Return to NH	23	26
New NH admission	8	10
Off-site rehab	7	1
Convalescence	1	1
Other (inpatient)	1	0

One patient (1.1%) required an unplanned return to theatre by 30 days, there were none further by 120 days.

At 30 days, the average new mobility score was 5. Then, 89 (99%) were using a walking aid. At 120 days, the average score was 6 with 39 patients (42% using a walking aid.

At 30 days, 77 patients (86%) were prescribed bone protection. Eight patients (9%) were prescribed bone protection at their 30-day follow-up. Four patients (5%) were not prescribed bone protection due to contraindications. At 120-day follow-up, all patients without contraindications were still prescribed their regular bone protection.

EQ-5D-5L average scores improved from 45/100 at 30 days to 55/100 at 120 days indicating that patients, on average, felt their overall health improved in this interim period (p < 0.001).

If there are concerns with regards to any patients’ wounds/X-rays etc., a pathway was developed in which the ANP can contact the orthopaedic registrar on call for review. There were no known cases of post-surgical complications being inappropriately missed during the clinic.

Discussion

Data collection

This study has implications for planning the national hip fracture audit in Ireland. While the IHFD has previously focused on acute admission KPIs, comparison to international standards requires longer term results. The FFN suggests 120 days post-hip fracture as an ideal time frame for assessment of meaningful recovery. The Irish hip fracture report 2023 details pilot results of assessing patient outcomes at 120 and 365 days (3).

Our study shows that ANPs with specialized training can lead this longer term hip fracture audit, our model provides a template to other hospitals in Ireland to ensure they collect high-quality data.

Mortality

The 30-day mortality rate was 3.6%; this is comparable with a recent meta-analysis of Irish studies which reported a 30 day mortality of 4.7% (2). There were no further confirmed mortalities at 120 days; however, the considerable loss to follow-up may explain this.

Unplanned return to theatre

There was one patient who required an unplanned return to theatre, unfortunately for an excision arthroplasty post recurrent early dislocation of a hemiarthroplasty for a neck of femur fracture. This patient was a complex case with a background of Parkinson’s disease and poor self-care and presented with a fracture of unknown duration. They were discharged to a rehab facility with the ability to transfer from bed to chair and to mobilise to the toilet using a frame.

Mobility

As expected, the new mobility score increased from 30 to 120 days. This score predicts one-year mortality post-hip fracture. In the future, comparison to pre-injury mobility score could be added to the clinic protocol to help us determine how well our patients are doing.

Residence

There were no new patients who required change in residence from home to a nursing home in the analysed period. This likely reflects the fact that patients who were able to attend the clinic were the patients with higher functional baselines and recoveries.

Bone protection

All patients captured in the clinic, who did not have contra-indications, were prescribed bone protection by their 120-day follow-up. Other variables that could be captured include receipt of DXA scan, diagnosis of osteoporosis and osteopenia, vertebral fractures, subsequent fractures, levels of vitamin D, calcium and parathyroid hormone, T-scores, bone mass density, and other bone markers.

EQ-5D-5L

EQ-5D-5L is a generic instrument for describing and valuing health. As predicted, patients scores improved as they progressed on their recovery from 30 to 120 days. It is a questionnaire that includes five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Mobility is already captured by the new mobility score. In the future, it may be helpful to subclassify patients EQ-5D-5L score to aid decision making and service provision.

Relief of burden on trauma clinic

All the patients seen in our hip fracture clinic did not require follow-up in the general trauma clinic. This means 151 clinic appointments were taken out of the trauma clinic over eight months. Our hospital has the youngest and fastest growing population in Ireland [13], resulting in a progressive increase in trauma clinic need; however, capacity has not changed, so this relief of pressure on the service is welcome. Furthermore, to comprehensively assess a patient recovering from hip fracture surgery and to properly assess and document their outcomes as per the FFNs standardized dataset would not be feasible in a busy trauma clinic that is following the safe clinic guidelines [14]. Looking forward, the role and practise of orthopaedic ANP could be expanded to continue to accommodate the increased need for outpatient services.

Selection bias

This study is at risk of selection bias such that patients that attended the clinic are more likely to be functioning at a higher level than patients that were unable to attend the clinic.

Another limitation of the study includes the number of patients lost to follow-up. Reasons for this include our hospitals large rural catchment area with some patients being as far as 150 km from the hospital. This vulnerable cohort often rely on friends/family for transport and this is not consistently possible. Virtual clinics can be used to overcome this, but equally, these are also not suitable for patients with hearing difficulties or that do not speak English. Looking forward patient satisfaction with the service could be investigated to aid this.

Conclusions

ANP led hip fracture clinic contributes to safe, holistic hip fracture care. It addresses an urgent care gap in the management of bone health post-hip fracture. Furthermore, this is the first example in Ireland of an ANP led clinic collecting the FFNs recommended common dataset for hip fracture audit. As clinical need grows, the scope of practise of this role may need to increase.

Funding

Open Access funding provided by the IReL Consortium.

Declarations

Conflicts of interest

None.