Victoria Ryan Senior Occupational Therapist Hull and East Yorkshire Hospitals NHS Trust

1. An Audit of The Discontinuation of Hip Precautions With Hemiarthroplasty Patients Within An Acute Hospital Setting Victoria Ryan Senior Occupational Therapist Hull and East Yorkshire Hospitals NHS Trust

2. Introduction • Current literature/evidence around joint surgery and post-operative precautions reviewed • Plan to complete audit within the OT service covering trauma and elective orthopaedics across two sites. • The audit aimed to evaluate the impact of not using hip precautions with patients who have undergone a hemiarthroplasty procedure.

3. Background • Inconsistencies in practice between Trusts in the region • No solid evidence base supporting the use of hip precautions • Large financial impact to the Trust in enforcing the precautions • Other options previously explored to increase efficiency and reduce cost to the Trust were not effective – this also increased the need for audit.

4. Literature review • British Geriatric Society (BGS) suggested hip precautions were not necessary with hemiarthroplasties completed using an anterolateral approach – recommended approach by NICE. • Precautions have a negative impact on a patients function • Restricting function does not decrease the risk of dislocation – more influenced by patient selection and surgical outcomes/ approaches. • Evidence suggests over 40% of hemiarthroplasty patients had a cognitive impairment – may have difficulty retaining information regarding the hip precautions –therefore ineffective.

5. Aims/Objectives of Audit • 1. To evaluate the impact on patients who have undergone a hemiarthoplasty procedure in not using hip precautions. • 2. To evaluate the potential financial impact on the OT Service and HEY Trust of not using hip precautions with hemiarthroplasty patients who have had an anterolateral surgical approach. • 3. To reduce length of stay for hemiarthoplasty patients • 4. To enable the orthopaedic team to have consistent approach to treating patients following hemiarthroplasty.

6. Methodology • Presented idea to orthopaedic consultants at Governance meeting to gain support • Proposal put forward to Trust audit team • Random sample of 15 patients used to gather information on current practice using audit tool.

7. Audit tool Excel spreadsheet –password protected and saved on a secure file due to confidential information Only orthopaedic/surgery OT team could access this

8. Methodology continued… • Hip precautions stopped on 01 January 2017. • Collected data on first 15 patients who had hemiarthroplasty surgery on or after this date, using same audit tool. • Patients followed up 8 weeks post-operatively via telephone. • Consultants to advise the OT team if there were any readmissions due to dislocations.

9. Questions used for the follow up telephone interview. Consent gained from the patient at the time of the telephone interview, for completion of this stage of the audit.

10. Results

11. Outcome of follow up calls

12. Results • Huge cost savings to the Trust and OT service • (Based on costings given by the Personal Social Service Research Unit (2016) http://www.pssru.ac.uk/project-pages/unit-costs/2016/)

13. Results continued • Less equipment issued (also a cost saving) • No significant impact on discharge destinations • Majority of patients were managing their activities of daily living independently and none raised any concerns.

14. Limitations of the study • Small sample size – may benefit from repeating study with larger sample • Not known how long patients spent in rehabilitation units – therefore if there was an impact on community services also. • Changes in Trust paperwork during the course of the audit may have impacted on reducing OT time spent with patients.

15. Impact on OT role • Not having precautions promotes a more patient-focussed approach • Not limiting patients function unnecessarily –promoting independence • Smoother patient journey and OT process • More efficient and effective working • Completion of audit and promoting change- increased OT profile within orthopaedic service and the Trust.

16. Conclusion • Hip precautions no longer used with hemiarthroplasty patients at Hull and East Yorkshire NHS Trust. • Positive impact on OT role • Consultants are now working towards stopping hip precautions with total hip replacements completed within both elective and trauma orthopaedics at HEY NHS Trust.

17. References • British Orthopaedic Association, British Geriatrics Society. The Care of Patients with Fragility Fracture. London: BOA; 2007. • Coole C., Edwards C., Brewin C., Drummond A (2013) What do clinicians think about hip precautions following total hip replacement? British Journal of Occupational therapy, July 2013, 76 (7) • Fox R, Halliday R, Barnfield S, Roxburgh J, Dunford J, Chesser TJS (2011) Hip precautions after hemiarthroplasty: what is happening in the UK and at what cost? Ann R CollSurgEngl 2011, 93, 396-39 • Kelmanovich D, Parks M L, Sinha R, Macaulay W (2003) Surgical Approaches to Total Hip arthroplasty, Journal of the Southern Orthopaedic Association • NICE guidelines (2011) Hip fracture surgery

18. References • Parker MJ, Pervez H (2002) Surgical approaches for inserting hemiarthroplasty of the hip, Issue 3. • Smith To, Cross H YA, Henderson C, Sahota O, Fox C (2015) Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Database of Systematic Reviews, issue 6. • Stewart L S., McMillan (2011) How necessary are hip restrictions for avoiding dislocation following hemiarthroplasty or total hip arthroplasty in older patients with a hip fracture? British Journal of Occupational Therapy March 2011 74(3)

19. Any Questions?