Orthopaedics
Metropolitan hospital

Learn how staff in Sydney’s Liverpool Hospital investigated and addressed variation in delays before surgery for hip fracture. Data from the Australian and New Zealand Hip Fracture Registry, and making a case for additional theatre time, were key in reducing delays.

To view the summarised case study, you can skip to At a glance.

Last updated on 19 October 2022

Step 1. Select priority areas
Step 1. Select priority areas

Uncovering the problem – delayed surgery

The head of the Orthopaedic Surgery Department in Sydney’s Liverpool Hospital chose to investigate variation in management of hip fracture because it makes up a large part of the department’s activity, and it is a high-risk condition. Providing surgery within 48 hours of presentation if no clinical contraindication exists, and the patient prefers surgery, was identified as the first priority for attention because it improves clinical outcomes, and it is part of the Australian Clinical Care Standard for hip fracture. 

Addressing this issue also helps the hospital meet Action 1.7 of the NSQHS Governance Standard because it involves following a Clinical Care Standard.

Step 2. Plan the project
Step 2. Plan the project

Finding the right tool for the job – one that allows comparisons

The department already contributes data to the Australian and New Zealand Hip Fracture Registry (ANZHFR), which monitors practice according to the Hip Fracture Care Clinical Care Standard. The Registry online portal includes a dashboard showing the hospital’s results in seven aspects of care specified in the clinical care standard, and the annual report of the ANZHFR shows each contributing hospital’s performance, as well as the state/territory and national averages. 

As a starting point, the head of department asked the orthopaedic registrar to present the hospital’s Registry results, and the state and national averages from the latest annual report, at the monthly department meeting.

Step 3. Measure and review
Step 3. Measure and review

Assessing the findings – do they measure up to the standard of care?

Review of three month’s data showed that only 50% of the hospital’s patients with hip fracture underwent surgery within 48 hours, compared to the national average of 77%. The department felt this poor result needed to be addressed urgently, and a team made up of orthopaedic surgeons, nurses, and geriatricians was created to investigate the issue and find potential solutions.

The department also noted that their total length of stay for hip fracture patients was well above average, and it was possible that the delays to theatre were contributing to the overall increase in total length of stay.

Step 4. Explore reasons
Step 4. Explore reasons

Getting to the root of the problem – look for all the angles

After the Clinical Nurse Consultant ruled out errors in data entry as a factor, the team met to discuss the possible reasons for the delays in surgery. A comparison of the reasons for delay in the hospital, compared with national averages in the registry annual report, showed that:

  • The proportion of delays due to patients being medically unfit for surgery, or lack of surgeon availability, were similar to those in other hospitals
  • Length of stay in the emergency department was also similar 
  • A lack of theatre availability was substantially higher than the national average. 

A discussion about theatre access highlighted a number of areas for improvement. Patients presenting on Fridays or the weekend had the greatest delays because no theatre time was allocated on Saturdays or Sundays for hip fracture surgery. The group also noted that patients with hip fracture often had their surgery cancelled when cases seen as more urgent were brought into the hospital. This contributed to delays, and also led to prolonged and unnecessary fasting for patients.

Step 5. Act to improve
Step 5. Act to improve

Putting the changes in place – a multi-faceted approach

The group made a case to the hospital manager for introducing a Sunday morning theatre list dedicated to hip fracture surgery. They presented the hospital’s performance compared with the national average, and against the clinical care standard quality statements.

The hospital manager determined that reducing delays in surgery for hip fracture was a priority for improving patient care, and introduced the additional, dedicated theatre time.

Step 6. Monitor and report
Step 6. Monitor and report

Looking at the impact – celebrate success and build on it

Follow up monitoring showed a reduction in delays to surgery, and the hospital became close to the national average. Reports generated from the hip fracture registry portal are discussed at a quarterly meeting between the orthopaedic surgery and geriatric departments, and are included in the hospital’s regular safety and quality reports to the Board. 

The department continues to check that delays to surgery are minimised, and is focussing on the quality indicators for pain management in the hip fracture clinical care standard next.

At a glance

Issues
  • Only half of patients with hip fracture underwent surgery within 48 hours of admission, which is a clinical quality indicator and can affect clinical outcomes
  • Worst delays for patients admitted on Fridays or weekends
  • Above average length of stay for hip fracture patients
Barriers
  • Lack of theatre time on Saturdays or Sundays for hip fracture surgery
  • Patients with hip fracture often had their surgery cancelled when cases seen as more urgent were brought into the hospital
Enablers
  • The Australian and New Zealand Hip Fracture Registry
  • Presenting the hospital’s registry results, and the state and national averages from the latest annual report, at the monthly department meeting
  • Hip Fracture Care Clinical Care Standard
  • Presenting a case to the hospital manager for introducing a Sunday morning dedicated theatre list, based on the hospital’s performance compared with the national average, and against the clinical care standard
Solutions