Background
The number of adults older than 65 years globally is projected to nearly double within the next 30 years, with profound implications for healthcare sustainability (Wan, Goodkind, & Kowal, 2016). A fragility hip fracture is a devastating injury commonly afflicting older people and their families. People with fragility hip fractures require extensive care at significant healthcare costs (Nikitovic, Wodchis, Krahn, & Cadarette, 2013). The outcomes after hip fracture are poor and include impaired mobility, diminished functional status, increased reliance on others, and sometimes death (Carpintero et al., 2014; Gjertsen, Baste, Fevang, Furnes, & Engesaeter, 2016; Maher et al., 2012; Panula et al., 2011). These poor outcomes depend, in part, on individual characteristics such as comorbidities and frailty, the specific injury, and healthcare delivery (Lund, Moller, Wettersley, & Lundstrom, 2014; Sheehan, Sobolev, Chudyk, Stephens, & Guy, 2016). However, many who survive never regain their prefracture level of independence (Bertram, Norman, Kemp, & Vos, 2011), and injury-related deaths extend beyond the period of injury, with mortality as high as 10% at 1 month and 20%-30% at 1 year after fracture (Bentler et al., 2009; Guerra et al., 2016; Lisk & Yeong, 2014; Meessen et al., 2014).
The association between care delivery and outcomes prompted several nations worldwide to invest in registries, research, and quality improvement initiatives for this vulnerable population (American College of Surgeons, 2017; Dy, Bumpass, Makhani, & Bozic, 2016; National Institute for Health and Care Excellence, 2014; National Office of Clinical Audit, 2015; Royal College of Physicians, 2015; Thorngren, 2008). These initiatives defined surgical and medical quality indicators to improve outcomes after fragility hip fracture. The audit of these indicators in practice led to demonstrable improvements in care processes and patient outcomes (Neuburger et al., 2015). It is imperative that these standards are consistently applied in practice settings to enhance recovery both for patients and for healthcare sustainability.
In 2010, the International Collaboration of Orthopaedic Nursing (ICON) identified improving care of patients with fragility hip fracture as a priority for action. ICON is an organization that unites national orthopaedic nurses' associations in promoting best practice for orthopaedic patients on a global scale (Meehan, Maher, & Hommel, 2015). Building on the success of the national initiatives noted earlier, ICON formed a Hip Fracture Work Group to synthesize the evidence on best practice nursing care for older adults with fragility hip fracture. The team consisted of national orthopaedic nursing leaders and researchers from nine countries across four continents.
The work group reviewed the literature and, via Skype, identified evidence-supported best practice recommendations for this population. Through this process, the team achieved consensus on a set of international care standards that were relevant and applicable across participants' nations and care settings. This work culminated in the publication of a two-part, peer-reviewed article (Maher et al., 2012,2013). This information was also presented at a number of nursing and multidisciplinary conferences internationally.
Recognizing that knowledge alone does not improve practice, the Hip Fracture Work Group, using the identified evidence-supported care standards as a foundation, developed and validated the Best Practice Care Standards Audit Tool. This audit tool was designed to assist point-of-care leaders in identifying the requisite clinical practices that support optimal patient outcomes. It was postulated that clinical leaders who completed the audit would identify care gaps, and this process could serve as a catalyst for improvement activity. Therefore, the purpose of this article is to:
1. Outline the process for developing and validating the audit tool; and
2. Identify the extent to which evidence-based care practices are reflected in nursing policy and procedures at select acute care settings around the world.
Methods
Using a qualitative and unstructured round approach, the team met repeatedly on Skype to draft the audit and supporting evidence. The audit contains 12 quality indicators that, with the exception of timing of surgery, are considered nurse-sensitive. These nurse-sensitive indicators include ensuring early mobility, malnutrition prevention, catheter-associated urinary tract infection (CAUTI) prevention, pain management, delirium assessment and prevention, pneumonia prevention, constipation prevention and management, venous thromboembolism (VTE) prevention, pressure injury prevention, care transitions, and bone health. Each indicator is interrogated with four to five yes/no questions and color coded for ease of identification.
The audit was beta tested using a mixed-methods approach. The initial round included a purposeful sample of five hospitals selected from each of five countries for a total of 25 hospitals. Each participating hospital performed a minimum of 100 hip fracture surgical procedures a year. Each national representative recruited sites from his or her own country. Orthopaedic clinical leaders at these sites were electronically provided a package consisting of (1) brief instructions for completing the audit, (2) a copy of the audit tool, (3) a rationale document with evidence supporting each component of the audit (ICON Hip Fracture Work Group, 2016), and (4) a user experience survey to determine any concerns with the length, clarity, applicability, and relevance of the survey and whether they intended to make changes as a result of participating in the audit process.
Respondents identified items that were subject to misinterpretation (e.g., aggregate data on patient volumes, gender) and clarified that to effectively complete the audit, the orthopaedic clinical leader must be directly involved at the point of care. Participants also indicated that it would be useful to note whether participating sites provided nursing staff with information about specific quality indicators during orientation, ongoing competency training, or other professional development initiatives. On the basis of these results and discussions, the team generated a set of audit criteria:
* The audit will be comprehensive, encompassing relevant care.
* Each care standard is evidence-based.
* Each care standard is deemed relevant and applicable across nations.
* Nursing care influences the achievement of the standard.
* The audit language is clear and understandable across clinical sites and nations.
* Requested data are readily retrievable by clinical leaders.
* The audit is succinct and easy to complete.
On the basis of the beta-testing feedback and applying the aforementioned criteria, the audit, instructions, and user experience survey were revised and disseminated again to a sample of nurses in point-of-care leadership roles across 35 sites representing seven countries: Australia, Canada, Denmark, Ireland, New Zealand, Sweden, and the United States.
Results
Hospital Characteristics
In total, 35 hospitals completed the survey between June 1, 2016, and August 31, 2016. The survey participants included eight hospitals in Canada, five in the United States, three in Australia, one in New Zealand, and six each in Denmark, Sweden, and Ireland. More hospitals were teaching hospitals (77%) than nonteaching hospitals (23%) (see Table 1).
Quality Indicators
Timing of Surgery
Overall, 32 hospitals (91%) reported a policy for timing of surgery: 17 (49%) for surgery within 24 hours, one (3%) within 36 hours, and 14 (40%) within 48 hours. One hospital in Canada and two in the United States reported no policy for the timing of surgery (see Table 2).
Early and Frequent Mobility
Overall, 23 hospitals (70%) promoted mobility on the day of surgery and during mealtimes. Twenty-four hospitals (73%) promoted mobilizing patients twice daily beginning within 2 days of surgery, whereas 23 hospitals (68%) reported a policy for patients to be out of bed for at least two meals beginning the day after surgery. Twenty-seven hospitals (79%) reported nurses ensure that mobility standards are met (see Table 2).
Malnutrition Prevention
Overall, 28 hospitals (82%) promoted a nutrition screen on admission. Preoperatively, three hospitals (9%) promoted a high carbohydrate drink within 4 hours before surgery, 11 hospitals (32%) promoted clear fluids up to 2 hours before surgery, and 25 hospitals (74%) provided a meal if surgical waiting time exceeds 8 hours. Postoperatively, 33 hospitals (97%) promoted diet as tolerated and 25 hospitals (74%) provided nutritional supplements (see Table 2).
CAUTI Prevention
Overall, 22 hospitals (69%) supported avoiding the routine use of indwelling urinary catheter, with 24 hospitals (73%) inserting only if predetermined criteria were met. Postoperative catheter removal was promoted within 24 hours for 15 hospitals (60%), 36 hours for one hospital (4%), 48 hours for eight hospitals (32%), and 72 hours for one hospital (4%). Nurses removed catheters at 24 hospitals (73%) (see Table 2). Ten hospitals (27%) did not complete the survey item related to the time of removal of indwelling urinary catheters.
Pain Management
All 35 hospitals (100%) supported regular pain assessment and reassessment with a valid tool. Overall, 30 hospitals (86%) promoted a multimodal approach to pain management, 33 hospitals (94%) scheduled administration of pain medication, and 26 hospitals (84%) supported using geriatric appropriate pain medication and dosage. Regional pain block was available at 15 hospitals (44%). Nurses administered regional pain block at three hospitals (9%) (see Table 2).
Delirium
Overall, 23 hospitals (68%) supported completing a cognitive screen and 24 hospitals (71%) reported a policy directing completion of a delirium screen on admission. Daily delirium screening was supported by policy in 15 hospitals (43%). A protocol that limits medication use to harmful behaviors was reported in 28 hospitals (82%) (see Table 2).
Pneumonia Prevention
Six hospitals (18%) promoted dysphagia screening prior to the first postoperative meal, 21 hospitals (64%) used a mouth care protocol, and 17 hospitals (53%) supported elevating the head of the bed to 30[degrees] (see Table 2).
Constipation Prevention
Overall, 28 hospitals (80%) followed a bowel protocol, 34 hospitals (97%) assessed bowel movement daily, and 32 hospitals (94%) reported having a policy supporting administration of laxatives prophylactically (see Table 2).
VTE Prevention
All 35 hospitals (100%) followed a VTE prophylaxis protocol (see Table 2).
Pressure Injury Prevention
All 35 hospitals (100%) reported completion of a valid pressure injury risk assessment on admission, and 31 hospitals (91%) promoted a head-to-toe skin assessment on admission. Overall, 33 hospitals (94%) followed a pressure injury care plan (see Table 2).
Care Transitions/Preparing for Home
Overall, 22 hospitals (63%) reported having written patient self-management instructions whereas nine hospitals (28%) reported a process that recommends a follow-up with a family practitioner within 4 weeks of discharge (see Table 2).
Bone Health
Overall, 18 hospitals (53%) promoted bone health follow-up (see Table 2).
Education Regarding Quality Indicators
During beta testing, participants suggested adding a question to ascertain whether staff received education about specific quality indicators, either in orientation, as part of annual competencies, or in other professional development initiatives. A question regarding staff education was added to the final audit under each quality indicator. Results revealed that half or more of participating hospitals provided standards education about VTE (100%), pressure injury (85%), constipation (85%), pain (79%), CAUTI prevention (79%), nutrition (75%), mobility (62%), delirium (56%), care transition (53%), and pneumonia prevention (50%). Only bone health education (42%) was covered by less than 50% of hospitals (see Table 2).
User Experience Survey
A review of the user experience surveys found that (1) the survey typically took 15-30 minutes to complete, (2) the content was viewed as relevant and applicable to the practice setting, and, most important, (3) several site respondents noted they intend to embark on improvement activities as a result of completing the audit such as:
* Including baseline cognitive assessment in the care plan;
* Strengthening/developing a delirium protocol;
* Early identification, screening, and planning for dysphagia as part of pneumonia prevention; and
* Assessing/addressing nutritional needs.
Discussion
This article describes the process of developing an international audit tool for acute care nurses to identify, measure, and deliver best practice for older adults with fragility hip fracture. Expert orthopaedic nurses from nine countries across three continents contributed to this work, offering the additional perspective of standards successfully tested across diverse healthcare systems. Developing and testing an audit in one jurisdiction are valuable, but developing an international consensus tool to assess best practice care for hip fracture patents could be used to influence care globally. Defining best practice care standards highlights the vital care that nurses provide.
Regardless of jurisdiction, this common injury-fragility hip fracture-requires a very similar approach to care. This cohort of patients represents primarily a frail older population, and fragility hip fracture serves as a marker condition for not only how well care is delivered to older patients in an acute hospital but also how well an overall healthcare service functions. We have already seen the significant impact of hip fracture registries and audit programs to improving care delivery and outcomes in this frail group of patients (Fragility Fracture Network, 2015). Until now, these registries have focused mainly on medical, surgical, and secondary prevention standards, with limited attention to the impact of nursing care on outcomes. Apart from pressure injury development and the more recent addition of pain assessment and nutrition in the United Kingdom registry (Royal College of Physicians, 2016), nursing care data have not routinely been included.
Considering nurses are at the bedside 24 hours per day, their input and influence on outcomes are significant. This audit tool provides the first comprehensive list of care indicators related to nursing care of fragility hip fracture and should allow nurses in any country to use this audit to benchmark their practice against best evidence. A rationale document was provided that succinctly outlines evidence supporting each of the items included in the audit tool. This document may also inform national registries or audit programs of relevant nurse-sensitive indicators to consider for future inclusion (Hommel & Baath, 2015).
Beta testing of the audit highlighted the need for clarification and refinement as variances in resources, practice patterns, and terminology emerged. Common core standards were defined; however, there were some variations among countries (e.g., preoperative fasting times were shorter in the European countries surveyed). The specifics of the standards were left broad enough to account for regional resources and practices (e.g., multimodal analgesia did not define the specific drugs or doses to use for this population).
It is important to note that the audit was not designed to make comparisons across nations. Indeed, there was significant variation within nations, especially in those that do not have a national approach to standardized healthcare. The audit measures whether care standards are embedded in protocols, policies, and/or processes related to patient care but not whether the standards are actually applied in daily practice.
Implications for Nursing Practice
Respondents to the audit shared that completion of the questionnaire served as a gap analysis, identifying opportunities to improve care. They appreciated the accompanying rationale document, providing evidence supporting the surveyed items. Overall, results identified low percentages for standards education, particularly in the areas of bone health, pneumonia, delirium, and care transitions. Standards education for osteoporosis, prevention of postoperative complications (including delirium), and potential care transitions is often incorporated into undergraduate curriculum. Whether this information is reinforced through workplace educational offerings is unclear. In the context of finite resources, it may be suggested that clinical continuing education may be underprioritized over direct patient care (Clark et al., 2017). E-learning courses have shown promising results for improving nursing staff's knowledge of delirium (van de Steeg, IJkema, Wagner, & Langelaan, 2015). Such courses may present a viable and flexible opportunity for improving standards education among orthopaedic nurses.
Limitations
This study reports on an audit of 35 hospitals from seven countries. The audit reviewed the extent to which evidence-based standards were reflected in nursing policies and protocols; however, the results were not further validated with a chart review. Using a chart review may provide a better vehicle to confirm the presence or absence of best practice nursing care standards but would limit the number of hospitals that could be evaluated. Future research may wish to replicate this study to validate findings and determine whether the results are further reflected in patient care nursing documentation.
Despite the limitation of a small sample size, the testing of this audit tool demonstrates international agreement among orthopaedic nurses of a core set of quality indicators essential to ensuring optimal outcomes for older adults with fragility hip fracture.
Conclusion
Developing and testing an audit of nurse-sensitive quality indicators for older adults with fragility hip fracture demonstrate consensus on common core best practices and highlight the collective will of nurses across multiple nations to provide optimal care. Nurses can tap into the wisdom of colleagues at home and abroad to facilitate practice improvements that enhance patient outcomes. This serves to strengthen the current evidence base for nursing care of older adults with fragility hip fracture as well as promote ICON's goal of the universal application of the highest standard of orthopaedic nursing care.
Acknowledgments
The authors thank Professor Boris Sobolev for his support of the project and express their deep appreciation to the clinical leads at the 35 sites who gave their time to complete the audit.
References