Since the institutions’ implementation of the Bone & Joint Canada - Hip Fracture Toolkit recommendations in 2011, the nursing care pathways have been revised to be more broadly applicable a wide range of post-surgical populations, and hip fracture specific prompts for post-operative care were removed from the pathway in 2015. We did not know if the care prompts served as important reminders for the nursing staff, and we did not know the level of early mobility activities undertaken by health care providers. The 2017 publication of the HQO recommendations prompted a needs assessment to identify local evidence-to-practice gaps that may exist in the area of early mobility after surgery. Returning to the French & Green  four-step method, the chart audit information will be utilized to work through, specifically, step one: identifying if an evidence-to-practice gap exists, clinical behaviours that may be a target for change and who performs these behaviours, and when / where are these behaviours performed.
Identifying the evidence-to-practice gap
To identify the evidence-to-practice gap, we will compare the results of the chart review with HQO Standards (2017) (2).
HQO 2017 Standard 8: “Ensure protocols, pathways, medical directives, and standardized order sets are in place to facilitate patients achieving weight-bearing as tolerated within 24 hours following surgery” (p. 23). The institution’s adoption of HQO recommendations in 2009 had set out that the surgical teams are to repair the fragility fracture in a method that allows for early total weight-bearing, thereby avoiding the potential for prolonged bedrest post-operatively. Following surgery, prescribers also have the responsibility of ordering several interventions aimed at facilitating early mobility: a) weight-bearing as tolerated, b) physiotherapist assessment immediately after surgery, c) appropriate pain management medication, and d) early removal of medical interventions (i.e., urinary catheter and intravenous fluids). The pre-printed order sets with checklists for weight-bearing as tolerated, pain medication options, and automatic referrals to physiotherapy and occupational therapy were utilized in 99% of the cases.
HQO 2017 Standard 9: “Following surgery, ensure patients with hip fracture are mobilized at least once daily by a member of the health care staff. Where possible, family members or caregivers should be encouraged to assist with mobilization” (p. 26). Within the Standard, HQO defines mobility as a progression through a continuum of functional activities (i.e., sit at bedside, transfer to chair with assistance, transfer to chair independently, walk with assistance) (2). It is important to note that the definition of expected outcomes is not clearly stated within the Standard, nor does it indicate an outcome for measurement. Thus, it was difficult to ascertain what percentage of patients ‘met’ the criteria of daily mobility due to this lack of a clear definition. However, our data indicate a range of 50% − 89% of patients got up to chair, meaning that 11% − 50% are not participating in this activity in the first five days, and thus potentially not meeting HQO criteria. Even though there was a high rate of physiotherapy assessments on the first day (92%), only 51% of patients were able to get up to chair. When pre-fracture function is taken into consideration, one would expect that those patients with high pre-fracture function would be better able to participate in these activities, but only 45% of this group was up to chair on the first day after surgery. There may be several reasons for these low rates of participation - it is unclear if patients are not participating in the activity, or the documentation is not reflective of practice. The physiotherapists document each progressive activity performed, whereas the nursing documentation is more general, primarily reflecting time spent in chair. As physiotherapy assessments decline over time, the chart review data changes from identification of specific tasks (i.e., edge of bed) to time in chair. A further study of practices on the unit may be required to assess the actual rates of participation. The differences in documentation style, and lack of consistent language within the documentation makes it difficult to determine patient progression throughout the post-operative days.
One of the HQO recommended progressive activities is walking with assistance, yet no identification of goals for distances are provided. Within our cohort, by postoperative day five, only two patients in the high pre-functional group walked over 50 metres, with one patient walking 200 metres. Similar findings of limited tolerance for walking have been reported during the acute post operative recovery phase (28, 37). Literature has suggested that assessment of functional level and utilization of care pathways based on pre-fracture functional status may be feasible (34).
The HQO standards recommend that patients receive daily physiotherapy and occupational therapy, regardless of a patient’s cognitive status. Cognitive impairment (CI) has been identified as one of the most common barriers to early mobilization (38). However, in our chart review, in the first two days after surgery this population has a higher rate of achieving mobility activities than those with no cognitive impairment (Chart 1). Of the 48% that experienced some level of cognitive impairment, either from admission or new-onset after surgery, 54% patients were up to chair on the first day after surgery, compared to only 48% of those with no cognitive impairment. By the second day, those with no cognitive impairment have a higher rate of up to chair. The highest occurrence of up to chair for the cognitively impaired group did not occur until post operative day three (78%). The rationale for the differences between pre-fracture functional groups and cognitive status are unclear from the chart review, further assessment of local factors which may be influencing these findings is needed.
Clinical behaviours that may be a target for change (who performs the behaviours)
HQO (2017) has outlined daily mobilization should be facilitated by all members of the healthcare team, inclusive of family members. The chart review has confirmed that prescribers are utilizing the pre-printed order sets, not requiring further intervention at this time. There was no documentation within the physiotherapy or nursing notes about the inclusivity of family members in early mobility activities. This finding is interesting in that one wonders the extent to which family members are educated by staff to be involved in mobility activities, and even if they are involved, do the health care provider staff feel that family involvement is a documentable intervention? Family member involvement in mobility activities is an area of interest that would be worth exploring directly with the patients and their family members. It would be worthwhile to assess if a patient’s cognitive status impacts the level of involvement from family members. The patient and family member involvement may be an opportune target for behaviour change.
HQO (2017) indicates any health care provider involvement, including nursing, should be utilized to facilitate early mobility. In our chart audit, the mobility activity documented most by nursing staff was time spent in chair. The nursing documentation tool also has blank areas for ‘sitting at edge of bed’, ‘sit to stand’, ‘ambulation’, but this information was rarely completed. It is unclear whether this incomplete nursing documentation reflects a practice gap or inconsistent/missing documentation. Studies have suggested that the most frequent nurse initiated mobility activities in the older adult population are standing and transferring (39). It would be of interest to ask nurses if they consider the associated activities (i.e., sit at edge of bed) when they are documenting the patient time in chair. There was very little evidence of nursing proceeding to walk with patients. There is evidence to suggest that nurses may experience barriers with early mobility in this older adult population. Studies have identified that fear of the patient falling, lack of assistive devices, and lack of staff influenced nurses’ decisions about ambulating older patients (31). Doherty-King and Bowers (40) also found that nurses perceive risks related to injury to the patient (fall) or self (back) if they engaged older patients in walking. Further conversations with the nursing team about their barriers and facilitators to mobility activities with patients after hip fracture is warranted.
Literature has identified barriers to rehabilitation in patients with CI symptoms, including a limited ability to initiate activities; a demonstrated lack of insight/judgment, loss of purposeful movements, loss of recognition; and memory problems or language impairments (41). It is not clear from the chart review documentation if health care providers limit their time with patients related to facilitating early mobility activities in this patient population. Not all health care providers providing direct patient care have equal knowledge about effective strategies for rehabilitation in those with CI, resulting in diminished health care processes (41). Our chart review data confirms that there is an apparent disparity of physiotherapy assessments with those who are documented to have a cognitive impairment and low pre-fracture functional ability. This area would be one of interest to explore with health care providers.
Previous studies have identified medical interventional barriers such as intravenous lines, oxygen tubing, and urinary catheters (31). In our chart review, these barriers did exist; however, there was no documentation of these items listed as a cause of being unable to mobilize a patient. Additionally, we could find no mention of solutions or alternatives to address these tangible barriers (e.g., intravenous disconnected to allow for mobility). Based on this chart review alone, it is unclear if these medical interventions are a perceived barrier by health care providers or patients.
When and where are these behaviours performed
Although not specifically outlined by the HQO standard, one could picture the early mobility progression as a patient being assisted to sit at the edge of bed, transfer to a chair for meals, participate in physiotherapy, and continue with exercises as tolerated with the help of health care staff or family members. Performance of daily personal care and activities of daily living would be an opportune time for patients to engage in mobility activities – for example, having a patient ambulate to the bathroom for daily hygiene activities. Early mobility activities are the responsibility of the entire health care team, inclusive of a preliminary assessment by the physiotherapy team, involvement of occupational therapy, and finally incorporating education about early mobility for assistance by family members.
As stated, current documentation is fragmented across health care providers, making it difficult to track progress in mobility activities throughout a patient’s stay. Additionally, there was no information reflective of the patient and/or family perspective about early mobility activities, this may be a potential area for future change.