Twenty-nine participants were enrolled in the study; 26 (90%) were both interviewed and completed the questionnaire and 3 (10%) completed questionnaires only as they could not identify any particular reason why they were still in hospital. Fifteen (52%) of the participants were health care professionals, 8 (27%) were patients and 6 (21%) relatives. Patient participants’ mean age (SD [range] was 81 (7 [72 – 94]). Twenty-four percent (7) of participants were males and 75.9% (22) were females (table 1).
Table 1.
Themes
Five key themes and two subthemes were identified from the analysis (Figure 1). Individual themes are presented below with detailed supporting extracts from individual participants. Themes complement each other though there is some overlap.
Figure 1.
Medical conditions
This theme broadly encompasses both medical and surgical complications and its classified further into two sub- themes; comorbidities and post-operative morbidities. Both medical and surgical complications identified include; infections (wound, chest, urine), pain, delirium/confusion, dementia, cardiac issues, bleeding, DVT, blood transfusion, low blood pressure, gastrointestinal (e.g. constipation, ileus).
Pre-fracture comorbidities
The impact of an individual patient’s previous medical conditions as opposed to their current main reason of admission (fractured hip) was one of the key concepts outlined by eight participants. They acknowledged the complex nature of certain medical issues that individuals already have before the fracture. Furthermore, most patients are admitted with multiple medical problems.
“A lot of our patients are elderly with a lot of complex medical problems for example dementia”, NUH 096 (HCP).
“Some of them have high comorbidities unfortunately”, UHL 01 (HCP).
“The fact that they just don’t come with a hip fracture, they’ve got multiple other medical issues going on”, UHL 06 (HCP).
Circumstances relating to the current fall and underlying causes of fracture were seen to be influenced by inter-current illness and also potentially undiagnosed or new medical conditions. Once patients are admitted, it's more likely to take some time for other new medical conditions to be fully diagnosed and treated. Even though the hip has been fixed, patients remain in hospitals for other things.
“It can be numerous things that could have gone wrong with them that they may be unaware of any or they could be under treatment with the GP and these are things that actually go wrong more than the main fracture, and that is one of the biggest causes that keep patients in hospital. The comorbidities as we call them. That’s what keeps them mainly here”, UHL 01.
“One of the reasons could be the reason that caused them to break their hip in the first place. If it isn’t like trauma fracture, they could have a back history of falls. They could have medical reasons why they have fallen and broken their hip. They could have heart problems, blood pressure and things like that... They could have poor mobility” UHL 05 (HCP).
Post-operative morbidities
Nearly all participants gave detailed interview reports of factors involving post-operative complications. Complications arising from hip fracture surgery were perceived to be fairly common; significantly prolong hospital stay and a likely cause of patient death.
“If someone has got a chest infection, which is the most common cause of death after hip fracture, normally, it approximately delays discharge for 4-5 days. If original plan was to be discharge them in 10 days, it takes about two weeks”, UHL 04 (HCP).
“And other things you have got, infection of the wounds and quite a major one for keeping people here longer is leaky wounds. So that can hold people back because rehab destinations may not take patients with a leaky wound. And chest infections are another biggy”, UHL 08 (HCP).
“Some people come in with pneumonia already, or chest infection already or UTI already. Some people get them from us obviously we are catheterising them they can get the infection from that. So infection is a big one as well”, NUH 198 (HCP).
“And so we have got cases of developing DVT”, UHL 07 (HCP).
Effects of delirium and memory loss;
“In all the medical clinical memory tests she had, they gave her 3 or 5 words and 30seconds later asking her these words she does not remember the words”, NUH 202 (relative).
Pain influenced other functional aspect of recovery.
“It hurts” NUH 156 (patient).
“It’s painful and unbearable” NUH 157 (patient).
“Because she is in pain and she is not able to function properly”, UHL 11 (relative).
“Pain is a big issue, they suffer in pain and don’t want to weight bear on it”, UHL 02 (HCP).
Age
Age and frailty, particularly from health care professionals’ and relatives’ points of view, were considered precursors of the fracture itself with further influence on other themes such as medical conditions and recovery process. They reported that most fractures are due to falls, and elderly frail patients are unable to avoid falls possibly as a result of slow reflex/reaction deficit attributed to age. It also limits expected recovery ability performance of patients such that there is an expectation for them to stay in hospital longer.
“Parents stay in hospital to recover and that recovery depends upon age and characteristics of each patient”, NUH 202 (relative).
“We are talking about patients 70 plus. They are not the strongest of the patients and unfortunately some of them take a long time to get back from this, sometimes they don’t that’s why the mortality is high in our wards”, UHL 01 (HCP).
“She finds it difficult to function anywhere at 95 years old. I thought she would be here for another two weeks. The state of her and her age”, UHL11 (relative).
Psychological aspects
Concerns of vulnerability, mental well-being and fear of falling were prominent factors. For example, they may result in reduction and avoidance of activities patients remain capable of performing. Consequently the degree of confidence in carrying out daily activities with the inhibition of fear of falling impact considerably on the physical, social and mental status [21].
"If you are living alone, you lose confidence in yourself thinking I might fall over again", NUH 155 (patient).
"Not doing well in themselves, they become depressed, frightened to go home if they are alone", NUH 189 (patient).
"Patients become worried about coping" [at home after discharge] NUH 191 (HCP).
"Some patients it’s fear, some patients don't want to go home, some patients are not motivated", UHL 02 (HCP).
While the fear of falling was evident, there was a concern that some patients would not freely express their concerns making it challenging to progress with their discharge plans.
"So if you sit and talk to them, you will find out its probably just fear, but they don't want all the people to see that they are frightened about falling. So all that, can delay their going home", UHL02 (HCP).
Recovery process
Mobility and rehabilitation aspects were considered to be part of the recovery process - where patients have to regain their minimal or baseline ability to perform daily activities of living before discharge. As part of rehabilitation, patients' usual environment might require some modification to assist with post-fracture functioning and serve to reduce the likelihood of future falls. Comparison between pre- and post-fall functioning as related to changes in activities was a concern. There was an expected reduction in flexibility and physical strength and inability to function as well as before hip fracture. Performing simple tasks around the house once discharged was perceived to be going to be a challenge by many participants as a result of stamina and dexterity loss.
"They never quite seem to get back to the same level of mobility as they had before falling and breaking their hip, and that means they cannot look after themselves, or if a patient has a hip fracture and they are from a residential home for example, that can be managed there if they are fairly mobile, then they have a fall they may not be able to get back to the same care home, then you have to get through the process of finding another one, that means a referral to social services assessments etc., and that might take some time", NUH 096 (HCP).
Association between themes;
"We cannot get them out of bed or do much with them in the early stages, so that kind of impact, everything else because they are not mobilising", NUH 197 (HCP).
Social aspects
Compromised social interaction after hip fracture was associated with self-limited activities. This may have repercussions on quality of life by limiting and changing social contacts and/ or leisure activities. Being alone was a huge concern associated with lack of family support.
"We have to look after ourselves, no reason to go home if I can't look after myself", NUH 157 (patient).
"Depends on home situation, if they are going to be on their own they will like it here”, (staying in hospital) NUH 158 (patient).
For those who require social care or placement in nursing or residential institutions, the process is perceived to be unnecessarily long.
“Socially it can be difficult for patients who are unable to return back to their homes and needing to have discharge to nursing and care homes, so that can be quite a lengthy process. There have been recently, a couple of patients, who have been having their discharge to complete in the ward and that was because they have behavioural problems, due to cognitive issues and it did feel like most of the care homes don’t want to take these particular patients, and then they stayed in hospital for quite a long time when perhaps they didn’t need to be if there had been a care home happy to assess them out there, but it was about perception. So that’s difficult. Socially people mostly stay because the care agencies at home are not able to provide these packages of care, whether that might be funding needs too”, UHL 06 (HCP).
“And in terms of some discharge destinations, arranging that can take time and obviously you have got to get the whole team input, so if you are arranging a package of care, that’s what usually holds people back most, trying to work out whether it suits everyone”, UHL 08 (HCP).
Variations in aspects of importance
When asked which factors are highly important, of the eight participants who answered the question in detail, six participants pointed out medical reasons were the most important. However, one participant considered all aspects to be of equal importance and one considered mobility to be important. There was a distinct variation in aspects identified by different participatory groups; HCP identified a broad spectrum of factors outlining all themes, while relatives and patients focused more on the recovery process and the functional ability (psychosocial) aspects. They appeared to be more concerned about individual patients' coping abilities after the fracture.
Table 2 shows the overall median scores and individual participating group scores per domain as measured by a 5-point Linkert scale. Eight domains: pulmonary, infectious, gastrointestinal, cardiovascular, neurological, haematology, wound and pain were found to be clinically significant with median >3. There was a similar reflection among individual participant groups, with some discrepancy in agreement on the endocrinology and mobility factors.
Table 2.