Abstract
Purpose
Hip fractures are the most common injury requiring hospitalization in both men and women over the age of 65. There is significant mortality associated with hip fracture and delay to surgical treatment increases this rate. We undertook an ethnographic study exploring organizational barriers to timely hip fracture surgery.
Method
Using purposive sampling, over 30 interviews were conducted at a large teaching hospital with various professionals involved in the process of getting a patient from ED to surgery and to surgical discharge. This included anaesthetists, surgeons, emergency and internal medicine physicians, nurses, social workers and senior administrative personnel. An additional twelve patient interviews were conducted and reported separately. Following transcription of each tape, a small study team met over the course of several months to read and discuss each transcript in detail. A coding template was developed and each transcript coded with emerging themes noted.
Results
Several important themes emerged which impact time to hip fracture surgery. We have classified these as: 1) issues related to inter and intra-professional collaboration; 2) social admissions or “failure to cope” (FTC) patients who are referred to surgical orthopaedic ward beds; 3) difficulties in discharge to rehabilitation; and 4) the disconnect between hospital administration's discourse of efficiency while insufficient resources choke optimal patient flow of care.
Conclusion
Inter and intra-professional collaboration has been recognized as central to the provision of excellent, patient-centred care yet not often been studied empirically. Our study revealed obstacles at several stages that stretched from admission at the ED to post-surgical discharge. Tensions were reported between medical, anaesthetic and surgical specialists in relation to consults, anticoagulation and pre-op testing that frustrated attempts to operate within the current Ontario wait time standard of 48 hours. Competition for scarce hospital beds also increased this tension and sense of frustration. In addition, non-operative fracture patients are often referred from ED to orthopaedic surgical wards, thus further delaying access for patients requiring emergent hip fracture surgery due to lack of surgical bed availability. On the basis of these findings our team hopes to advance recommendations designed to address these issues and improve wait times that will be applicable to other hospitals. These recommendations may include the inclusion of a geriatrician or hospitalist on orthopaedic wards as well as harmonized guidelines and care pathways. In addition, we are adding to the understanding of the social organization of acute care in complex and demanding environments.
