Background and purpose: As hip fracture patients are common and constitute an increasing health problem it is important to use available resources effectively and provide high quality care. Correct treatment can start in the ambulance with administration of oxygen, pain relief and intravenous glucose liquid according to the Lean Production concept. The basis of Lean Production is that the employees themselves develop their work as a natural part of the job. In the case of health care, this involves learning what it are that really benefits the patients, what it is that creates added value. Anything that does not benefit the patients is to be removed.

The aim of this study was to improve the preopera-tive care of hip fracture patients.

Subjects : During the period 2007-04-01 to 2007-12-31 totally 365 hip fracture patients were consecutively admitted to the University Hospital. Of them 117 (mean age 82.8) patients were included in the project and 248 patients (mean age 81.3) were controls.

Method: Patients with a suspected hip fracture (shortened and externally rotated leg) were supposed to be included in the study. Exclusions criteria were medical unfit patients with for example ongoing hearth problems or stroke. Already in the ambulance the patient’s identification was established, blood samples were drawn and electrocardiography was taken. At admission to the hospital the ambulance personnel directly followed the patient to the x-ray unit and further to the orthopaedic ward without passing the acute and emergency unit.

Results: Patients included in the project felt that they were in safe hands and were satisfied with the handling time from the ambulance until they were at the ward. This time has diminished from 4 hours to half a hour. The mean time from admission to surgery was 29 hours for patients in the control group versus 21 hours for patients included in the project. Furthermore, the personnel at the x-ray unit are satisfied with the new organisation since there are more personnel lifting a better pain relieved patient from the trolley to the x-ray table.

Conclusion: When we are working in multi professional and multi functional teams with the LEAN concept, safety and quality of care can be improved if the preop-erative care of hip fracture patients is speeded up.

Due to an ageing population the numbers of patients with hip fractures are increasing. They often suffer from concomitant diseases and are therefore prone to be affected by complications such as pressure ulcers. The prevention of pressure ulcers among patients with a hip fracture is crucial. The aim of this study was to improve the quality of care and patient safety in patients with a hip fracture. A new evidence based clinical pathway was introduced to prevent hospital acquired pressure ulcers. Furthermore the purpose was to bring the staff’s attention to pressure ulcer prevention and to facilitate changes in clinical practice to improve quality of care and patient safety. A total of 478 patients with a hip fracture were consecutively included between April 1st 2003 and March 31 st 2004. The new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. In the intervention group hospital acquired pressure ulcers decreased by 50% (p< 0.007). It is possible to reduce the development

Background and Aims: Patients with a hip fracture often have a poor nutritional status which is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention.

Methods: A quasi-experimental study of 478 patients consecutively included between April 1st 2003 and March 31st 2004. A new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article.

Results: The total number of patients with a hospital acquired pressure ulcer was in the intervention group, 19 patients, and in the control group 39 patients (p=0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p=0.05), calf circumference (CC) (p=0.038) and body mass index (BMI) (p=0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) < 10th percentile and AMC < 10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the four patients in the intervention group developed pressure ulcers. However two of the 12patients in the control group were affected.

Conclusions: It is possible to reduce the development of hospital acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. The results in this study indicate the value of the new clinical pathway, as the number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.

Hip fractures constitute a major cause of hospital admission and length of stay in the elderly, resulting in increased disability and mortality. In this study the influence of optimized treatment of consecutively included patients with hip fracture on time to operation, bed days, reoperations and mortality within one year were investigated. The study period was April 1st 2003 and March 31st 2004. Comparisons are made between the 210 first patients and the 210 last patients who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24 hours, was not associated with reduced mortality, but it was significantly associated with reduced length of stay (p< 0.001). Significantly more patients operated with osteosynthesis for femoral neck fracture, were reoperated compared to all other types of surgery (p< 0.001) also when reoperations with extraction of the hook-pins in healed fractures were excluded. Mortality was higher in men than in women at four (p = 0.025) and twelve months (p = 0.001) after the fracture. Mortality was significantly higher in medically fit patients with administrative delay to surgery compared to patients with no delay (p< 0.001).

The health care system has to deal with substantial health care costs, which are expected to continue to rise due to the increasingly elderly populations. One way of saving has been a reduction of the amount of beds at hospitals. The consequence is that acute patients inappropriately are admitted to non specialized wards because of limited beds. These patients are also known as ‘outliers’. In this study consecutive patients with a hip fracture treated at the orthopaedic department (n=273) are compared with patients treated at other departments (n=147) according to incidence of complications and length of stay (LOS) before and after introduction of an evidence based clinical pathway. There was no medical difference between the populations. However the strict demands of saving costs, with limited beds, have resulted not only in economic consequences with prolonged hospitalization, but also in patient suffering and inconvenience of postoperative complications because of an increasing number of complications.

Patients treated at non specialized wards had an extra LOS of stay of 3.7 days in the acute hospital settings and furthermore 13.6 days of LOS including rehabilitation compared to patients treated at the orthopaedic department. In addition we consider the implemented evidence based clinical pathway to be successful since the number of complications was reduced. It is a major challenge to establish effective treatment and rehabilitation for patients after a hip fracture aiming to avoid complications and reduce LOS. Theses fragile patients with a hip fracture ought to be treated at the orthopaedic department, or at departments with geriatric and rehabilitation knowledge. Physiotherapists, occupational therapists and nurses specialising in orthopaedics and geriatricians should take an active part in these patients care, to improve the quality of care and patient safety in patients with a hip fracture.