Conquering distance for timely transfer of hip fracture patients

Fiona Stanley Hospital Geriatrician Dr Hannah Seymour knows better than most that time can be a crucial factor when treating people who break their hip – especially when facing geographical barriers.

From her experience of working closely with older patients who have had a hip fracture, Dr Seymour understands that prompt surgery reduces pain, hastens recovery and reduces time spent in hospital.

Yet as hip fracture surgery can only be performed at larger hospitals with suitable facilities, some people in regional and remote areas must be transferred large distances. In 2022, 14 per cent of hip fracture patients were transferred from another hospital for their surgery.

Across Australia, there is stark variation in the average time to surgery for hip fracture – from 16 to 92 hours for all patients last year.

This is set to improve with the updated Hip Fracture Clinical Care Standard (2023), released by the Australian Commission on Safety and Quality in Health Care.

The standard has reduced the recommended time to surgery from 48 to 36 hours, in line with international guidelines – even when the patient must be transferred from the first hospital they attend. In 2022, the average time to surgery was 38 hours for non-transferred patients but 51 hours for transferred patients.

The revised standard calls on healthcare services to build effective systems and networks with other facilities to ensure coordinated transfer and help all patients receive timely surgery.

For Dr Seymour, this change in the standard will be a key driver to improve time to surgery for all patients.

“Nationally, we haven’t reduced our average time to surgery and are failing patients. It is disappointing and needs to change because older people are lying in hospitals in pain for longer than they need to be.

“We know that it is possible to reduce the time to surgery if you have the right systems in place,” she said.

“We’ve shown in WA that it often takes just as long for a patient being transferred for surgery from a hospital 45 minutes away by car, as it does for someone flown in from hundreds of kilometres away.

It doesn’t matter where you transfer from, all patients are waiting, even if they are just down the road.”

WA Health has streamlined the interhospital transfer of patients. There are now clear arrangements, so hospitals in smaller WA towns know where they need to transfer the patient.

WA Country Health Service’s partnership with the Royal Flying Doctor Service (RFDS) and St John Ambulance via the Acute Patient Transfer Coordination unit has set a target for patient transfer to a metropolitan hospital within 24 hours as well as the requirement for nerve blocks to be administered prior to transfer.

For 85-year-old Esperance grandmother Jill Bower, it was a relief to know she was in good hands when she arrived by ambulance at Esperance Hospital after fracturing her hip. The ED team swung into action to transfer Jill from the coastal town to Fiona Stanley with the RFDS.

Jill, who slipped while having a quiet night at home in late July, said she couldn’t fault the care she received from healthcare workers throughout her journey.

“The staff caring for me were all truly wonderful. At Esperance they gave me the nerve block in my groin for pain before they moved me, which was great.

“Early the next morning they put me on the RFDS flight, and I arrived in Perth by midday. I went straight to Fiona Stanley Hospital because they’d been warned – so I got a bed straight away, I didn’t have to wait,” Jill explained.

The whole process meant that Jill had surgery less than 48 hours after presenting to Esperance Hospital. The next day, she began her recovery under the care of Dr Seymour.

“They got me up the day after surgery on a tall frame and I felt good. Later they changed me onto a four-wheel walker and had me walking up the hallways once a day, using the side rails to keep me moving.”

Jill completed her recovery in two smaller hospitals where she was able to build up her strength before heading home to Esperance on a regional flight.

Dr Seymour explained: “If a patient like Jill falls and breaks their hip in Esperance, the local hospital team knows to deliver a nerve block and to get in touch with the metro hospitals. The patient is put on our surgery list when they call, so are in the queue based on the time of fracture.

“Established communication channels are now in place, and much of the time we can operate in that 36-hour window because we have a system with transfer protocols and straight-to-ward arrangements."

The WA Country Health Service team worked hard with their emergency departments to ensure staff were well trained to deliver a nerve block prior to moving patients, ensuring effective pain relief.

Dr Seymour said it was encouraging that 90 per cent of hip fracture patients nationally now receive nerve blocks before surgery, but sometimes only in the operating theatre. She supports the increased emphasis in the revised standard on patients receiving nerve blocks before transfer to decrease pain during transportation.

Jill, says she feels like the winner in a system that’s working well. “Everybody has been absolutely wonderful to me, and I felt very well cared for, even when they moved me.

After seven weeks, Jill felt in good shape and was pleased to go home in late August. As she reflects upon her experience, Jill offers a word of warning to others: “If you break your hip, definitely have a nerve block, and get up walking the day your surgery – but not too fast!” she chuckles.