Evidence
Alert

People who are active on the day of hip surgery, or the day after, are twice as likely to be home within a month

People over 60 who need surgery after breaking a hip are discharged from hospital sooner if they get moving quickly.  The largest study of its kind found that those who get out of bed on the day of hip surgery, or the day after, were twice as likely to leave hospital within 30 days. 

The benefit of early mobilisation is so striking that targets should be introduced to support hospital staff in getting more hip fracture patients out of bed soon after surgery, the study authors suggest.

At present, about one in five patients are still in bed two or more days after their surgery. As well as prolonging their stay in hospital, such delays in mobilisation might increase the risk of pneumonia, and loss of muscle strength. These complications may in turn reduce survival.   

What’s the issue?

Some 66,000 older people need hip fracture surgery in the UK each year. Most want to leave hospital and get home as quickly as possible. One way to help make this happen is for hospital staff to support patients to get out of bed and walk around soon after their operation. Current NICE guidelines recommend patients are mobilised on the day after hip fracture surgery.

Previous research has found that different centres have different rates of early mobilisation. In some, less than half the patients are mobile the day after surgery. Overall, about one in five people are not up and moving in the first day or so after hip surgery. This can be down to post-operative complications such as low blood pressure and delirium, or because there are not enough staff to support all patients to mobilise early. 

Targets and financial incentives for hospitals – called Best Practice Tariffs – are already in place to reward six clinical standards of care in hip surgery (such as that surgery takes place within 36 hours of admission, or that people are assessed by a geriatrician before surgery). But before this study, the evidence for the benefits of early mobilisation was not convincing enough to lobby for a Best Practice Tariff for early mobilisation.

What’s new?

The study analysed data on 135,105 people aged 60 years or older. They all had surgery for hip fracture in 2014-16 in hospitals in England and Wales. The study looked at whether they were mobilised on the day of or day after their operation, and how long they spent in hospital before they were discharged. To test the association between the two, the study accounted for other factors that could make a difference, including people’s age, sex, ethnicity, other illnesses they had and the type of fracture.   

The study found: 

  • four in five (79%) of the patients were mobilised early (on the day of surgery or the day after)
  • early mobilisation was associated with earlier discharge
  • patients mobilised early were twice as likely to go home within 30 days of surgery.

Why is this important?

In this study, people’s experience after hip surgery was observed and recorded; they were not randomly allocated to receive (or not receive) early mobilisation. Such randomised controlled trials are considered the most reliable for testing interventions.

However, it is the largest study to date to test the benefits of early mobilisation. The results offer convincing evidence that getting hip fracture patients up and active within a day or so of surgery, should become the standard of care

The authors are among experts who believe that early mobilisation should now attract a Best Practice Tariff. This pay-for-performance scheme is in place for other aspects of care; it is estimated to have led to 7,600 fewer deaths among hip fracture patients in England between 2010 and 2016.

What’s next?

The Best Practice Tariff scheme the authors identify as a suitable pay-for-performance mechanism to incentivise early mobilisation is currently suspended because of the COVID-19 pandemic. When it reopens, the study authors intend to lobby for the new target to be included, of mobilisation by the day after surgery.

Further research is also needed to better understand the reasons why one in five people with hip fractures do not currently receive early-mobilisation – and how barriers could be overcome. Low blood pressure and delirium after surgery could, for example, be tackled with different procedures around the time of surgery. 

The current study did not explore why or how early mobilisation seems to have such a significant benefit on early discharge from hospital. One suggestion is that it can reduce the risk of complications after surgery for hip fractures. Previous research has suggested that delayed mobilisation is linked to an increased risk of pneumonia or delirium. But this is not proven and more research is needed to understand what is happening among different groups of patients, for example to compare those who were active before their fracture with those who were not. 

The researchers also suggest that it would be helpful to understand more about the effect of early mobilisation on long term function and mobility, months after surgery.    

You may be interested to read

The full study: Sheehan K, and others. Discharge after hip fracture surgery by mobilisation timing: secondary analysis of the UK National Hip Fracture Database. Age and Ageing 2021;50:415–422 

Editorial on the paper: Sallehuddin H, and Ong T. Get up and get moving—early mobilisation after hip fracture surgery. Age and Ageing  2021;50:356-357

The national audit of physiotherapy after hip fracture: Physiotherapy Hip Fracture Sprint Audit (PHFSA)

The National Hip Fracture Database (NHFD) Annual Report 2020

Funding

This project was funded by the NIHR Research for Patient Benefit programme. 

Commentaries

Study author

The most important thing for most older adult patients is to get home again. And especially with a higher risk of coronavirus in hospitals, they want to be discharged. 

I was pleased to see such a strong association between early mobilisation and discharge. Healthcare professionals work hard to get these patients out of bed and active and it’s great to be able to generate the evidence to show their efforts are worth it.

Katie Sheehan, Senior Lecturer in Rehabilitation, King’s College London 

Research physiotherapist 

The recommendation of mobility as a new Best Practice Tariff is forward-thinking. The Chartered Society of Physiotherapy has already implemented local standards for care after hip fracture. This now needs to be made a national driver so that healthcare providers are accountable for this measure to the commissioners, and the public are aware of what care they should be expecting to receive as part of best practice.

The National Hip Fracture Database (NHFD) is robust, with the majority of hospitals in England and Wales feeding regularly into it. It records if a patient mobilises on day 0 or day 1 but it will need to start collecting the exact time for Trusts to determine whether patients are mobile within the recommended 36 hours.

Further research is needed to explore the link between early mobilisation and reduced length of stay, and what other factors early mobilisation contributes to a patient’s recovery.

Ruth Halliday, Research Physiotherapist in Trauma & Orthopaedics, North Bristol NHS Trust 

Conflicts of Interest

None declared.