Psychiatrist-led rehab program improves functional outcomes in hip fracture patients

Patients show significant functional improvements following a psychiatrist-led postoperative hip fracture inpatient rehabilitation program in an acute hospital (AH), reports a Singapore study. In addition, the program boasts of a high discharge-to-home rate and low in-hospital mortality.

From January 2010 to December 2016, a team of researchers retrospectively reviewed the database of postoperative hip fracture patients who underwent a psychiatrist-led AH-based inpatient rehabilitation.

Functional improvement, the primary outcome, was assessed by functional independence measure (FIM) and FIM efficiency. Length of stay (LOS), successful discharge to home rate, mortality rate, and complication rate served as secondary outcomes.

Overall, 293 patients participated in this study. Their mean total FIM rose from 83.9 to 93.9 (p<0.001) and motor FIM from 47.1 to 56.1 (p<0.001) after completing the inpatient rehabilitation program. [Proc Singap Healthc 2022;doi:10.1177/20101058221129713]

Most of the patients (n=269, 91.8 percent) were successfully discharged home, and only one (0.3 percent) died. The rate of complications during inpatient rehabilitation was 16.0 percent, with urinary tract infection being the most common (10.2 percent). The median LOS for inpatient rehabilitation was 19 days (range, 15‒28).

Some studies in Singapore have explored hip fracture pathways and assessed the effectiveness of community hospital-based rehabilitation programs, but only a few evaluated hip fracture programs in the AH setting. [Ann Acad Med Singap 2014;43:209-215; Arch Orthop Trauma Surg 2014;134:351-357; Proc Singapore Healthc 2016;25:13-18]

Psychiatrist team leader

In the current study, a multidisciplinary team led by a psychiatrist provided the inpatient rehabilitation program in an AH ward. Previous studies showed that multidisciplinary team care for hip fracture patients resulted in better clinical outcomes. [Clinics (Sao Paulo, Brazil) 2012;67:547-556; J Am Geriatr Soc 2005;53:1476-1482; Hong Kong Med J 2018;24(Suppl 2):45-47]

“Having a physiatrist as the team leader enables the most updated exercise guidelines to be administered and tailored to the individual’s need, and facilitates more effective communication with the therapists,” the researchers said.

The program also stressed the importance of early initiation of rehabilitation, intensive rehabilitation, and continuity of care. For instance, the input from a psychiatrist or a rehabilitation medicine-trained advanced practice nurse was obtained within 48 hours following surgery. The program started as soon as the patient was medically fit.

Of note, “serial functional assessment with FIM allowed for dynamic monitoring and feedback to guide the planning of an individualized rehabilitation program,” the researchers said. “Various outcome measures used in hip fracture have been discussed in previous literature. [Arch Orthop Trauma Surg 2011;131:1687-1695]

FIM is widely accepted as a functional assessment tool for activity and participation evaluation. Previous hip fracture studies have also used this as the outcome measurement. [Pm r 2014;6:493-497; Geriatr Gerontology International 2018;18:1143-1146; Geriatr Gerontol Int 2016;16:963-968]

The current study was limited by the absence of a control group and a postdischarge follow-up of the study group, as well as the lack of data on the number of patients with dementia or cognitive impairment. The cost-effectiveness of conducting rehabilitation programs in AH was also not evaluated.

Furthermore, the researchers only analysed patients transferred to Department of Rehabilitation Medicine for inpatient rehabilitation but not those who were potentially eligible.