Ward 31: Acute Orthopaedic Hip Fracture Ward

In the Emergency Department

When your relative arrives in the hospital they will be seen in the Emergency Department. They will be assessed by the Emergency Team. As part of this assessment, they will:

• receive pain relief, this may be tablets, injection or a local anaesthetic block
• have an x-ray of the injured limb
• have their skin checked for injuries or pressure areas

Once their condition is stable and a bed is available, they will be transferred to the Acute Orthopaedic Hip Fracture Ward (Ward 31).

Ward 31: Acute Orthopaedic Hip Fracture Ward

The orthopaedic team meets at 0800 each morning to discuss new admissions and management plans, including surgery.

Here is some useful information about Ward 31:

Charge Nurses:

• The main board as you enter the ward advises you who is in charge of the ward each day – they wear a red badge on their uniform.

Communication:

• We would encourage you to speak to the named nurse and nursing auxiliary who are most involved with your relative’s day to day care, and physiotherapy or occupational therapy staff when you are in to visit.
• You may need to make an appointment to speak to the doctor.

Contacting the ward by phone:

The direct line number to Ward 31 is 01592 729331.

• We ask that you chose one family member as the main point of contact. This reduces the number of phone calls and gives the staff more time to care for your relative and our other patients.

Ward 31 Visiting times:

• We welcome visitors and have open visiting so you can visit at any time.
• There will be times when we may ask you to leave to respect the privacy and dignity of other patients.
• Also be aware that your relative may need rehabilitation and investigations during the day.

Protected Mealtimes in Ward 31:

• Breakfast is 0800, lunch 1145, dinner 1645, supper 2000

• To allow your relative to have time to enjoy their meals we aim to restrict interruptions by staff as much as possible.

• If your relative has difficulty eating, we would be happy for family to come in and assist at mealtimes. Please speak to the nursing staff if you wish to do this.

• Encourage your relative to eat and drink regularly to help recovery. Include foods with good amounts of protein.

Infection control and safety:

• Have only two visitors to each bed.
• Use the alcohol gel provided to clean your hands on entering and leaving the ward. You can also wash and dry your hands at the sink.
• Do not sit on the hospital beds or patient chairs.
• Do not bringing in flowers or plants.
• Where appropriate, we can store small amounts of food for your relative in the fridge. We have no facilities to re-heat food.

For safety:

• Give your relative the call bell on leaving the ward.
• Put the visitors’ chairs away.
• Tidy away any bags in the locker provided.

How can you help when your relative comes into hospital?

You can help by:

• Bringing in all medication and tablets prescribed by your relative’s GP.
• Advising the staff of their situation at home, the daily tasks they can manage and any help they receive at home.
• Telling us how well they walked at home. Do they use a walking aid (stick, frame)?
• Telling us how many falls they have had in the last year.
• Informing the staff if you have any concerns about your relative’s safety.
• Bringing in any spectacles or hearing aids.
• As soon as possible bring in a few changes of day clothes, nightwear and suitable footwear
• Providing toiletries for washing and grooming. For example, soap, toothbrush, toothpaste, shampoo, comb, razor, tissues.  
• Bring in their favourite snacks – higher energy and protein ones are best.
• Provide Power of Attorney details, if available.

What we discuss with you before surgery takes place?

• The surgeon will discuss any risks and complications with your relative before their surgery. 
• The doctor may also talk to your relative about putting a plan in place if, during the operation and the recovery period, they become very ill and they stop breathing or their heart stops. 

If your relative is confused following their injury, or has dementia, the doctor may discuss the risks of surgery with the next of kin or those with “Welfare Power of Attorney”.

Consent for surgery

Before operating on your relative, we need to obtain consent to do the surgery. There are three ways we do this:

1) From the patient if they can remember and understand what is being discussed i.e., they are not confused or suffering from dementia or delirium.

2) From a Welfare Power of Attorney (POA) or Welfare Guardian. This may be a family member who possesses legal powers to speak on behalf of the patient on welfare issues.

3) Senior medical staff – in cases where the patient cannot give consent and there is no POA. The medical team may then grant consent to treat.  Where possible we will discuss this decision with the family before any operation.  

Anaesthetic 

An anaesthetist will see your relative in the morning before the operation and assess them. They will discuss the type of anaesthetic they will receive. This may be a Spinal or a General anaesthetic.

Fasting

Your relative will fast before their operation. They will stop eating at least 6 hours before the operation.  They may have sips of clear fluids until they go to theatre. The nursing staff will liaise with the theatre and keep you and your relative informed.

False Teeth in theatre

Your relative can wear teeth when going to theatre. The anaesthetist will decide if they need to remove them during surgery. We provide a container to put teeth in.

Most people will need an operation to fix the broken hip. This can be by replacing all or part of their hip joint or fixing the broken hip with plates or screws. Ideally, this will be on the first or second day of admittance to hospital. 

Please see a few different operations described below:

• Hemi-arthroplasty: the ball of the broken hip is replaced with a metal ball and stem (figures a & b)  
• Total Hip Replacement: the ball and socket are both replaced (figure c).

Getting better after a broken hip 

Early surgery and a rehabilitation programme will help to improve the life of a person who has had a broken hip. It helps them get walking and reduce the time they spend in hospital. 

Out of every 100 patients one to two are not fit enough to have surgery to treat the broken hip. If this happens, we aim to keep your relative as comfortable as possible; it may be possible to get them up to sit in a chair or even walking with an aid.

Treatment in the ward

Early treatment will start in the ward. The: 

• Ward Doctor will admit the patient and check their recovery after the operation.
• The Medicine of the Elderly team will assess the falls and oversee the medical care on the ward.
• Physiotherapy and Nursing Staff will help your relative to move in bed, and to get out of bed for the first time.
• Occupational Therapy Staff will find out about your relative's home circumstances. They will look at their ability to manage everyday tasks.
• Physiotherapy Staff will start an exercise, standing and walking programme.
• The Dietician will help support good nutrition to aid your recovery.

What can you do to help with rehabilitation?

Footwear: 

• As soon as possible please bring in well-fitting flat shoes or supportive slippers.
• These make walking and balancing safer when your relative starts walking again. 
• After the injury and operation, the legs may be more swollen. Please allow for this by considering footwear which is a larger size or with adjustable straps. 

Clothes: 

• Wearing clothes helps us get back to normal, feel less like a patient and more comfortable when attending the gym. 
• As soon as possible bring in a few changes of clothes. 
• The hip will be swollen, make sure trousers or skirts are not too tight.

Exercises: 

• You can find these on the exercise sheet at the bedside. 
• Feel free to encourage your relative to do exercises in the chair at visiting time.

Walking: 

• When your relative is walking safely and independently in the ward it is good to encourage them to walk with you at visiting time. 
• Please discuss this with the Physiotherapist or Nurses.

“Getting going” in the gym

There is a therapy gym close to the ward. As your relative feels better, they can have their therapy in the gym.

If we have a group of patients at a similar level of recovery, we may have an exercise class. If your relative is well enough to attend, the class will include: 

• Exercises to help movement and strength  
• Activities to improve balance 
• Walking practice with walking aids

Encourage your relative to take a nourishing drink or snack after exercise. Make sure drinks and snacks are easily reached.

Please ask the physiotherapy staff any questions about your relative’s rehabilitation programme.

The dietician can advise you on the best drinks and snacks to improve nutrition.

Making progress

We know patients vary in how they progress following a broken hip. There are many reasons for this, both physical and psychological. 

You can help by showing interest and encouraging your relative to tell you how they are getting on with their walking and exercises.

The average length of stay in this Acute Orthopaedic Hip Fracture ward is 10 - 14 days.  Depending on progress, your relative may be able to return home earlier than this or their recovery may be slower.

Going home

Once your relative can walk on their own with their walking aid and manage everyday tasks then they can be discharged home. 

• Your relative may need support and continuing rehabilitation. The multidisciplinary team will refer them to the ICASS Community Rehabilitation Team
• If discharged home with the Community Rehabilitation Team, you may need a Key Safe to allow the team to access the house. Families are responsible for providing this. We can provide information to help you organise the Key Safe.
• We may assess your relative as independent walking, washing, dressing and managing simple tasks in the kitchen. If we do, we may discharge them home without support.

Slow Recovery and Down Stream Beds in the Community Hospitals

Many patients who break their hip have a history of other illnesses, falls and a poor ability to walk which can slow their recovery. Once they are medically stable, we may move them to a community hospital. They will have further rehabilitation and more time to reach their potential and prepare to go home.   Care is provided by NHS staff.

These Down Stream Beds are at:

• Adamson Hospital, Cupar
• Cameron Hospital, Windygates
• St Andrews Community Hospital
• Glenrothes Hospital
• Queen Margaret Hospital, Dunfermline

A member of the Orthopaedic Hip Fracture team will make the referral for a downstream bed and keep you informed.  In most instances the hospital closest to home will be selected but cannot be guaranteed.

The average length of stay in this Acute Orthopaedic Hip Fracture ward is 10 - 14 days.  Depending on progress, your relative may be able to return home earlier than this or their recovery may be slower.

Prepare for going home

Some suggestions that may help:

• De-clutter all rooms.
• Remove loose rugs and repair any worn floor coverings.
• Rearrange furniture to create space for walking with an aid.
• Address maintenance issues such as faulty heating systems. 

Consider issues such as shopping and domestic tasks. Who may be able to assist your relative with this when they are home?

• Make sure there is food in the house, see the leaflet “Hands up For Nutrition” for advice on food to aid recovery.
• Check the house is warm for the day they come home.
• Bring in an outdoor jacket and shoes to wear when they leave hospital.
• Do you feel your relative would benefit from a community falls alarm?  You can help by referring them to the Social Work Services before they go home. Phone no. 03451 551503
• A booklet with Shopping Service advice is also available.

Problems and complications following a broken hip

Some people may take a while to recover from a broken hip.  Others may not be as good on their feet as they were before their broken hip. Complications can also arise from the injury.  

Slow recovery 

• Not everyone will recover completely after having a broken hip. It depends on how healthy they were before the injury. A hip fracture is a serious injury in a frail person.
• Some people may not get back their previous ability to walk. They may no longer be able to live at home independently. 
• About three in every ten people who have had a hip fracture die within a year. Around a third of these deaths are directly related to the fracture.

Confusion

Following a hip fracture some patients can have episodes of confusion which we call delirium. Delirium can be more common if your relative is:

• Older and frail
• Diagnosed with dementia
• Dehydrated
• Constipated
• Severely ill
• On a lot of medication
• Has hearing or visual impairment
• Malnourished

Delirium is a state of mental confusion that can happen if you become unwell. Illness, surgery and medications can all cause delirium. It often starts suddenly, but usually improves when the condition causing it gets better. It can be frightening – not only for the person who is unwell, but also for carers, relatives and friends.

Delirium can cause: 

• Confusion
• Restless behaviour
• Sleepiness
• A complete change in personality
• A physical change in the patient’s condition, such as difficulty walking, swallowing or speaking

Patients with delirium may not recognise even their closest family. They may become paranoid, developing an extreme and irrational fear or distrust of others. It is common for patients to hallucinate (seeing or hearing things that are not there). 

Delirium can take time to improve. We target treatment at the underlying cause. Delirium can improve quickly but sometimes persists for weeks or months after we treat the causes.

Your relative may not remember what has happened, particularly if they had memory problems beforehand. However, delirium can leave them with unpleasant and frightening memories. It can be helpful to sit down with someone who can explain what happened. This might be a family member, a carer or a doctor. They can go through a diary of what happened each day. Most people feel relieved when they understand what happened and why. 

Complications from surgery

All operations carry risks. Complications that can happen after a hip operation include:

(1) Infection - using antibiotics at the time of the operation and careful sterile techniques reduce the risk. Infection occurs in about 1-3% of cases. The infection may need further treatment and operation. This operation may involve removing the new hip. If there is significant infection, and in an elderly patient, it is often not possible to put a new hip back in at a later date. 

(2) Blood clots - can form in the deep veins of the leg, known as deep vein thrombosis (DVT), or in the lung (pulmonary embolus (PE)). They can happen due to reduced movement. Walking, exercise, medication and encouraging your relative to take regular drinks of water can reduce the risk.

(3) Pressure ulcers  (bedsores) - can occur on areas of skin that are under constant pressure from being in a chair or bed for long periods. 

(4) Hip dislocation - this is rare but can occur in the early months following the operation. 

(5) Medical Complications - around the time of surgery there is a risk of existing medical problems becoming worse. There can also be new medical problems (chest infection, urinary infection, and kidney or heart problems). These can delay the operation, slow recovery and can be serious.

(6) Problems with metal plates and screws - the plate or screws can cause discomfort under the skin if they are prominent. The plate and screws can break or loosen before the broken bones have time to heal. We may need to remove them.