BMJ Open Quality Implementing an advanced physiotherapy outpatient triaging service as a model for improvement for patients recently discharged following surgical intervention for hip fracture

Rebecca Ferrier,1 Jack Bell,2 Katie J Sheehan,3 Emma Sutton © 4,5

To cite: Ferrier R, Bell J, Sheehan KJ, et al. Implementing an advanced physiotherapy outpatient triaging service as a model for improvement for patients recently discharged following surgical intervention for hip fracture. BMJ Open Quality 2023;12:e002348. doi:10.1136/ bmjoq-2023-002348

Received 17 March 2023
Accepted 30 July 2023

R) Check for updates

© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Physiotherapy Department, The Prince Charles Hospital, Chermside, Queensland, Australia
2Allied Health Research Collaborative, The Prince Charles Hospital, Chermside, Queensland, Australia 3Academic Department of Physiotherapy, King's College London, London, UK 4School of Nursing ΑΗΡ and Midwifery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 5Institute of Clinical Sciences, School of Nursing and Midwifery, University of Birmingham, Birmingham, UK
Correspondence to
Dr Emma Sutton;
Emma.Sutton@uhb.nhs.uk

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ABSTRACT
Every year there are 1.3 million hip fractures globally; this is expected to rise to 6 million by 2050. Estimates of global cost is 1.75 million disability adjusted life years, and in established market economies, costs associated with hip fracture represent 1.4% of the total healthcare burden. New models of care will be required to meet this demand. Advance physiotherapy roles in elective arthroplasty across global settings have demonstrated benefit in safely reducing time burden on surgical teams and healthcare costs. The utility of similar roles in the care of hip fracture is unclear. This quality initiative (2020-2023) aimed to implement and evaluate a new model of care substituting a surgical registrar with an advanced physiotherapist in a post-discharge hip fracture clinic. Across many nonlinear, action/reflection cycles, a multi-disciplinary team engaged to operationalize key implementation strategies, mapped to the Expert Recommendations for Implementing Change (ERIC) project. Across the reporting period, 346 patients were seen by an advanced physiotherapist. Eighty-one patients seen by an advanced physiotherapist required informal discussion with the consultant surgeon. Fifteen patients required a formal consultant review. There were no patient complaints, critical incidents or other unintended consequences. The net surgical time realized over the three years was 110 hours.
Every year, there are 1.3 million hip fractures globally; this is expected to rise to 6 million by 2050. Estimates of global cost are 1.75 million disability-adjusted life-years, and in established market economies costs associated with hip fracture represent 1.4% of the total healthcare burden.1 New models of care will be required to meet this demand, particularly given workforce shortages, particularly for skilled surgical specialists. Advance physiotherapy roles in elective arthroplasty across global settings have demonstrated benefit in safely reducing time burden on surgical teams and healthcare costs,2 3 although further economic evaluation work is needed to explain patient costs.4 The utility of similar roles in the care of hip fracture is unclear. This quality initiative aimed to implement and evaluate a new model of care substituting a surgical registrar with an advanced physiotherapist in a postdischarge hip fracture clinic.
Implementation and evaluation considered constructs within key process models56 determinant frameworks6 7 and evaluation frame- works.8 9 After engaging executive and senior leadership support, an interdisciplinary team was established. This purposively targeted those with clinical leadership, technical expertise and day-to-day leadership. The final team led by a physiotherapist included orthopaedic surgeons, an administration officer, nurses and interdisciplinary outpatient staff. Across many non-linear, action/reflection cycles, the team engaged broadly to (1) consider the clinical problem, (2) garner evidence to support change, (3) plan, select, test and implement locally tailored changes, (4) identify, collect, report and adapt evaluation opportunities and measures to understand the context, (5) inform the next steps and outcomes evaluation and (6) embed sustainability into the translation to practice approach. Although not exhaustive, some key implementation strategies, mapped to the Expert Recommendations for Implementing Change project, are provided in table 1.10
A basic flow diagram highlighting the process for the new model is provided in figure 1.
The primary outcomes measure was a crude estimate of surgical time released calculated as the total number of patients seen by the advanced physiotherapist multiplied by the scheduled clinic time (20 min). Rudimentary cost comparison data considered the difference in 2022 hourly rates for advanced physiotherapy (top tier, $A68/hour) and medical registrar (mid-tier, $A65/hour).

for patients varied and included 42% intramedullary nail, 22% hemiarthroplasty, 17% dynamic hip screws, 9% total hip arthroplasty, 3% cannulated screws and 7% other including periprosthetic fracture fixation. There was some fluctuation in the number of patients seen across the course of the programme (October—December 2020:

Patients are on shared list and reviewed by

Figure 1 Flow diagram: model for improvement for patients recently discharged following surgical intervention for hip fracture. NOF, neck of femur.

BMJ Open Quality: first published as 10.1136/bmjoq-2023-002348 on 2 October 2023. Downloaded from https://bmjopenquality.bmj.com on 28 January 2026 by guest. Protected by copyright, including for uses related to text and data mining, Al training, and similar technologies.

Table 1 Key implementation strategies
ERIC discrete
Key implementation strategies applied	implementation strategy
►		Engaged executive and interdisciplinary professional leads through presentations, formal and informal meetings	Create new clinical teams ►	Created an interdisciplinary team to oversee implementation of new model	Build a coalition
►		Accessed reports demonstrating patients requiring follow up compared with actual appointments being offered over 3 Audit and provide month period	feedback ►	Concluded 30% deficit (missed bookings) in actual appointments being offered	Conduct local needs ►	Reported back to clinicians and administrators to build case for change	assessment
►		Identified changes that are likely to make an improvement - NHS and Victorian models demonstrated advanced	Capture and share local physiotherapist with skills to review post orthopaedic surgery patients, largely elective not trauma but transferrable	knowledge
►		Once our clinic established, clinician became lead project officer in roll out strategy to other QH facilities (both elective and NOF)
►		Clinical innovation—establishing NOF clinic; local stakeholders felt this was a problem that was important and needed Conduct local consensus addressing	discussions
►		Identified, applied/adapted toolkits for implementation, competency frameworks, learning modules developed by Develop education modifying existing modules from Victoria	materials
►		Sharepoint site established for QH dissemination and clinic implementation and data presented at state-wide and Distribute education national level	materials
►		In early stage of implementation, advanced physiotherapist shadowed in orthopaedic clinic to directly observe	Shadow other experts consultations	Visit other sites
►		Advanced clinician attended existing arthroplasty clinic prior to commencing NOF clinic to identify how to optimise processes around referral and escalation pathways to surgeons
►		For succession planning designated clinician identified to cover leave and were orientated to specific learning material Train the trainer strategies and offered shadow opportunity to experts
►		Over the 3 years, our follow up timeframes have been changed based on increasing volume of throughput	Promote adaptability
ERIC, Expert Recommendations for Implementing Change; NHS, National Health Service; NOF, neck of femur; QH, Queensland Health.
RESULTS
Data were presented from implementation of the new model (October 2020) to end January 2023. Across the reporting period, 346 patients (median age 75 years, 63% female, median time from surgery to clinic 101 days) were seen by an advanced physiotherapist. Surgical type
Home dwelling patient booked
into NOF clinic at time of
discharge from acute ward

BMJ Open Quality: first published as 10.1136/bmjoq-2023-002348 on 2 October 2023. Downloaded from https://bmjopenquality.bmj.com on 28 January 2026 by guest. Protected by copyright, including for uses related to text and data mining, Al training, and similar technologies.

n=52; 2021: n=170; 2022: n=111; January 2023: n=13). Eighty-one (23.4%) patients seen by an advanced physiotherapist required brief (<5 min) informal discussion with the consultant surgeon during physiotherapy management sessions (with no extra clinic allocations or scheduling). Fifteen patients required a formal consultant review and ongoing management by the surgeon; these were routinely patients with complex pain management (n=6) or requiring surgical revision (n=5). There have been no patient complaints, critical incidents or other unintended consequences following implementation. The overall net surgical time realised over the 3 years was 110 hours. Cost comparative data suggest a very small cost of $A330 across the entirety of the programme. Wliile there were no physiotherapy overtime hours, 5347 hours of registrar surgical overtime were incurred during the evaluation period.
DISCUSSION
This is the first Australian study, and to the authors knowledge the first globally, to demonstrate that an advanced physiotherapist model in hip fracture care is cost neutral, may reduce overtime and associated penalty payments, and free up surgical registrar time for full scope surgical tasks, without adversely influencing patient satisfaction or leading to harm.
While this is encouraging, key unanswered questions should be considered prior to recommending broad uptake. For example, was the fluctuating numbers of patients across die course of implementation related to changes in clinic throughput, referral rates or limited availability of advanced physiotherapists. Results presented are inadequate to enable a formal comparison between patients seen by the advanced physiotherapist and the surgical registrar. Ongoing works must consider, for example, process measures such as comparisons between referral and escalation rates. Differences in patient reported experience or outcomes measures, health outcomes measures, cost-effectiveness or balancing measures (such as the number of referrals to other health professionals) also required evaluation. Exploratory qualitative interviews or focus groups might also be useful to unpack potential barriers and enablers to implementation, to support both iterative improvements to the process locally and uptake elsewhere.
Nevertheless, this single site quality initiative provides a passing glance at the potential benefit of an advanced physiotherapy clinic for hip fracture patients. The authors look forward to ongoing research to rigorously evaluate this innovative approach to meeting the foreseen challenge of unmet surgical demand for service in this vulnerable population.

Twitter Jack Bell ©doctadiet and Emma Sutton @emmasuttPhysio
Acknowledgements We thank The Prince Charles Hospital - Queensland Health for supporting RF and JB in collecting and analyzing the data presented.
Contributors RF led the study design/methodology and data collection, RF and JB analysed and presented the data, all authors contributed to study design, editing the manuscript and dissemination.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests ES and JB are co-chairs of the Fragility Fracture Network (FFN) Fragility Fracture Recovery Research Special Interest Group, which is the organising committee for the supplement. FFN has also provided financial contribution to support publication of the special edition.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.Org/licenses/by-nc/4.O/.
ORCID ID
Emma Sutton http://orcid.org/0000-0003-4318-9555
REFERENCES
1		Barts Bone Joint Health: Cochrane bone, joint and muscle trauma special collection: the management of hip fracture in older adults; 2023.
2		Walton Μ, Walton J, Bell M, et al. The effectiveness of physiotherapist led Arthorplasty follow up clinics. Annals 2008;90:117-9.
3		Harding Ρ, Burge A, Walter K, et al. Advanced musculoskeletal Physiotherapists in post Arthroplasty review clinics: a state wide implementation program evaluation. Physiotherapy 2018;104:98-106.
4		Lafrance S, Demont A, Thavorn Κ, et al. Desmeules F economic evaluation of advanced practice Physiotherapy models of care: a systematic review with meta-analyses. BMC Health Serv Res 2021;21:1214.
5		Improvement, l.f.H. How to improve; 2023.
6		Young AM, Cameron A, Meloncelli Ν, et al. Developing a knowledge translation program for health practitioners: Allied health translating research into practice. Front Health Serv 2023;3:1103997.
7		Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50.
8		Glasgow RE, Harden SM, Gaglio Β, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health 2019;7:64.
9		Proctor E, Silmere Η, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011;38:65-76.
10		Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project. Implement Sci 2015;10:21.