jep-vol.7 no.5 2016

Original Article Egyptian Journal of Health Care, 2020 EJHCVol. 11 No. 2

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Effect of Pre and Post Hospital Discharge Instructions onFunctional Abilities of Patients with Hip Fractures

Fatma Mostafa Mahrous and Jackleen Faheem GendyMedical-Surgical Nursing Department, Faculty of Nursing, Ain Shams University, Egypt

Abstract

Background: Hip fracture represents one of the commonest causes of disability andhospitalization in the patient population, resulting in increased morbidity and mortality andimpaired functional capacity, particularly for basic and instrumental activities of daily living(IADLs). The aim of this study was to evaluate the effect of pre and post hospital dischargeinstructions on functional abilities of patients with hip fractures. Design: A quasiexperimental research design was used in this study. Setting: The study was conducted in theorthopedic department and orthopedic outpatient clinic at El-Demerdash University Hospital.Subjects: A purposive sample of 60 patients with hip fractures divided into two equal groups(study and control) where each group consists of 30 patients. The experimental groupreceived the discharge instructions beside routine care in hospital, whereas, control groupreceived only the routine hospital care according to inclusion and exclusion criteria. Tools:Five tools were used for data collection I. Patients` Structured Interview Questionnaire. II.Short Portable Mental Status Scale (SPMSS). III. Barthel Index of Activities of Daily Living.IV. Lawton and Brody Instrumental Activities of Daily Living Scale Lawton and BrodyInstrumental Activities of Daily Living Scale .V. Self-care practices of patients with hipfracture checklist. Results: The total activities of daily living (ADLs) score were higher atthree months following discharge from the hospital in the study group compared with thosein the control group. Although applying the discharge instructions lead to significant increasein postoperative ADLs score than those in the control group, yet more than half of thesubjects in the study group could not recover their pre- fracture level of ADLs. Conclusion:Applying the discharge instructions on patients with hip fracture was effective in enhancingrecovery rate for performing ADLs. Positive but insignificant recovery rate was found insome IADLs. Recommendation: Stress the importance of applying the dischargeinstructions for patients with hip fracture in order to accelerate their recovery and preventcomplications.Keywords: hip fracture, functional abilities, patients, discharge instructions.Corresponding author: [email protected]

Hip fracture is any fracture thatoccurs somewhere between the femoralhead edge and 5 cm below the lessertrochanter in the proximal femur. Hipfracture is a dangerous and costly publichealth problem that can have dramaticeffect on the independence and quality of

life of patients .Osteoporosis and falls arethe most dominant causes of hip fractureamong patients (Kangau, 2011andLeland, et al., 2015).

Hip fractures occur after falls are aglobal public health problem. The totalnumber of hip fracture every year is

mailto:[email protected]


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projected to reach more than 36,000 in2020 and 65,000 in 2050. The majority(90.0-95.0%) of hip fracture is surgicallytreated (Dyer, et al. 2016). Hip fractureswere associated with a high prevalence ofprolonged disability, large health carecosts, poor quality of life, and increasedmortality. Despite advances in surgicaland anesthetic techniques over time,morbidity and mortality after hip fracturesurgery remain high (Huang, et al., 2020).

Patient with hip fracture surgeryconsider increase in mobility andfunctions to be the preferred outcomeswhen asked about their recoveryexpectations following hip fracturesurgery. Still, some patients do not regaintheir pre fracture basic mobility level inthe acute orthopedic ward; and some donot return directly to their previousresidence own home. Patients who losebasic mobility, the ability to walk, to getin and out of bed, and to sit down in andget up from a chair also lose essentialaspects of their quality of life andpotentially need more health care supportthan those who do not lose their basicmobility (Hassaan, et al., 2017).

Postoperative complications of thisprocedure are still relevant, and mayaffect around 20% of patients with hipfracture. Cognitive and neurologicalalterations, cardiopulmonary affectionsalone or combined, venousthromboembolism, gastrointestinal tractbleeding, urinary tract complications, peroperative anemia, electrolytic andmetabolic disorders, and pressure scarsare the most important medicalcomplications after hip surgery in termsof frequency, increase of length of stayand per operative mortality. Pressurescars result from an imbalance betweenextrinsic mechanical forces acting on skinand soft tissue, and the intrinsicsusceptibility to tissue to collapse (Pedro,et al., 2014).

Mobility is an important factor inthe rehabilitation phase for hip fracturepatients. Among many factors affectingpostoperative mobility, stability of thestem following hemiarthroplasty isconsidered crucial for early mobility(Kim and Lee, 2016). Early dischargefrom hospital should be the aim of thetreatment in patients with hip fracturesurgery (Espen, et al., 2017). There aremany causes of prolonged hospital stay inthese patients; poor mobility is one of themajor factors. Patients with poor mobilityalso need extended support at discharge(Beaupre, et al., 2016 and Pioli, et al.,2017). Several possible factors affectingpoor recovery of walking have beenreported, including age, co-morbidities,pre fracture mobility, cognitiveimpairment, length of stay before/aftersurgery, dependence on activities of dailyliving, partial weight-bearing aftersurgery, prolonged catheterization, andliving arrangements (Buecking, et al.,2015).

The main indicator of functionalrecovery after hip fracture surgery isrestoration of walking status to prefracture levels. Recovery of walkingstatus is an essential prerequisite forpatient living in a community-dwellingenvironment. In addition, patientrecognizes functional ability in daily lifeas a health indicator (Vergara, et al.,2014).Therefore, walking status as ametric of physical recovery following hipfracture surgery is worth to investigate(Pajulammi, et al.,2015). Althoughpatients usually receive home exerciseguidance before discharge, follow-ups forwalking recovery are rarely conducted.Thus, understanding post-hip fracturesurgery walking status and its associatedfactors can provide healthcare providerswith valuable information for facilitatingmobility and independence to the patient.The catastrophic impact after hip fracturesurgery is likely to be explained by the


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percentage of immobile patients(Salpakoski, et al., 2014).

Although hip fracture mortalityrate might be on the decline, the numbersof reported co-morbidities have increasedover the same period, with evidencegrowing to suggest that the presence ofco-morbidities influence both theoccurrence and the outcome from fall-related injury. Approximately 50% ofpatients will have greater permanentfunctional disability than that beforefracture (Hoogeboom, et al. ,2014).

In general, patients with lowerbaseline function seem to experiencegreater pain and worse function comparedwith those with higher baseline function.This is called the “better in, better out”concept; that is, the better condition of thepatient coming into the hospital, the betterand more quickly patient leaves thehospital. Therefore, improving eachpatient’s health status before surgeryshould produce better outcomes at anindividual level. Unfit patients might beadvised to postpone surgery to optimizepreoperative functional status, whereasother patients might benefit fromundergoing surgery earlier in the courseof functional decline (Pioli, et al., 2017).

Mobilization is a major componentof post-operative care and rehabilitation.Various mobilization strategies are in use.These aim to get people out of bed, backon their feet, weight-bearing, moving andwalking. Other strategies for mobilizationrelate to the nature of the physiotherapyor exercise regimens used. Othercomplications of fracture healing thatmay occur are non-union of the fracturethat is failure of the fracture to heal andavascular necrosis of the femoral headalso termed segmental collapse or asepticnecrosis (Khan, et al., 2014).

The disability, reduced functional

status, and poor mental health caused byhip fracture can have a profound impacton the quality of the individual’s life.Also, hip fracture is a major cause of theneed for long-term nursing home care anda major contributor to healthcare costs.The nurse helps patient with hip fracturesurgery to prevent or reducecomplications through improvedassessment and interventions. Nursesneeded to understand the multiple factorsuch as age, gender, type of fracturerepair, general medical condition,confessional state, depression andiatrogenic complications that also affect(Mizrahi, et al., 2013).

Significance of study

Hip fracture represents one of thecommonest causes of disability andhospitalization in the patient population.Because of high residual disability, andhigh morbidity and mortality rates,overall prognosis for patient whoexperience hip fracture is far from beingaccurate (Neuhaus, et al., 2013). Threeor more co-morbidities could serve asindicators in predicting a high risk ofdevelopment of complications in thesepatients (Shah, et al., 2018).

Discharge instructions are theprocess by which the patients are assistedto develop a plan of care for ongoingmaintenance and improvement of healthconditions, even after their dischargefrom the acute care hospital. In otherwords, it is referred to as continuity ofcare. A discharge instruction seeks toprovide services that enable patient toenhance or restore independency. It mayinclude cognitive screening, functionalassessment, provision of counseling andeducation, coordination of aninterdisciplinary team, activation ofcommunity services, follow-up andevaluation (Sibai, 2014). The dischargeinstructions concerning patients with hip


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fracture could significantly improve thetreatment’ outcome, reduce readmission,and achieve a successful rehabilitation.This will lead to prevent deteriorating infunctional status and accelerate restoringof independence of persons (Crotty, etal.,2020).

Aim of the study:

The aim of this study was toevaluate the effect of pre and posthospital discharge instructions onfunctional abilities of patients with hipfractures.

Research hypothesis: Applyingthe pre and post hospital dischargeinstructions on patients with hip fracturewould have a positive effect on enhancingfunctional abilities and recovery rate forperforming ADLs.

Subjects and methods

Design: A quasi experimentalresearch design was used in this study.

Setting: The study was conductedin the orthopedic department andorthopedic outpatient clinic at El-Demerdash University Hospital.

Subjects: A purposive sample of60 patients with hip fractures attendingthe previous setting. The subjects weredivided into two equal groups (study andcontrol) where each group consists of 30patients. Selection of the subjects wasbased on the following eligible criteria:

Inclusion criteria:

1. Age range between 18 to < 65years.

2. Adult patients from both gender.

3. Any type of hip fractureregardless of the cause.

4. Patients with normal cognitivefunctions or mild cognitive impairmenti.e. scoring of (0-2) and (3-4) respectivelyby using the Short Portable Mental StatusQuestionnaire.

Exclusion criteria:

1.Patients with hip fracturesadmitted to the ICU. This is becausethose who are admitted to ICU are usuallyfragile and frail, treated under specializedprotocols, and may stay long periodunconscious. All these factors hinder theapplication of the discharge instruction.

2.Patients with moderate or severecognitive impairment are excluded fromthe study because they are usuallydisoriented to time, place, and persons,have lost their learning ability due tosevere memory deficit, and havedifficulty following directions. Therefore,those patients might require differentprotocols for the rehabilitationintervention after hip fracture.

3.Subjects refuse participation inthe study.

Sample size:

The sample size was calculatedusing Epi info7 program, the outputnumbers was 54, then 10% of the numberwas added in order to overcome issues ofmortality and withdrawal from the study,the total subjects’ amounted 60 patients.

Tools of data collection:

Tool I: Patients` StructuredInterview Questionnaire:

The tool was developed by theresearcher and included two parts as the


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following:

Part 1: Demographiccharacteristics: It was designed to assesspatients` demographic data of the patientsunder the study such as age, gender,social status, occupation and level ofeducation.

Part 2: Patient`s medical data:the researcher designed it after reviewingthe related literature. It was consist ofpre-fracture comorbidities, sensory status,and use of any assistive devices.

Tool II: Short Portable MentalStatus Scale (SPMSS)

The short portable mental statusquestionnaire was developed by Pfeiffer(1975). The scale is widely used to detectthe presence of mental impairment and todetermine its degree. It is quick and easyto administer. It consists of 10 items.Scoring is based on 10 total points.Patients scoring from 0-2 are consideredto have NO cognitive impairment; thescoring 3-4 indicates mild cognitiveimpairment, from 5-7 moderate cognitiveimpairment and from 8-10 severecognitive impairment. This scale wastranslated into Arabic language and testedfor its validity and reliability byMahrous(2012), reliability value was (r = 0.89).

Tool III: Barthel Index ofActivities of Daily Living:

This scale was developed byBarthel (1965) and consists of 10 itemsthat measure the ability of patient toperform basic activities of daily living.The items include feeding, moving fromchair to bed and return, grooming,transferring to and from a toilet, bathing,walking on level surface, going up anddown stairs, dressing, and continence ofbowels and bladder. The responses ofeach item are two to four with

corresponding values (0, 5, 10, 15)depending on the item, an increased valueindicates more independency inperforming related tasks. These responsesare then summed to a total score thatranges between 0 and 100 with higherscores indicating better functioning inperforming ADLs, The Arabic version ofthis scale was used in this study, it wastranslated by Hallaj (2007) and tested forvalidity and reliability (r = 0.97).

IV: Lawton and BrodyInstrumental Activities of Daily LivingScale:

This Scale was developed byLawton and Brody in 1969 to assess theability of patients to perform instrumentalactivities of daily living. The scaleincludes eight items: telephoning,shopping, food preparation, housekeeping,laundering, use of transportation, use ofmedicine, and financial behavior. Theeight different functions are measured andscored according to the self-report ofindividual actual performance of theseactivities. Women are scored on all 8areas of function, but, for men, the areasof food preparation, housekeeping,laundering are excluded. Each item wasscored from one to three values indicatinglevels of dependency, where threeindicates performing the activityindependently “without any assistance”.Two indicates activity performed withsome help “with partial assistance”, andone indicates that patient cannot performthe activity at all. A sum score rangesfrom 8 (totally dependent) to 24 (totallyindependent) for women and from 5 to 15for men. It was translated into Arabiclanguage and validated on Egyptianpopulation by Shehatta( 1997) and testedfor reliability in a study carried out atAlexandria by Elsayed (2007), reliabilitywas 0.83.

Tool (V): Self-care practices of


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patients with hip fracture checklist:

This checklist was developed bythe researchers based on thorough reviewof relevant literature, it comprisedstatements to evaluate subjects’adherence to self-care and rehabilitativeactivities after hip fracture repair surgery.These include activities related tonutritional habits, preventingcomplication of immobility,recommended exercise, and proper use ofassistive devices. Every activity adoptedby the patient was scored one point.

Procedures:

Preparatory phase:

During this phase the researcherwas obtained official permission from thehead of orthopedic department and out-patient clinics to collect the necessarydata. Collecting the review materials andpreparing the tools for data collectionthrough reviewing the related literaturesusing books, articles, periodicals andmagazines. The discharge instructionbooklet was prepared in simple Arabiclanguage with simple photo illustrations(this was revised by 5 healthprofessionals).

Informed consent was obtainedfrom each participant fulfilling the studycriteria after they were informed aboutthe purpose and methods of the study andthat they were free to withdraw fromstudy any time without penalties.

A pilot study was carried out on 6patients diagnosed with hip fractures atthe study setting. Those patients wereincluded in the study subjects. The datacollection covered a period of 6 monthsfrom the beginning of September 2019 tothe end of February 2020.

Implementation phase

1) Baseline assessment wasconducted in the preoperative period.Every subject meeting the eligible criteriawas interviewed in order to complete thebaseline information using tool II. Thetelephone number and address of everypatient was taken. Clinical data such astype of fracture, planned operativeprocedure was obtained from patient’sfile. The pre-fracture functional abilitiesthat concerning basic and instrumentalactivities of daily living were assessedusing tools III and IV.

2) The proposed dischargeinstructions were developed by theresearchers after review of literature. Thedischarge instructions covered thefollowing topics:

Instructions related to generalKnowledge about hip fractures such asDefinition, causes, symptoms, treatmentand types of surgical treatment.

Instructions related topreoperative period such as position inbed, managing pain, dealing with memoryproblems, after hospital admission timethat wait for surgery and when I will beable to get out of bed and startphysiotherapy after surgery.

Measures to avoid post-operativecomplications such as deep veinthrombosis, immobility and reduce risk offalling.

Rehabilitative interventionswhich aim to improve functional abilitiessuch as, safe exercise, adaptivetechniques for performing activities ofdaily living, and nutritionalrecommendations.

3) The activities of the dischargeinstructions were written in printed


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booklets. The discharge instruction was asummarized booklet that contains conciseand precise instruction given to patientsto guide them during in-homerehabilitation. The booklet was written inArabic language, and entails mainlypictures for more clarity and to overcomeprevalence of illiteracy among patientspopulation.

4) The period of implementing thedischarge instructions extended fromhospital admission through three monthsafter the operation.

a.Experimental group: This groupreceived the discharge instruction besidethe routine care followed in the hospital.The discharge instruction was deliveredby the researchers through individualsessions with the patient and theirrelatives at orthopedic ward in the studysetting. Two sessions were conductedpreoperatively, and other three sessionswere held post operatively till patientdischarge from the hospital. Each sessiontook 15- 30 minutes.

b.Control group: Patients in thecontrol group received the routinehospital care provided for all patientswith hip fractures regardless of their ageor type of hip fractures.

5) The researchers met thepatients during the follow up threeappointments in the outpatient clinic, butsome patients were given additionalappointments especially in case ofdelayed wound healing. Telephone callswere conducted regularly (every twoweeks) with subjects from bothexperimental and control groups and theresearchers were available for patients bytelephone seven days a week.

Evaluation phase:

After 3 months from the operation

date, the researchers interviewed patientsin the experimental and control groups toevaluate their functional abilities by usingthe study tools III and IV.

Ethical considerations:

The research was approved by theethics committee in faculty of nursing, awritten consent was obtained frompatients participating in the work afterexplaining the nature and purpose of thestudy. Patients were assured dataconfidentiality, and the researchersinitially introduced themselves to thestudy subjects and patients were informedthat their participation is voluntary andthey can withdraw at any time from thework.

Statistical analysis:

Data entry and statistical analysiswere done using SPSS ver.23 statisticalsoftware packages. Data were presentedusing descriptive statistics in the form offrequencies and percentages forqualitative variables, mean and standarddeviations for the quantitative variables.The level of significance was set at (p= .05) to detect any indication ofdifferences found in the data available.

Results

Table I shows that the mean ageof the study group was71.70±10.01 years,and the mean age for the control groupwas 72.17±7.896. The majority of thesubjects in both study and control groups(76.7% and 83.3% respectively) wereread &write. (63.3%) of the study groupand (76.7) of the control group were notworking. No statistical significantdifference was found between bothgroups in relation to demographiccharacteristics.


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Fig. 1 illustrate that females weredominant among the studied subjects andconstituted 60.0% of the study group and56.7% of the control group.

Table II shows the distribution ofpatients with hip fracture among the studyand control groups according to their pre-fracture cognitive and physical status.Based on the eligible criteria, onlypatients with intact cognitive functions ormild cognitive impairment were includedin this study. Those with mild cognitiveimpairment were more prevalent in bothstudy and control groups, 63.3% and53.3% respectively. Regarding visualstatus, the majority of patients in bothstudy and control groups reported novisual problems (60.0% and 53.3%respectively). In relation to hearing status,about three quarters of the study subjects(73.3%) and the majority of the controlgroup (86.7%) reported having no hearingproblems. Concerning the ambulationstatus of the subjects before theoccurrence of fracture, the majority of thepatients in the study and control groupswere able to ambulate independently(80.0% and 86.7 % respectively). Nostatistical significant difference wasfound between both groups in relation tocognitive, visual, hearing or ambulationcapacity before the occurrence of fracture.

Table (III) shows the comparisonbetween patients with hip fracture amongthe study and control groups according tothe recovering of their pre fracture levelof ADLs 3 months postoperatively. Allpatients (100%) in the study and controlgroups recovered their pre fracture levelin feeding and bowel continence.96.6% ofthe study group compared to 100% of thecontrol group recover pre fracture level inbladder continence with no statisticallysignificant difference. All except twopatients in the study group recover prefracture level in grooming. Whereas 76.6in the control group recover pre fracture

level in grooming, the difference is notstatistically significant p=0.053.Concerning ability to dressing, 83.3% ofthe study group compared to 60.0% of thecontrol group recovers their pre fracturelevel, with no statistical significantdifference p=0.052.Recovering the abilityto transfer from bed to chair and returnwas reported by 83.3% of the study groupcompared to 46.7% of the control group,with statistical significant differencep=0.006.( 76.7%) from study grouprecover pre fracture ability of toileting.However, among control group 53.3%recovers pre fracture ability. Thedifference isn’t statistically significantp=0.061. (70.0%) of the study grouprecovers their pre fracture ability ofwalking compared to 33.3% of the controlgroup with statistically significantdifference p=0.017. In relation to bathing70.0% of the study group recovers the prefracture level. While among control group,40.0% recover pre fracture ability, thedifference is not statistically significantp=0.063.The most difficult task wasclimbing stairs; 58.6 % of the study grouprecovers their pre fracture level and41.4% became more dependent. 37.0 %of the control group recovers their prefracture level and 63.0% became moredependent, yet the difference is notstatistically significant p=0.106.Consequently, (46.7%) of the study grouprecover their pre fracture ability ofperforming ADLs and (53.3%) becamemore dependent. On the other hand,23.3% of the control group recovers theirpre fracture level of ADLs and 76.7%became more dependent, the difference isstatistically significant p=0.042.

Table (IV) shows the comparisonbetween study and control groups ofpatients with hip fracture according to therecovering of their pre fracture level ofIADLs 3 months postoperatively. Abilityto use telephone was recovered among allsubjects (100%) in both study and control


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groups. The second recovered task washandling finance, followed by takingmedications, laundry, shopping, with nostatistical significant difference betweenboth groups in relation to these tasks.Concerning food preparation, 63.2%compared to 26.3% of the females in thestudy and control groups respectivelyrecover pre fracture level with statisticalsignificant difference p=0.034. This wasfollowed by housekeeping, andtransportation, but no detected statisticalsignificant difference between study andcontrol group. Overall 23.3% of the studygroup recovers their pre fracture level ofthe study group and 76.7% became moredependent. Whereas 3.3% of the controlgroup recover their pre fracture level ofindependence and (96.7%) became moredependent, yet the difference isn’tstatistically significant p=0.062.

Table (V): shows the relationsbetween demographic characteristics ofpatients with hip fracture among the studyand control groups of and ADLs score 3months of the operation. There is agradual decline in ADLs with increasingage of the subjects in both the study andcontrol groups, these differences arestatistically significant in the study grouponly p=0.034. Both male and femalepatients reported higher mean in ADLsamong the study group than the controlgroup. This difference in ADLs meanscore between males and females isstatistically significant in the study groupp=0.039 and NOT statistically significantin the control group p=0.391.Concerningliving status, patients living alonereported the highest ADLs mean score inthe study and control groups followed bythose living with relatives, then those wholiving with a spouse whereas those who

live with their children reported thelowest ADLs mean score, no statisticalsignificant difference found in eitherstudy or control group according to socialstatus p=0.578 and p=0.482 respectively.

Table (VI) shows the relationsbetween chronic diseases, cognition status,and physical status of patients among thestudy and control groups with hip fractureand ADL score after 3 months ofoperation. Although there was a gradualdecrease in ADLs score with increasingnumber of suffered chronic diseases inboth groups. Yet, this difference is notstatistically significant in both groupsp=0.088 and p=0.234 respectively.Concerning cognitive status, the tableshows that patients with intact cognitivefunctions have higher ADLs score thanthose with mild cognitive impairment inthe study and control groups, yet thisdifference is not statistically significantp=0.125.In relation to visual status, thetable shows that having visual problemsaffect inversely recovering ADLs amongpatients from study and control groupsbut this effect is statistically significantamong control groups only p=0.032.Hearing problems also leads to lowerADLs score in the study and controlgroups after 3 months but the differenceis not statistically significant in neitherstudy group p=0.146 nor control groupp=0.068.With regard to the ambulationstatus, independent patient have higherADLs score in both study and controlgroup, followed by those who use cane,and then by those who use walker. Thedifferences in ADLs score according toambulation capacity is statisticallysignificant in the study group p=0.000 butnot statistically significant in the controlgroup p=0.291.

Table (I): Distribution of demographic characteristics of the studied patients.


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Items Study group Control group χ2 P-valuen (30) % n (30) %Age (in years)

0.200 0.84245 - < 60 years 19 63.3 21 70.060 - < 75 years 6 20.0 5 20.075 and above 5 16.7 3 10.0Mean ± SD 71.70±10.01 72.17±7.896

OccupationNot workingWorking

1911

63.336.7

237

76.723.3 2.733 0.26

Educational levelIlliterate 5 16.7 4 13.3Read &write only 23 76.7 25 83.3 1.581 0.664Secondary 1 3.3 1 3.3University 1 3.3 0 0.0

Fig. (1) Number and percentage distribution of the patients in the study andcontrol groups according to their gender.


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Table (II): Distribution of patients with hip fracture among the study andcontrol groups according to their pre-fracture cognitive and physical status.

Items Study group Control group χ2 P-valuen (30) % n (30) %Cognitive status

Intact cognitive functionsMild cognitive impairment

1119

36.763.3

1416

46.753.3 0.617 0.432

Visual statusNo visual problem 18 60.0 16 53.3Use eye glasses 4 13.3 9 30.0 2.733 0.255

Visual problem and notusing eye glasses 8 26.7 5 16.7

Hearing statusNo hearing problem 22 73.3 26 86.7Use a hearing aid 1 3.4 0 0.0 2.549 0.280

Hearing problem and notusing hearing aid 7 23.3 4 13.3

Ambulation capacityIndependent 24 80.0 26 86.7Use cane 4 13.3 3 10.0 2.405 0.301Use walker 2 6.7 1 3.3

* Significance at p≤ 0.05

Table (III): Comparison between patients with hip fracture among the study andcontrol groups according to the recovering of their pre fracture level of ADLs 3 monthspostoperatively.

ADLs

Study group (n=30) Control group (n=30)

χ2 \ p- valueRecover to the pre-

fracture levelRecover to the pre-

fracture levelYes No Yes No

N (%) N (%) N (%) N (%)Feeding 30 100 0 0.0 30 100 0 0.0 FET 1.000Bowels continence 30 100 0 0.0 30 100 0 0.0 FET 1.000Bladder continence 29 96.6 1 3.4 30 100 0 0.0 FET 1.000Grooming 28 93.1 2 6.9 23 76.6 7 23.4 3.754 0.053Dressing 25 83.3 5 16.7 18 60.0 12 40.0 3.783 0.052TransferringChair/bed

25 83.3 5 16.7 14 46.7 16 53.3 7.472 0.006*

Toileting 23 76.7 7 23.3 16 53.3 14 46.7 3.511 0.061Walking 21 69.0 9 30.0 10 33.3 20 66.7 5.731 0.017*Bathing 21 70.0 9 30.0 12 40.0 18 60.0 3.451 0.063Climbing stairs 18 58.6 12 41.4 11 37.0 19 63.0 2.690 0.106Total ADL 14 46.7 16 53.3 7 23.3 23 76.7 4.134 0.042*



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Table (IV): Comparison between study and control groups of patients with hipfracture according to the recovering of their pre fracture level of IADLs 3 monthspostoperatively.

IADLs

Study group (n=30)Male=11Female=19

Control group (n=30)Male=11Female=19

χ2 \ P value

Recover to the pre-fracture level

Recover to thepre-fracture level

Yes No Yes Non (%) n (%) n (%) n (%)

Telephoning 30 100 0 0.0 30 100 0 0.0 - -Handling finance 27 90.0 3 10.0 20 66.7 10 33.3 4.389 0.036*Medication 24 80.0 6 20.0 20 66.7 10 33.3 1.140 0.286Laundry (Female only) 13 68.4 6 31.6 6 31.6 13 68.4 2.892 0.089Shopping 13 43.3 17 56.7 13 43.3 17 56.7 0.054 0.817Food preparation (Femaleonly) 12 63.2 7 36.8 5 26.3 14 73.7 4.480 0.034*

Housekeeping (Female only) 8 42.0 11 58.0 6 31.5 13 68.5 0.216 0.642Transportation 10 33.3 20 66.7 13 43.3 17 51.7 0.582 0.446Total IADL 7 23.3 23 76.7 1 3.3 29 96.7 FET 0.062


Table (V): Relations between demographic characteristics of patients with hipfracture among the study and control groups and ADLs score 3 months postoperatively.

Demographic characteristicsStudy group (n=30) Control group (n=30)

ADLs score (After 3 months) ADLs score (After 3 months)Mean±SD Mean±SD

Age (in years)

45 - < 60 years60 - < 75 years75 and above

87.89±17.2670.83±24.7862.50±20.61

70.7 ±24.4563.00±28.4161.67±30.13

ANOVA test F= 3.871 p=0.034* F=0.296 p=0.746Gender

Male 85.00±16.12 78.89±24.04Female 63.18±27.95 71.88±22.94t-test t=2.242 p=0.039* t=0.867 p=0.391

Living status (residency)Alone 100.00 100.00

With relatives 92.50±10.60 85.00±0.00With spouse 83.33±12.24 72.50±27.64With children 77.06±25.43 64.41±24.86ANOVA test F=0.670 p=0.578 F=0.752 p=0.482



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Table (VI): Relations between chronic diseases, cognition status, and physicalstatus of the patients with hip fracture among the study and control groups and ADLscore after 3 months ofoperation

ITEM

Study group (n=30) Control group (n=30)ADLs score (After 3 months) ADLs score (After 3 months)

Mean ±SD Mean ±SDChronic diseases:

No 88.00 ± 26.83 87.50 ± 8.661or 2 85.00 ± 12.50 66.05 ± 25.683-5 65.71 ± 29.07 60.00 ± 27.38

ANOVA test F= 2.677 p=0.088 F= 1.543 p=0.234Cognitive status

Intact cognitive functions 92.27±11.69 77.27±26.11Mild cognitive impairment 73.89±22.91 62.19±22.94

t-test t = 2.850 p=0.008* t = 1.587 p=0.125Visual status

No visual problem 82.94±19.28 69.33±26.31Use eye glasses 81.25±37.50 80.00±17.72Visual problem and not using eyeglass 76.25±17.67 41.25±9.46

ANOVA test F=0.257 p=0.775 F=3.984 p=0.032*Hearing status

No hearing problem 85.00±20.41 72.50±24.23Hearing problem and not usinghearing aid 65.83±20.59 50.00±21.21

t-test t = 2.072 p=0.146 t = 3.647 p=0.068Ambulation capacity

Independent 89.13±11.74 71.09±23.35Use cane 46.25±21.74 58.33±36.17Use walker 55.00±21.21 35.00

ANOVA test F=20.428 p=0.000* F=1.302 p=0.291


Discussion

Hip fractures are important causesfor morbidity, mortality, and loss offunctional abilities among people.Discharge instructions for patients withhip fracture are coordinated approachaiming to reduce disability and recoverpre-fracture level of functional abilityKristensen, et al., 2016). Dischargeinstructions coordinating patients’ andcaregivers’ expectations into the careprocess which starts by patientassessment, development of anappropriate plan, provision of education

to the patient and caregivers and follow-up and evaluation (Neuburgar, et al.,2015).

Demographic characteristics ofpatients in this study deserve attention.The greatest percent in both groups werefemale, not working with the mean age ofthe study group was71.70±10.01 years,and the mean age for the control groupwas 72.17±7.896. This is less than themean age reported in other studiesconducted by Lin et al. (2018);Deschodt et al. (2012), and by Moyanoet al. (2013) where the mean age ranged


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from 79±699to 82±703 years. Thisdifference may be related to the increasedrisks of falling among studied subjects inthe community due to increasedenvironmental hazards whether in homeor community. Prevalence of educationallevel among the study subjects were read&write only this may be related to thelow social status of the subjects and thecharacteristics of the study setting asgovernmental non paid hospital.

The primary objective in this studyis to determine how the implementationof the discharge instructions affectedfunctional recovery after hip fracture. Inthe present study, the total ADLs scorewere higher at three months followingdischarge from the hospital in the studygroup compared with those in the controlgroup. Many previous studies conductedby Crotty et al. (2020); Huang et al.(2020) and Stenvall et al. (2010)demonstrated that discharge instructionimproved the ADLs of hospitalizedpeople with hip fracture. Zidén etal.(2010) conducted two randomizedcontrolled trials in 2008 and 2010 tostudy the effect of rehabilitativeintervention on functional abilities ofadult with hip fracture and found asignificant increase in ADLs score of thestudy group compared to the controlgroup. In a study carried out in by Tsengand Lin (2016), the researcher examinedthe effect of a 3-month interdisciplinaryprogram that included patientsconsultation services, a continuousrehabilitation program, and discharge-planning services, the researcher foundthat the probabilities of poor or moderaterecovery for participants who received theintervention were only 5% or 17% of theprobability for those who received routinecare. Sipilä et al. (2014) studied theeffect of multi-component home-basedrehabilitation program on functionalabilities of patients with hip fracturesover 3, 6 and 12 months. The program

improved the mobility recovery ofpatients with hip fracture over routinecare.

On the other hand, other studiesconducted by Tinetti et al. (2013);Vidan et al. (2011) ; Deschodt etal.(2012), and Edgren, et al(2012)reported that intervention and multicomponent rehabilitation program was nomore effective in promoting recoverythan usual care. Orwig et al. (2011)studied a six-month intervention,comprising an exercise module and a self-efficacy based motivational module,implemented by physiotherapists. Noneof these interventions had any significantadvantage over standard care. Due to thedifferences in healthcare organization andrehabilitation routines and differinginterventions provided in these studies,observation times and outcomes measures,this becomes difficult to compare studiesfrom different countries. Theimprovement of the present study maycome from the improved services giventhrough proposed discharge instructionscompared to the hospital routine care, theparticipants in the study group receivedexercise module, counseling about propernutrition preventive measures of possiblecomplications as well as personalcommunication through telephone.Participants of the control group did notreceive any of these activities. Alsoabsence of routine physical therapy in thestudy settings may make the effect ofapplying the discharge plan much obviousthan other studies which demonstrated noeffect of applying discharge instruction insettings where physical therapy was givenas a routine care for all patients.

Although applying the dischargeinstructions lead to significant increase inpostoperative ADLs score than those inthe control group, yet more than half ofthe subjects in the study group could notrecover their pre- fracture level of ADLs.


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Our findings are consistent with aprevious study by Zidén et al. (2010)which showed that approximately half ofthe patients did not regain theirindependence in performing ADLs, andwithin the range reported by other studiesby Young (1997), and by Shyu (2019)where the percent of regaining pre-fracture level ranged from 44–60%.

The present study revealed thatADLs that recovered to the pre-fracturelevel three months post discharge werefeeding, bowel and bladder continencewhere almost all subjects in both thestudy and the control groups reached thepre-fracture level of these tasks. Moderateincrease in dependency than pre-fracturelevel was seen in activities like grooming,dressing, and transferring, with asignificant difference between bothgroups in favor of the study group. Thesewere followed by activities of toileting,walking, bathing, and climbing stairs thatshowed more difficulty in recovering pre-fracture level. Difficulty of recoveringactivities like climbing stairs, walkingand bathing is logic as these activitiesneed more coordination in movement andhigh balance and self-confidence to beconducted. Also, these activities maytrigger fear of falling more than otheractivities because of fear of slipping ortripping, which are the main causes of fallamong subjects in this study. A studycarried out by Lin et al. (2018) reportedsimilar results where the majority ofpatients in intervention group hadrecovered the pre-fracture level in feeding,bowel and bladder continence,transferring, and grooming, whereas therate of recovering pre-fracture level weremore difficult in other tasks such as usingtoilet, dressing, bathing, and climbingstairs task. This is supported by a studycarried out by Stenvall et al. (2016) whoinvestigated the effect of interventionconsisted of staff education,individualized care planning and

rehabilitation, active prevention, detectionand treatment of postoperativecomplications. They found a significantimprovement in ADLs in the study groupthan the control group after 4 months ofthe operation, the most recovered taskswere feeding, following by transfer,toileting, continence, walking, dressingand bathing.

Concerning ability of performingIADLs, in this study the female patientswere evaluated regarding eight activities,but for males the activities of laundry,food preparation, and housekeeping wereexcluded. This recommendation was putwhen designing the scale and used inmany other studies in different areas, alsoit may be more suitable to eastern culturewhere it is uncommon to see subjectmales taking part in these activitiesespecially when they are living with theirspouses, relatives or siblings. After 3months of the operation, the ability to usetelephone was not affected by hip fracturewhere all subjects in both the study andcontrol groups

had no problem in using the phone.This is understandable after the increaseusing of mobile telephone which do notneed transferring or moving to the placeof telephone to dial or answer calls.Handling finance and medication werethe second most recovered tasks. The rateof increased dependency in activities oflaundry, food preparation andhousekeeping are less but not significantin the study group than the control group.The activities of shopping andtransportation were the most difficult taskwhere nobody either in the study or thecontrol group was able to perform themduring three months of follow up. Thesefindings goes in line with otherprospective cohort study of six monthsfollow up carried out by Vergara etal .(2014) on 557 patients with hipfracture due to a fall found that only


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24.9% of patients recover to the pre-fracture level of IADLs. On the otherhand, a randomized controlled trialconducted in Taiwan by Leland et al.(2015) studied the effect of nutritionalbased intervention of functional recoveryafter hip fracture demonstrated betterperformance in IADLs among the studygroup than the control group. In presentstudy, many people reported living withtheir sibling, spouse or relatives, whichmay rational the low mean score obtainedin assessing the performance of IADLseven among female patients who areusually dependent on their relatives inhelping in these tasks.

The positive relationship betweenbetter cognitive function and earlyfunctional recovery among patients afterhip fracture has been reported in severalstudies (Montalbán et al., 2012; Lee etal., 2014 and Ismael et al., 2016). Thepresent study showed that an impairedcognitive function is negativelyassociated with recovering functionalrecovery. This is supported by a recentlarge retrospective study on 5053 patientswith hip fracture conducted in Korea(2014) to investigate the prognosticfactors predicting the recovery of pre-fracture functional mobility; it was foundthat the early recovery of functionalmobility was associated with pre-injurycognitive function. However, this doesn’tmean that cognitively impaired patientsdo not benefit from rehabilitationprograms. In another study, beingcognitively impaired had only a littleinfluence on functional regain comparingto normal patientsMorghen et al.(2011).But those subjects who reportedfunctional regain among cognitivelyintact subjects had a significantly betterpre-fracture functional abilities and lesscomorbidity than their counterparts.

In the present study, presence ofcomorbidity was negatively rather not

significantly associated with recoveringto the pre-fracture level of functionalabilities .This is supported by a studycarried out by Tseng and Lin (2018)where the number of comorbidity atadmission was not associated with rate ofrecovering ADLs. Findings from otherstudies conducted by Koval et al. (1998) ;Sipilä et al. (2014) and Vergara etal.(2014), and are in contrast withfindings of the present study and suggestthat patients whose functional statusworsened had higher degree ofcomorbidity. The different findings maybe due to the different number of chronicdiseases in the studies, where those whoreported negative relation betweencomorbidity and functional regainreported higher number of chronicdiseases among their subjects than studieswhich reported no relation. In our study,the mean number of chronic diseases inthe study and control groups was1.83±1.41 and 1.50±1.16 respectivelywhich is near to other reported by Tsengand Lin (2018) which reported 1.49chronic diseases, but less than otherreported from contraindicated studywhere number of comorbidity by Sipiläet al. (2014) was 3 ± 2 and subjects whosuffered more 2 and more chronicdiseases amounted to78% of total subjectsby Vergara et al .(2014).

Concleusion

Based on the findings of thepresent study, it can be concluded that thedischarge instructions that wasimplemented for the patients with hipfracture had a significant and positiveeffects on recovering patients to their prefracture level in most of the activities ofdaily living. Whereas, a positive rathernot significant effect was found inrecovering pre fracture level ofperforming instrumental activities ofdaily living. Increasing age, being female,cognitively impaired, and lower of pre


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fracture ambulation capacity, werenegatively affected the rate of recoveringfunctional ability after hip fracture.

The main recommendations were:

1) Stress the importance ofapplying the discharge instructions forpatients with hip fracture in order toaccelerate their recovery and preventcomplications.

2) Handout of printed booklet toeach patient with hip fracture admitted tothe hospital. This will help in theirunderstanding and follow the maininstructions to avoid complications.

3) In service training for nursesabout components of the dischargeinstructions and encourage them to applyits content to patients with hip fractureson admission to the hospital.

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