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Hip, Hip, Hooray for Sahlgrenska!

Three simple questions have revolutionized paramedical management of hip-fractured patients. The method is now known as a model of reform for emergency care in Sweden and abroad. It all happend because an ambulance staff at Sahlgrenska University Hospital (SUH) in Gothenburg thought a gender based statistics might help.

It all started because the ambulance care staff at SUH came up with the idea of segregating statistics by gender.

Patients with fractured hip or femoral neck (collum femoris) constitute the single largest  category of orthopaedic injuries which is dealt with by paramedics. Mortality rate within the injury is high and most of the concerned patients are vulnerable.

The head of the ambulance care unit at SUH, Mats Kihlgren, wanted to find out more about this group of patients.

“75% of collum patients proved to be women, with an average age of 85. They were treated as a lower priority than men at SOS Alarm, and received pain relief less often than the men,” relates Ingela Wennman, project developer and manager for the Hip Fracture Project in SUH.

“Are men given higher priority because they’re more unusual in this group? Or do people think, perhaps, “Oh dear, here comes another old biddy with a broken hip? Do men and women describe their own situation differently?”

The answer was not at all simple, but it was clear that things could not proceed the same as before.

Pain Relief for All

Ingela Wennman, a nurse with 20 years of experience in the Accident and Emergency (A&E) department, and her colleagues immediately began to address the fact that women were given lower priority than men and received pain relief less often.

Wennman knows that admission to A&E can be a major bottleneck and significantly delay response.

“Some practices at A&E can be done in the ambulance, and if they do, it will equally benefit both the patient and the department.”

Wennman and her colleagues selected an ambulance station and an A&E entrance, and tested a new way of working. The ambulances were developed into mobile A&E departments.

The first step was to ensure that every patient received pain relief, whether they complained or not.

“Breaking your hip is painful, and it hurts when a patient has to be moved from one stretcher to another, if not before,” Wennman points out in her down to earth way.

Hip fixation started to be carried out in the ambulance, where the paramedics arranged an X-ray referral and drove the patient straight to the X-ray department, instead of going to A&E.

Dry Shirts Save Lives

“And we gave the patient a new, dry shirt. When old people fall and break a hip, it can be so painful that they lose bladder control,” Wennman says.

These elderly people may also lie injured for a long time and they get wet and cold by the time someone finds them.

Since these patients are not a high priority at A&E, once in hospital they may still have to lie unattended for several hours, suffering an elevated risk of other complications, such as pressure sores, that can at worst result in death.

When the new procedure was evaluated, the outcome gave a clear message.

“We needed 27 minutes extra work input in the ambulance to reduce or eliminate time at A&E. As a result, the preoperative stage was cut by several hours, without the patient having to be moved so many times.”

The number of pressure sores was also reduced, while the incidence of states of confusion fell from 50% to 20%.

“We knew that already that confusion lengthens people’s hospital stay”, says Wennman.

The new procedure helps to reduce patients’ hospital stay and enable more of them to return to their own homes afterwards.

‘Acute’ Self-image

“The model has now been adopted by the hospital management so that everyone is treated accordingly. The work procedures are included on the management’s scorecard,” adds Wennman.

The senior ambulance staff are also systematically reviewing all the major patient categories: cardiac, stroke and geriatric patients.

They are analyzing the scope for a fast-track response so that patients are straigtly taken care of. “The gender aspects are ‘crystal-clear’ from this scrutiny,”says Wennman . The staff realize that a small change benefits both the patient and SUH. They work accordingly and this can yield great gains for the organization further along the care chain.

Wennman also describes certain difficulties in implementing the change among the staff.

“It’s a question of attitudes and values. The staff see themselves as dealing with acute situations. In an emergency you can turn yourself upside down in a wrecked car and attach a drip, but lying on a bathroom floor isn’t always associated with the professional role.”

These days, everything done in ambulance care has a gender perspective. This has become self-evident.

“If we hadn’t separated the findings by gender, we wouldn’t have been able to tackle the differences — it’s that simple. But there are other important perspectives too. The next thing we’re going to do is to look at ethnic factors,” Ingela Wennman concludes.

Three Crucial Questions

What, then, were the three almost naïve questions posed by the paramedics? They were,

  • Who are the patients?
  • How does SOS Alarm (the Swedish company in charge of 112 emergency calls) respond to them?
  • How do we treat them?

And all the answers are classified by gender, of course.

That is it!

Lena Gunnarsson
Edited: 14 Oct 2016
Published: 13 Feb 2014
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