Transcript An Update on Hip Precautions following Elective Surgery
An Update on Hip Precautions following Elective Surgery .
University of Nottingham
Three parts
1.
National survey of occupational therapy 2.
Interviews with key staff 3.
Evaluation of hip literature for patients
Question
1. National survey
What is routine practice in occupational therapy in advising on hip precautions following THR?
Hip precautions following PRIMARY total hip replacement; a national survey of current occupational therapy practice. Drummond A, Coole C, Brewin C & Sinclair E. British Journal of Occupational Therapy 2012; 75(4) 164-170.
Movements to avoid
flexion (173; 99%), adduction (166; 95%) internal/external rotation (156; 90%) other movements to avoid lifting [1] and driving [1]. (14%) as twisting [13 respondents], certain sleeping positions [5], crossing legs [4], bending [2], sitting on low furniture [2], active abduction [1], stretching [1],
Activities discussed
The most common activities discussed were kitchen activities (163; 94 % ), bath/shower transfers (161; 93% ), car transfers (160; 92% ), strip washing (159; 91% ) dressing techniques (140; 82% )
Activities practised
The most common activities practised were; bed transfers (169; 97% ), chair transfers (167; 96% ), toilet transfers (165; 95% ), and dressing practise (144; 83% ).
Time precautions observed
Many occupational therapists supplied a range of time; responses reflect this and varied from 6 to over 12 weeks.
The majority of OTs recommended precautions were followed for 12 weeks post op (84: 48 % ).
Why does your service/department teach hip precautions? Response Yes n (%) No n (%) Missing n (%) Surgical approach Surgical opinion Hospital policy OT policy 74 (42.5) 126 (72.4) 50 (28.7) 93 (53.4) Team decision Evidence base Reduce LOS 71 (40.8) 38 (21.8) Other 16 (9.6) 21 (12.1) 99 (56.9) 47 (27) 123 (70.7) 80 (46) 102 (58.6) 135 (77.6) 157 (90.2) 151 (86.8) 1 (0.6) 1 (0.6) 1 (0.6) 1 (0.6) 1 (0.6) 1 (0.6) 1 (0.6) 1 (0.6)
2. Staff interviews
The purpose of this study was to report the views and experiences of clinicians on the use of hip precautions by occupational therapists.
16 semi-structured telephone interviews with surgeons, nurses and therapists. (6 regions; 4 using precautions; 6 occupational therapists, 4 orthopaedic surgeons, 3 physiotherapists and 3 nurses) Data was analysed thematically.
Themes
the rationale, and disadvantages of, routine hip precautions; the barriers and facilitators to relaxing hip precautions; the contextual factors of service change and support for further research.
Hip precautions- what do the clinicians think? Submitted and under review
Rationale
“You need the posterior capsule to try to repair up, so there is a little bit of logic in not wanting to stress the posterior capsule, which is – sort of worse in flexion, internal rotation, until the piriformis heals up… so there is some logic in restricting their movement early on, trying to get some soft tissue, to tether down”
(168, surgeon)
Historical reasons
“…..and although procedures have moved forward, we’ve stuck to exactly the same post operative routines with them”
(163, nurse)
Negative aspects
“I think if you’re telling them don’t do this don’t do that…we’d often have patients sat there doing nothing, and it’s not good for them. I think we treated them still as an invalid ”
(163, nurse)
Equipment
“We did a bit of a survey and I think about 25% of the equipment never got touched and that’s a lot of money and it’s a bit of a waste of time”.
(172, occupational therapist)
Change
“I’m sure changing physios’ mind-set would be vastly easier than changing senior consultants’ mind-set, and I suspect OTs are on the whole a very sensible bunch, so I suspect if you gave them the rationale for change , I think they’d probably be happy to change as well”
(168, surgeon)
3. Patient literature
Aim To analyse the literature provided to patients after elective hip surgery in the UK
What do we tell patients after their elective total hip replacement in the UK? Paper submitted and under review.
Three areas
A.
B.
C.
Accessibility audience.
of information to a lay Scope of information.
Specific activities of daily living ( ADL s) presented.
Results
121 leaflets / information booklets examined.
10 excluded; 9 were duplicates, 1 not specific to hip replacement.
10 further leaflets were noted to be paired with one or more other documents (a total of 21 leaflets).
A. Accessibility of information to a lay audience.
Checklist
Everyday language Overall size Overall lay out Typeface Diagrams Patient involvement Person/department Contact details Language help Space for notes Referenced statements
A. Accessibility of information to a lay audience.
The shortest publication was a single side of paper and the longest was a 50 page booklet. The overall scores ranged from 13% to 83% (mean 45% ; SD 15).
The highest total score was 83%, followed by 71%.
clear text useful diagrams headings including clear title logical order contact details for help, guidance for obtaining copies in another language or Braille. one had space for own notes
Lowest score was 13% ( 2)
one and two pages long respectively poor quality diagram in each. one had handwritten text inserted on the final copy- which was difficult to read. title of one was ‘Precautions’ and it was not initially clear that this referred to hip precautions.
B. Scope of information.
49 ( 44% ) described the actual operation, 39 ( 35 % ) advice on pre-operative care 40 ( 36 % ) covered medical aspects such as pain relief, complications e.g. DVT, wound infection.
Scope of information.
49 ( 44% ) described the actual operation, 39 ( 35 % ) advice on pre-operative care 40 ( 36 % ) covered medical aspects such as pain relief, complications eg DVT, wound infection.
46 ( 41 % ) advice on general health issues e.g. keeping fit before and after surgery, 44 ( 40 % ) included specific exercises 109 ( 98 % ) generic advice on hip precautions such as not bending or twisting.
C. Specific activities of daily living (ADLs) presented.
Activities Sitting Bathing Driving a car Sleeping Dressing/ undressing Being a (car) passenger Using the toilet General domestic activities Modifying the home environment Sex Bed transfers Stairs Leisure Walking Social support Bending down/ picking something up from the floor Work Other* 29 39 41 47 49 51 62 65 66 69 No n (%) 12
(11)
24 26
(22) (23)
27 29
(24) (26) (26) (35) (37) (42) (44) (46) (56) (59) (60) (62)
81
(73)
85 96
(77) (87)
82 72 70 64 62 60 49 46 45 42 Yes n (%) 99
(89)
87 85
(78) (77)
84 82
(76) (74) (74) (65) (63) (58) (56) (54) (44) (44) (41) (38)
30
(27)
26 15
(23) (7)
Messages
National picture- variations even regionally in activities taught and practised and in time recommendations.
Differing opinions on hip precautions Literature produced- range in scope and quality
Hip studies/trials to date
No control or inadequate comparator Under powered Outcome of hip dislocation at expense of patient satisfaction, pain, quality of life, function, mood.