Early mobility after fragility hip fracture: a mixed methods embedded case study

BACKGROUND: Following a hip fracture up to 60% of patients are unable to regain their pre-fracture level of mobility. For hospitalized older adults, the deconditioning effect of bedrest and functional decline has been identified as the most preventable cause of ambulation loss. Recent studies demonstrate that this older adult population spends greater than 80% of their time in bed during hospitalization, despite being ambulatory before their fracture. We do not fully understand why there continues to be such high rates of sedentary times, given that evidence demonstrates functional decline is preventable and early mobility recommendations have been available for over a decade. METHODS: A descriptive mixed method embedded case study was selected to understand the phenomenon of early mobility after fragility hip fracture surgery. In this study, the main case was one post-operative unit with a history of recommendation implementation, and the embedded units were patients recovering from hip fracture repair. Data from multiple sources provided an understanding of mobility activity initiation and patient participation. RESULTS: Activity monitor data from eighteen participants demonstrated a mean sedentary time of 23.18 h. Median upright time was 24 min, and median number of steps taken was 30. Qualitative interviews from healthcare providers and patients identified two main categories of themes; themes external to the person and themes unique to the person. We identified four factors that can influence mobility; a patient’s pre-fracture functional status, cognitive status, medical unpredictability, and preconceived notions held by healthcare providers and patients. CONCLUSIONS: There are multi-level factors that require consideration with implementation of best practice interventions, namely, systemic, healthcare provider related, and patient related. An increased risk of poor outcomes occurs with compounding multiple factors, such as a patient with low pre-fracture functional mobility, cognitive impairment, and a mismatch of expectations. The study reports several variables to be important considerations for facilitating early mobility. Communicating mobility expectations and addressing physical and psychological readiness are essential. Our findings can be used to develop meaningful healthcare provider and patient-centred interventions to address the risks of poor outcomes.