Considering the importance of good rehabilitation in the overall quality and cost-effectiveness of hip fracture care, the relevant evidence base is somewhat disappointing. Factors such as complexity of case-mix, service context, details of service organisation and multidisciplinary inputs, and even health care reimbursement systems, can add greatly to the problems normally associated with the organisation of large-scale clinical trials involving older patients. However, a number of systematic reviews have reported in recent years.^162,163,164

9.1 Early assessment

Early assessment by medical and nursing staff, physiotherapist and occupational therapist to formulate appropriate preliminary rehabilitation plans has been shown to facilitate rehabilitation and discharge.^165,166 Evidence level 2+

Premorbid mental state, mobility and function are the most reliable predictors of the success of rehabilitation, and can be used as screening tools to assess a patient's early rehabilitation needs and potential.^{167,168,169,170} Evidence level 2++

Within 48 hours of admission, a corroborated history should be obtained, which should include: premorbid function and mobility available social support current relevant clinical conditions mental state.

Patients from home, who are relatively alert and fit, are most likely to benefit from supported discharge schemes. Patients previously precarious at home may require longer periods of inpatient rehabilitation to maximise their chances of return home. Cognitive status has a bearing on functional abilities, length of stay and outcome.^{167,168,169,170,171} Evidence level 2++

Patients with co-morbidity, poor functional ability and low mental test scores prior to admission should undergo rehabilitation in a Geriatric Orthopaedic Rehabilitation Unit (GORU).

Maintaining balance during daily activities is a useful predictor of subsequent hospitalisation, care home placement and mortality.¹⁷²

9.2 Rehabilitation

9.2.1 NUTRITION AND REHABILITATION

Elderly patients with hip fractures are often malnourished on admission and their nutritional status will not necessarily improve in hospital. Dietary surveys in the postoperative period have recorded inadequate dietary intake. Poor nutrition can lead to mental apathy, muscle wasting and weakness, impaired cardiac function and lowered immunity to infection.¹⁶⁴

Oral multinutrient feeds provide protein, energy, some vitamins and minerals and may reduce complications whilst in hospital, although they have no effect on mortality. The presence of protein in an oral feed may reduce the number of days spent in rehabilitation. Nasogastric feeding may be of benefit to very malnourished patients and may reduce their length of stay in hospital.¹⁶⁴ Evidence level 1++

The studies were unclear regarding how long supplementation should continue; the duration varying from study to study. In practice, the duration of supplementation will depend on assessment of the needs of each individual patient, in consultation with a dietitian.

Supplementing the diet of hip fracture patients in rehabilitation with high energy protein preparations containing minerals and vitamins should be considered.

Patients' food intake should be monitored regularly, to ensure sufficient dietary intake.

9.2.2 MULTIDISCIPLINARY REHABILITATION

Multidisciplinary team working is generally considered to be effective in the delivery of hip fracture rehabilitation. The professions, grades and interrelationships of members of the "multidisciplinary team" vary between studies and, because these characteristics are rarely described in detail, the effectiveness of different approaches to team working is not yet well understood.^{165,166,173,174,175} Rehabilitation should be commenced early to promote independent mobility and function. The initial emphasis should be on walking and activities of daily living (ADL) e.g. transferring, washing, dressing, toileting. Balance and gait are essential components of mobility and are useful predictors in the assessment of functional independence.^{167, 172} Evidence level 2++

9.2.3 MEDICAL MANAGEMENT AND REHABILITATION

Collaboration between orthopaedic surgeons, physicians in geriatric medicine and other members of the multidisciplinary team should be sought to assist in medical management and rehabilitation. The benefits of shared postoperative management by orthopaedic surgeons and geriatricians include trends towards earlier functional independence, reduced length of stay, improved management of medical conditions and decreased future need for institutional care, including nursing home care.^{173,175,176,177,178,179} Evidence level 2++

Multidisciplinary team working facilitates the rehabilitation process.

9.3 Discharge

9.3.1 SUPPORTED DISCHARGE

Supported discharge and early supported discharge (ESD) schemes comprise an identified team of staff (schemes vary but the teams tend to include designated medical, nursing, physiotherapy, occupational therapy and social work personnel) whose role is to assess patients on admission, to identify those suitable for supported discharge, to facilitate early mobilisation and rehabilitation and arrange appropriate support on discharge and follow up. ^{166,174,180,182} Most schemes have an identified discharge coordinator or liaison nurse.

Patients who are mentally alert, medically well and mobile postoperatively are most likely to benefit from a supported discharge scheme,^{167,170,174,180} and should be identified by multidisciplinary team assessment. Such patients who have been admitted from home can be discharged directly back home, without compromising the patient's recovery. Supported discharge schemes have also been shown to improve patients' abilities to carry out activities of daily living^170,174,180 and increase the overall proportion of patients discharged home.¹⁷⁴

Supported discharge and hospital at home schemes reduce length of acute stay and appear to free resources without transferring unacceptable costs to community health and social services.^{165,166,170,174,180,181,182} These costings do not include informal support from carers. Evidence level 2++

Local circumstances will dictate the nature of local arrangements between hospital and community health and social services.¹⁷⁵

Supported discharge schemes should be used to facilitate the safe discharge of elderly hip fracture patients and reduce acute hospital stay.

9.3.2 GERIATRIC ORTHOPAEDIC REHABILITATION UNITS

Geriatric orthopaedic rehabilitation units (GORUs) are multidisciplinary inpatient facilities catering for the frailer, more dependent patient and were originally associated with larger orthopaedic units. Medical care and rehabilitation are supervised by a geriatrician, often with the help of a specialist GP. Orthopaedic cover from a visiting surgeon should be available.

Geriatric service interventions after hip fractures are complex and it is not easy to quantify conclusively the effectiveness of each different type of co-ordinated inpatient rehabilitation.^162,163 The observed trends favour GORU over conventional management, with a reduction in deaths and an increase in functional improvement.¹⁶² GORUs can increase the efficiency of acute bed use by taking on potentially long stay patients, for example, patients needing prolonged rehabilitation prior to discharge or patients who are unable to return home and are awaiting an alternative placement. Evidence level 1+

There is no evidence that length of stay is reduced in a GORU compared to a conventional unit.¹⁶³ In both cases, excessive lengths of stay are primarily related to non-medical problems such as care needs and social support, as well as cognitive impairment.¹⁶⁸ As GORUs tend to increase the chance of a patient returning to their own home, they may be cost-effective in reducing the costs of residential care.¹⁶²

9.3.3 PATIENTS ADMITTED FROM INSTITUTIONAL CARE WITH FRACTURED HIP

Data from the Scottish Hip Fracture Audit⁷⁴ reveals that in the past five years over one third of female hip fracture patients were admitted from institutional care. One fifth of admissions were from care homes. Of these, one third die within four months of admission compared to only 14% of patients admitted from home. Short length of stay can be predicted in medically fit patients who are from care homes because of the supportive care available. A longer length of stay can be predicted in patients from institutions which do not provide nursing care. Although many can be returned to their original placement with the benefit of familiar care, outcomes are poor, with one-year mortality well over 50%.

9.4 Discharge management

Multidisciplinary discharge management, involving community and hospital nurses, hospital doctors and general practitioners, physiotherapists, occupational therapists, social workers and family^{166,170,174,175,180} has been shown to improve planning and implementation of discharging patients. For example, prior to discharge, the patient may have a continued fear of falling, leading to loss of confidence and increased dependency. Supported discharge schemes with liaison nurse follow up can monitor patient progress at home and help to alleviate some of these fears.^165,171,180

The patient should be central to discharge planning, and, where realistic, their needs and wishes taken into consideration. The views of a carer are also important. Liaison between hospital and community (including social work department) facilitates the discharge process. Occupational therapy home assessments assist in preparing patients for discharge. Patient, carer, GP, and other community services should be given as much notice as possible of the date of discharge. Discharge should not take place until arrangements for postdischarge support are in place and the patient is fit for discharge. Written information on medication, mobility, expected progress, pain control and sources of help and advice should be available to patient and carer. General practitioners have an important role to play in postdischarge rehabilitation and should receive early and comprehensive information on hospital stay, services arranged and future follow up arrangements. Complicated discharges that may have considerable impact on the primary care team should be discussed in advance with the GP. Consideration should be given to the prevention of falls with particular attention being paid to potential household hazards, footwear, provision of adaptive equipment/walking aids and alarm systems.