SMART Project: Hip Fracture Pain Management

Executive Summary

The SMART project aims to bridge the evidence-policy/practice gap in hip fracture pain management in Australia. With approximately 19,000 hip fracture cases annually, this project is important. Evidence-based guidelines for pain management exist. Still, their implementation falls short, leading to adverse patient outcomes and increased healthcare costs. The project's multidisciplinary team, led by an experienced orthopedic surgeon will develop and implement a comprehensive hip fracture pain management protocol. This protocol includes standard pain assessment, multimodal analgesia, education, and quality improvement initiatives. The project's timeline spans 12 months with a clear budget allocation for resources and training. Stakeholder engagement, including healthcare professionals such as surgeons, nurse specialists, anaesthetists, and patients is central to the project's success. The change strategy involves overcoming barriers through tailored interventions, piloting, and scaling the change. Continuous monitoring and evaluation will track knowledge and attitude shifts, patient and provider outcomes, and healthcare system improvements. Sustainability measures will ensure lasting positive changes. The dissemination plan encompasses various channels from traditional publications and presentations to modern methods like webinars, social media, and training courses. This comprehensive approach ensures that the project's findings reach and benefit a broad audience, ultimately improving hip fracture pain management in Australia and beyond.

1. Background

1.1 Problem

The evidence-based gap in hip fracture pain management in Australia is a serious problem for patients and the healthcare system. In Australia, 19,000 persons suffer hip fractures annually (ACSQHC, 2023). Even though there are evidence-based recommendations and guidelines for managing pain in hip fracture cases, there is still a significant gap between these best practices and the actual clinical treatment (Nguyen & Swiontkowski, 2023). For instance, a study by Jiang et al. (2021) involving a tertiary hospital in Sydney, revealed that a sizable percentage of hip fracture patients did not receive proper pain management per recognised criteria. This serves as a critical piece of evidence supporting the presence of this gap. According to the research by Horn & Kramer (2019), insufficient pain management was linked to more prolonged hospital admissions and post-operative problems, resulting in lower patient health outcomes.

1.2 Significance

Effective pain management is essential for hip fracture patients, most of whom are elderly patients. A patient's quality of life may be significantly impacted by severe consequences like pneumonia, pressure ulcers, and delayed movement that result from insufficient pain treatment (Jaul et al., 2018). Additionally, there are significant economic consequences. Prolonged hospitalisations due to suboptimal pain management significantly burden healthcare resources and increase healthcare costs. A report from the Australian Institute of Health and Welfare (AIHW) highlights that hip fractures are associated with a substantial economic cost, and improving pain management can help mitigate these costs (AIHW, 2018).

1.3 Alignment to priorities 

This project aligns with local, state, and national healthcare priorities. In Australia, improving healthcare quality and patient safety is a top priority, as articulated in the Global Patient Safety Action Plan (WHO, 2023). Bridging the evidence-based gap in hip fracture pain management directly contributes to this priority by enhancing patient safety and outcomes (WHO, 2023). Additionally, the National Aged Care Quality Indicator Program, which emphasises the quality of care for the elderly aligns with this project as hip fractures are more prevalent in the elderly population (Australian Government, 2023).

2. Evidence Policy/Practice Gap

2.1 Evidence of gap

Addressing the evidence-policy/practice gap in hip fracture pain management is crucial to improve patient outcomes and align clinical practices with the best available evidence. Multiple sources of evidence, both local and international, clearly indicate the existing gap (Leland et al., 2018). The Australian and New Zealand Hip Fracture Registry (ANZHFR) has documented disparities in pain management practices across various healthcare facilities, highlighting variations in pain assessment, analgesic administration, and overall pain relief outcomes (ANZHFR, 2021). This local data demonstrates that current practices in Australia must follow evidence-based guidelines, leaving room for improvement consistently. For instance, a systematic review by Voeten et al. (2018) encompassing studies from multiple countries, including Australia, emphasised the need for standardised, evidence-based approaches in hip fracture pain management. These findings support a global gap in best practices and emphasise the importance of addressing this issue.

2.2 Evidence strength and quality

The strength and quality of the evidence to be implemented is robust. It primarily involves clinical hip fracture pain management guidelines developed based on rigorous research, systematic reviews, and expert consensus and government reports. Strong evidence supports these recommendations, frequently including randomised controlled trials, observational research, and systematic reviews. Systematic reviews and meta-analyses of many facets of pain management in patients with hip fractures have been published by the Cochrane Library, a recognised source of evidence-based resources offering high-quality data to guide best practices. This information has been thoroughly examined and synthesised to guarantee its dependability and applicability to clinical practice, making it a reliable base for implementing evidence-based improvements.

2.3 Practice Change

A thorough hip fracture pain management protocol must be implemented as part of the suggested evidence-based practice change. To enable consistent adherence to evidence-based practices, this protocol will combine a variety of already available knowledge aids, including clinical pathways, checklists, and decision support tools (Musen et al., 2021). Standardised pain assessment is one of the protocol's components, ensuring that a standardised tool is consistently used to assess pain severity, location, and functional impact. These evaluations encourage the development of customised pain management plans that direct healthcare professionals in choosing the best analgesic interventions for each patient (Dydyk & Grandhe, 2023). A vital procedure component will be multimodal analgesia, which combines several analgesic techniques to maximise pain reduction while limiting adverse effects. Healthcare workers will be given the knowledge and skills they need to apply the new guidelines through education and training programmes successfully. Continuous monitoring and quality improvement will be implemented to ensure continual evaluation and improvement of pain management (Kaye et al., 2018).

3. Change Plan

3.1 Project Aim(s)

The SMART project aims to significantly improve hip fracture pain management within Australian healthcare facilities. Specifically, it seeks to bridge the evidence-policy/practice gap by enhancing adherence to evidence-based guidelines, leading to better patient outcomes, reduced complications, and more efficient utilisation of healthcare resources. Measurable through quantitative assessment of adherence rates and patient outcomes and achievable with the support of the expert project team, Relevant due to the clear evidence-based gap. The aim is realistic as its focus on hip fracture pain management, and Time-bound with a project duration of 12 months.

3.2 Team members

To ensure a multidisciplinary approach, the project team's members were carefully chosen, and each brought valuable knowledge. The Project Lead, a skilled orthopedic surgeon, thoroughly understands treating hip fractures and is ideally qualified to lead the project (Griffiths et al., 2021). It is essential for making changes in clinical practice that the clinical nurse specialist has extensive expertise in orthopedic nursing and pain management (O'Rourke, 2022). The anesthetist's knowledge of multimodal pain management approaches is crucial for creating robust plans (Griffiths et al., 2021). The Quality Improvement Specialist, who has experience with process optimisation will be crucial in determining how the changes will affect things and in promoting ongoing quality improvement. The executive sponsor will be selected depending on their capacity to get the required funding, integrate the project with organisational objectives, and ensure success (Marwaha et al., 2022).

3.3 Action plan

The action plan for the project specifies the crucial activities needed to accomplish the project's goal. The foundational phase that prepares the environment for evidence-based practice is protocol development, coordinated by the clinical nurse specialist and anesthetist. To guarantee that, healthcare workers are adequately prepared to apply the new procedure, the Quality Improvement Specialist will oversee the ensuing phase of training and education. The Project Lead and Clinical Nurse Specialist will supervise compliance and monitor patient outcomes during the Implementation and Monitoring phase. Under the direction of the Quality Improvement Specialist, continuous quality improvement ensures that the project is still receptive to new data and flexible enough to respond to changing conditions.

3.4 Timeline

The one-year recommended timetable begins with protocol creation and ends with continuing data analysis and improvement. The conclusion of the hip fracture pain treatment protocol, the execution of training programs for all pertinent healthcare personnel, the full implementation of the protocol, and the start of data collection and monitoring are important milestones.

3.5 Budget

The budget for the project will encompass financial resources for training, educational materials, data collection and analysis tools, and potential adjustments to clinical practices. While human resources will be allocated from within the healthcare facility, any additional training costs will be factored into the budget, subject to review and approval.

3.6 Project approvals

Project approvals will be sought locally, including approval from the hospital's administration, board, and relevant regulatory or quality improvement bodies. Collaboration with hospital leadership will be instrumental in obtaining these approvals and gathering support for the project.

4. Situational Analysis

4.1 Actors and actions

Identifying key actors and their required behaviour changes is crucial in improving hip fracture pain management. Orthopedic surgeons must adopt evidence-based pain management, shifting towards non-opioid approaches. Nurses will ensure protocol adherence, accurate assessments, and timely analgesic administration. Anesthetists should embrace multimodal techniques and non-opioid options. Rehabilitation specialists will focus on patient mobility and function while minimising pain. These behavioural shifts collectively create a holistic, evidence-based approach (Schwenk & Mariano, 2018).

4.2 Stakeholder analysis and management plan

Practical stakeholder analysis and management are paramount. Hospital administrators will be involved by showcasing alignment with strategic goals, improved patient care, and cost reduction potential. Senior medical leadership, like the Chief Medical Officer, can advocate for the project. Regulatory bodies will be kept informed to meet external standards. Patient engagement is vital; their feedback ensures a patient-centred approach.

4.3 Assessment of organisational culture

Assessing the organisational culture is fundamental to understanding how ready the healthcare facility is for change and what accommodations are necessary. Leadership support is pivotal, as hospital administrators and senior medical leadership must be fully on board with the project. If resistance is encountered, efforts should be made to explain the project's benefits, backed by evidence from successful implementations in other institutions (Mannion & Davies, 2018). Change management training can be valuable in facilitating cultural change helping staff understand the importance of evidence-based practices and their benefits. Effective and clear communication is crucial in ensuring that all staff members are well-informed about the project's goals, expected outcomes, and the significance of adhering to the new protocol (Barrow et al., 2022).

4.4 User engagement

Successful implementation relies on user participation. The knowledge and abilities required to execute evidence-based practices should be available to knowledge users, including directly involved healthcare professionals. Training programs, workshops, and frequent feedback sessions must be established to ensure they comprehend and feel at ease with the new procedures. Additionally, it's important to remember that individuals who would benefit from better hip fracture pain management are service consumers. They should be made aware of the modifications and urged to provide their opinions on pain management procedures. Their opinions can be constructive in further streamlining the process and improving patient-centred treatment (Hurley et al., 2018).

5. Change Strategy

5.1 Identifying barriers to change

Establishing a practice change in hip fracture pain care requires recognising and resolving barriers to change. Several obstacles have been noted, including healthcare professionals' complacency, organisational culture, lack of understanding, resource limitations, and opposition to change. We will interview healthcare professionals to understand their issues and opinions and uncover additional hurdles. A careful assessment of the available literature and comparison with related initiatives are essential to find any hidden issues (Xiao & Watson, 2017).

5.2 Adapting evidence to context

To make sure that the new practice is not just evidence-based but also realistic and practicable within the particular healthcare facility, it is crucial to adapt the evidence to the local situation (Duff et al., 2020). The evidence-based procedure will be adjusted to meet the facility's particular patient population, patient demographics, resource availability, and infrastructure. Ensuring the protocol's seamless incorporation into daily practice will be crucial to align with the organisation's current rules, practices, and culture (Pitsillidou et al., 2021).

5.3 Selecting implementation interventions

A diverse approach has been chosen for implementation interventions to overcome the identified challenges. Healthcare workers will have the knowledge and skills necessary to adopt the new standard owing to educational workshops and training. Mechanisms for audit and feedback will guarantee ongoing oversight and development. Standardised documentation will result in improved accountability and consistency in pain management procedures (Foy et al., 2020).

5.4 Piloting, implementing and spreading change

To verify its efficacy in a practical setting, the practice change will be piloted inside a particular department or unit of the healthcare facility. The practice modification will be scaled up and adopted facility-wide after a successful pilot. A knowledge transfer method will be employed to communicate the change to additional healthcare organisations. Sharing best practices, lessons learned, and protocol modifications can motivate other facilities to make the same adjustments, resulting in a broader shift in evidence-based methods for treating hip fracture pain (Prihodova et al., 2019).

6. Monitor, Evaluate and Sustain Change

6.1 Knowledge and attitude

Data will be collected, analysed, and presented as part of a systematic process to track the effect on knowledge and attitude. Healthcare professionals will be surveyed and given questionnaires before and after the project is implemented to gain insight into changes in their attitudes regarding the new protocol and their knowledge of evidence-based standards. Data analysis will involve comparing survey responses from before and after implementation to see if there has been a significant gain in knowledge and a change for the better in attitude. Reports or presentations detailing the findings will demonstrate how the study affected healthcare professionals and how they perceived and were aware of best practices for managing hip fracture pain (Emmerson et al., 2022).

6.2 Outcomes assessment

Another critical area of focus will be evaluating the effect on individuals, providers, and the healthcare system. Monitoring and analysing patient outcomes, such as pain alleviation, complications, and duration of hospital stay, will be done to see whether the new procedure has enhanced patient recovery and well-being. In order to identify benefits and problems, provider outcomes such as protocol adherence, reaction time to patient pain demands, and contentment with the new strategy will be evaluated (Altman et al., 2019). The project's effects on the healthcare system will be evaluated using system-level outcomes like resource use and cost reductions. A thorough picture of the project's effectiveness will be provided by this data, which will be displayed in reports, presentations, or dashboards (Kruk et al., 2018).

6.3 Sustainability

The project plan will strongly emphasise sustainability and include measures to ensure the beneficial changes stick around. The evidence-based methodology will continue to be used effectively by healthcare workers thanks to ongoing training and education. Mechanisms for ongoing quality improvement will make it easier to evaluate and modify the process frequently (Kruk et al., 2018). Adopting evidence-based practices in the broader context will be promoted by knowledge transfer and continued leadership support from hospital administrators and senior medical leaders. To ensure that the enhancements in understanding, behaviours, patient and provider outcomes, and medical system efficacy continue beyond the project's initial implementation and ultimately benefit both patients and the healthcare system, sustainability measures will be incorporated into the project (Figueroa et al., 2019)

7. Dissemination

7.1 Dissemination plan

The project's dissemination strategy adopts a comprehensive and multifaceted approach designed to effectively and extensively share its valuable findings with a diverse audience. This multifaceted approach encompasses various tactics, ensuring maximising the research's impact. To begin with, research findings will be disseminated through traditional means, such as presentations at conferences and seminars, as well as publication in peer-reviewed medical journals. This establishes credibility and reaches the professional healthcare community. Internal reports and presentations will also be valuable resources for internal stakeholders and collaborators (Hanneke & Link, 2019).

The project will employ a range of modern communication channels to reach a broader audience. Findings will be released as public publications and press releases, making them accessible to the general public. Webinars and online resources will facilitate engagement with a more comprehensive online audience, while collaborations with professional associations will foster partnerships and knowledge sharing within the industry (Atkočiūnienė & Siudikienė, 2021). Utilising social media platforms will enable the project to connect with a vast and diverse audience, including patients, their families, healthcare professionals, researchers, and administrators. Furthermore, the project's commitment to offering workshops and training courses ensures that its insights and best practices can be integrated into healthcare facilities, ultimately leading to improved patient care and outcomes in Australia and globally (Chen & Wang, 2021).

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