Background:
Low-trauma hip fractures are common, have significant morbidity, and often prolonged hospitalisation. Inpatient rehabilitation contributes to length of stay, patient flow burden, and risk of hospital-acquired complications. Early supported discharge programs such as Rehabilitation in the Home (RITH) offers an earlier return home, while reducing hospital bed pressure.
Change:
We launched a randomised trial of RITH across two hospitals in metropolitan Sydney. Our previous observational acute hospital substitution pilot study showed that many patients with hip fractures preferred to return home earlier, informing expectations of high recruitment, but recruitment was critically low. Resistance was not directed at RITH itself, but at the uncertainty introduced by the trial design.
For older people and their families, a hip fracture is sudden and often life-altering. Decisions regarding surgery and discharge planning occur rapidly. Introducing a randomised trial, offering only a chance of going home, added uncertainty when patients were seeking stability, and asked clinicians to work within a ‘toss-of-a-coin’ construct. Faced with this, many chose the perceived safety and simplicity of a pre-determined path of inpatient rehabilitation, despite a preference to recover at home.
In response, we transitioned to an observational-implementation design, prioritising patient preference, certainty, and autonomy in their recovery, and providing certainty for clinicians.
Learnings:
In healthcare, methodological hierarchy must consider person-centred care and realities of working within a clinical team. Timing, vulnerability, and carer burden are especially significant in aged care, if we aim to redesign systems for older people, our research approaches must reflect patient and carer needs.