Development of an Early Activation Hip Fracture Care Bundle and Implementation Strategy to Improve Adherence to the National Hip Fracture Clinical Care Standard

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Table 1 Barriers to Implementation of eHIP Categorised to the Theoretical Domains Framework

TDF Domains	Barriers to the Implementation of eHIP Identified by Clinical Staff
Knowledge (An awareness of the existence of something)	What is eHip? How is it activated and by whom? How will I know if it’s been done, or if I have to do it? What first, then what etc? Ie Xrays etc What pain relief do I use? Why? How does this affect ortho or med reg referral? When do we refer to anaesthetics, who, how? Who will refer to physiotherapy and dietician, when should this be done? What is the appropriate timeframe for follow up and review?
Skills (An ability or proficiency acquired through practice)	How do I actually activate eHIP? How do I order the x rays online? Do I need special accreditation/access? How to document analgesia online under the protocol? How to refer to ortho, anaesthetics, acute pain service, geriatricians, physiotherapist, dietician? How to record when the patient has been reviewed by the above teams? Not many staff know how to perform a Fascia iliac block For staff from outside the ED, how to find the patient? How to find and use PAINAD (Pain Assessment in Advanced Dementia (PAINAD) Scale)^Citation37 for pain assessment? How to perform cognitive assessment? Which cognitive assessment to use?
Social/ Professional Role and Identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting)	What do I have to do? Whose job is it to perform various tasks? Whose job to activate? Whose job to respond and follow up? Will I be supported by senior staff to do this role? What will be my role in this at various stages of the pathway? How does each individual interact with each other along the pathway, (eg What is EDs expectations of anaesthetics or physiotherapy? What can I ask of them, when will I see them?) What do I tell the staff that do not know about this pathway?
Beliefs about Capabilities Self-confidence (Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use)	Who do I tell if there is a problem with this system? Will anyone listen? What else happens on this pathway? Do I need to do anything differently? Is it easy to do? What do I have to tell ortho, geris, anaesthetics?
Optimism (The confidence that things will happen for the best or that desired goals will be attained)	Why bother? Does it matter when the physio or dietician sees the patient? Is this just more work for me? Who does this actually help? What if I am not told at handover whether eHiP has been activated or not?
Beliefs about Consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation)	How will we know what good and tangible difference will this make for ED flow, the patient, the ward, and staff? What happens in each step? What if it does not happen, does everything stop? Who can I ask about all this stuff? What if I do it and nothing happens? What if I do not see any actual benefits in ED of this process? Why keep doing it?
Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)	Is anyone going to check that I do it? What data is being collected and what is being followed up on? What are the consequences and contingencies that exist at each step? I am completing my step, but what about the others? What if one of the steps is failing? What will be done? Will the hospital support each staff member doing their role? How do I know if it’s working?
Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way)	How to encourage people to actually do it and remain engaged? On the wards why continue to involve all the extra staff that keep asking me to do extra tasks?
Goals (Mental representations of outcomes or end states that an individual wants to achieve)	Who is better off? The staff, the patient, the hospital? Does it really matter when all this gets done? How will I know what I have done has achieved something? What does ordering an xray achieve? What does referral and review achieve? Blocks need to be prioritised without impacting care of other patients
Memory, Attention and Decision Processes (The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives)	What if I cannot remember what to do? How will staff remember to notify and follow the pathway? How will I remember the individual steps? If I cannot remember what to do can I find the protocol somewhere?
Environmental Context and Resources (Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour)	How to notify? Can I get the clerk to do it? Will it be easy to access pathway/guidelines? Where do I find this stuff? I am too busy to do something else Is there availability of Operating time/staff? How do I find the patient once activated? We need availability of equipment to perform procedures, especially FIB (fascia iliac block) We need to know staff are available to perform each component The Cognitive screen needs to be easily available on eMR (electronic medical record) Staff to be released for training Availability of anaesthetic registrar (has several responsibilities including preop consults, pain round, labour epidurals, cardioversions, arrest.
Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours)	Nobody else does it why should I? I do it and do not see anything happening, people do not do what they are supposed to Is it working? What’s my part again? Do the bosses even care if I do this?
Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)	I just cannot do anything else I am overloaded We are all doing overtime and can barely do urgent patient care I am going to end up doing all of these when I am working with <name> Am I going to have all these doctors hassling me now? I am too busy! NO more pathways!
Behavioural Regulation (Anything aimed at managing or changing objectively observed or measured actions)	What’s the policy? How do I know if it’s working, if everyone is doing it? How will we know what good and tangible difference will this make for ED flow, the patient, the ward, and staff?

Note: TDF domains are emphasised in bold text and described within parentheses italicized.

Table 2 eHIP Mechanism to Meet Each ACSQHC Hip Fracture Care Clinical Care Standard

ACSQHC Hip Fracture Standard 1: Care at presentation
eHIP intervention	The Emergency Department (ED) triage nurse will identify potential hip fracture patients, order an x-ray and analgesia. “eHIP” page will be activated on confirmation of a hip fracture and activate a series of mandated assessments and treatments (Figure 1).
Expected Outcome	Early recognition and notification enables tailored patient care through a mandated rapid multidisciplinary response within 60 minutes 24/7, pain assessment and cognitive screening. Analgesia within 30 minutes
ACSQHC Hip Fracture Standard 2: Pain management
eHIP intervention	Nursing staff will document pain assessment as part of routine vital sign collection. Nurses will be empowered to initiate analgesia, FIBs and pain service referrals. The acute pain service will respond to eHIP page within 60 minutes 24/7 to facilitate daily assessment/review.
Expected Outcome	Recognition of analgesic needs at presentation and throughout hospital stay. Initiation and monitoring of effective and timely multimodal analgesia throughout patient’s hospital stay to enable early mobilisation
ACSQHC Hip Fracture Standard 3: Orthogeriatric model of care
eHIP intervention	Orthogeriatrics are part of the eHIP notification page and are aware of their initial and ongoing responsibilities including a daily consult service.
Expected Outcome	Orthogeriatric assessment in ED then ongoing coordination of needs including reassessment of cognition after surgery, discharge planning, falls and secondary fracture prevention.
ACSQHC Hip Fracture Standard 4: Timing of surgery (<48hrs)
eHIP intervention	Orthopaedic, anaesthetic, geriatric teams and bed manager will be notified when patient at triage. Will review patient within 60 minutes and expedite assessment and booking of operative intervention – replacing multiple, sequential delayed phone calls. Patients requiring transfer from SDMH to WH will not require repeat Anaesthetic consult and will be booked directly to the operative list
Expected Outcome	Early notification, inter-hospital transfer (if required), booking of operative intervention and risk screens to enable surgery <48hrs.
ACSQHC Hip Fracture Standard 5: Day 1 Mobilisation and weight-bearing
eHIP intervention	Automated referral to physiotherapy 7 days/week. Post-op patient prioritised. Physiotherapy team aware of need and empowered for day 1 mobilisation
Expected Outcome	Gold standard pain management, and recommended falls and delirium assessments will already have been completed so safe mobilisation can be imitated the day after hip fracture surgery unless contraindicated.
ACSQHC Hip Fracture Standard 6: Minimising risk of another fracture
eHIP intervention	Falls and bone health assessments/plans including bone protection medication will be part of eHIP. The nurse manager of each ward, along with the aged care nurse consultant will be empowered to ensure each ACSQHC Standard occurs, facilitated via a daily ward round that assesses eHIP compliance. This round includes early authentic carer engagement and shared decision making.
Expected Outcome	Tailored patient education on and intervention for risk factors for falls conducted by aged care nurse consultant and physiotherapy.
ACSQHC Hip Fracture Standard 7: Transition from hospital care
eHIP intervention	Optimised by the commencement of an individualised care plan early in the hospital stay by the orthogeriatric multidisciplinary team. A template will be developed to ensure a clear description of the patient’s ongoing care and goals following discharge. This includes collaboration with and “handover” to GP.
Expected Outcome	Consistent, reliable and streamlined “handover” to the patient’s GP

Note: ACSQHC hip fracture standards are italicized.

Figure 1 Flow chart summarising the eHIP policy and process. Red, green, and blue sections represent the notify, assess and treat, and plan and prevent stages of eHIP, respectively.

Abbreviations: #NOF, neck of femur fracture; SDMH, Shoalhaven District Memorial Hospital; WH, Wollongong Hospital; MRN, medical record number; eMR, electronic medical record; HIRAD, history, red flags, assessment, intervention, diagnostics; IDC, indwelling catheter; ECG, electrocardiograph; FBC, full blood count; UEC, urea, electrolytes, creatinine; CMP, calcium, magnesium, phosphate; LFT, liver function tests; Vit D, vitamin (D); G + H, group and hold; BTF, vital signs between the flags; GP, general practitioner.

Table 3 Mechanism, Intervention Functions, and Behavioural Change Technique Taxonomy (BCTT) as Identified Using the Behaviour Change Wheel

Mechanism	Intervention Functions	BCTTs
Formal policy that outlines eHIP roles	Incentivisation Restriction Enablement	Goals and planning 1.4 Action planning Feedback and monitoring 2.3 Self-monitoring of behaviour Shaping knowledge 4.1. Instruction on how to pe form the behaviour Associations 7.1 Prompts/cues Covert learning 16.1. Imaginary punishment
Video-Promo: of ehip process, expected behaviours, benefits, roles re activation and response. Use senior staff with credibility to model and reinforce, use frontliners for social influence. Make fun, short and easy to watch to emphasise ease and minimal changes. Enhance with music (Supplementary Video 1).	Education Persuasion Incentivisation Training Modelling Enablement	Goals and planning 1.4. Action planning 1.5. Review behaviour goal(s) 1.7. Review outcome goal(s) Shaping knowledge 4.1. Instruction on how to perform the behaviour Natural consequences 5.1. Information about health consequences Comparison of behaviour 6.1. Demonstration of the behaviour 6.2. Social comparison 6.3. Information about others’ approval Associations 7.8. Associative learning Reward and threat 10.4. Social reward 10.5. Social incentive Self-belief 15.1. Verbal persuasion about capability
Pager group: Meetings with multiple stakeholders to discuss methods of communication with appropriate staff. Setting up pagers or eMR based communication and responses. Discussing expected response to the page or communication.	Persuasion Incentivisation/Coercion Restriction Environmental restructuring Enablement	Feedback and monitoring 2.1. Monitoring of behaviour by others without feedback 2.3. Self-monitoring of behaviour Associations 7.1. Prompts/cues
Fascia Iliaca Block enabling Expansion of training to nurses, easier access to equipment. Encouragement and exposure to technique and benefits. Introduction of analgesia policy, decreasing use of other analgesics to favour this method Training in FIB, Ultrasound, education program obtained from NSW ACI, FIB box Special area for FIB catheters	Education Training Restriction Environmental restructuring Enablement	Shaping knowledge 4.1. Instruction on how to perform the behaviour Social support 3.2. Social support (practical) Comparison of outcomes 9.1. Credible source Antecedents 12.2. Restructuring the social Environment Self-belief 15.1. Verbal persuasion about capability
eMR modifications Set up of electronic notification package, order set for xrays and analgesia. Information on steps in pathway. Notification symbol. Order set for hip fracture blood order set, referral/consult Icon visible on eMR to reflect activation	Persuasion Restriction Environmental restructuring Enablement	Goals and planning 1.7. Review outcome goal(s) Feedback and monitoring 2.1. Monitoring of behaviour by others without feedback 2.2. Feedback on behaviour 2.3. Self-monitoring of behaviour 2.4. Self-monitoring of outcome(s) of behaviour 2.5. Monitoring of outcome(s) of behaviour without feedback 2.7. Feedback on outcome(s) of behaviour Natural consequences 5.5. Anticipated regret Associations 7.1. Prompts/cues Reward and threat 10.3. Non-specific reward 10.4. Social reward 10.5. Social incentive Covert learning 16.1. Imaginary punishment 16.2. Imaginary reward 16.3. Vicarious consequences
F2F formal and informal education that incorporates surgical and ED orientation processes, surgical grand rounds, regular ED education calendar. Initially: Info re consequences-health, social and environmental ie what happens when we follow this process, what happens to the patient when we follow this process. Info re roles, response, policy, components Instruction on HOW to perform tasks Environment-ie FIB box, procedure room Acknowledge complexity of patients and outcomes Subsequent: Feedback on performance, behaviour, and outcomes. Reminder of consequences	Education Persuasion Training Modelling	Goals and planning 1.1.Goal setting (behaviour) 1.9. Commitment Shaping knowledge 4.1. Instruction on how to perform the behaviour 4.2. Information about Antecedents Natural consequences 5.1. Information about health consequences 5.2. Salience of consequences Comparison of outcomes 9.1. Credible source 9.2. Pros and cons 9.3. Comparative imagining of future outcomes Self-belief 15.1. Verbal persuasion about capability 15.2. Mental rehearsal of successful performance 15.3. Focus on past success 15.4. Self-talk
Communication and prompts Short Comms (Posters, emails) Emails sent to each speciality head of department and distributed to staff about specific role, included link to video and protocol Newsletter item for ED, surgery SMIT (ED): short, snappy that includes Info consequences-for pt, for staff Roles and responsibilities How to activate Include info from credible sources ie CE, NUM etc	Education Persuasion Environmental restructuring Modelling Enablement	Goals and planning 1.8. Behavioural contract 1.9. Commitment Feedback and monitoring 2.2. Feedback on behaviour Social support 3.3. Social support (emotional) Comparison of behaviour 6.3. Information about others’ approval Associations 7.1. Prompts/cues Repetition and substitution 8.6. Generalisation of target behaviour Reward and threat 10.4. Social reward 10.5. Social incentive
Face to face reinforcement and modelling by clinical leaders. An implementation nurse was employed for 3 months to follow the patient journey and ensure implementation of each component. The leaders provided feedback on behaviour and patient outcomes, demonstrated best practice, and escalated problems to the relevant departmental managers as needed.	Education Persuasion Training Restriction Modelling	Goals and planning 1.6. Discrepancy between current behaviour and goal 1.8. Behavioural contract 1.9. Commitment Feedback and monitoring 2.1. Monitoring of behaviour by others without feedback 2.2. Feedback on behaviour Social support 3.1. Social support (unspecified) 3.2. Social support (practical) 3.3. Social support (emotional) Shaping knowledge 4.1. Instruction on how to perform the behaviour 4.2. Information about Antecedents Associations 7.1. Prompts/cues
Environmental restructuring that included the generation of a dedicated box containing equipment to perform a FIB. Access to a dedicated anaesthetics procedure room for blocks or insertion of regional anaesthesia catheters if the patient is on the ward awaiting surgery.	Environmental Training Restriction Modelling Enablement	Goals and planning 1.4. Action planning Social support 3.1. Social support (unspecified) Shaping knowledge 4.1. Instruction on how to perform the behaviour 4.2. Information about Antecedents Comparison of behaviour 6.3. Information about others’ approval Associations 7.7. Exposure Comparison of outcomes 9.1. Credible source 9.2. Pros and cons 9.3. Comparative imagining of future outcomes Self-belief 15.1. Verbal persuasion about capability
Reporting to end users Data collection processes refined, consolidated to enable reporting locally and to the ANZHFR. Implementation evaluation planned to measure patient and health service outcomes.	Education Persuasion Incentivisation Coercion	Goals and planning 1.6. Discrepancy between current behaviour and goal Feedback and monitoring 2.1. Monitoring of behaviour by others without feedback 2.2. Feedback on behaviour 2.7. Feedback on outcome(s) of behaviour Associations 7.1. Prompts/cues 7.7. Exposure 7.8. Associative learning Reward and threat 10.3. Non-specific reward

Note: Numbering within the “BCTT” column presents the BCTT in their hierarchical order described by Michie et al under their respective category in bold.

Figure 2 Screen shots from eHIP implementation video.

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