Early mobilisation in hip fracture recovery: transforming outcomes, tackling challenges

Editorial to accompany: Early mobilisation after hip fracture surgery reduces the risk of infection: an inverse probability of treatment weighted analysis. This retrospective analysis of the Danish Multidisciplinary Hip Fracture Registry found that mobilisation within 24 h of operation (i.e. ‘early’) reduced postoperative infection outcomes, notably pneumonia [ 1]. Patients who were first mobilised after 24 h (i.e. ‘late’ at 24–36 h) had greater numbers of comorbidities; this was a large dataset, and the effect still held after controlling for this issue. There may be large gains if early mobilisation were to be employed at scale (cost, antibiotic use); however, scalability in other countries may be challenging. Early mobilisation would likely need to be incentivised at government level (e.g. Best Practice Tariff) and via international guidelines to achieve consistent results. More research would be needed to corroborate the results seen in this body of work to achieve change in practice internationally. Each year, over 10 million people fall and break a hip globally [2, 3], with attendant risks of post-operative infection, functional decline and earlier death. Hip fracture protocols such as the best practice tariff in the UK have helped standardise care for patients by incentivising factors that improve quality of care—e.g. surgery within 36 h of arrival in an emergency department [4]. Early mobilisation in hospitalised patients has been shown to improve outcomes [5, 6], but in the UK, it is not included in the best practice tariff. Hjelholt and colleagues analysed routinely collected data in 36 229 patients and demonstrated a 2% reduction in all infection outcomes by mobilising patients within 18 h of operation, as compared with after 24 h. The primary benefit observed was a reduction in pneumonia rates, with significant differences emerging as early as day 5 in patients mobilised within 12 h post-surgery. This evidence underscores the potential of early mobilisation to address a key complication in hip fracture recovery, which at scale may reduce antibiotic use, hospital length of stay and potentially improve survival rates [7]. Given these data, we should consider whether and how we respond in terms of service delivery models. Practically, a variety of barriers to early mobilisation have been previously investigated in critical care settings [8]. Earlier mobilisation requires sufficiently qualified therapy staff (usually a physiotherapist plus assistant), relevant equipment and staffing ratios that enable prioritisation of early mobilisation of immediately post-operative patients, in addition to meeting the demands of patients who are receiving follow-up therapy. Twelve-hour working days, 7 days per week would likely be necessary, with attendant costs. Timing surgery for these patients would be a consideration, with earlier surgery facilitating same-day mobilisation. Clinically led multidisciplinary team meetings comprising surgeons, nurses, physiotherapists and infection control staff would motivate change in practice and maintain consistency. Analgesia is often necessary to facilitate mobilisation, requiring careful coordination of nursing staff and pre-planned medication regimens. Patient-specific factors, such as comorbidities, haemodynamic instability or resistance to mobilisation, may also present challenges [8], highlighting the need for personalised care pathways that balance the benefits of early mobilisation with patient safety and comfort. There may be biases in how staff choose which patients to approach for early mobilisation routinely; safety concerns, staffing limitations and patient-specific considerations may pose barriers to adoption. The reasons for not mobilising certain patients early are not clear from the work of Hjelholt et al. (they are a minority), nor whether additional time or other resources needed to achieve this would be balanced by sufficiently improved outcomes. However, other options which may be mooted, such as prophylactic antibiotics [9] or oral care bundles [10] which may reduce pneumonia, have their own implementation challenges, costs and consequences [11–13]. The adoption of early mobilisation protocols would require financial investment in both staff and rehabilitation infrastructure. In the UK, where post-operative mobilisation within 24 h is not yet standard, budget constraints will influence the adoption of new practices. In order to justify the costs of implementing early mobilisation, robust economic analyses are needed to demonstrate the cost-effectiveness of the intervention. Inverse probability of treatment weighting was used in this work to account for confounding variables, as there were baseline differences between the early and late mobilisation groups. While this approach helps mitigate potential biases, it may not fully capture all factors influencing the observed outcomes. The argument for early mobilisation becomes more compelling if it can be shown to improve functional outcomes, ambulation scores, survival rates and discharge destinations, as well as lead to reductions in length of stay and associated healthcare costs. The cumulative benefits should at least balance the required investment. The findings of Hjelholt et al. provide a credible case for integrating early mobilisation into hip fracture care protocols. However, to fully understand the impact and address potential confounders, randomised controlled trials (RCTs), particularly cluster RCTs, combined with qualitative research, are needed. These studies could help elucidate the barriers to early mobilisation, particularly in patients with complex comorbidities, and provide more robust data on the functional outcomes associated with early mobilisation. There may be benefits to simply sitting up rather than full mobilisation, which could provide a more cost-effective, achievable alternative to full mobilisation. International alignment of hip fracture care protocols, promoting early mobilisation where feasible, seems a logical next step, given the emerging evidence. However, this should be accompanied by rigorous evaluation and ongoing refinement based on real-world data to ensure that the benefits outweigh the resource demands and challenges associated with its implementation. The evidence supporting early mobilisation after hip fracture surgery is compelling; however, the scalability of this intervention depends on addressing key challenges related to staffing, training and resource allocation. A carefully planned and resourced strategy, supported by further research into its cost-effectiveness and long-term outcomes, is essential for widespread implementation. Aligning international protocols to encourage early mobilisation offers an opportunity to significantly improve outcomes for hip fracture patients, but its success will require careful consideration of local healthcare contexts and resource availability. None declared. None declared.