Transparency in hip fracture recovery over institutional boundaries: The transmural monitoring pathway

Wieke S. Nijmeijer*, Dieuwke van Dartel, Reinier de Groot, Sanne Woudsma, Ellis C. Folbert, Niala den Braber, Marloes Vermeer, Johannes H. Hegeman, Miriam M.R. Vollenbroek-Hutten, on behalf of the Up&Go after a hip fracture group

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

1 Citation (Scopus)


Objectives: To develop a transmural pathway for healthcare professionals across institutions to monitor the recovery of hip fracture patients. The secondary objectives were to evaluate the pathway's feasibility and initial outcomes. Design: Prospective cohort study. Method: Stakeholders of the hospital and geriatric rehabilitation institutions implemented a transmural monitoring pathway in which different geriatric health domains were monitored during three phases: The in-hospital, inpatient rehabilitation, and outpatient follow-up phase. The outcomes for the first 291 patients and the feasibility of the pathway were evaluated. If the outcomes of the clinimetrics significantly improved over time, progress in functional recovery was assumed. Feasibility was assessed according to the rate of adherence to the clinimetric tests. Results: During the in-hospital phase, patients showed a decline in functional level (the Katz index of independence in Activities of Daily Living (Katz-ADL) pre-fracture vs. discharge: 0 (0–2) vs. 4 (4–5), P < 0.001). Patients, in which 78.6% (n = 140) had cognitive impairment and 41.2% had malnutrition, showed the most progress (Katz-ADL 2 (1–3)) during the inpatient rehabilitation phase. In the outpatient follow-up phase, recovery remained ongoing, but most patients had not returned to their pre-fracture functional levels (Katz-ADL 1 (1–3)). The pathway feasibility during the first phase was excellent (>85%), whereas room for improvement existed during other phases (<85%). Conclusion: The transmural monitoring pathway provides insight into the entire recovery process for all involved healthcare professionals. Patients showed the most progress during the rehabilitation phase. The pathway feasibility was excellent during the in-hospital phase, but improvements could be made during other phases.

Original languageEnglish
Pages (from-to)1406-1419
Number of pages14
JournalClinical rehabilitation
Issue number10
Publication statusPublished - Oct 2023


  • elderly
  • Hip fracture
  • orthogeriatric
  • rehabilitation
  • surgery
  • 2024 OA procedure


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