Developmental dysplasia of the hip (DDH) is the most common musculoskeletal disorder in infants, and affects 1 in 100 births. In DDH, the socket of the hip is too shallow and the femoral head is not held tightly in place, resulting in a loose hip joint. In severe cases, the femur can dislocate. A missed or delayed DDH diagnosis can result in pain, gait abnormalities, degenerative arthritis, and permanent disability. When diagnosed early, most babies are successfully treated with conservative and economical methods such as a harness or a brace, whereas a delayed diagnosis often necessitates surgical management, with increased risks of complications. An estimated 10-23 per cent of all hip replacement surgeries are performed due to residual DDH.
Guidelines from the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons recommend babies with risk factors for DDH receive a screening hip ultrasound at six weeks of age to facilitate timely diagnosis and treatment initiation. In 2017-2018, baseline data from Royal Columbian Hospital (RCH) revealed 24 per cent of babies at risk of DDH did not have a screening hip ultrasound. Dr Shafique Pirani, pediatric orthopedic surgeon at RCH and a cohort 5 graduate of Fraser Health’s Physician Quality Improvement (PQI) program, formed a quality improvement team to identify reasons for the high missed ultrasound rate, and conducted a series of data-driven plan-do-study-act (PDSA) cycles to target the identified areas for improvement.
Changes implemented included:
- Increasing clinician awareness of DDH screening guidelines.
- Creation of a standardized referral pathway for neonates at risk of developing DDH. Pathway entry points included RCH labour/delivery, maternity, pediatric, and neonatal intensive care unit (NICU) wards.
- Creation of a new, one-stop, multidisciplinary Baby Hippy Clinic with ultrasound, orthotics, and pediatric orthopaedic.resources, allowing for family-centered care, and timely DDH assessment and treatments.
- Parental educational materials on DDH and emphasizing the importance of a screening hip ultrasound for high-risk babies.
Dr Pirani’s team consisted of representatives from medical imaging, family medicine, pediatrics, midwifery, clinical operations, community orthotics, and patient partners. Supported by PQI and the RCH Facility Engagement initiative, the project was a resounding success: the missed hip ultrasound rate decreased from 24 per cent in 2017/18 to 1.6 per cent in 2020. Since the launch of the specialty clinic, more than 900 referrals have been received from RCH for DDH screening. Parental surveys indicated high satisfaction levels with the clinic experience (93%), the information given (93%), and the overall process (88%).
“As a healthcare professional, I was aware of what hip dysplasia was, but it wasn’t until my daughter was diagnosed, did I grasp how common it truly is. In many ways, it’s a silent condition, one that isn’t on the radar of most parents. In the case of my daughter, she had no risk factors nor any family history of hip dysplasia. Being informed that my 10-week-old had hip dysplasia, to the extent that her one hip was dislocating with normal movement, was terrifying to hear. As a parent and as a healthcare professional, the hip clinic at Royal Columbian Hospital is essential in her treatment. I appreciate the fact that the clinic is located in my community, and has its own X-ray machine and technicians to complete X-rays during our appointments,” says Alyssa Lazzer, a patient partner of the team.
She continued, “Having trained staff that are incredibly knowledgeable in the harnesses and braces children are required to wear is a relief. The clinic is a busy place. It’s obvious that there are many families whose children are at various stages in their hip dysplasia journey. The support and guidance provided by Dr Pirani and his staff in the clinic is a necessity that Fraser Health needs to extend to other facilities in order to care for the needs of the children in our community. When I heard the hip clinic was being extended to include Surrey Memorial Hospital, I was ecstatic. Knowing that the care my daughter is currently receiving will potentially prevent future orthopedic surgery, chronic pain, and mobility issues gives me hope for a positive outcome for my daughter. I hope that in the future, additional space can be allocated to the clinic at Royal Columbia to better support the high volume of families they see on a daily basis.”
Dr Pirani has shared his experience with colleagues by presenting his findings at the 2021 Institute for Healthcare Improvement (IHI) Forum and the 2022 Quality Forum. More recently, the Baby Hippy QI Project was selected for a podium presentation at the 2022 Pediatric Orthopaedic Society of North America Annual Meeting. Dr Pirani has also spoken about the project at the Delhi Orthopaedic Association. There are approximately 1000 daily births in Delhi – almost as many as the entirety of Canada.
Armed now with support from Health System Redesign (HSR) and Spreading Quality Improvement (SQI), Dr Pirani and his team are in the process of implementing a similar program across other Fraser Health sites, starting at Surrey Memorial Hospital, the largest birthing center in Fraser Health. This comes at an opportune time as plans are underway to expand pediatric orthopedic care across Fraser Health.
As one of the first steps in the increase in services, Dr Magdalena Tarchala, a pediatric orthopedic surgeon who has trained at McGill University, the University of Toronto, and Harvard Medical School, has been recruited to Fraser Health and joined the Baby Hippy team in October 2022.
“Dr Pirani and this multidisciplinary team, including Fraser Health’s PQI program, has developed a standard referral pathway. Not only is this innovative and raises awareness of a common disorder, but it does so in a family-centred way. This will improve the lives of infants born at the Royal Columbian Hospital and at high risk of DDH. Ultimately with support, this project will spread across other Fraser Health sites. It is one of the many initiatives targeted to providing the children of Fraser Health with optimal musculoskeletal care,” says Dr Ralph Belle, Vice President of Medicine at Fraser Health.
If you are interested in learning more about the project, and/or would like to be involved in spreading the DDH screening initiative to your site, please contact Janice.Eng@fraserhealth.ca.