Raising standards in trauma care

The national clinical director for trauma care, Professor Keith Willett, has revealed plans to improve outcomes for patients with hip fracture and major trauma, at a recent conference organised by the Association of Anesthetists of Great Britain and Ireland (AAGBI). As well as improving quality, he claimed that raising standards in these two key focus areas would lead to major cost savings. As an estimated £20 billion will be taken out of the NHS in the next three to five years, this will be a key driver for change in the future, he pointed out. “When I took the role in April 2009, I was the first of the national clinical directors to be appointed without a multi-million pound budget to spend, but with a savings target instead,” he commented. One of the key policies he will be tasked with implementing is the transformation of care for older people – specifically in relation to fragility fractures. To highlight the scale of the problem, Prof. Willett pointed out to that there was a 50% lifetime risk of fragility fracture for every woman in the audience. Furthermore, the rate of fragility fractures is increasing with an ageing population. “Without a comprehensive prevention strategy, we are not going to reverse this trend in the next five years,” he warned. Hip fracture, in particular, has risen to the top of the Department of Health’s agenda, as it accounts for the vast majority of NHS costs associated with this type of injury. Each year the NHS in England and Wales treats over 70,000 patients with hip fracture, while approximately 120,000 patients undergo a hip or knee replacement. Together, the conditions account for 1.4% of the £100 billion NHS England budget. (NHS Institute for Innovation and Improvement.) In terms of bed day occupancy and costs, hip fracture is on a par with stroke, TIA, heart disease and heart attack, Prof. Willett explained, commenting: “It is critical that the NHS reduces the 1.2 million bed days per year attributed to this patient group. The average length of time that a bed is occupied by a patient with hip fracture is 28 days – when this is multiplied by the 70,000 hip fractures that occur each year, the total number of bed days is staggering. “At the end of this stay, the current quality of care means that 33% of patients will require more care support at home, and 15% to 20% will have a change of residence, which results in significant social care costs. This is completely unacceptable,” he continued. He claimed that this group of patient has been “neglected as a priority for decades” – mainly due to their old age and the lack of support of advocates to fight for their interests. Such patients also tend to be put at the end of lists or declined because they are perceived as clinically “difficult”. “Time and time again this patient group is treated inappropriately. Currently, one in three patients wait more than two days for surgery in England and Wales, for no good reason,” he exclaimed. In fact, an audit in 2008 found enormous variation in time to surgery, across the UK – with anywhere between 36% and 92% of patients being treated within 48 hours. “Personally, I do not think that even 48 hours is an appropriate measure. The sun should not set twice on a hip fracture. There needs to be prompt, good surgery and anaesthesia,” he exclaimed. “Every pre-op day after hip fracture adds another 2-3 days to hospital stay. Patients become less mobile and lose muscle strength within 24 hours. Patients who experience delays do not rehabilitate as quickly and lose motivation – the whole process must be speeded up.”

Prof. Willett added that many people do not appreciate quite how old and demanding the hip fracture patient group is in the broader context of healthcare and in the commissioning of hospital management. “Some 20% of presentations are ‘unfit’ when they arrive and require some adjustment such as warfarin reversal or pacemaker check; 30% have dementia, while there is a one-year mortality rate of 30% and a 30-day mortality rate of 10% for most UK units.” He further stressed the importance of ensuring that these patients are admitted under joint protocols between orthopaedics, anaesthetics and geriatric medicine, commenting that the latter should lead during the critical perioperative care period. At present, around 75% of elderly patients with co-morbidities have little or no input from geriatric medicine. “This geriatrics input is vital as these patients’ co-morbidities will challenge most orthopaedic consultants. It is frustrating when these patients present to the anaesthetist unprepared and mismanaged,” he continued. Prof. Willett highlighted a case study in which a hospital had significantly reduced its 30-day mortality rates by introducing an improvement programme. This included ensuring surgery within 48-hours, making two more trauma lists available, and appointing a part-time ortho-geriatrician. The case study demonstrated that such practice changes offer advantages for the NHS as well as the patient in terms of the quality of rehabilitation, post-op mobilisation and length of stay in hospital. At the study hospital, the time taken for more active patients to return home was reduced by two days; for patients returning to care homes, the time was reduced by five days; while for those leaving via the community hospital rehabilitation unit, the time was reduced by 12 days. The NHS Institute for Innovation and Improvement, which has now developed a rapid improvement programme for orthopaedics, believes that if the average length of stay achieved at the top performing Trusts became the national standard, savings of £75 million for hip fracture alone would be released.

Prof. Willett pointed out that this does not take into account the vast savings that could be achieved in terms of social care, however. The potential for major savings has persuaded the DH to push forward on incentivising improvements, with the introduction of the Best Practice Tariff. The Best Practice Tariff is aimed at areas of healthcare where there is high volume and inexplicable variation – such as gall bladder removal, laparoscopic day case surgery, cataract day case surgery, stroke and hip fracture. For hip fracture, the quality factors that can be measured include: time to surgery, the involvement of geriatrics and anaesthetics in joint admission for perioperative care, along with the provision of rehabilitation and fracture prevention programmes. The DH believes that, by ensuring early surgery and early geriatrics input, the average length of hospital stay could be reduced by up to seven days. Prof. Willett also pointed out that there are now an increasing number of hospitals returning data (90%) to the hip fracture database, supporting national quality audit. Part of the reason for this increased reporting is the fact that it will not be possible to obtain extra money under the Best Practice Tariff without this data. A hospital treating 300 hip fractures per year will have more than £100,000 extra to invest in the hip fracture service, annually, if a patient receives best practice. The Best Practice Tariff commences in April 2010.