Improving hip fracture care

Hip fracture is a common, serious injury sustained by around 70,000 older people every year in the UK. As the population ages it is likely to become an even more common problem. For patients, it can bring loss of mobility and independence, and the UK healthcare costs, both in acute care and in providing for subsequent dependency, amount to around £2 billion per year. Since its launch in 2007, the National Hip Fracture Database (NHFD), together with the Department of Health’s Best Practice Tariff (BPT) initiative,1 has been promoting the ideal of collaborative care, with orthopaedic surgeons, anaesthetists, orthogeriatricians and their teams working together to provide safer, better and more cost-effective care for hip fracture patients. The aim of the NHFD is to improve the care and secondary prevention of hip fracture. In 2009, it was recognised by the National Clinical Audit Advisory Group for central funding for 2009-2012 as a national clinical audit under the auspices of the Healthcare Quality Improvement Partnership. It is a web-based audit of hip fracture care and secondary prevention in England, Wales, Northern Ireland and the Channel Islands. Audit coverage has expanded steadily since 2007, with all 191 eligible hospitals in England, Wales, Northern Ireland and the Channel Islands now registered with NHFD, 189 of which regularly contribute data. Participating units upload case mix, care and outcome details in a standard dataset format, and receive regular feedback, with benchmarking at regional and national level that enables clinicians and managers to monitor and improve the care they provide. Care is measured against six quality standards set out in the BOA/BGS Blue Book on the care of patients with fragility fracture,2 which cover: prompt admission to orthopaedic care; early surgery; the prevention of pressure ulcers; access to acute orthogeriatric care; assessment for bone protection therapy; and falls assessment. Since April 2009 additional fields – including surgery within 36 hours – have been added to meet the needs of the Best Practice Tariff initiative. Around 76% of the estimated 70,000 cases of hip fracture occurring annually are now documented by NHFD. The total number of cases recorded since its launch in 2007 is now over 132,000, making the NHFD the largest and fastest-growing national hip fracture audit in the world. The NHFD 2011 National Report does highlight some improvements in hip fracture care, at a time when care of the elderly in other areas has given rise to concern. The report covers casemix, care and outcomes of 53,443 cases of hip fracture submitted between April 2010 and March 2011 by 176 hospitals meeting the case threshold of 100 (or a high percentage submission rate in smaller hospitals). In comparison with the findings of the 2010 National Report 58% of patients are now admitted to an orthopaedic ward within four hours (up from 57% in 2010); 87% receive surgery within 48 hours (up from 80%); 3% are reported as having developed pressure ulcers (down from 6%); 37% are assessed preoperatively by an orthogeriatrician (up from 31%); 66% are discharged on bone protection medication (up from 57%); and 81% received a falls assessment prior to discharge (up from 63%). It is encouraging that compliance has improved year on year for all six of the audit standards.

The six standards

 Evidence has shown that hip fracture patients are best treated in specialist wards, and should generally be ‘fast tracked’ to their definitive bed with minimal delay. In practice it is difficult to achieve this within an hour of arrival, but four hours should give enough time for clinicians to complete all the necessary investigations and assessments prior to transfer. Although 87% of patients now receive surgery within 48 hours, the 2011 report also identified that the percentage of patients who have surgery within 36 hours ranges from 9% to 88%, demonstrating that there is still considerable scope for improvement. However, there has been a fall in the proportion of patients whose surgery was delayed for medical rather than administrative reasons, suggesting an improvement in the preoperative medical care of patients. The majority of patients can be optimised for surgery within 48 hours and there is evidence to show that delaying surgery beyond this time will delay discharge. However, for safety reasons, hip fracture surgery should normally occur on planned daytime lists. Most hip fracture patients will require surgery, except those in whom the fracture is already healing in a satisfactory alignment at the time of presentation; and those whose expected survival is, for reasons unrelated to hip fracture, very brief. The authors of the NHFD 2011 National Report, therefore find it encouraging that the number of patients treated without surgery is less than 3%. However, it is of concern that while the range was from 0% to 10% in 2010 there are two hospitals participating in the audit who are not operating on more than 10%. It was advised that clinicians in these hospitals should review their criteria for surgery, and their outcomes. The audit indicates that a relatively high proportion of patients are treated without surgery (5.5%). This may be due to patients presenting late as this injury may result in relatively minor symptoms. Of the patients with a known operation, 53% of patients have an internal fixation while 47% have some form of arthroplasty. Although this is a lower arthroplasty rate than in previous reports it does remain a concern to the report authors, as undisplaced intracapsular fractures that are treated surgically should generally be treated by internal fixation. Data quality issues, perhaps arising from the use of non-clinical or untrained audit staff, may explain this anomaly. Hospitals that report a high percentage of undisplaced fractures tend to have a higher rate of hemiarthroplasty. In contrast, 92% of displaced Intracapsular fractures are treated with some form of arthroplasty, while 8% have a reduction and internal fixation. These figures remain unchanged from the 2010 report. Because of the likely disruption of the blood supply to the femoral head, patients older than 70 years are generally treated with an arthroplasty. In younger patients, internal fixation may be attempted in order to avoid the longer term problems of arthroplasty. These patients may require more revision operations in the short term.