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Hip fracture remains the most serious consequence of a fall and the commonest cause of accident related death in older people.

The numbers of hip fractures has been rising by 2 per cent annually from 1999 to 2006 and is predicted to continue rising¹. Ten per cent of people will die within the first month after a hip fracture and after one year, a third would have died ^2,3. Less than 50 per cent will regain their former level of independence and up to 20 per cent of people will require some form of continuing care^4,5,6. There have been guidelines for many years advocating the evidence base for timely and coordinated multi- disciplinary management that improves outcome for these patients, but the figures have not improved over the last few years. (The Scottish Intercollegiate guideline network sign (No. 56)⁷ Hip Facture Management was published in 2002 and the first blue book, the Care of Fragility Fracture Patients⁸ from the British Orthopaedic Association guidelines all have similar themes as to the best practice into hip fracture care.

The profile of hip fracture care in England has been raised with the publication of the Department of Health’s prevention package⁹ for older people containing guidance on managing hip fractures. With the introduction of the best practice tariff in April 2010 for patients with hip fracture, all Trusts will need to review the pathway of care for these patients in order to ensure the full tariff. At the time of writing the indicators are: Time to surgery as defined by Arrival in A&E (or diagnosis if an inpatient) to start of anaesthesia and Involvement of an (ortho)-geriatrician. This is to include all of the following domains:

• Admitted under the joint care of a Consultant Geriatrician and a Consultant Orthopaedic Surgeon
• Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia
• Assessed by a Geriatrician in the perioperative period - Geriatrician defined as Consultant, Non consultant career grade, or ST3+; - Perioperative period defined as within 72 hours of admission
• Postoperative Geriatrician-directed: Multiprofessional rehabilitation team and Fracture prevention assessments (falls and bone health)

These tariffs will be reviewed for 2011 following the publication of the NICE guidance for hip fracture care which are expected in autumn 2010.

How does a Trust actually implement and improve the pathway?
In 2006 the NHS Institute for Innovation and Improvement published a Focus on document¹⁰ that highlighted the large variation both in the length of stay and mortality after hip fracture with indicators on how to improve the quality and value of care to these patients. The document was designed by undertaking site visits to both high and less well performing Trusts and the team spent time observing, watching, listening and looking at the flow and process of care and drew up an optimal pathway which was published in the document. This was tested at sites.

Over the last year the NHS Institute has been working with ten NHS Trusts in England on the rapid improvement programme for orthopaedics promoting the findings from the Focus On document. The aims of the programme were to work with an individual Trust on a service improvement programme for a 12 week period. It included providing participating trusts with a full insight to the key findings in the focus on document, a practical knowledge of the pathway supporting toolkit and service improvement tools. The programme has allowed participants to hear from colleagues who have shifted their orthopaedic service and provided time for networking, discussion, debate and planning. The learning has been shared and adopted through regional network meetings.

The teams worked with the Trust over a period of 12 weeks. The Trusts were challenged to look at the pathway of care for hip fracture and to identify the problem areas. A multi professional team and steering group were established and objectives and timescales were agreed.

As part of the assessment the team “walked the patient pathway”. Representatives from the multidisciplinary team went from the Emergency Department to the discharge lounge, questioning staff on the way and the processes used in the care of hip fracture patients. The team gained valuable insight into the current pathway and bottlenecks and this led to ways of thinking differently and understanding the roles of each department. It was found that one can never assume one knows what goes on in one’s own hospital or department.

The main issues identified in all trusts were:

• Fast track to the appropriate ward from the Emergency Department
• Early involvement of the Geriatrician and Anaesthetist
• Optimisation of patients for theatre within 48 hours
• Mobilisation post surgery
• Early conversations with Social Services & Primary Care regarding discharge
• Collection of data to understand where there were bottlenecks

Many generic solutions were found and included:

• Standardisation of patient information and the setting of an Estimated Date of Discharge, ensuring this is communicated to the patient and carer as well as within the team.
• Dedicated unit or area for admission and ongoing treatment of patients with hip fracture. All the team understands the pathway and works to a common goal.
• In order to facilitate rapid admission, some Trusts have established an ambulance service pre- alert in association with fast tracking through the Emergency Department
• Anaesthetic guidelines for hip fracture surgery have ensured a consistent approach and reduced wait for theatre.
• Trials of senior orthogeriatric review have been used resulting in business cases for permanent appointment.
• Review of theatre lists has led to establishment of daily trauma lists (including weekends) or dedicated slots for hip fractures allowing patients to access theatre more rapidly.
• 7 day therapy input and training of non-therapy staff to ensure patients are mobilised over weekends and bank holidays.
• Key measures for improvement have allowed teams to identify on a weekly basis where the pathway needs to be reviewed.

Despite only focussing on 3 or 4 areas of the pathway that were particularly difficult, significant gains were made throughout the patient journey leading to improved quality of care, reducing waits for surgery and reduced length of stay (figure 1). All Trusts that implemented the Rapid Improvement Programme showed significant improvements in their pathway of care for these hip fracture patients.

Key factors for success in all Trusts were the people. It is clear that there is a need to have both clinical and managerial engagement and that the organisation wants to change and sets realistic goals. Without these factors the sustainability of the improvement programme is limited. Ensuring the baseline data and tracking the data in real time allows the improvements to be rapidly demonstrable and gives positive feedback and encouragement to the team. In addition it will identify areas of difficulties that the team will need to concentrate on. The National Hip Fracture Database will provide the evidence for the best practice tariff and can provide monthly trends of preference for individual Trusts with comparative data from the SHA and England.

What does it mean for the geriatricians?
The hip fracture patient is often one of the frailest patients admitted acutely. For years they have been neglected. With the introduction of best practice tariff commissioners will have to ensure the involvement of our services – a welcome move forward and one that is long overdue. By using the principles of the key characteristics of the Focus on Document together with development of pathways of care significant improvements in hip fracture care can be made. The evidence from the Rapid Improvement Programme is that pathway change in a few areas can lead to wide ranging improvements to care. Many of these changes will be led by the geriatricians. Let us strive to improve the quality of care for the vulnerable group and at the same time see financial reward.

E Aitken, P Roberts
Clinical Leads, Orthopaedic Rapid Improvement Programme, NHS Institute for Innovation and Improvement

References

1. Department of Health. Hospital Episode Statistics (England) 2006.
2. Keene GS, Park er MJ Pryor GA. Mortality and morbidity after hip fracture. BMJ 1993;307: 1248
3. Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications
4. Magaziner J, Simonsick E, Kashner T et al. Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study. J Gerontol 1990; 45: M101-7.
5. Magaziner J, Simonsick E, Kashner T et al. Survival experience of aged hip fracture patients. Am J Public Health 1989; 79: 274-8
6. Marottoli R, Berkman L, Leo-Summers L et al. Predictors of mortality and institutionalization after hip fracture: The New Haven EPESE cohort. Am J Public Health 1994; 84: 1807-11
7. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fractures in older people. SIGN Publication No. 56 (l)
8. British Orthopaedic Association. The Care of Patients with Fragility Fracture.
9. Falls & Fractures: Effective Intervention in Health & Social Care. Department of Health July 2009
10. Focus on: Fractured Neck of Femur NHS Institute for Innovation and Improvement

BGS Newsletter, February 2010
Issue 25 ISSN 1748-634000 25