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Hip fracture: management [CG124]

Measuring the use of this guidance

Recommendation: 1.1.1

Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negative X-rays of the hip of an adequate standard. If MRI is not available within 24 hours or is contraindicated, consider computed tomography (CT).).

What was measured: Proportion of emergency departments with a written protocol or pathway which specifies when a MRI or CT should be performed for a patient with a normal x-ray.
Data collection end: December 2017
49%
Number that met the criteria: 56 / 114
Area covered: UK
Source: Royal College of Emergency Medicine. Fractured Neck of Femur Clinical Audit.


Recommendation: 1.2.1

Perform surgery on the day of, or the day after, admission.

What was measured: Proportion of people with hip fracture who receive surgery on the day of, or the day after, admission.
Data collection end: December 2014
72.1%
Data collection end: December 2015
71.5%
Data collection end: December 2016
70.6%
Data collection end: December 2017
69.4%
Data collection end: December 2018
70.1%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.3.1

Assess the patient's pain: • immediately upon presentation at hospital and • within 30 minutes of administering initial analgesia and • hourly until settled on the ward and • regularly as part of routine nursing observations throughout admission

What was measured: Proportion of patients who had their pain re-evaluated during admission on the emergency department.
Data collection end: December 2017
40%
Area covered: UK
Source: Royal College of Emergency Medicine. Fractured Neck of Femur Clinical Audit.


Recommendation: 1.3.6

Consider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief, or to limit opioid dosage. Nerve blocks should be administered by trained personnel. Do not use nerve blocks as a substitute for early surgery

What was measured: Proportion of emergency departments that have the necessary equipment and staff to perform a nerve block.
Data collection end: December 2017
93%
Number that met the criteria: 122 / 131
Area covered: UK
Source: Royal College of Emergency Medicine. Fractured Neck of Femur Clinical Audit.


Recommendation: 1.4.1

Offer patients a choice of spinal or general anaesthesia after discussing the risks and benefits.

What was measured: Proportion of patients who were administered general anaesthesia.
Data collection end: December 2016
51%
Data collection end: December 2017
50.6%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of patients who were administered spinal anaesthesia.
Data collection end: December 2016
43.3%
Data collection end: December 2017
44.2%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.4.2

Consider intraoperative nerve blocks for all patients undergoing surgery.

What was measured: Proportion of patients who received general anaesthetic who also received a pain relieving nerve block.
Data collection end: December 2015
58.6%
Data collection end: December 2016
64.2%
Data collection end: December 2017
70.8%
Data collection end: December 2018
56.1%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of patients who received spinal anaesthetic who also received a pain relieving nerve block.
Data collection end: December 2015
33%
Data collection end: December 2016
40.2%
Data collection end: December 2017
50.1%
Data collection end: December 2018
38.7%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.5.2

Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures.

What was measured: Proportion of surgeries which are supervised by consultant surgeon and anaesthetist.
Data collection end: December 2016
56.6%
Data collection end: December 2017
60.7%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.6.3

Offer total hip replacements to patients with a displaced intracapsular fracture who: were able to walk independently out of doors with no more than the use of a stick AND are not cognitively impaired AND are medically fit for anaesthesia and the procedure.

What was measured: People with displaced intracapsular fractures treated with total hip replacement if clinically eligible.
Data collection end: March 2014
26.1%
Data collection end: December 2015
26.9%
Data collection end: December 2016
30.4%
Data collection end: December 2017
31.4%
Data collection end: December 2018
33.5%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.6.5

Use cemented implants in patients undergoing surgery with arthroplasty.

What was measured: Proportion of arthroplasties which are cemented.
Data collection end: December 2014
82.3%
Data collection end: December 2015
83.6%
Data collection end: December 2016
86.1%
Data collection end: December 2017
88.9%
Data collection end: December 2018
91.4%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.6.7

Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).

What was measured: People with trochanteric fractures who receive extramedullary implants such as a sliding hip screw.
Data collection end: December 2015
79.8%
Data collection end: December 2016
80.8%
Data collection end: December 2017
78.8%
Data collection end: December 2018
78.9%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.6.8

Use an intramedullary nail to treat patients with a subtrochanteric fracture

What was measured: Intramedullary nails used for subtrochanteric fractures
Data collection end: December 2015
79.2%
Data collection end: December 2016
84.1%
Data collection end: December 2017
86.5%
Data collection end: December 2018
89.3%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.7.1

Offer patients a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery.

What was measured: People with hip fracture who are mobilised out of bed the day after surgery.
Data collection end: March 2014
73.3%
Area covered: England and Wales
Source: Royal College of Physicians. National Audit of Inpatient Falls audit report.

What was measured: People with hip fracture who are mobilised out of bed the day after surgery.
Data collection end: December 2015
71.9%
Data collection end: December 2016
77.3%
Data collection end: December 2018
79.6%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: People with hip fracture who have physiotherapy assessment by the day after surgery.
Data collection end: December 2015
71.9%
Data collection end: December 2016
90.2%
Data collection end: December 2017
94.5%
Data collection end: December 2018
95.4%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of patients who had undergone hip surgery who were able to get out of bed by the day after their operation.
Data collection end: October 2017
68.4%
Area covered: England and Wales
Source: Royal College of Physicians. The Physiotherapy Hip Fracture Sprint Audit (PHFSA).

What was measured: Proportion of patients who had undergone hip surgery who were assessed by a physiotherapist on the day after surgery.
Data collection end: October 2017
97.3%
Area covered: England and Wales
Source: Royal College of Physicians. The Physiotherapy Hip Fracture Sprint Audit (PHFSA).

What was measured: People with hip fracture who are mobilised out of bed the day after surgery.
Data collection end: December 2017
79%
Area covered: UK
Source: Royal College of Emergency Medicine. Fractured Neck of Femur Clinical Audit.


Recommendation: 1.8.1

From admission, offer patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme that includes all of the following: • orthogeriatric assessment • rapid optimisation of fitness for surgery • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing • continued, coordinated, orthogeriatric and multidisciplinary review • liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.

What was measured: Proportion of patients who received perioperative orthogeriatric assessment.
Data collection end: December 2015
88%
Data collection end: December 2016
88.7%
Data collection end: December 2017
88.8%
Data collection end: December 2018
89.6%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.8.3

Healthcare professionals should deliver care that minimises the patient's risk of delirium and maximises their independence, by: •actively looking for cognitive impairment when patients first present with hip fracture •reassessing patients to identify delirium that may arise during their admission •offering individualised care in line with NICE's guideline on delirium.

What was measured: People with hip fracture have a preoperative score of cognitive function.
Data collection end: March 2013
87.8%
Data collection end: December 2013
92%
Data collection end: December 2014
94.5%
Data collection end: December 2015
94.9%
Data collection end: December 2016
95.6%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: People with hip fracture have a delirium assessment in the week following surgery.
Data collection end: December 2016
54.7%
Data collection end: December 2017
85.7%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of people with hip fracture that had a mental test score recorded on admission.
Data collection end: December 2016
95.6%
Data collection end: December 2017
94.8%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


Recommendation: 1.8.6

Patients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme. [2011]

What was measured: Proportion of physiotherapy services that can offer community rehabilitation to patients admitted from a care or nursing home if they return to their original care home after hip fracture.
Data collection end: October 2017
88.2%
Area covered: England and Wales
Source: Royal College of Physicians. The Physiotherapy Hip Fracture Sprint Audit (PHFSA).


Recommendation: 1.9.1

Offer patients (or, as appropriate, their carer and/or family) verbal and printed information about treatment and care including: •diagnosis •choice of anaesthesia •choice of analgesia and other medications •surgical procedures •possible complications •postoperative care •rehabilitation programme •long-term outcomes •healthcare professionals involved. [2011]

What was measured: Proportion of emergency departments that have written information about hip fracture available for patient and/or their relatives and carers.
Data collection end: December 2017
35%
Number that met the criteria: 46 / 131
Area covered: UK
Source: Royal College of Emergency Medicine. Fractured Neck of Femur Clinical Audit.



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