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Hip fracture: the management of hip fracture in adults [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: The proportion of patients having MRI imaging for suspected occult hip fracture where the scan was done within 24 hours.
Data collection end: March 2012
56%
Data collection end: July 2013
72%
Area covered: UK
Source: Tiwari S, De Rover, WS, Dawson S, Moran C (2014) Rapid access imaging for occult fractured neck of femur. Osteoporosis International 26 1 407-410.


Recommendation: 1.2.1

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

What was measured: People with fractured necks of femur are operated on within 36 hours of admission.
Data collection end: March 2011
61.6%
Data collection end: March 2012
67%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: People with hip fracture have surgery on the day of, or the day after, admission.
Data collection end: March 2013
70.6%
Data collection end: December 2013
71.7%
Data collection end: December 2014
72.1%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: People with hip fracture who receive surgery on the day of, or the day after, admission.
Data collection end: December 2015
71.5%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: People with hip fracture who receive surgery on the day of, or the day after, admission.
Data collection end: December 2016
70.6%
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: Pain assessed immediately upon presentation at hospital
82%
Number that met the criteria: 41 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747

What was measured: Pain assessed within 30 minutes of administering initial analgesia
48%
Number that met the criteria: 24 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747

What was measured: Pain assessed hourly until settled on the ward
48%
Number that met the criteria: 24 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747


Recommendation: 1.3.2

Offer immediate analgesia to patients presenting at hospital with suspected hip fracture, including people with cognitive impairment

What was measured: Patients who were offered immediate analgesia
4%
Number that met the criteria: 2 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747


Recommendation: 1.3.4

Offer paracetamol every 6 hours preoperatively unless contraindicated

What was measured: Patients who received paracetamol
16%
Number that met the criteria: 8 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747


Recommendation: 1.3.5

Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief.

What was measured: Patients who received opioids
76%
Number that met the criteria: 38 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747


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: Patients who received a nerve block
0%
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747


Recommendation: 1.3.9

Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended.

What was measured: Patients who did not receive an NSAID
98%
Number that met the criteria: 49 / 50
Area covered: Local
Source: Dingle M, Palmer C, Hassanali N (2012) An audit of hip fracture pain management in a hospital emergency department. Academic Emergency Medicine. Vol 19, p747


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 spinal anaesthesia.
Data collection end: July 2013
44%
Area covered: UK
Source: Royal College of Physicians. National Hip Fracture Database - Anaesthesia Sprint Audit of Practice.

What was measured: Proportion of patients who were administered general anaesthesia.
Data collection end: December 2016
51%
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%
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 a pain relieving nerve block.
Data collection end: July 2013
56%
Area covered: UK
Source: Royal College of Physicians. National Hip Fracture Database - Anaesthesia Sprint Audit of Practice.

What was measured: Proportion of people with hip fracture who received a fascia-iliac block in A&E or at induction of anaesthesia.
Data collection end: August 2013
54%
Data collection end: December 2013
67%
Area covered: Local
Source: Callear J. (2016) Analgesia in hip fractures. Do fascia-iliac blocks make any difference? BMJ Quality Improvement Reports 5 (1)

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%
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%
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: Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures
Data collection end: December 2016
56.6%
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: Proportion of people with intracapsular neck of femur fracture who were offered a total hip arthroplasty
Data collection end: December 2012
17%
Number that met the criteria: 3 / 18
Area covered: Local
Source: Mahapatra PL (2014) Total hip arthroplasty to treat fracture neck of femurs E are nice guidelines being implemented? International Journal of Surgery, Conference (var.pagings): November.

What was measured: People with displaced intracapsular fracture are offered total hip replacement if clinically eligible (displaced intracapsular fracture, who were ASA 1–2, with a normal mental test score, and able to walk outside using no more than a stick).
Data collection end: December 2013
19.1%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of patients with displaced intracapsular fracture that received a total hip replacement.
Data collection end: March 2013
41%
Number that met the criteria: 32 / 78
Area covered: Local
Source: Walker LC, Lee LH, Webb, et al. (2016) Provision of total hip replacement for displaced intracapsular hip fracture and the outcomes: audit of local practice based on NICE guidelines Hip International 26 (2) : 153-157.

What was measured: People with displaced intracapsular fractures treated with total hip replacement if clinically eligible.
Data collection end: March 2012
15.6%
Data collection end: March 2013
20.7%
Data collection end: December 2013
19.1%
Data collection end: March 2014
26.1%
Data collection end: December 2015
26.9%
Number that met the criteria: 3335 / 12473
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: March 2011
68.2%
Data collection end: March 2012
73.4%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of arthroplasties which are cemented.
Data collection end: March 2013
77.2%
Data collection end: December 2013
80.2%
Data collection end: December 2014
82.3%
Data collection end: December 2015
83.6%
Data collection end: December 2016
86.1%
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%
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: March 2011
71%
Data collection end: March 2012
67.6%
Data collection end: March 2013
74.1%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Intramedullary nails used for subtrochanteric fractures
Data collection end: December 2015
79.2%
Data collection end: December 2016
84.1%
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 2015.

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%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: Proportion of people who receive physiotherapist-led daily mobilisation from the day after surgery.
Data collection end: December 2015
71.9%
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 2016
90.2%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.


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%
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%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.

What was measured: People with hip fracture have a preoperative score of cognitive function.
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%
Area covered: National
Source: Royal College of Physicians. National Hip Fracture Database.



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