The National Hip Fracture Database (NHFD) annual report 2018 shows dramatic results of an innovative programme of screening for delirium which has been the focus of attention and investment through NHS England’s best practice tariff.
Key recommendations
- Hospitals should examine their own NHFD data in dashboards and run charts and those with poor rates of orthogeriatric assessment should consider the implications of this for the quality of initial assessment, preoperative optimisation, perioperative medical care, rehabilitation, discharge planning, and survival that are described in this report.
- Hospitals should examine their own NHFD data in dashboards and run charts and those with poor performance should establish what proportion of delays in surgical operations are the result of avoidable inefficiencies in preoperative planning or in the organisation of theatre lists.
- Those providing or commissioning hip fracture services must examine their run charts and dashboards, and challenge units which report low rates of THR in eligible cases, or low rates of SHS for A1/A2 fractures – such findings would suggest that these groups of patients are not being treated in a cost-effective way that is in line with NICE guidance.
- Physiotherapy leads must be included in hip fracture programme governance meetings and if the key performance indicator ‘Prompt mobilisation after surgery’ identifies a concern this must lead to development of plans to improve multidisciplinary working and avoid people being unable to get up promptly as a result of pain, low blood pressure or delirium.
- Clinical teams must review the new key performance indicator ‘proportion of patients not delirious when tested after operation’ for their unit. If dashboards and benchmarking tables highlight poor performance then multidisciplinary clinical governance meetings must consider, discuss and develop plans to improve the perioperative care they are providing to their patients.
Overview
Hip fracture is the most common serious injury in older people. It is also the most common reason for older people to need emergency anaesthesia and surgery, and the commonest cause of death following an accident.
Patients may remain in hospital for a number of weeks, leading to one and a half million hospital bed days being used each year. Since 2016, the overall length of stay has fallen slightly (from 20.6 to 20.0 days), but, at any one time, patients recovering from hip fracture still occupy over 3,600 hospital beds (3,159 in England, 325 in Wales and 133 in Northern Ireland), a figure equivalent to 1 in 45 beds in England and Northern Ireland, and 1 in 33 beds in Wales.
Only a minority of patients will completely regain their previous abilities, and increased dependency and difficulty walking mean that a quarter will need long-term care. As a result, hip fracture is associated with a total cost to health and social services of over £1 billion per year. This one injury carries a total cost equivalent of approximately 1% of the whole NHS budget. The care provided to people with hip fracture provides an unparalleled example of how frail and older people are managed by the modern NHS.