The National Hip Fracture Database (NHFD) annual report 2019 demonstrates that mortality has continued to improve with 564 fewer patients dying in 2018 than 2017. However, increased numbers of hip fractures in winter months contribute to increased mortality at a time of increased pressure on trauma services.
Key recommendations
- Patient experience should be central to the design of hip fracture services. Information leaflets must be made available to inform and empower patients and their families. In addition, patient experience and views on their care should be measured and routinely fed back to teams.
- Orthogeriatric care has transformed trauma services and serves as a model for collaborative working. Hospitals should examine their own NHFD data in dashboards and run charts and those with poor rates of orthogeriatric assessment should review their staffing of this key service. Involvement of geriatricians in training will help in this and will provide these doctors with experience that will be vital if they work in this role, or in the liaison roles that are developing in other surgical specialties.
- Teams should use quality improvement work to examine reasons for delays to theatre to inform efficient planning and use of trauma lists. Clinical factors that commonly lead to delay are well-defined and protocols for their management need to be established and their prompt correct use monitored through local audit work.
- There is wide variation in the type of hemiarthroplasty implants being used by sites, with significant cost implications for the NHS. Over a quarter of patients are undergoing an operation that is not the one recommended by NICE. More should be done to embed standardised, evidence-based decision-making around surgical implant choices. NHFD clinical leads should review current surgical practice and local implant inventories to ensure consistency across consultant-led teams.
- One in five patients are still not able to get out of bed on the day after surgery. Prompt mobilisation after surgery is everyone’s responsibility and is key to patients’ successful return to pre-fracture activities and residence. Surgical and anaesthetic factors limiting early mobilisation should be monitored and addressed in regular clinical governance meetings involving the whole multidisciplinary team.
- Prevention, recognition and management of delirium is everyone’s responsibility. As delirium commonly compromises patient experience and recovery, screening for delirium should be a priority in the first days after surgery. Effective management of pain, fluids, anaemia and nutrition requires a multidisciplinary approach, and delirium rates should be monitored and addressed in regular governance meetings involving the whole team.
- Most people want to return to their previous independence after a hip fracture. NICE guidance highlights the need for hip fracture programmes to be responsible for seamless care between hospital and community services if they are to deliver improved outcome and reduced costs. Hip fracture programme teams in the acute ward must ensure close links with rehabilitation and community services, and follow up their patients.
- Increased numbers of hip fractures add to other pressures on hospital services in December and January, and contribute to a higher risk of mortality. Such factors must be considered when organising trauma services if services are to avoid the 325 additional deaths which occur each winter.
- Hip fracture mortality figures continue to improve, but teams need to examine each case individually to ensure that lessons are learned by the whole multidisciplinary team and that the needs of patients, and of those close to them, are anticipated at the end of life. Next year NHFD will launch casemix adjusted mortality run charts: local teams should use these to spot trends in mortality and to stimulate routine examination of their root causes of mortality.
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 of all hospital beds in England and Northern Ireland, and 1 in 33 hospital 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.