Hip fracture quality improvement project saves lives

Hip fracture is the most common serious injury for older people and the most common reason for emergency surgery for older people. Emergency hip fracture care costs the NHS more than £1 billion a year and its associated length of hospital stay represents the largest portion of the cost. 

Patients may remain in hospital for several weeks, occupying around 1.5 million bed days each year. This equates to the continuous occupation of more than 3,600 NHS beds across England, Wales and Northern Ireland at any one time.

To tackle these challenges, in 2015, Northumbria Healthcare NHS Foundation Trust successfully gained funding from the Health Foundation for an ambitious quality improvement project to setup a ‘scaled-up’ hip fracture cross-hospital collaborative. This was the perfect way to share hip fracture pathway protocols, which we had introduced and developed at Northumbria since 2009.  

The protocols ranged from routine delivery of a pain relieving nerve block upon diagnosis of hip fracture, to standardised anaesthetic and surgical peri-operative procedures and the use of ward based nutritional assistants to ensure adequate nutrition is delivered to patients at risk of malnutrition.

This long-running project was named HipQIP (Hip fracture Quality Improvement Project). Clinical leads from five hospitals looking to improve their hip fracture service were approached to join the collaborative. The project ran over two years from August 2016 to December 2018, with a focus on improving care and outcomes for people admitted to hospital with a fragility hip fracture.   

The quality improvement aims of the HipQIP scaling up project were to provide hip fracture care of the highest quality using a pathway approach that ensured consistent care. This was achieved by focussing on key interventions including:

• better pain management
• access to nerve blocks in the Emergency Department
• improved in-hospital nutritional support (by the appointment of dedicated ward-based nutritional assistants at each site).

The independent British Orthopaedic Association was particularly helpful in gaining essential organisational support by providing peer evaluations to each hospital site as these provided a baseline of where the trusts currently were and where they should focus their efforts.

The Royal College of Physicians’ Falls and Fragility Fracture audit programme (FFFAP) team were instrumental in the evaluation of the HipQIP ‘scaled-up’ project. Utilising data from its long standing National Hip Fracture Database (NHFD), provided formative data to collaborative sites and the Northumbria project team.

Key findings

Across the four English HipQIP hospitals 30 day mortality fell by around a third from 9.2% in the year before the scaling up work started to just 5.8% for patients in the year to August 2018. 

Mortality also fell slightly (down to 7.7%) in 16 matched control hospitals that were recording the same 30 day mortality figure at baseline. The four English HipQIP collaborative hospitals (Northumbria Specialist Emergency Care Hospital, Gloucestershire Royal Hospital, Great Western Hospital (Swindon) and Western General Hospital) recorded 119 fewer deaths than would have been expected if mortality had remained at the baseline figure of 9.2%. 

The true impact of the HipQIP intervention is shown by the fact that the collaborative hospitals prevented 77 deaths – above and beyond the effect of any changes the control hospitals made in the same period.

The human cost of hip fracture includes distress, pain, injury, loss of confidence, loss of independence as well as mortality. It also affects family members and carers of people who have suffered hip fractures. Retaining independence and dignity are a greater priority. So it was essential for HipQIP to also focus on whether patients who were admitted from their own home successfully returned to live there.

Further analysis of the data by the NHFD was able to demonstrate an additional 238 patients successfully returned to their own home because of the ‘scaled-up’ work when compared with the control hospitals’ data. 

The collaborative approach to the programme and the supportive learning environment played a significant part to the project’s success. Staff had also benefitted by improved team working and a renewed sense of purpose.

The success of the HipQIP scaling up project has just been recognised by winning the Perioperative and Surgical Care award at the 2019 HSJ Patient Safety Awards. We hope to build on this success by creating a new collaborative in the not so distant future. Watch this space.