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Audit of standards of practice in suspected hip fracture
International Emergency Nursing (2012) 20, 236– 242
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Audit of standards of practice in suspected hip fracture Rebecca Taylor MSc, RN (Staff Nurse) *, Stuart Nairn PhD, MA, RGN, PGCHE (Lecturer) University of Nottingham, United Kingdom Received 2 July 2011; received in revised form 16 September 2011; accepted 18 September 2011
KEYWORDS Clinical audit; Emergency Department; Hip fracture; Standards of care
Abstract Background: Hip-fracture is a common orthopaedic injury presenting to the Emergency Department, particularly within the elderly population. Standards of practice dictating the care of these patients include the early administration of analgesia and an accurate clinical assessment. Once a hip-fracture has been confirmed with diagnostic-imaging, the patient should be transferred to an orthopaedic ward as soon as possible. These standards have been identified from a range of national policies and evidence-based literature. Aim: To identify standards of best-practice for the care of patients with a suspected hip-fracture in the Emergency Department and to audit compliance with these standards. Method: A retrospective-audit of 185 Emergency Department Information System records for adult patients admitted with a suspected hip-fracture was conducted using a purpose-designed data-extraction spread-sheet based on discrete standards of audit. Findings: It was found that the Emergency Department performed well on some audit standards, such as the medical assessment of patients. However, some problems of assessment were identified in relation to pressure-care, the timely transfer of patients to a suitable ward and the delivery of pain-relief. Conclusions and recommendations: There were examples of good practice in this audit, but also areas that require improvement. We recommend that a care bundle be implemented to focus on improvements in pain-relief, pressure-care and fast-tracking.
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Introduction Corresponding author. Tel.: +44 07590986038. E-mail address: [email protected] (R. Taylor).
Hip-fracture is one of the most common and potentially serious musculoskeletal injuries worldwide (Woolfe and
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Audit of standards of practice in suspected hip fracture Pfleger, 2003). The National Hip Fracture Database (2010) estimates that there are currently over 76,000 hip-fractures per year in the United Kingdom (UK). According to Greaves et al. (2009), older, and in particular, female adults are more likely to sustain a hip-fracture since they are more prone to falling and injury. Associated morbidity rates following a hip-fracture are reported to be high, and attributed mortality within 12 months of the injury is also claimed to be between 20% (Dawood and Holt, 2008) and 33% (Keene et al., 1993). It is widely agreed that best patient outcomes are achieved with surgery as soon as possible after the injury has occurred ( Santy, 2005; Smith, 2005). However, prior to surgical admission, nearly all patients who sustain a hip-fracture initially present to the Emergency Department (ED). Emergency Departments have a fast-turnover of patients presenting with a range of different healthcare needs (Jones, 2008) and a suspected hip-fracture is a common presenting injury. This project identified ED best practice standards and monitored whether these standards were being implemented in one major UK hospital.
Background-overview of literature and related policies The background provides an overview of the applicable standards of practice and guidance documents available. No single policy specific to providing care for patients with a suspected hip fracture in the ED was identified in the local and national literature reviewed, therefore the audit standards were selected from a range of documents. A list of relevant standards of practice was comprised from guidance by established associations governing clinical
237 practice, including the ED ‘fast-track’ section of the hipfracture care pathway (National Health Service (NHS) Institute for Innovation and Improvement (NIII, 2006); The Department of Health (DH, 2007); The College of Emergency Medicine (CEM, 2010); and The Scottish Intercollegiate Guidelines Network (SIGN, 2009). From these guidelines, a list of ideal practice standards were compiled around topics as outlined in Table 1. A thorough literature review was conducted to further examine the evidence base for the audit standards, as is recommended by Morrell and Harvey (1999), Norman and Redfern (1995) and NICE (2002). The quality of the evidence on which these guidelines and articles were based was appraised according to a hierarchy of evidence (Fain, 2004). As part of the initial patient assessment, or ‘primary survey’, it was expected that a set of vital-signs or ‘observations’ would be taken, as identified by National Institute for Health and Clinical Excellence (NICE, 2007), SIGN (2009) and Baraff et al. (1997). A check of the patient’s blood-glucose-level was also included as an audit standard, since Baraff et al. (1997) cites this as a baseline investigation in a patient who has had a fall. Morley (1998), Considine and Hood (2000), Parker and Johansen (2006), and the Audit Commission (2000) all agree that early pressure-area-assessment and care is important since patients with hip-fractures are vulnerable to developing pressure-ulcers. A randomised controlled trial (RCT) conducted by Gunningberg et al. (2001), demonstrated the effectiveness of implementing pressure-area-assessment tools and interventions in the ED for hip-fracture patients on reducing the rates of pressure-ulcers in these patients on hospital discharge. The final standard expected in the initial assessment of patients included undertaking an electrocardiogram (ECG), as required by the NIII (2006) and local guidelines. This is necessary be-
Table 1 A table outlining the five broad topics audited, and the individual standards which were measured for each patient who met audit criteria. Topic for audit
Standards measured
Initial patient assessment (primary survey)
Base line observations/vital-signs
Pain assessment and management Medical assessment/history taking (secondary survey)
Diagnostic imaging
Time patient spent in ED, before transfer to a ward
Respiration rate Oxygen Saturations Heart rate Blood pressure Temperature
Electro-cardiogram (ECG) Blood glucose monitoring (BM) Pressure-area assessment/pressure ulcer risk score Pain assessment method Time and type of analgesia first offered Past medical history Social history Current medications Allergy status Mechanism of injury Hip X-ray Chest X-ray Referral for MRI if diagnosis inconclusive Within 2 h Within 4 h
238 cause cardiac problems are a common and potentially serious affliction within elderly patients presenting with a fall (Baraff et al. 1997; Davies and Kenny, 1996). There is consensus amongst the literature reviewed that pain is a serious problem presenting in patients with a suspected hip-fracture (FitzSimmons and Wardrope, 2005; Holdgate et al., 2010; Jackson, 2010; Pines and Hollander, 2008; Chambers and Guly, 1993; Herr and Titler, 2008; Morley, 1998). Pain can in itself lead to further complications such as cardiac arrhythmias (Vassiliadis et al., 2002). It is therefore recommended that patient pain is assessed as soon as possible (Herr and Titler, 2008), and analgesia be promptly administered, since this is a key part of the efficient, quality-care service of the hip-fracture fast-track pathway (Vassiliadis et al., 2002; Considine and Hood, 2000; Gholve et al., 2004). In terms of the medical assessment and history-taking standards (‘secondary survey’), it is recommended that all patients who have fallen are assessed to try to determine the cause of the fall (Davies and Kenny, 1996). Baraff et al. (1997) adds that this assessment should include a history of medical conditions and medications, a history of the patient’s fall, and their functional and social history. To confirm the diagnosis of any classification of hip-fracture, an X-ray of the hip is essential, and can often give a definitive diagnosis (NIII, 2006; DH, 2007; Parker and Johansen, 2006). According to NIII (2006) and Baraff et al. (1997), it is expected that patients with a suspected hip-fracture also receive a chest X-ray to rule out any underlying lung conditions or thoracic injury. However, the NIII (2006) and SIGN (2009) describe an ideal ‘fast-track’ procedure for all patients with a confirmed isolated hip-fracture in the ED. According to these published guidelines all of the above care and diagnostic practices must be done as quickly as possible to avoid delay of transferring the patient to an orthopaedic ward- ideally within 2 h of admission (Casaletto and Gatt, 2003; Bottle and Aylin, 2006). Morley (1998) and Chia et al. (2008) found that long waits in the ED for hip-fracture patients are detrimental, with the Audit Commission (2000) adding that long waits on hospital trolleys are linked to increased risks of developing pressure-sores. At the time of audit, the standard of a less-than 4 h wait before transfer for 98% of patients was also measured (DH, 2007), and as discussed above, this was seen as an important benchmark for ensuring the comfort and safety of hip-fracture patients.
Aims and objectives of the study The main aim of the study was to determine the standards for the best practice of care for ED patients with a suspected hip fracture, and to examine using clinical audit the degree to which these standards were being met within one urban UK hospital. The results and discussion focus mainly on areas of concern as revealed by the audit, and how improvements may be made in these areas.
Methodology The study used clinical-audit to assess the performance of one particular ED. In accordance with NICE etal. (2002), Shaw (1992) and Morrell and Harvey (1999), this methodology in-
R. Taylor, S. Nairn cluded the review of relevant policies and literature as outlined above in order to define the standards for audit. A full overview of the methods can be found in Taylor (2011).
Sample A retrospective convenience sample of the Emergency Department Information System (EDIS) records was selected for all adult patients admitted to the chosen ED within three consecutive months (May–July, 2010), who were suspected to have sustained any classification of hip fracture. The large teaching hospital audited treats over 750 patients with hip fracture per year (The National Hip Fracture Database, 2010). The criteria yielded an EDIS data set of 185, and the units of analysis were documents.
Data collection Based upon the ideal standards of practice identified by the policy and literature review and appraisal, a data-extraction-tool was created, which allowed basic patient demographics such as age and gender, plus compliance to the standards to be recorded. Although the majority of these standards were recordable as either present or absent, occasional descriptive details were also taken, such as explanations for non-compliance. This data-extraction-tool was piloted on five sets of records prior to the audit and found to be efficient and easy to use. Reliability and validity of the tool were also tested through this pilot, by re-auditing the same set of five records 2 weeks later, and obtaining the same results using the tool (Nolan and Mock, 2000).
Ethical considerations This audit did not require ethics-board approval as it did not involve any direct contact or questioning of patients or staff. However, the confidential patient information accessed was handled in accordance with the Data Protection Act (1998). This audit was registered with the NHS trust, and Trust Audit Committee approval was gained, which authorised access to patient records, and the recommendation of changes to practice (DH, 2005).
Data analysis Coded data was transferred to SPSS for statistical analysis, and summarised into mainly descriptive statistics. Notes made during the audit process were also discussed in relation to the audit findings.
Findings Patient demographics Of the 185 patients whose records were audited, 132 were female (71.4%) and 53 were male (28.6%), with a mean age of 81.3 years. The demographics of this sample concur with the findings in the literature that patients presenting with hip-fracture tend to be elderly females (Currie et al., 2003; Parker and Johansen, 2006; Downing and Wilson, 2005).
Audit of standards of practice in suspected hip fracture
239 stay in the ED. There was also considerable variance in the pain-assessment methods used, with a total of eight different instruments used to measure pain. The times at which patients first received analgesia was also noted, since it was included in the standards set for this audit that the College of Emergency Medicine (CEM) (2010) recommends that 50% of patients with hip-fracture in moderate/severe pain should receive analgesia within 20 min of arrival to the ED, 75% should receive analgesia within 30 min, and 98% should receive analgesia within an hour of arrival. A chi-squared goodness-of-fit test was carried out to see if the observed values matched the expected values, see Table 2. This demonstrated that the observed values for analgesia administration time were significantly lower than the CEM (2010) expected values for all three of the published targets.
Fig. 1 A composite-bar-chart demonstrating the proportions of compliance and non-compliance with the standard of carrying out a blood-glucose level test, an ECG and a pressure-ulcer risk-assessment on suspected hip fracture patients in the ED.
Medical assessment of patients The ‘secondary survey’ seemed to be the highest area of standard-achievement in the audit. A medical history and mechanism of injury was recorded for all patients, whilst one hundred and eighty patients had their medications recorded (97.3%), 178 (96.2%) had their allergy status noted and 154 (83.2%) had a social history recorded. It was also noted that history-taking was difficult for some patients due to a lack of co-operation, or communication difficulties, often as a result of severe dementia.
Initial assessment of patients (primary survey) Assessments of basic vital signs were generally recorded within 85–99% of patients, although these findings may have been an under-representation due to problems of data collection. Of the other three initial assessment standards audited, 45 (24.3%) patients were found to have had their blood glucose levels checked, 144 (77.8%) had an ECG recorded, and fifteen patients had a pressure-ulcer riskassessment in the ED (8.1%). All of these figures are below what might be expected as reasonable standards, given the stressed importance of these assessments in the reviewed literature and policy; see Fig. 1.
Diagnostic imaging Whilst 178 (96.2%) of patients received a specific hip X-ray, and those who did not had pelvic X-rays in which the hip region could be seen, only 109 (58.9%) received a chest X-ray. Although all 185 patients presented with a suspected hipfracture, only 121 (65.4%) had a fracture confirmed in the ED, six patients had an inconclusive diagnosis (five of these were referred for an MRI) whereas the other 58 (31.4%) were diagnosed as not having sustained a hip fracture.
Pain assessment and treatment Of the patients sampled, one hundred and seventy were recorded as having their pain assessed (91.9%). However, only 128 (69.2%) were given or offered any analgesia during their
Table 2 A table demonstrating the chi-squared goodness-of-fit tests applied to the standards for analgesia administration with published expected compliance rates. Standard
Observed value
Expected value
Degrees of freedom
50% patients should receive analgesia within 20 min of arrival at the ED
Yes = 63
Yes = 92.5
1
No = 122
No = 92.5
Yes = 65
Yes = 138.8
No = 120
No = 46.2
Yes = 81
Yes = 181.3
No = 104
No = 3.7
75% patients should receive analgesia within 30 min of arrival at the ED
98% patients should receive analgesia with 60 min of arrival at the ED
Chi-squared value 4.758
p-Value (to 3 s.f.)
Outcome
0.000
p < 0.001, therefore reject H0 (v2 = 4.758, d.f = 1, p = 0.000)
1
157.128
0.000
p < 0.001, therefore reject H0 (v2 = 157.128, d.f = 1, p = 0.000)
1
2774.432
0.000
p < 0.001, therefore reject H0 (v2 = 2774.432, d.f = 1, p = 0.000)
240
Fig. 2 A flow-chart demonstrating the numbers of patients suitable for fast-track and of these, the number transferred to the ward with 2 h.
R. Taylor, S. Nairn (24.3%). The seemingly low rate of blood-glucose monitoring is particularly worrying since three of the patients who did not have one recorded were noted to be diabetic. Only 8.1% of patients had their pressure-ulcer risk assessed within the ED, despite SIGN (2009) and Gunningberg et al. (2001) suggesting elderly hip-fracture patients are vulnerable to the development of pressure-ulcers. It was noted only the patients at very high-risk of developing ulcers were assessed in the ED. The fact that this audit revealed just 6.2% of the ‘fasttrackable’ patients were transferred to the ward within 2 h is also disappointing, since Gholve et al. (2004), SIGN (2009), Morley (1998) and Chia et al. (2008) suggest long waits in the ED increase the risk of patients with hip-fractures developing dehydration and pressure-ulcers; problems which, as revealed by this audit, may in themselves be under-identified and dealt with in this ED. Pain-assessment and management also seemed to be a problem within this ED, as following statistical-tests, it was revealed that none of the standards required by the CEM for providing analgesia for a set percentage of hip-fracture patients within 20, 30 and 60 min of arrival were met. Since 30.8% of patients apparently received no analgesia at all, these findings unfortunately seem to concur with those of Holdgate et al. (2010) and Pines and Hollander (2008) that a significant proportion of hip-fracture patients do not receive any analgesia within the ED, and those who do often experience long delays before pain-relief is finally administered.
Admission to the ward/fast-tracking All patients were subsequently admitted to a ward from the ED – those without obvious orthopaedic trauma were admitted for physiotherapy and analgesia. Of the 121 patients with a confirmed fracture, 69% met the #NOF fast-track criteria. However, of these, only 6.2% were fast-tracked to an orthopaedic ward within 2 h of arrival to the ED, as is demonstrated by Fig. 2. Common reasons reported for transfer delay included lack of orthopaedic bed availability; patient still receiving treatment; and one patient was worryingly delayed because their ‘fast-track checklist’ had not been completed. Of all of the 185 patients, 172 (93%) were transferred to a ward within the national ED 4 h target, (DH, 2007; CEM, 2010). However, a chi-squared goodness-of-fit test revealed that there is a statistically significant difference between the observed achievement and the 98% expected compliance level for this target (v2 = 23.853, d.f. = 1, p = 0.000), i.e. the transfer rate within 4 h was found in this case to be well below the government operational target.
Discussion Whilst some aspects of patient care observed in this audit showed good practice according to the defined standards, such as good medical-history taking, there are several areas of concern. Hip fractures tend to occur in vulnerable older adults who often have co-morbidities such as diabetes, lung and cardiovascular problems and possible polypharmacy, (Syed et al., 2005; Baraff et al., 1997), so there is concern regarding low rates of compliance for chest X-rays (65.4% done), ECGs (77.8% done) and blood-glucose-levels
Limitations There were a number of problems and limitations with the audit which may have affected the results, the most significant being problems with auditor access to all areas of the EDIS database. This may have particularly caused distortion to the perceived vital-signs recording rates, as there is a separate section on EDIS where a patient’s vitals may be recorded, although unfortunately it was not possible to access this. It was also discovered that although the majority of patient information and assessment is recorded on EDIS, there are still specific aspects of care which are recorded by hand on paper within this ED, and these were not accessed for this audit. Also, although attempts were made to ensure validity and reliability of the data-extraction-tool used, it was not possible to check the inter-rater reliability of the tool, and as this exact set of standards have never been used before, the construct-validity of these standards, and the data-extraction form upon which they are based are as yet unknown (Bruce et al., 2008). The audit sample may also be unrepresentative due to seasonal bias, as Downing and Wilson (2005) found that the workload in the ED tends to be much heavier in the winter.
Implications and recommendations for future practice Observations and assessment Despite the problems discussed with data access, there were apparently severe short-comings in patient assessment
Audit of standards of practice in suspected hip fracture with regards to blood-glucose testing and ECG being undertaken for all patients. This is despite NICE (2007) and the hospital’s own guidelines requiring such measures be undertaken, and Syed et al. (2005), and Baraff et al. (1997) warning that patients presenting with hip-fractures often have other potentially serious co-morbidities, which could be identified with such simple assessments.
Analgesia The findings of this audit suggest that this ED was failing to meet published standards for timely analgesia administration to suspected hip-fracture patients. Pain has also been found to be undertreated in the ED in other studies, particularly amongst the elderly (Holdgate et al., 2010; and Pines and Hollander, 2008), therefore it is recommended that the pain assessment and analgesia practices for patients presenting with a suspected hip-fracture are reviewed. Patients should have their pain assessed as soon as possible after their arrival to the department, and the administration of appropriate pain-relief should not be delayed following the initial patient assessment.
Management of problems associated with long waits in the ED Hardly any of the patients who met the hip-fracture ‘fasttrack’ criteria were transferred to the ward within 2 h of arrival as recommended by SIGN (2009) and NIII (2006). However, the policies reviewed express no published expected compliance-rate for this standard, and since there often seemed to be delays in patient transfers due to orthopaedic beds not being ready (which may be a separate organisational issue which needs attention), it may be unrealistic to expect a high compliance-rate of this standard. Studies and audits by Syed et al. (2005), the Audit Commission (2000), and Youde et al. (2009) have confirmed that compliance to targets for the fast-track of hip-fracture patients to the wards have been consistently found to be low. The Audit Commission (2000) and Gholve etal. (2004) state problems such as dehydration, pain and pressure-area damage can be exacerbated by long waits in the ED. Therefore, it seems reasonable that a balance should be struck between the length of time hip-fracture patients must spend in the ED and the pressure-area-assessment and care they receive in this time. Although it may not be practical to transfer the majority of patients with confirmed hip-fractures to orthopaedic wards within 1–2 h of arrival, if long waits within the ED for these patients are expected, practice standards should be improved in terms of providing them with sufficient pain-relief and IV fluids, and in such cases, pressure-areaassessments and care should be carried out for these patients, to minimise their risk of developing further complications (Gunningberg, 2001; Lindholm et al., 2008). Although the 4 h operational standard is soon going to be set at a lower compliance level of 95% as part of the ‘clinical quality indicators’ which are being established in Emergency Departments, (Sprinks, 2011) it is still important to balance the risks to vulnerable patients of long waits in the ED under the new regime.
241 Finally this audit showed similar characteristics to a recent national audit (Royal College of Physicians, 2011) which also identified issues around pain-relief, pressure area care, IV fluids and speed of throughput. They recommend a structured and comprehensive care-bundle approach to focus care on these areas of clinical practice for elderly patients who may have suffered a hip fracture: a recommendation which we support.
Conclusion This audit revealed that quality care provision to patients presenting to the ED with a suspected hip-fracture is subject to meeting a number of standards, which have been cited in a wide range of policy and literature as best-practice. However, for whatever reason, the ED of one major UK hospital did not meet some of these standards, which seems also to be reflected at national level (Royal College of Physicians, 2011). Therefore recommendations include a review of these practices of concern, and also the implementation of an action-plan and care bundle to ensure the risks from potentially long ED waits to vulnerable patients of developing pressure-ulcers, severe pain or dehydration are managed. This is something which may continue to pose a challenge as new national clinical-quality indicators replace the 4-h operational standard.
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Audit of standards of practice in suspected hip fracture Rebecca Taylor MSc, RN (Staff Nurse) *, Stuart Nairn PhD, MA, RGN, PGCHE (Lecturer) University of Nottingham, United Kingdom Received 2 July 2011; received in revised form 16 September 2011; accepted 18 September 2011
KEYWORDS Clinical audit; Emergency Department; Hip fracture; Standards of care
Abstract Background: Hip-fracture is a common orthopaedic injury presenting to the Emergency Department, particularly within the elderly population. Standards of practice dictating the care of these patients include the early administration of analgesia and an accurate clinical assessment. Once a hip-fracture has been confirmed with diagnostic-imaging, the patient should be transferred to an orthopaedic ward as soon as possible. These standards have been identified from a range of national policies and evidence-based literature. Aim: To identify standards of best-practice for the care of patients with a suspected hip-fracture in the Emergency Department and to audit compliance with these standards. Method: A retrospective-audit of 185 Emergency Department Information System records for adult patients admitted with a suspected hip-fracture was conducted using a purpose-designed data-extraction spread-sheet based on discrete standards of audit. Findings: It was found that the Emergency Department performed well on some audit standards, such as the medical assessment of patients. However, some problems of assessment were identified in relation to pressure-care, the timely transfer of patients to a suitable ward and the delivery of pain-relief. Conclusions and recommendations: There were examples of good practice in this audit, but also areas that require improvement. We recommend that a care bundle be implemented to focus on improvements in pain-relief, pressure-care and fast-tracking.
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Introduction Corresponding author. Tel.: +44 07590986038. E-mail address: [email protected] (R. Taylor).
Hip-fracture is one of the most common and potentially serious musculoskeletal injuries worldwide (Woolfe and
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Audit of standards of practice in suspected hip fracture Pfleger, 2003). The National Hip Fracture Database (2010) estimates that there are currently over 76,000 hip-fractures per year in the United Kingdom (UK). According to Greaves et al. (2009), older, and in particular, female adults are more likely to sustain a hip-fracture since they are more prone to falling and injury. Associated morbidity rates following a hip-fracture are reported to be high, and attributed mortality within 12 months of the injury is also claimed to be between 20% (Dawood and Holt, 2008) and 33% (Keene et al., 1993). It is widely agreed that best patient outcomes are achieved with surgery as soon as possible after the injury has occurred ( Santy, 2005; Smith, 2005). However, prior to surgical admission, nearly all patients who sustain a hip-fracture initially present to the Emergency Department (ED). Emergency Departments have a fast-turnover of patients presenting with a range of different healthcare needs (Jones, 2008) and a suspected hip-fracture is a common presenting injury. This project identified ED best practice standards and monitored whether these standards were being implemented in one major UK hospital.
Background-overview of literature and related policies The background provides an overview of the applicable standards of practice and guidance documents available. No single policy specific to providing care for patients with a suspected hip fracture in the ED was identified in the local and national literature reviewed, therefore the audit standards were selected from a range of documents. A list of relevant standards of practice was comprised from guidance by established associations governing clinical
237 practice, including the ED ‘fast-track’ section of the hipfracture care pathway (National Health Service (NHS) Institute for Innovation and Improvement (NIII, 2006); The Department of Health (DH, 2007); The College of Emergency Medicine (CEM, 2010); and The Scottish Intercollegiate Guidelines Network (SIGN, 2009). From these guidelines, a list of ideal practice standards were compiled around topics as outlined in Table 1. A thorough literature review was conducted to further examine the evidence base for the audit standards, as is recommended by Morrell and Harvey (1999), Norman and Redfern (1995) and NICE (2002). The quality of the evidence on which these guidelines and articles were based was appraised according to a hierarchy of evidence (Fain, 2004). As part of the initial patient assessment, or ‘primary survey’, it was expected that a set of vital-signs or ‘observations’ would be taken, as identified by National Institute for Health and Clinical Excellence (NICE, 2007), SIGN (2009) and Baraff et al. (1997). A check of the patient’s blood-glucose-level was also included as an audit standard, since Baraff et al. (1997) cites this as a baseline investigation in a patient who has had a fall. Morley (1998), Considine and Hood (2000), Parker and Johansen (2006), and the Audit Commission (2000) all agree that early pressure-area-assessment and care is important since patients with hip-fractures are vulnerable to developing pressure-ulcers. A randomised controlled trial (RCT) conducted by Gunningberg et al. (2001), demonstrated the effectiveness of implementing pressure-area-assessment tools and interventions in the ED for hip-fracture patients on reducing the rates of pressure-ulcers in these patients on hospital discharge. The final standard expected in the initial assessment of patients included undertaking an electrocardiogram (ECG), as required by the NIII (2006) and local guidelines. This is necessary be-
Table 1 A table outlining the five broad topics audited, and the individual standards which were measured for each patient who met audit criteria. Topic for audit
Standards measured
Initial patient assessment (primary survey)
Base line observations/vital-signs
Pain assessment and management Medical assessment/history taking (secondary survey)
Diagnostic imaging
Time patient spent in ED, before transfer to a ward
Respiration rate Oxygen Saturations Heart rate Blood pressure Temperature
Electro-cardiogram (ECG) Blood glucose monitoring (BM) Pressure-area assessment/pressure ulcer risk score Pain assessment method Time and type of analgesia first offered Past medical history Social history Current medications Allergy status Mechanism of injury Hip X-ray Chest X-ray Referral for MRI if diagnosis inconclusive Within 2 h Within 4 h
238 cause cardiac problems are a common and potentially serious affliction within elderly patients presenting with a fall (Baraff et al. 1997; Davies and Kenny, 1996). There is consensus amongst the literature reviewed that pain is a serious problem presenting in patients with a suspected hip-fracture (FitzSimmons and Wardrope, 2005; Holdgate et al., 2010; Jackson, 2010; Pines and Hollander, 2008; Chambers and Guly, 1993; Herr and Titler, 2008; Morley, 1998). Pain can in itself lead to further complications such as cardiac arrhythmias (Vassiliadis et al., 2002). It is therefore recommended that patient pain is assessed as soon as possible (Herr and Titler, 2008), and analgesia be promptly administered, since this is a key part of the efficient, quality-care service of the hip-fracture fast-track pathway (Vassiliadis et al., 2002; Considine and Hood, 2000; Gholve et al., 2004). In terms of the medical assessment and history-taking standards (‘secondary survey’), it is recommended that all patients who have fallen are assessed to try to determine the cause of the fall (Davies and Kenny, 1996). Baraff et al. (1997) adds that this assessment should include a history of medical conditions and medications, a history of the patient’s fall, and their functional and social history. To confirm the diagnosis of any classification of hip-fracture, an X-ray of the hip is essential, and can often give a definitive diagnosis (NIII, 2006; DH, 2007; Parker and Johansen, 2006). According to NIII (2006) and Baraff et al. (1997), it is expected that patients with a suspected hip-fracture also receive a chest X-ray to rule out any underlying lung conditions or thoracic injury. However, the NIII (2006) and SIGN (2009) describe an ideal ‘fast-track’ procedure for all patients with a confirmed isolated hip-fracture in the ED. According to these published guidelines all of the above care and diagnostic practices must be done as quickly as possible to avoid delay of transferring the patient to an orthopaedic ward- ideally within 2 h of admission (Casaletto and Gatt, 2003; Bottle and Aylin, 2006). Morley (1998) and Chia et al. (2008) found that long waits in the ED for hip-fracture patients are detrimental, with the Audit Commission (2000) adding that long waits on hospital trolleys are linked to increased risks of developing pressure-sores. At the time of audit, the standard of a less-than 4 h wait before transfer for 98% of patients was also measured (DH, 2007), and as discussed above, this was seen as an important benchmark for ensuring the comfort and safety of hip-fracture patients.
Aims and objectives of the study The main aim of the study was to determine the standards for the best practice of care for ED patients with a suspected hip fracture, and to examine using clinical audit the degree to which these standards were being met within one urban UK hospital. The results and discussion focus mainly on areas of concern as revealed by the audit, and how improvements may be made in these areas.
Methodology The study used clinical-audit to assess the performance of one particular ED. In accordance with NICE etal. (2002), Shaw (1992) and Morrell and Harvey (1999), this methodology in-
R. Taylor, S. Nairn cluded the review of relevant policies and literature as outlined above in order to define the standards for audit. A full overview of the methods can be found in Taylor (2011).
Sample A retrospective convenience sample of the Emergency Department Information System (EDIS) records was selected for all adult patients admitted to the chosen ED within three consecutive months (May–July, 2010), who were suspected to have sustained any classification of hip fracture. The large teaching hospital audited treats over 750 patients with hip fracture per year (The National Hip Fracture Database, 2010). The criteria yielded an EDIS data set of 185, and the units of analysis were documents.
Data collection Based upon the ideal standards of practice identified by the policy and literature review and appraisal, a data-extraction-tool was created, which allowed basic patient demographics such as age and gender, plus compliance to the standards to be recorded. Although the majority of these standards were recordable as either present or absent, occasional descriptive details were also taken, such as explanations for non-compliance. This data-extraction-tool was piloted on five sets of records prior to the audit and found to be efficient and easy to use. Reliability and validity of the tool were also tested through this pilot, by re-auditing the same set of five records 2 weeks later, and obtaining the same results using the tool (Nolan and Mock, 2000).
Ethical considerations This audit did not require ethics-board approval as it did not involve any direct contact or questioning of patients or staff. However, the confidential patient information accessed was handled in accordance with the Data Protection Act (1998). This audit was registered with the NHS trust, and Trust Audit Committee approval was gained, which authorised access to patient records, and the recommendation of changes to practice (DH, 2005).
Data analysis Coded data was transferred to SPSS for statistical analysis, and summarised into mainly descriptive statistics. Notes made during the audit process were also discussed in relation to the audit findings.
Findings Patient demographics Of the 185 patients whose records were audited, 132 were female (71.4%) and 53 were male (28.6%), with a mean age of 81.3 years. The demographics of this sample concur with the findings in the literature that patients presenting with hip-fracture tend to be elderly females (Currie et al., 2003; Parker and Johansen, 2006; Downing and Wilson, 2005).
Audit of standards of practice in suspected hip fracture
239 stay in the ED. There was also considerable variance in the pain-assessment methods used, with a total of eight different instruments used to measure pain. The times at which patients first received analgesia was also noted, since it was included in the standards set for this audit that the College of Emergency Medicine (CEM) (2010) recommends that 50% of patients with hip-fracture in moderate/severe pain should receive analgesia within 20 min of arrival to the ED, 75% should receive analgesia within 30 min, and 98% should receive analgesia within an hour of arrival. A chi-squared goodness-of-fit test was carried out to see if the observed values matched the expected values, see Table 2. This demonstrated that the observed values for analgesia administration time were significantly lower than the CEM (2010) expected values for all three of the published targets.
Fig. 1 A composite-bar-chart demonstrating the proportions of compliance and non-compliance with the standard of carrying out a blood-glucose level test, an ECG and a pressure-ulcer risk-assessment on suspected hip fracture patients in the ED.
Medical assessment of patients The ‘secondary survey’ seemed to be the highest area of standard-achievement in the audit. A medical history and mechanism of injury was recorded for all patients, whilst one hundred and eighty patients had their medications recorded (97.3%), 178 (96.2%) had their allergy status noted and 154 (83.2%) had a social history recorded. It was also noted that history-taking was difficult for some patients due to a lack of co-operation, or communication difficulties, often as a result of severe dementia.
Initial assessment of patients (primary survey) Assessments of basic vital signs were generally recorded within 85–99% of patients, although these findings may have been an under-representation due to problems of data collection. Of the other three initial assessment standards audited, 45 (24.3%) patients were found to have had their blood glucose levels checked, 144 (77.8%) had an ECG recorded, and fifteen patients had a pressure-ulcer riskassessment in the ED (8.1%). All of these figures are below what might be expected as reasonable standards, given the stressed importance of these assessments in the reviewed literature and policy; see Fig. 1.
Diagnostic imaging Whilst 178 (96.2%) of patients received a specific hip X-ray, and those who did not had pelvic X-rays in which the hip region could be seen, only 109 (58.9%) received a chest X-ray. Although all 185 patients presented with a suspected hipfracture, only 121 (65.4%) had a fracture confirmed in the ED, six patients had an inconclusive diagnosis (five of these were referred for an MRI) whereas the other 58 (31.4%) were diagnosed as not having sustained a hip fracture.
Pain assessment and treatment Of the patients sampled, one hundred and seventy were recorded as having their pain assessed (91.9%). However, only 128 (69.2%) were given or offered any analgesia during their
Table 2 A table demonstrating the chi-squared goodness-of-fit tests applied to the standards for analgesia administration with published expected compliance rates. Standard
Observed value
Expected value
Degrees of freedom
50% patients should receive analgesia within 20 min of arrival at the ED
Yes = 63
Yes = 92.5
1
No = 122
No = 92.5
Yes = 65
Yes = 138.8
No = 120
No = 46.2
Yes = 81
Yes = 181.3
No = 104
No = 3.7
75% patients should receive analgesia within 30 min of arrival at the ED
98% patients should receive analgesia with 60 min of arrival at the ED
Chi-squared value 4.758
p-Value (to 3 s.f.)
Outcome
0.000
p < 0.001, therefore reject H0 (v2 = 4.758, d.f = 1, p = 0.000)
1
157.128
0.000
p < 0.001, therefore reject H0 (v2 = 157.128, d.f = 1, p = 0.000)
1
2774.432
0.000
p < 0.001, therefore reject H0 (v2 = 2774.432, d.f = 1, p = 0.000)
240
Fig. 2 A flow-chart demonstrating the numbers of patients suitable for fast-track and of these, the number transferred to the ward with 2 h.
R. Taylor, S. Nairn (24.3%). The seemingly low rate of blood-glucose monitoring is particularly worrying since three of the patients who did not have one recorded were noted to be diabetic. Only 8.1% of patients had their pressure-ulcer risk assessed within the ED, despite SIGN (2009) and Gunningberg et al. (2001) suggesting elderly hip-fracture patients are vulnerable to the development of pressure-ulcers. It was noted only the patients at very high-risk of developing ulcers were assessed in the ED. The fact that this audit revealed just 6.2% of the ‘fasttrackable’ patients were transferred to the ward within 2 h is also disappointing, since Gholve et al. (2004), SIGN (2009), Morley (1998) and Chia et al. (2008) suggest long waits in the ED increase the risk of patients with hip-fractures developing dehydration and pressure-ulcers; problems which, as revealed by this audit, may in themselves be under-identified and dealt with in this ED. Pain-assessment and management also seemed to be a problem within this ED, as following statistical-tests, it was revealed that none of the standards required by the CEM for providing analgesia for a set percentage of hip-fracture patients within 20, 30 and 60 min of arrival were met. Since 30.8% of patients apparently received no analgesia at all, these findings unfortunately seem to concur with those of Holdgate et al. (2010) and Pines and Hollander (2008) that a significant proportion of hip-fracture patients do not receive any analgesia within the ED, and those who do often experience long delays before pain-relief is finally administered.
Admission to the ward/fast-tracking All patients were subsequently admitted to a ward from the ED – those without obvious orthopaedic trauma were admitted for physiotherapy and analgesia. Of the 121 patients with a confirmed fracture, 69% met the #NOF fast-track criteria. However, of these, only 6.2% were fast-tracked to an orthopaedic ward within 2 h of arrival to the ED, as is demonstrated by Fig. 2. Common reasons reported for transfer delay included lack of orthopaedic bed availability; patient still receiving treatment; and one patient was worryingly delayed because their ‘fast-track checklist’ had not been completed. Of all of the 185 patients, 172 (93%) were transferred to a ward within the national ED 4 h target, (DH, 2007; CEM, 2010). However, a chi-squared goodness-of-fit test revealed that there is a statistically significant difference between the observed achievement and the 98% expected compliance level for this target (v2 = 23.853, d.f. = 1, p = 0.000), i.e. the transfer rate within 4 h was found in this case to be well below the government operational target.
Discussion Whilst some aspects of patient care observed in this audit showed good practice according to the defined standards, such as good medical-history taking, there are several areas of concern. Hip fractures tend to occur in vulnerable older adults who often have co-morbidities such as diabetes, lung and cardiovascular problems and possible polypharmacy, (Syed et al., 2005; Baraff et al., 1997), so there is concern regarding low rates of compliance for chest X-rays (65.4% done), ECGs (77.8% done) and blood-glucose-levels
Limitations There were a number of problems and limitations with the audit which may have affected the results, the most significant being problems with auditor access to all areas of the EDIS database. This may have particularly caused distortion to the perceived vital-signs recording rates, as there is a separate section on EDIS where a patient’s vitals may be recorded, although unfortunately it was not possible to access this. It was also discovered that although the majority of patient information and assessment is recorded on EDIS, there are still specific aspects of care which are recorded by hand on paper within this ED, and these were not accessed for this audit. Also, although attempts were made to ensure validity and reliability of the data-extraction-tool used, it was not possible to check the inter-rater reliability of the tool, and as this exact set of standards have never been used before, the construct-validity of these standards, and the data-extraction form upon which they are based are as yet unknown (Bruce et al., 2008). The audit sample may also be unrepresentative due to seasonal bias, as Downing and Wilson (2005) found that the workload in the ED tends to be much heavier in the winter.
Implications and recommendations for future practice Observations and assessment Despite the problems discussed with data access, there were apparently severe short-comings in patient assessment
Audit of standards of practice in suspected hip fracture with regards to blood-glucose testing and ECG being undertaken for all patients. This is despite NICE (2007) and the hospital’s own guidelines requiring such measures be undertaken, and Syed et al. (2005), and Baraff et al. (1997) warning that patients presenting with hip-fractures often have other potentially serious co-morbidities, which could be identified with such simple assessments.
Analgesia The findings of this audit suggest that this ED was failing to meet published standards for timely analgesia administration to suspected hip-fracture patients. Pain has also been found to be undertreated in the ED in other studies, particularly amongst the elderly (Holdgate et al., 2010; and Pines and Hollander, 2008), therefore it is recommended that the pain assessment and analgesia practices for patients presenting with a suspected hip-fracture are reviewed. Patients should have their pain assessed as soon as possible after their arrival to the department, and the administration of appropriate pain-relief should not be delayed following the initial patient assessment.
Management of problems associated with long waits in the ED Hardly any of the patients who met the hip-fracture ‘fasttrack’ criteria were transferred to the ward within 2 h of arrival as recommended by SIGN (2009) and NIII (2006). However, the policies reviewed express no published expected compliance-rate for this standard, and since there often seemed to be delays in patient transfers due to orthopaedic beds not being ready (which may be a separate organisational issue which needs attention), it may be unrealistic to expect a high compliance-rate of this standard. Studies and audits by Syed et al. (2005), the Audit Commission (2000), and Youde et al. (2009) have confirmed that compliance to targets for the fast-track of hip-fracture patients to the wards have been consistently found to be low. The Audit Commission (2000) and Gholve etal. (2004) state problems such as dehydration, pain and pressure-area damage can be exacerbated by long waits in the ED. Therefore, it seems reasonable that a balance should be struck between the length of time hip-fracture patients must spend in the ED and the pressure-area-assessment and care they receive in this time. Although it may not be practical to transfer the majority of patients with confirmed hip-fractures to orthopaedic wards within 1–2 h of arrival, if long waits within the ED for these patients are expected, practice standards should be improved in terms of providing them with sufficient pain-relief and IV fluids, and in such cases, pressure-areaassessments and care should be carried out for these patients, to minimise their risk of developing further complications (Gunningberg, 2001; Lindholm et al., 2008). Although the 4 h operational standard is soon going to be set at a lower compliance level of 95% as part of the ‘clinical quality indicators’ which are being established in Emergency Departments, (Sprinks, 2011) it is still important to balance the risks to vulnerable patients of long waits in the ED under the new regime.
241 Finally this audit showed similar characteristics to a recent national audit (Royal College of Physicians, 2011) which also identified issues around pain-relief, pressure area care, IV fluids and speed of throughput. They recommend a structured and comprehensive care-bundle approach to focus care on these areas of clinical practice for elderly patients who may have suffered a hip fracture: a recommendation which we support.
Conclusion This audit revealed that quality care provision to patients presenting to the ED with a suspected hip-fracture is subject to meeting a number of standards, which have been cited in a wide range of policy and literature as best-practice. However, for whatever reason, the ED of one major UK hospital did not meet some of these standards, which seems also to be reflected at national level (Royal College of Physicians, 2011). Therefore recommendations include a review of these practices of concern, and also the implementation of an action-plan and care bundle to ensure the risks from potentially long ED waits to vulnerable patients of developing pressure-ulcers, severe pain or dehydration are managed. This is something which may continue to pose a challenge as new national clinical-quality indicators replace the 4-h operational standard.
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