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The national clinical audit of falls and bone health: The clinical management of hip fracture patients
Injury, Int. J. Care Injured 40 (2009) 1226–1230
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The national clinical audit of falls and bone health: The clinical management of hip fracture patients Jane Youde a,*, Janet Husk b, Derek Lowe b, Robert Grant b, Jonathan Potter c, Finbarr Martin d,e a
Royal Derby Hospital, Uttoxeter Road, Derby, De22 3NE, United Kingdom The National Falls and Bone Health Audit, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, United Kingdom c Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, United Kingdom d Guys and St Thomas’ NHS Foundation Trust, United Kingdom e Falls and Bone Health, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 22 June 2009
Background: The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver ‘The National Clinical Audit of Falls and Bone Health for Older People’. Methods: The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site. Results: Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2 h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240 min. 35% (1080/3088) of #NOF patients were operated on within 24 h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24 h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10–27 days. Conclusions: There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Hip fractures Aged Clinical management Hospital care Accident and emergency
Background Falls in older people are associated with a high morbidity and mortality with potentially life-threatening consequences including fractures, ‘‘long lies’’ resulting in hypothermia, pressure sores and pneumonia, and significant psychological problems associated with the fear of falling.5,21 It is estimated that 30% of the population over 65 years of age fall every year with an estimated 8–9% of the population over 70 years of age presenting to hospital Accident and Emergency departments each year due to a fall.20,23,27 Patients
* Corresponding author. Tel.: +44 01332 340131. E-mail address: [email protected] (J. Youde). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.06.167
who present with fractured necks of femur (#NOF), which are the commonest reason for orthopaedic admission in this age group,16 as a result of a fall is associated with a 1 year mortality of up to 33%8,17 and an annual cost of £1.7 billion in the UK in 1999. The length of stay in these patients shows a wide variation across the UK (11–38 days) with differing in-patient mortality rates. The NHS Institute for Innovation and Improvement has reviewed and observed best practice in the UK and produced guidance on implementing process change and improvements in patient care.15 In recent years 3 major documents, the evidence-based NICE guideline 21,12 the NSF for Older People (Standard 6)26 and the recently published joint guidelines by the British Orthopaedic Association (BOA) and the British Geriatric Society (BGS), The Care of Patients with Fragility Fracture (The Blue Book)3 have defined
J. Youde et al. / Injury, Int. J. Care Injured 40 (2009) 1226–1230
the service standards for the management of older people with falls and #NOF. All three documents advocate a multi-disciplinary approach with integrated services that reflect published evidence for the effective treatment of older people with falls. Different service models are given for orthogeriatric care with the favoured one being that of a jointly managed ward with consultant input from both Orthopaedics and Medicine for Older People. There is some evidence that this model can reduce the length of stay and improve outcomes1,6,7 though there is not rigorous evidence of benefit if the collaboration is restricted to post-operative rehabilitation.4 In 2005 the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians was commissioned by the Healthcare Commission to evaluate the falls related aspects of the NSF for Older People most of which is contained in Standard 6. The audit ‘National Audit of the Organisation of service for fall and Bone Health for Older People’19 reported in 2006. Key findings from this regarding older people with fractures included a low level of input from specialist falls services into A&E and orthopaedics with consequently low levels of falls risk assessment, only 50% of trusts reporting the establishment of an orthogeriatric ward though 88% trusts recording having processes designed to have a time to theatre of <24 h with patients with a #NOF. To assess trusts responses to these audit results and assess the full integration of falls services in practice at the level of the individual patient, the Healthcare Commission commissioned further clinical audit. The audit was planned to assess the implementation not only of the documents listed above, but also the SIGN Guideline 5625 NICE Guideline CG2112 and the NICE Guidance Technology Appraisal (TAG) 087 on secondary prevention treatment of osteoporosis.13 This paper presents the findings of the clinical audit regarding the hospital care of patients presenting with a #NOF. The results for the secondary prevention of fragility fractures including the assessment of falls risk factors and bone health in this patient group will be reported separately. Methods Governance of the audit The audit steering group included members from different disciplines and agencies to allow the different facets of care fracture patients receive to be accurately represented. The audit population The audit sample was consecutive patients aged >65 years attending hospital emergency departments with proven fractures of the hip for a 3-month period. The sample was restricted to those alive at April 2007 and excluded patients sustaining multiple fractures or having a documented life expectancy of less than 1 year. Target numbers were 20 per site for hip fractures to allow meaningful inter-site comparisons for benchmarking.
1227
chief executives of all 173 acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England. The CEEU project management supported the data collection process with regular contact both by e-mail and enewsletters. Ethics, information governance and the public interest The Healthcare Commission advised on the data collection and sharing of information. Results Of the 172 acute trusts recruited to participate in the audit 157 (91%) submitted data with 84% of eligible PCTs involved in data collection. Data was entered for 3184 patients who sustained their #NOF from a fall between October and December 2006. The majority of the cases were women (80% 2555/3184), the median age was 83 years and most were of white British origin where ethnicity data was submitted (94% 2365/2522) and admitted from their own home (68% 2152/3184). Presentation and pre-operative care Over 97% (3172/3184) #NOF patients presented to the A&E department and predominantly on the same day as the fall (88% 2813/3184). There was a consistent spread of patients presenting during the week and most presented to the A&E department between the hours of 08:00 and 20:00. The time in the A&E department was less than 2 h, as recommended in the SIGN guidelines, in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240 min (Table 1). Of concern were 5 sites where the median time in A&E was >360 min. In a small number of the cases the time in A&E was not available (n = 51). With regards to the pre-operative care received by the #NOF patients 95% (3019/3184) received analgesia, 46% (1442/3184) within 60 min of presentation to hospital. 46% (1456/3184) were risk assessed for pressure ulcers with 54% (789/1456) of those having appropriate pressure relieving equipment used. It should be noted that there was a wide variation in audit responses between sites for this (11–81%) as some centres consider all #NOF patients at high risk for pressure ulcers and nurse all #NOF patients on pressure relieving mattresses and therefore do not assess individually for risk. The prevalence of other pre-operative assessments as recommended by SIGN are shown in Table 2. The low rates of formal Table 1 Time in A&E.
120 min 121–240 min >240 min Unrecorded
#NOF (%)
#NOF (number)
20 57 23
640/3133 1777/3133 716/3133 51
Development of audit indicators The audit steering group used a Delphi process to evaluate standards from the national guidelines available. A web tool for the data collection was designed and piloted. The tool used had 52 questions with mainly yes/no responses. Recruitment and preparation of sites Sites for the audit were recruited from England, Wales, Northern Ireland and the Channel Islands with agreement from
Table 2 Prevalence of pre-operative assessments as recommended by SIGN. Assessment
Number
%
Past medical history recorded History of cognitive impairment recorded Assessment of cognitive function Medication list Record cardiac murmurs if present Renal function recorded Oxygen saturation on room air
2583/3184 1346/3184 934/3184 2896/3184 2537/3184 2641/3184 2880/3184
81 42 29 91 80 83 90
J. Youde et al. / Injury, Int. J. Care Injured 40 (2009) 1226–1230
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Fig. 2. Median length of stay. Fig. 1. Median time to theatre from registration.
Sample validity and reliability assessment or recording of prior cognitive function is of note as this can affect rehabilitation outcomes and increases the risk of post-operative delirium. There was a similarly low level of assessment of cognitive function post-operatively at 28% (880/ 3088). 79% (2518/3184) of patients were prescribed some form of thromboprophylaxis in the form of aspirin or sub-cutaneous heparin. A medical assessment by a senior member of the medical team was undertaken in 28% (901/3184) cases, 47% (426/901) of which were on-call reviews, thus routine specialist medical review pre-operatively was seldom available. Surgery and post-operative care Overall 35% (1080/3088) of #NOF patients were operated on within 24 h of admission though 4 sites had a median time of >96 h (Fig. 1). There were several documented reasons for delay to theatre including awaiting medical review (59% 566/956), organisational reasons (29% 278/956) or awaiting orthopaedic diagnosis/investigation (8% 77/956). Other reasons recorded were related to the use of warfarin or clopidrogel. In 83% (2550/3088) of the operations the presence of a consultant or trained specialist was recorded for orthopaedics and 79% (2441/3088) for anaesthetics. While there was a good level of pre-operative recording of preoperative function (86% 2642/3088) to facilitate multi-disciplinary treatment and discharge planning there were low levels of evidence of this approach post-operatively with 39% (1216/3088) of notes indicating a multi-disciplinary team meeting. Just under half of the patients were sat out of bed within 24 h, medical reasons being the explanation cited for delay and 87% (2678/ 3088) were seen by a physiotherapist within 72 h of their operation. Despite standard 6 of the NSF for Older people recommending that care of #NOF patients should occur within a dedicated orthogeriatric unit with multi-disciplinary team working only 35% (1115/3184) of patients were cared for in such a clinical environment. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10–27 days (Fig. 2). Of these patients 59% (1864/3184) were discharged to their normal place of residence in the community with 37% (456/1249) discharged to their own home receiving support from an early or supportive discharge team.
Most of the participating sites submitted lists of consecutive #NOF patients patients with reasons for inclusion and exclusion from the audit. Unavailability of the clinical notes did not appear to be a major issue and the sample audited appeared to be representative. Of the participating sites 153 submitted double data on 821 cases. The median kappa score was 0.74 indicating good agreement of this categorical data.10 Discussion The audit of UK practice in the management of patients with #NOF highlights the wide variation in aspects of this pathway perhaps best reflected in the differences in time in A&E and time to theatre. These differences cannot be explained by differences in case mix alone and would strongly suggest that there are both process and clinical issues to be addressed as has been reported by the NHS Institute for Innovation and Improvement.15 This audit will allow trusts to benchmark their current practice against national results and redesign service delivery to improve outcomes and hopefully reduce the significant variations in care currently seen. Time to theatre has been demonstrated as important in determining outcomes in patients with #NOF and should be adopted as a key performance indicator for #NOF services.2,11 Delays to theatre were divided into three main categories: awaiting medical assessment, delay in orthopaedic diagnosis and organisational. The commonest reason was delay to medical assessment (59%) notably with most of the opinions given by oncall medical personnel. This is important in terms of outcome as this group of patients are high risk patients with a poor outcome if surgery is delayed, which can be predicted using the Nottingham Hip Fracture Score.9 This data would strongly suggest that in the majority of trusts, despite national recommendations and previously reported national audit results, orthogeriatric services either do not exist or are unable to respond in a timely manner for the needs of these patients. Provision of a dedicated orthogeriatric service would significantly improve the consistency of medical advice and reduce the wait for a medical opinion and thence reduce time to theatre in these patients leading to improved outcomes.17 There is a need for PCTs to commission orthogeriatric services and it is anticipated that a commissioning toolkit for PCTs in England being developed by the Department of Health in collaboration with professional bodies will support this.
J. Youde et al. / Injury, Int. J. Care Injured 40 (2009) 1226–1230
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Box 1. National hip fracture standards. Standard
Audit result
1. All patients with hip fractures should be admitted to an acute orthopaedic ward within 4 h of presentation 2. All patients with hip fracture who are medically fit should have surgery within 48 h of admission, and during normal working hours 3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer 4. All patients presenting with a fragility fractures should be managed on an orthopaedic ward with routine access to acute orthogeriatric support from the time of admission
77% (2417/3133) were admitted within 4 h
Another cause of delay to theatre was if patients were admitted taking warfarin or clopidrogel. There is an increased use of clopidrogel in the UK for patients with cardiovascular disease and it appears that practises and opinions vary at local levels as to when patients are considered safe for spinal anaesthesia, which is normal practice in the UK.22 As yet there is no national guidance on this or large trials assessing this issue. There is an urgent need for research projects to be commissioned to address this growing clinical risk area. Regarding the recommended pre-operative assessments two areas warrant further comment from this audit. The low level of formal cognitive assessment or recording of dementia is important as the presence of dementia increases the risk of post-operative delirium and thus outcomes including length of stay.18 The results of an abbreviated mini-mental test score or other such score will be influenced by pain and analgesia, e.g. morphine on initial presentation and post-operatively. Education of staff who will initially assess such patients on this aspect of their pre-operative state may increase compliance in this area. The optimum timing for assessment and the screening tool to be used needs further consideration and perhaps study. The level of pressure sore risk assessment in the audit was again highly variable reflecting different processes and policies in this area of patient care. There were no outcome measures on the prevalence or incidence of pressure sores or cost/benefit analysis regarding this in this audit and this may warrant further evaluation. Pharmacological thromboprophylaxis, using heparin or aspirin was not recorded as being universally prescribed in all #NOF patients and if not prescribed the reasons for this were not consistently documented. However the audit did not include the use of other preventative measures such as AV boots which may account for some patients not being prescribed pharmacological agents. The SIGN guidelines24 recommend the use of heparin or aspirin for 35 days post-operatively with similar recent recommendations from NICE.14 Following subsequent consultation with the BOA it has been agreed that the guidance was not based on operation specific evidence and that the BOA would produce detailed operation and context specific guidance on thromboprophylaxis. To inform this process and further guidelines in this area the Health Technology Assessment programme of the National Institute for Health Research have invited NICE and the BOA to develop research protocols in this area. The RCP Bone Health audit has raised several important questions around the wide variation in the processes of care for patients with fragility fractures in the UK. The audit results have allowed trusts to benchmark their performance against national outcomes and target clinical and service developments. The accuracy of the recording of key information for the collection of the audit data has been highlighted with comments from participants on the difficulties on determining timings in the process, e.g. time in A&E. The compliance with the 4-h wait in A&E is a key performance indicator for trusts and this deficit
69% (2122/3088) were operated on within 48 h 46% (1456/3184) had an assessment 35% (1115/3184) were managed within a dedicated orthogeriatric unit
should be rectified, perhaps with the greater and accurate use of technology. To address this area and raise the standards of care for #NOF patients the National Hip Fracture Database (NHFD) has been launched in conjunction with the ‘Blue Book’, supported by The Information Centre for Health and Social Care’s National Clinical Audit Support Programme. It is anticipated that this will impact in a similar way the Myocardial Infarction National Audit Project (MINAP) database for cardiovascular disease has with improvement in national and local standards of care and audit. The NHFD monitors six evidencebased standards of care as set out in the Blue Book. The first four standards that relate to the results from this audit are summarised in Box 1. Participation in this database will allow casemix-adjusted benchmarking for trusts in this service area over longer periods of time than this audit as well as allowing for large scale research projects to be achieved. To achieve this with improved outcomes for the group of older complex patients all clinicians and trusts are strongly encouraged to participate in this initiative. Conclusions There are currently unacceptable wide variations in the delivery of essential areas of clinical services to older people with a #NOF in the UK. Recent joint initiatives with the BGS, BOA and Department of Health in developing service improvements in this area should lead to improved outcomes for patients. Acknowledgements Ms. Michelle Spencer-Williams, BA Hons Project Co-ordinator, National Falls and Bone Health Audit, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians. The Falls and Bone Health Steering Group. References 1. Adunsky A, Arad M, Rami L, et al. Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients. Disabil Rehabil 2005;27(18–19):1123–7. 2. Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. Br Med J 2006;332:947–51. 3. British Orthopaedic Association. The care of patients with fragility fractures; 2007. 4. Cameron ID, Handoll HH, Finnegan TP, et al. Co-ordinated multi-disciplinary approaches for inpatients rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev 2001;3 (CD000106). 5. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age Ageing 1999;28:121–5. 6. Elliot JR, Wilkinson TJ, Hanger HC, et al. The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. N Z Med J 1996;109:72–3. 7. Hershkovitz A, Kalandariov Z, Hermush V, et al. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil 2007;88(7):916–21. 8. Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ 1993;307:1248–50.
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9. Maxwell MJ, Moran CG, Moppett IK. Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery. Br J Anaesth 2008;101:511–7. 10. McGinn T, Wyer PC, Newman TB. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). Can Med Assoc J 2004;171: 1369–73. 11. Moran CG, Wen RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 2005;87:483–9. 12. National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people; 2004. www.nice.org.uk/ nicemedia/pdf/CG21fullguidelines/pdf. 13. National Institute for Clinical Excellence. Bisphophonates (aledronate, etironate, risedronate) selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fracture in postmenopausal women; 2005. www.nice.org.uk/ guidance/TA87. 14. National Institute for Clinical Excellence Venous Thromboembolism Guidelines; 2007. www.nice.org.uk/CG046. 15. NHS Institute for Innovation and Improvement. Delivering quality and value: focus on: fractured neck of femur; 2006. 16. Perker M, Johansen A. Hip fracture. BMJ 2006;333:27–30. 17. Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. Br Med J 2006;331:1374–6. 18. Royal College of Physicians. The prevention, diagnosis and management of delirium in older people; 2006.
19. Royal College of Physicians, Clinical Effectiveness and Evaluation Unit, National ‘National Audit of the Organisation of service for Falls and Bone Health for Older People’; 2006. 20. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006;35-S2:ii37–41. 21. Salkeld G, Cameron ID, Cumming RG, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. Br Med J 2000;320: 341–6. 22. Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur. Anaesthesia 2008;63:250–8. 23. Sattin RW, Lambert Huber DA, DeVito CA, et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol 1990;131: 1028–37. 24. Scottish Intercollegiate Guidelines Network (SIGN). Prophylaxis of venous thromboembolism. SIGN Publication No. 62. Edingburgh: SIGN; 2002. www.sign.ac.uk/guidelines/fulltext/62/index.html. 25. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fracture in older people. SIGN Publication No. 56. Edingburgh: SIGN; 2002. www.sign.ac.uk/guidelines/fulltext/56/index.html. 26. Secretary of State for Health National. Service framework-for older people; 2001. p. 76–89. www.doh.dov.uk/nsf/olderpeople.htm. 27. Stalenhoef PA, Crembolder HFJM, Knottnerus JA, van der Horst FGEM. Incidence, risk factors and consequences of falls among elderly subjects living in the community. Eur J Public Health 1997;7:328334.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The national clinical audit of falls and bone health: The clinical management of hip fracture patients Jane Youde a,*, Janet Husk b, Derek Lowe b, Robert Grant b, Jonathan Potter c, Finbarr Martin d,e a
Royal Derby Hospital, Uttoxeter Road, Derby, De22 3NE, United Kingdom The National Falls and Bone Health Audit, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, United Kingdom c Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, United Kingdom d Guys and St Thomas’ NHS Foundation Trust, United Kingdom e Falls and Bone Health, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 22 June 2009
Background: The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver ‘The National Clinical Audit of Falls and Bone Health for Older People’. Methods: The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site. Results: Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2 h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240 min. 35% (1080/3088) of #NOF patients were operated on within 24 h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24 h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10–27 days. Conclusions: There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Hip fractures Aged Clinical management Hospital care Accident and emergency
Background Falls in older people are associated with a high morbidity and mortality with potentially life-threatening consequences including fractures, ‘‘long lies’’ resulting in hypothermia, pressure sores and pneumonia, and significant psychological problems associated with the fear of falling.5,21 It is estimated that 30% of the population over 65 years of age fall every year with an estimated 8–9% of the population over 70 years of age presenting to hospital Accident and Emergency departments each year due to a fall.20,23,27 Patients
* Corresponding author. Tel.: +44 01332 340131. E-mail address: [email protected] (J. Youde). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.06.167
who present with fractured necks of femur (#NOF), which are the commonest reason for orthopaedic admission in this age group,16 as a result of a fall is associated with a 1 year mortality of up to 33%8,17 and an annual cost of £1.7 billion in the UK in 1999. The length of stay in these patients shows a wide variation across the UK (11–38 days) with differing in-patient mortality rates. The NHS Institute for Innovation and Improvement has reviewed and observed best practice in the UK and produced guidance on implementing process change and improvements in patient care.15 In recent years 3 major documents, the evidence-based NICE guideline 21,12 the NSF for Older People (Standard 6)26 and the recently published joint guidelines by the British Orthopaedic Association (BOA) and the British Geriatric Society (BGS), The Care of Patients with Fragility Fracture (The Blue Book)3 have defined
J. Youde et al. / Injury, Int. J. Care Injured 40 (2009) 1226–1230
the service standards for the management of older people with falls and #NOF. All three documents advocate a multi-disciplinary approach with integrated services that reflect published evidence for the effective treatment of older people with falls. Different service models are given for orthogeriatric care with the favoured one being that of a jointly managed ward with consultant input from both Orthopaedics and Medicine for Older People. There is some evidence that this model can reduce the length of stay and improve outcomes1,6,7 though there is not rigorous evidence of benefit if the collaboration is restricted to post-operative rehabilitation.4 In 2005 the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians was commissioned by the Healthcare Commission to evaluate the falls related aspects of the NSF for Older People most of which is contained in Standard 6. The audit ‘National Audit of the Organisation of service for fall and Bone Health for Older People’19 reported in 2006. Key findings from this regarding older people with fractures included a low level of input from specialist falls services into A&E and orthopaedics with consequently low levels of falls risk assessment, only 50% of trusts reporting the establishment of an orthogeriatric ward though 88% trusts recording having processes designed to have a time to theatre of <24 h with patients with a #NOF. To assess trusts responses to these audit results and assess the full integration of falls services in practice at the level of the individual patient, the Healthcare Commission commissioned further clinical audit. The audit was planned to assess the implementation not only of the documents listed above, but also the SIGN Guideline 5625 NICE Guideline CG2112 and the NICE Guidance Technology Appraisal (TAG) 087 on secondary prevention treatment of osteoporosis.13 This paper presents the findings of the clinical audit regarding the hospital care of patients presenting with a #NOF. The results for the secondary prevention of fragility fractures including the assessment of falls risk factors and bone health in this patient group will be reported separately. Methods Governance of the audit The audit steering group included members from different disciplines and agencies to allow the different facets of care fracture patients receive to be accurately represented. The audit population The audit sample was consecutive patients aged >65 years attending hospital emergency departments with proven fractures of the hip for a 3-month period. The sample was restricted to those alive at April 2007 and excluded patients sustaining multiple fractures or having a documented life expectancy of less than 1 year. Target numbers were 20 per site for hip fractures to allow meaningful inter-site comparisons for benchmarking.
1227
chief executives of all 173 acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England. The CEEU project management supported the data collection process with regular contact both by e-mail and enewsletters. Ethics, information governance and the public interest The Healthcare Commission advised on the data collection and sharing of information. Results Of the 172 acute trusts recruited to participate in the audit 157 (91%) submitted data with 84% of eligible PCTs involved in data collection. Data was entered for 3184 patients who sustained their #NOF from a fall between October and December 2006. The majority of the cases were women (80% 2555/3184), the median age was 83 years and most were of white British origin where ethnicity data was submitted (94% 2365/2522) and admitted from their own home (68% 2152/3184). Presentation and pre-operative care Over 97% (3172/3184) #NOF patients presented to the A&E department and predominantly on the same day as the fall (88% 2813/3184). There was a consistent spread of patients presenting during the week and most presented to the A&E department between the hours of 08:00 and 20:00. The time in the A&E department was less than 2 h, as recommended in the SIGN guidelines, in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240 min (Table 1). Of concern were 5 sites where the median time in A&E was >360 min. In a small number of the cases the time in A&E was not available (n = 51). With regards to the pre-operative care received by the #NOF patients 95% (3019/3184) received analgesia, 46% (1442/3184) within 60 min of presentation to hospital. 46% (1456/3184) were risk assessed for pressure ulcers with 54% (789/1456) of those having appropriate pressure relieving equipment used. It should be noted that there was a wide variation in audit responses between sites for this (11–81%) as some centres consider all #NOF patients at high risk for pressure ulcers and nurse all #NOF patients on pressure relieving mattresses and therefore do not assess individually for risk. The prevalence of other pre-operative assessments as recommended by SIGN are shown in Table 2. The low rates of formal Table 1 Time in A&E.
120 min 121–240 min >240 min Unrecorded
#NOF (%)
#NOF (number)
20 57 23
640/3133 1777/3133 716/3133 51
Development of audit indicators The audit steering group used a Delphi process to evaluate standards from the national guidelines available. A web tool for the data collection was designed and piloted. The tool used had 52 questions with mainly yes/no responses. Recruitment and preparation of sites Sites for the audit were recruited from England, Wales, Northern Ireland and the Channel Islands with agreement from
Table 2 Prevalence of pre-operative assessments as recommended by SIGN. Assessment
Number
%
Past medical history recorded History of cognitive impairment recorded Assessment of cognitive function Medication list Record cardiac murmurs if present Renal function recorded Oxygen saturation on room air
2583/3184 1346/3184 934/3184 2896/3184 2537/3184 2641/3184 2880/3184
81 42 29 91 80 83 90
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Fig. 2. Median length of stay. Fig. 1. Median time to theatre from registration.
Sample validity and reliability assessment or recording of prior cognitive function is of note as this can affect rehabilitation outcomes and increases the risk of post-operative delirium. There was a similarly low level of assessment of cognitive function post-operatively at 28% (880/ 3088). 79% (2518/3184) of patients were prescribed some form of thromboprophylaxis in the form of aspirin or sub-cutaneous heparin. A medical assessment by a senior member of the medical team was undertaken in 28% (901/3184) cases, 47% (426/901) of which were on-call reviews, thus routine specialist medical review pre-operatively was seldom available. Surgery and post-operative care Overall 35% (1080/3088) of #NOF patients were operated on within 24 h of admission though 4 sites had a median time of >96 h (Fig. 1). There were several documented reasons for delay to theatre including awaiting medical review (59% 566/956), organisational reasons (29% 278/956) or awaiting orthopaedic diagnosis/investigation (8% 77/956). Other reasons recorded were related to the use of warfarin or clopidrogel. In 83% (2550/3088) of the operations the presence of a consultant or trained specialist was recorded for orthopaedics and 79% (2441/3088) for anaesthetics. While there was a good level of pre-operative recording of preoperative function (86% 2642/3088) to facilitate multi-disciplinary treatment and discharge planning there were low levels of evidence of this approach post-operatively with 39% (1216/3088) of notes indicating a multi-disciplinary team meeting. Just under half of the patients were sat out of bed within 24 h, medical reasons being the explanation cited for delay and 87% (2678/ 3088) were seen by a physiotherapist within 72 h of their operation. Despite standard 6 of the NSF for Older people recommending that care of #NOF patients should occur within a dedicated orthogeriatric unit with multi-disciplinary team working only 35% (1115/3184) of patients were cared for in such a clinical environment. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10–27 days (Fig. 2). Of these patients 59% (1864/3184) were discharged to their normal place of residence in the community with 37% (456/1249) discharged to their own home receiving support from an early or supportive discharge team.
Most of the participating sites submitted lists of consecutive #NOF patients patients with reasons for inclusion and exclusion from the audit. Unavailability of the clinical notes did not appear to be a major issue and the sample audited appeared to be representative. Of the participating sites 153 submitted double data on 821 cases. The median kappa score was 0.74 indicating good agreement of this categorical data.10 Discussion The audit of UK practice in the management of patients with #NOF highlights the wide variation in aspects of this pathway perhaps best reflected in the differences in time in A&E and time to theatre. These differences cannot be explained by differences in case mix alone and would strongly suggest that there are both process and clinical issues to be addressed as has been reported by the NHS Institute for Innovation and Improvement.15 This audit will allow trusts to benchmark their current practice against national results and redesign service delivery to improve outcomes and hopefully reduce the significant variations in care currently seen. Time to theatre has been demonstrated as important in determining outcomes in patients with #NOF and should be adopted as a key performance indicator for #NOF services.2,11 Delays to theatre were divided into three main categories: awaiting medical assessment, delay in orthopaedic diagnosis and organisational. The commonest reason was delay to medical assessment (59%) notably with most of the opinions given by oncall medical personnel. This is important in terms of outcome as this group of patients are high risk patients with a poor outcome if surgery is delayed, which can be predicted using the Nottingham Hip Fracture Score.9 This data would strongly suggest that in the majority of trusts, despite national recommendations and previously reported national audit results, orthogeriatric services either do not exist or are unable to respond in a timely manner for the needs of these patients. Provision of a dedicated orthogeriatric service would significantly improve the consistency of medical advice and reduce the wait for a medical opinion and thence reduce time to theatre in these patients leading to improved outcomes.17 There is a need for PCTs to commission orthogeriatric services and it is anticipated that a commissioning toolkit for PCTs in England being developed by the Department of Health in collaboration with professional bodies will support this.
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Box 1. National hip fracture standards. Standard
Audit result
1. All patients with hip fractures should be admitted to an acute orthopaedic ward within 4 h of presentation 2. All patients with hip fracture who are medically fit should have surgery within 48 h of admission, and during normal working hours 3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer 4. All patients presenting with a fragility fractures should be managed on an orthopaedic ward with routine access to acute orthogeriatric support from the time of admission
77% (2417/3133) were admitted within 4 h
Another cause of delay to theatre was if patients were admitted taking warfarin or clopidrogel. There is an increased use of clopidrogel in the UK for patients with cardiovascular disease and it appears that practises and opinions vary at local levels as to when patients are considered safe for spinal anaesthesia, which is normal practice in the UK.22 As yet there is no national guidance on this or large trials assessing this issue. There is an urgent need for research projects to be commissioned to address this growing clinical risk area. Regarding the recommended pre-operative assessments two areas warrant further comment from this audit. The low level of formal cognitive assessment or recording of dementia is important as the presence of dementia increases the risk of post-operative delirium and thus outcomes including length of stay.18 The results of an abbreviated mini-mental test score or other such score will be influenced by pain and analgesia, e.g. morphine on initial presentation and post-operatively. Education of staff who will initially assess such patients on this aspect of their pre-operative state may increase compliance in this area. The optimum timing for assessment and the screening tool to be used needs further consideration and perhaps study. The level of pressure sore risk assessment in the audit was again highly variable reflecting different processes and policies in this area of patient care. There were no outcome measures on the prevalence or incidence of pressure sores or cost/benefit analysis regarding this in this audit and this may warrant further evaluation. Pharmacological thromboprophylaxis, using heparin or aspirin was not recorded as being universally prescribed in all #NOF patients and if not prescribed the reasons for this were not consistently documented. However the audit did not include the use of other preventative measures such as AV boots which may account for some patients not being prescribed pharmacological agents. The SIGN guidelines24 recommend the use of heparin or aspirin for 35 days post-operatively with similar recent recommendations from NICE.14 Following subsequent consultation with the BOA it has been agreed that the guidance was not based on operation specific evidence and that the BOA would produce detailed operation and context specific guidance on thromboprophylaxis. To inform this process and further guidelines in this area the Health Technology Assessment programme of the National Institute for Health Research have invited NICE and the BOA to develop research protocols in this area. The RCP Bone Health audit has raised several important questions around the wide variation in the processes of care for patients with fragility fractures in the UK. The audit results have allowed trusts to benchmark their performance against national outcomes and target clinical and service developments. The accuracy of the recording of key information for the collection of the audit data has been highlighted with comments from participants on the difficulties on determining timings in the process, e.g. time in A&E. The compliance with the 4-h wait in A&E is a key performance indicator for trusts and this deficit
69% (2122/3088) were operated on within 48 h 46% (1456/3184) had an assessment 35% (1115/3184) were managed within a dedicated orthogeriatric unit
should be rectified, perhaps with the greater and accurate use of technology. To address this area and raise the standards of care for #NOF patients the National Hip Fracture Database (NHFD) has been launched in conjunction with the ‘Blue Book’, supported by The Information Centre for Health and Social Care’s National Clinical Audit Support Programme. It is anticipated that this will impact in a similar way the Myocardial Infarction National Audit Project (MINAP) database for cardiovascular disease has with improvement in national and local standards of care and audit. The NHFD monitors six evidencebased standards of care as set out in the Blue Book. The first four standards that relate to the results from this audit are summarised in Box 1. Participation in this database will allow casemix-adjusted benchmarking for trusts in this service area over longer periods of time than this audit as well as allowing for large scale research projects to be achieved. To achieve this with improved outcomes for the group of older complex patients all clinicians and trusts are strongly encouraged to participate in this initiative. Conclusions There are currently unacceptable wide variations in the delivery of essential areas of clinical services to older people with a #NOF in the UK. Recent joint initiatives with the BGS, BOA and Department of Health in developing service improvements in this area should lead to improved outcomes for patients. Acknowledgements Ms. Michelle Spencer-Williams, BA Hons Project Co-ordinator, National Falls and Bone Health Audit, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians. The Falls and Bone Health Steering Group. References 1. Adunsky A, Arad M, Rami L, et al. Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients. Disabil Rehabil 2005;27(18–19):1123–7. 2. Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. Br Med J 2006;332:947–51. 3. British Orthopaedic Association. The care of patients with fragility fractures; 2007. 4. Cameron ID, Handoll HH, Finnegan TP, et al. Co-ordinated multi-disciplinary approaches for inpatients rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev 2001;3 (CD000106). 5. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age Ageing 1999;28:121–5. 6. Elliot JR, Wilkinson TJ, Hanger HC, et al. The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation. N Z Med J 1996;109:72–3. 7. Hershkovitz A, Kalandariov Z, Hermush V, et al. Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil 2007;88(7):916–21. 8. Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ 1993;307:1248–50.
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9. Maxwell MJ, Moran CG, Moppett IK. Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery. Br J Anaesth 2008;101:511–7. 10. McGinn T, Wyer PC, Newman TB. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). Can Med Assoc J 2004;171: 1369–73. 11. Moran CG, Wen RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 2005;87:483–9. 12. National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people; 2004. www.nice.org.uk/ nicemedia/pdf/CG21fullguidelines/pdf. 13. National Institute for Clinical Excellence. Bisphophonates (aledronate, etironate, risedronate) selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fracture in postmenopausal women; 2005. www.nice.org.uk/ guidance/TA87. 14. National Institute for Clinical Excellence Venous Thromboembolism Guidelines; 2007. www.nice.org.uk/CG046. 15. NHS Institute for Innovation and Improvement. Delivering quality and value: focus on: fractured neck of femur; 2006. 16. Perker M, Johansen A. Hip fracture. BMJ 2006;333:27–30. 17. Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. Br Med J 2006;331:1374–6. 18. Royal College of Physicians. The prevention, diagnosis and management of delirium in older people; 2006.
19. Royal College of Physicians, Clinical Effectiveness and Evaluation Unit, National ‘National Audit of the Organisation of service for Falls and Bone Health for Older People’; 2006. 20. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006;35-S2:ii37–41. 21. Salkeld G, Cameron ID, Cumming RG, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. Br Med J 2000;320: 341–6. 22. Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur. Anaesthesia 2008;63:250–8. 23. Sattin RW, Lambert Huber DA, DeVito CA, et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol 1990;131: 1028–37. 24. Scottish Intercollegiate Guidelines Network (SIGN). Prophylaxis of venous thromboembolism. SIGN Publication No. 62. Edingburgh: SIGN; 2002. www.sign.ac.uk/guidelines/fulltext/62/index.html. 25. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fracture in older people. SIGN Publication No. 56. Edingburgh: SIGN; 2002. www.sign.ac.uk/guidelines/fulltext/56/index.html. 26. Secretary of State for Health National. Service framework-for older people; 2001. p. 76–89. www.doh.dov.uk/nsf/olderpeople.htm. 27. Stalenhoef PA, Crembolder HFJM, Knottnerus JA, van der Horst FGEM. Incidence, risk factors and consequences of falls among elderly subjects living in the community. Eur J Public Health 1997;7:328334.