Table 5 Recommendations
ALONG THE HIP FRACTURE CARE PATHWAY | ||
Domain | National target/ standard | Recommendations |
Emergency Department Admission | Admission to an acute hip fracture ward within 4Â h of presentation (BOA) | 1. Promptly notify orthopaedic, orthogeriatric and nursing staff of new hip fracture patients in the ED 2. Plan for specialist nurse(s) to monitor ED presentations, coordinate admissions and rapid ward transfers 3. Conduct training to routinely deliver fascia iliaca nerve blocks in ED, by ED staff, with equipment reliably accessible in ED |
Pre-operative Care | 1. Provide care for hip fracture patients in designated hip fracture wards 2. Deliver care through specialist trained teams | |
Perform surgery within 36 h (BPT) Perform surgery on the day of, or the day after, admission (NICE) | 1. Ensure coordinated MDT decision-making when planning surgery 2. Agree that patients should not be cancelled by any one single member of the MDT, but only after consultation with at least one other senior member of the MDT 3. Ensure anaesthetists review patients early before an operation to maximise optimisation of patients 4. Trauma lists should:  ➢ Be published early (ideally the night before)  ➢ Start with a ‘golden patient’ who has been prepared the day before  ➢ Include an extra list on a Friday  ➢ Have access to elective theatre space when needed  ➢ Be monitored, with progress and changes communicated promptly to the MDT via agreed routine information systems, such as a live electronic trauma feeds | |
Post-operative care | All patients presenting with a fragility fracture should be managed on a hip fracture ward with routine access to acute orthogeriatric medical support from the time of admission (NICE; BPT) | 1. Provide timetabled orthogeriatrican input for all hip fracture patients 2. Train specialist hip fracture nurses (ANPs) to upskill nursing staff e.g., patient mobilisation 3. Provide specific hip fracture training for ward-based junior doctors, including explaining targets for care 4. Hip fracture nurses and orthogeriatricians should provide support to junior doctors from medicine and surgery 5. Physiotherapists and occupational therapists should undertake joint patient assessments and maintain shared plans for patient rehabilitation and discharge 6. Agree discharge destination early and review plans daily with MDT members 7. Employ discharge coordinators to work 7Â days a week 8. Provide training so that a range of health professionals can undertake falls assessments e.g., ACPs, physiotherapists |
ACROSS THE HIP FRACTURE CARE PATHWAY | ||
Domain | Target | Recommendations |
Communication & Coordination | Multidisciplinary management (NICE) Adults with hip fracture are cared for within a Hip Fracture Programme at every stage of the care pathway | 1. Co-design hip fracture pathway documents collaboratively between clinical leads from orthopaedics, orthogeriatrics, anaesthetics, physiotherapy, occupational therapy and nursing teams 2. Explain hip fracture pathway documents at induction and training of junior doctors and nurses 3. Ensure documents are used and completed daily by MDT members 4. Provide shared, or adjacent office space, for MDT members 5. Organise daily face-to-face meetings or ‘huddles’, ward-based meetings and daily board rounds between MDT members 6. Invest in efficient joined-up IT systems for information sharing between the MDT 7. Ensure reliable electronic communication systems are available to monitor theatre activity and manage outliers, e.g., ‘bedview’ |
Service improvement and clinical governance: | Clinical and service governance which is responsible for all stages of the pathway of care and rehabilitation, including those delivered in the community. (NICE) | 1. Allocate time for hip fracture clinical leads to develop robust clinical governance processes 2. Name a hospital-level executive lead, who reports to Trust board, to promote hip fracture care delivery as a Trust priority 3. Hold regular, minuted, hip fracture governance meetings to drive service improvement, with attendance from orthopaedic, orthogeriatric, anaesthetic, therapy and nursing teams 4. Allocate time for (3) within professional job plans and provide access to management training and managerial support to drive service improvement 5. Nominate specific personnel to consistently enter national hip fracture audit data, with time for this role specified in their job plan 6. Routinely monitor service performance against national targets/standards and feedback results regularly to the MDT 7. Trigger automatic investigations when targets/standards are not met and/or if mortality increases 8. Conduct regular mortality reviews, with documentation of learning points and routine feedback to the MDT |