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Hip fracture

Short Text

The management of hip fracture in adults

Introduction

This pathway covers the management of hip fracture in adults.
Hip fracture is a major public health issue due to an ever increasing ageing population. About 70,000 to 75,000 hip fractures occur each year and the annual cost (including medical and social care) for all UK hip fracture cases is about £2 billion. About 10% of people with a hip fracture die within 1 month and about one-third within 12 months. Most of the deaths are due to associated conditions and not to the fracture itself, reflecting the high prevalence of comorbidity. Because the occurrence of fall and fracture often signals underlying ill health, a comprehensive multidisciplinary approach is required from presentation to subsequent follow-up, including the transition from hospital to community. This pathway covers the management of hip fracture from admission to secondary care through to final return to the community and discharge from specific follow-up.
In order to ensure comprehensive management and continuity, the following NICE guidance should be referred to when developing a complete programme of care for each patient:

Source guidance

The NICE guidance that was used to create the pathway.
Hip fracture. NICE clinical guideline 124 (2011)

Quality standards

Quality statements

Hip Fracture Programme

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture are offered a formal Hip Fracture Programme from admission.

Quality measure

Structure
a) Evidence of local arrangements to ensure people with hip fracture are offered a formal Hip Fracture Programme from admission.
b) Evidence of local arrangements to ensure that the Hip Fracture Programme team includes a social care worker.
Process
Proportion of people with hip fracture who receive a formal Hip Fracture Programme from admission.
Numerator: the number of people in the denominator who receive a formal Hip Fracture Programme from admission.
Denominator: the number of people with hip fracture.
Outcome
Continuous inpatient spell.

Description of what the quality statement means for each audience

Service providers ensure systems are in place that offer all people with hip fracture a formal Hip Fracture Programme from admission.
Healthcare professionals offer all people with hip fracture a formal Hip Fracture Programme from admission.
Commissioners ensure that they commission hip fracture services with a formal Hip Fracture Programme in place for all people with hip fracture from admission.
People admitted to hospital with hip fracture are offered a programme of care, called a Hip Fracture Programme, from admission that includes regular assessment and continued rehabilitation from a range of healthcare professionals with different skills.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.8.1 (key priority for implementation), 1.8.5 and 1.8.6.

Data source

Structure
a) and b) Local data collection.
Process
Local data collection. The National Hip Fracture Database contains an important but partial audit standard for this measure based on the following from the 2007 British Orthopaedic Association and British Geriatrics Society 'The care of patients with fragility fracture ('blue book')':
Standard 4 All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission.
Also contained within NICE audit support for hip fracture (NICE clinical guideline 124): Hip Fracture Programme, criterion 1.
Outcome: Local data collection.

Definitions

NICE clinical guideline 124 recommendation 1.8.1 states that people with hip fracture should be offered from admission a formal, acute orthogeriatric or orthopaedic ward-based Hip Fracture Programme that includes all of the following:
  • orthogeriatric assessment
  • rapid optimisation of fitness for surgery
  • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing
  • continued, coordinated, orthogeriatric and multidisciplinary review
  • liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services
  • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.
NICE clinical guideline 124 (full version) defines a Hip Fracture Programme as formal 'orthogeriatric' care – with the geriatric medical team contributing to joint preoperative patient assessment, and increasingly taking the lead in postoperative medical care, multidisciplinary rehabilitation and discharge planning.
Multidisciplinary rehabilitation is a key component of a Hip Fracture Programme . NICE clinical guideline 124 (full version) defines multidisciplinary rehabilitation as rehabilitation after hip fracture that incorporates assessment and management, including medicine, nursing, physiotherapy, occupational therapy and social care, and may also include dietetics, pharmacy and clinical psychology.
NICE clinical guideline 124 states that the Hip Fracture Programme should be based in an orthopaedic or orthogeriatric ward in the acute hospital. However for those patients clearly considered by the Hip Fracture Programme team to require intermediate care (continued rehabilitation in a community hospital or residential care unit) for an optimal and maximally efficient outcome, the criteria are outlined in recommendation 1.8.5, which states intermediate care should only be considered if all of the following criteria are met:
  • intermediate care is included in the Hip Fracture Programme and
  • the Hip Fracture Programme team retains the clinical lead, including patient selection, agreement of length of stay and ongoing objectives for intermediate care and
  • the Hip Fracture Programme team retains the managerial lead, ensuring that intermediate care is not resourced as a substitute for an effective acute hospital programme.

Equality and diversity considerations

NICE clinical guideline 124 recommendation 1.8.6 states that patients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme.

Analgesia

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture receive prompt and effective pain management, in a manner that takes into account the hierarchy of pain management drugs, throughout their hospital stay.

Quality measure

Structure
Evidence of local arrangements, including a written clinical protocol, to ensure people with hip fracture receive prompt and effective pain management, in a manner that takes into account the hierarchy of pain management drugs, throughout their hospital stay.
Process
a) Proportion of people with hip fracture who receive a formal, recorded pain assessment immediately on admission to the emergency department and within 30 minutes of initial analgesic administration.
Numerator: the number of people in the denominator who receive a formal, recorded pain assessment immediately on presentation to the emergency department and within 30 minutes of initial analgesic administration.
Denominator: the number of people with hip fracture.
b) Proportion of people with hip fracture who are offered paracetamol as first-line analgesia on admission to the emergency department and every 6 hours preoperatively, unless contraindicated.
Numerator: the number of people in the denominator who are offered paracetamol as first-line analgesia on admission to the emergency department and every 6 hours preoperatively.
Denominator: the number of people with hip fracture and without contraindications to paracetamol.
c) Proportion of people with hip fracture who are offered paracetamol every 6 hours postoperatively.
Numerator: the number of people in the denominator who are offered paracetamol every 6 hours postoperatively.
Denominator: the number of people with hip fracture who have undergone surgery.
Outcome
Patient satisfaction with pain management.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to receive prompt and effective pain management, in a manner that takes into account the hierarchy of pain management drugs, throughout their hospital stay.
Healthcare professionals give people with hip fracture prompt and effective pain management, in a manner that takes into account the hierarchy of pain management drugs, throughout their hospital stay.
Commissioners ensure they commission services for people with hip fracture that include prompt and effective pain management, in a manner that takes into account the hierarchy of pain management drugs, throughout their hospital stay.
People with hip fracture are given prompt and effective pain relief medication throughout their hospital stay, starting with paracetamol and using stronger drugs if needed.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.3.1, 1.3.2, 1.3.4, 1.3.5, 1.3.7, 1.3.8, 1.3.9.

Data source

Structure
Local data collection.
Process
a) Local data collection. The Royal College of Physicians' National audit of falls and bone health records whether there was a documented assessment of pain severity (for example, a pain score) within the place of first presentation. Also contained in NICE audit support for hip fracture (NICE clinical guideline 124): analgesia, criterion 1.
b) Local data collection. Contained in NICE audit support for hip fracture (NICE clinical guideline 124): analgesia, criteria 2 and 4.
c) Local data collection. Contained in NICE audit support for hip fracture (NICE clinical guideline 124): analgesia, criterion 9.
Outcome
Local data collection.

Definitions

NICE clinical guideline 124 (full version) recommends a logical hierarchy for the use of analgesic agents. Although not all stages are applicable, an adapted World Health Organization pain relief ladder for cancer may be used. Adapted for hip fracture, this would involve the initial use of non-opioids (for hip fracture this would be paracetamol) and then directly moving to strong opioids such as morphine if non-opioids are not effective.
NICE clinical guideline 124 recommendations 1.3.5 and 1.3.8 state that patients should be offered additional opioids if paracetamol alone does not provide sufficient pain relief.

Equality and diversity considerations

NICE clinical guideline 124 recommendation 1.3.2 specifies that the recommendations on timely analgesia apply to patients with cognitive impairment.

Intracapsular fracture

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with displaced intracapsular fracture receive cemented arthroplasty, with the offer of total hip replacement if clinically eligible.

Quality measure

Structure
Evidence of local arrangements to ensure people with displaced intracapsular fracture receive cemented arthroplasty, with the offer of total hip replacement if clinically eligible.
Process
a) Proportion of people with displaced intracapsular fracture who receive cemented arthroplasty.
Numerator: the number of people in the denominator who receive cemented arthroplasty.
Denominator: the number of people with displaced intracapsular fracture.
An audit standard of less than 100% should be expected for process measure a), to allow for cases where the practitioner considers it not in the best interests of the person to have surgery.
b) Proportion of people with displaced intracapsular fracture who are offered total hip replacement if clinically eligible.
Numerator: the number of people in the denominator who are offered total hip replacement.
Denominator: the number of people with displaced intracapsular fracture who are clinically eligible for total hip replacement.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with displaced intracapsular fracture to have cemented arthroplasty, with the offer of total hip replacement if clinically eligible.
Healthcare professionals perform cemented arthroplasty, with the offer of total hip replacement if clinically eligible.
Commissioners ensure they commission services for people with displaced intracapsular fracture to have cemented arthroplasty, with the offer of total hip replacement if clinically eligible.
People with a hip fracture that is within (rather than outside) the hip joint receive either a half replacement of the hip joint or a full hip replacement if they were fit and active before the fracture and are well enough to have the operation.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.6.2, 1.6.3, (key priorities for implementation) and 1.6.5.

Data source

Structure
Local data collection.
Process:
a) Local data collection. Contained in NICE audit support for hip fracture (NICE clinical guideline 124: surgical procedures, criteria 2 and 5.
b) Local data collection. Contained in NICE audit support for hip fracture (NICE clinical guideline 124: surgical procedures, criteria 3 and 5.
a) and b) The National Hip Fracture Database records procedure type for intracapsular displaced fracture and cementing of arthroplasties.

Definitions

NICE clinical guideline 124 recommendation 1.6.3 states that people with a displaced intracapsular fracture should be offered (and are therefore clinically eligible for) total hip replacement if they:
  • were able to walk independently out of doors with no more than the use of a stick and
  • are not cognitively impaired and
  • are medically fit for anaesthesia and the procedure.

Extracapsular fracture

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2) receive extramedullary implants such as a sliding hip screw in preference to an intramedullary nail.

Quality measure

Structure
Evidence of local arrangements to ensure people with fractures above and including the lesser trochanter (AO classification types A1 and A2) receive extramedullary implants such as a sliding hip screw in preference to an intramedullary nail
Process
Proportion of people with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2) who receive extramedullary implants such as a sliding hip screw.
Numerator: the number of people in the denominator who receive extramedullary implants such as a sliding hip screw.
Denominator: the number of people with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2) to receive extramedullary implants such as a sliding hip screw in preference to an intramedullary nail.
Healthcare professionals use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in people with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).
Commissioners ensure they commission services for people with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2) that use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail.
People with a hip fracture that is outside (rather than within) the hip joint receive an implant, consisting of a screw mounted on a plate, to hold the broken part of the thigh bone in place while it is healing.

Source clinical guideline references

NICE clinical guideline 124 recommendation 1.6.7 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. The National Hip Fracture Database records procedure type for intertrochanteric fracture. Contained within NICE audit support for hip fracture (NICE clinical guideline 124): surgical procedures, criterion 7.

Early supported discharge

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture are offered early supported discharge (if they are eligible), led by the Hip Fracture Programme team.

Quality measure

Structure
Evidence of local arrangements to ensure people with hip fracture are offered early supported discharge (if they are eligible), led by the Hip Fracture Programme team.
Process
Proportion of people with hip fracture who receive early supported discharge (if they are eligible), led by the Hip Fracture Programme team.
Numerator: the number of people in the denominator who receive early supported discharge led by the Hip Fracture Programme team.
Denominator: the number of people with hip fracture who are eligible for early supported discharge.
Outcome
Number of people receiving early supported discharge readmitted to any acute hospital within 30 days of discharge.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to be offered early supported discharge (if they are eligible), led by the Hip Fracture Programme team.
Health and social care professionals offer people with hip fracture early supported discharge (if they are eligible), led by the Hip Fracture Programme team.
Commissioners ensure they commission services that offer people with hip fracture early supported discharge (if they are eligible), led by the Hip Fracture Programme team.
People with hip fracture are offered the option to go home soon after their operation (if they are fit enough to be discharged from hospital) with ongoing support and involvement from the Hip Fracture Programme team to continue rehabilitation.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.8.1, 1.8.4 (key priorities for implementation) and 1.8.6.

Data source

Structure
Local data collection.
Process
Local data collection. The Royal College of Physicians National audit of falls and bone health records whether the patient had rehabilitation or support at home from a specialist early supported discharge team. The Health and Social Care Information Centre's Compendium of clinical and health indicators contains annual hospital episode statistics-based indicators plus trends on timely return to usual place of residence.
Outcome
Local data collection.

Definitions

NICE clinical guideline 124 (full version) defines a Hip Fracture Programme as formal 'orthogeriatric' care, with the geriatric medical team contributing to joint preoperative patient assessment, and increasingly taking the lead in postoperative medical care, multidisciplinary rehabilitation and discharge planning.
NICE clinical guideline 124 recommendation 1.8.1 (key priority for implementation) states that a HFP includes the following:
  • orthogeriatric assessment
  • rapid optimisation of fitness for surgery
  • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to prefracture residence and long-term wellbeing
  • continued, coordinated, orthogeriatric and multidisciplinary review
  • liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services
  • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.
NICE clinical guideline 124 (full version) defines early supported discharge as when patients are discharged home from the acute trauma ward, or in some cases a subsequent rehabilitation ward within the hospital, with a supported 4-6 week rehabilitation package.
NICE clinical guideline 124 recommendation 1.8.4 suggests that early supported discharge should be considered as part of the Hip Fracture Programme, provided the Hip Fracture Programme multidisciplinary team remains involved, and the patient:
  • is medically stable and
  • has the mental ability to participate in continued rehabilitation and
  • is able to transfer and mobilise short distances and
  • has not yet achieved their full rehabilitation potential, as discussed with the patient, carer and family.

Equality and diversity considerations

NICE clinical guideline 124 recommendation 1.8.6 states that patients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme.

Physiotherapy and mobilisation

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture are offered a physiotherapist assessment the day after surgery and mobilisation at least once a day unless contraindicated.

Quality measure

Structure
Evidence of local arrangements to ensure people with hip fracture are offered a physiotherapist assessment the day after surgery and mobilisation at least once a day unless contraindicated.
Process
a) Proportion of people who receive a physiotherapist assessment the day after surgery unless contraindicated.
Numerator: the number of people in the denominator who receive a physiotherapist assessment the day after surgery.
Denominator: the number of people with hip fracture who have undergone surgery and have no contraindications for physiotherapy.
b) Proportion of people who receive physiotherapist-led daily mobilisation from the day after surgery unless contraindicated.
Numerator: the number of people in the denominator who receive physiotherapist-led daily mobilisation from the day after surgery.
Denominator: the number of people with hip fracture who have undergone surgery and have no contraindications for physiotherapy.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to have access to a physiotherapist assessment the day after surgery and mobilisation at least once a day unless contraindicated.
Healthcare professionals offer people with hip fracture a physiotherapist assessment the day after surgery and mobilisation at least once a day unless contraindicated.
Commissioners ensure they commission services for people with hip fracture that provide a physiotherapist assessment the day after surgery and mobilisation at least once a day unless contraindicated.
People with hip fracture are offered a physiotherapist assessment the day after surgery and are offered exercises to promote movement, strength and recovery at least once a day, unless there are medical or surgical reasons for this not to occur.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.7.1 and 1.7.2 (key priorities for implementation).

Data source

Structure
Local data collection.
Process
a) Local data collection. Contained in NICE audit support for hip fracture (NICE clinical guideline 124): mobilisation, criterion 1.
b) Local data collection. The Royal College of Physicians National audit of falls and bone health records whether an attempt was made within 24 hours of surgery to mobilise the patient. Contained in NICE audit support for hip fracture: mobilisation, criteria 2 and 3.
H2 Definitions
NICE clinical guideline 124 (full version) defines mobilisation as the process of re-establishing the ability to move between postures (for example sit to stand), maintain an upright posture, and to ambulate with increasing levels of complexity (speed, changes of direction, dual and multi-tasking).
The 'hands-on' role of the physiotherapist after initial assessment is discretionary by agreement with physiotherapist and other healthcare professionals (for example nursing staff).

Planning the theatre team

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture have their surgery scheduled on a planned trauma list, with consultant or senior staff supervision.

Quality measure

Structure
Evidence of local arrangements to ensure that people with hip fracture have their surgery scheduled on a planned trauma list, with consultant or senior staff supervision.
Process
a) Proportion of people with hip fracture who receive surgery on a planned trauma list.
Numerator: the number of people in the denominator who receive surgery on a planned trauma list.
Denominator: the number of people with hip fracture having surgery.
b) Proportion of people with hip fracture having surgery who receive surgery with consultant or senior staff supervision.
Numerator: the number of people in the denominator who receive surgery with consultant or senior staff supervision.
Denominator: the number of people with hip fracture having surgery.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture that schedule their surgery on a planned trauma list, with consultant or senior staff supervision.
Healthcare professionals schedule hip fracture surgery on a planned trauma list, with consultant or senior staff supervision.
Commissioners ensure they commission services for people with hip fracture that schedule their surgery on a planned trauma list, with consultant or senior staff supervision.
People with hip fracture having surgery go onto a planned list of daily operations, with senior surgeons, anaesthetists and theatre staff supervising the surgery.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.5.1 (key priority for implementation) and 1.5.2.

Data source

Structure
Local data collection.
Process
a) The National Hip Fracture Database records the proportion of patients having surgery within 48 hours and during normal working hours.
b) The Royal College of Physicians' National audit of falls and bone health records the percentage of patients operated on by consultant surgeons.

Definitions

NICE clinical guideline 124 (full version) states that a planned trauma list is one with a rostered senior anaesthetist, senior surgeon and dedicated theatre time. It consists of a period of time allocated to the surgical management of patients with unplanned admissions following musculoskeletal injury.
NICE clinical guideline 124 (full version) states that the level of supervision required for a trainee or junior staff member for a particular case depends on two main factors: the junior's ability and the complexity of the case. It is therefore implicit that the senior staff responsible for the trauma list must have knowledge of both of these factors before determining the level of supervision required.

Timing of surgery

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture have surgery on the day of, or the day after, admission.

Quality measure

Structure
Evidence of local arrangements to ensure people with hip fracture have surgery on the day of, or the day after, admission.
Process
Proportion of people with hip fracture who receive surgery on the day of, or the day after, admission.
Numerator: the number of people in the denominator who receive surgery on the day of, or the day after, admission.
Denominator: the number of people with hip fracture having surgery.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to have surgery on the day of, or the day after, admission.
Healthcare professionals perform hip fracture surgery on the day of, or the day after, admission.
Commissioners ensure they commission services for people with hip fracture to have surgery on the day of, or the day after, admission.
People with hip fracture have their surgery carried out on the day of, or the day after, admission to hospital.

Source clinical guideline references

NICE clinical guideline 124 recommendations 1.2.1 and 1.2.2 (key priorities for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. The Health and Social Care Information Centre's Compendium of Clinical and Health Indicators records emergency hospital admissions and timely surgery: fractured proximal femur. The National Hip Fracture Database records data on patients with hip fracture who are medically fit who have surgery within 48 hours of admission, and during normal working hours. Contained in NICE audit support for hip fracture (NICE clinical guideline 124): timing of surgery, criteria 1 and 2.

Definitions

NICE clinical guideline 124 (full version) states that it should be anticipated that many patients with hip fractures will be frail and have comorbidities, and that although rarely this may lead to a delay in surgery, provided these problems are identified and measures initiated to correct them are taken promptly, the majority of patients can be optimised within 24 hours. NICE clinical guideline 124 recommendation 1.2.2 (key priority for implementation) therefore states that comorbidities should be identified and treated so that surgery is not delayed by:
  • anaemia
  • anticoagulation
  • volume depletion
  • electrolyte imbalance
  • uncontrolled diabetes
  • uncontrolled heart failure
  • correctable cardiac arrhythmia or ischaemia
  • acute chest infection
  • exacerbation of chronic chest conditions.

Cognitive assessment

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture have their cognitive status assessed, measured and recorded from admission.

Quality measure

Structure
Evidence of local arrangements to ensure people with hip fracture have their cognitive status assessed, measured and recorded from admission.
Process
a) Proportion of people with hip fracture receiving recorded preoperative cognitive assessment and measurement using a validated tool.
Numerator: the number of people in the denominator who receive a recorded preoperative cognitive assessment and measurement using a validated tool.
Denominator: the number of people with hip fracture.
b) Proportion of people with hip fracture who have undergone surgery receiving a recorded postoperative cognitive assessment and measurement using a validated tool.
Numerator: the number of people in the denominator who receive recorded postoperative cognitive assessment and measurement using a validated tool.
Denominator: the number of people with hip fracture who have undergone surgery.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to have their cognitive status assessed, measured and recorded from admission.
Healthcare professionals assess, measure and record cognitive status for people with hip fracture from admission.
Commissioners ensure they commission services for people with hip fracture to have their cognitive status assessed, measured and recorded from admission.
People with hip fracture receive an assessment to check for any understanding or memory problems at admission to hospital and are monitored and reassessed throughout their hospital stay.

Source clinical guideline references

NICE clinical guideline 124 recommendation 1.8.1 (key priority for implementation) and 1.8.3.
NICE clinical guideline 103 recommendations 1.1.1 and 1.2.1 (key priorities for implementation), and 1.1.2.

Data source

Structure
Local data collection.
Process
a) Local data collection. The National Hip Fracture Database records the Abbreviated Mental Test score. Also contained in NICE audit support for delirium (NICE clinical guideline 103), criteria 1 and 2.
b) The Royal College of Physicians' National audit of falls and bone health records whether a formal assessment of cognitive function was performed within 72 hours of surgery.

Continuity of clinical and service governance

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

The Hip Fracture Programme team retains a comprehensive and continuing clinical and service governance lead for all stages of the pathway of care, including the policies and criteria for both intermediate care and early supported discharge.

Quality measure

Structure
Evidence of local arrangements (including a written operational policy and governance procedures) to ensure the Hip Fracture Programme team retains a comprehensive and continuing clinical and service governance lead for all stages of the pathway of care, including the policies and criteria for both intermediate care and early supported discharge.
Process
Proportion of people with hip fracture transferred from hospital for early supported discharge or intermediate care for whom the Hip Fracture Programme team makes (and documents the reasons for) the decision to transfer.
Numerator: the number of people in the denominator for whom the Hip Fracture Programme team makes (and documents the reasons for) the decision to transfer.
Denominator: the number of people transferred from hospital for early supported discharge or intermediate care.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for the Hip Fracture Programme team to retain a comprehensive and continuing clinical and service governance lead for all stages of the pathway of care, including the policies and criteria for both intermediate care and early supported discharge.
Health and social care professionals in the Hip Fracture Programme team retain a comprehensive and continuing clinical and service governance lead for all stages of the pathway of care, including the policies and criteria for both intermediate care and early supported discharge.
Commissioners ensure they commission services where the Hip Fracture Programme team retains a comprehensive and continuing clinical and service governance lead for all stages of the pathway of care, including the policies and criteria for both intermediate care and early supported discharge.
People with hip fracture are cared for by the Hip Fracture Programme team, who coordinate all aspects of care and rehabilitation both in hospital and after discharge.

Source clinical guideline references

NICE clinical guideline 124 recommendation 1.8.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Bone health assessment

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture are offered a bone health assessment to identify future fracture risk and offered pharmacological intervention as needed before discharge from hospital.

Quality measure

Structure
Evidence of local arrangements to ensure that people with hip fracture are offered a bone health assessment to identify future fracture risk and offered pharmacological intervention as needed before discharge from hospital.
Process
a) Proportion of people with hip fracture who receive a bone health assessment before discharge from hospital.
Numerator: the number of people in the denominator who receive a bone health assessment before discharge from hospital.
Denominator: the number of people with hip fracture.
b) Proportion of people aged 74 years and under with a hip fracture, in whom a dual-energy X-ray absorptiometry (DXA) scan is either completed prior to discharge or is scheduled post discharge from hospital.
Numerator: the number of people in the denominator in whom a DXA scan is either completed prior to discharge from hospital or is scheduled post discharge from hospital.
Denominator: the number of people with hip fracture aged 74 years and under.
c) Proportion of people aged 75 years and over with a hip fracture, who are discharged on appropriate medication to help prevent further fractures.
Numerator: the number of people in the denominator who are discharged on appropriate medication to help prevent further fractures.
Denominator: the number of people aged 75 years and over with a hip fracture.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to have a bone health assessment and pharmacological intervention as needed before discharge from hospital.
Health and social care professionals offer people with hip fracture a bone health assessment to identify future fracture risk and pharmacological intervention as needed before discharge from hospital.
Commissioners ensure they commission services for people with hip fracture that offer a bone health assessment to identify future fracture risk and pharmacological intervention as needed before discharge from hospital.
People with hip fracture are offered an assessment of their risk of further fractures, and offered bone-strengthening drugs if the assessment suggests they are needed, before discharge from hospital.

Source clinical guideline references

Data source

Structure
Local data collection.
Process
a), b), and c) The NICE menu of Quality and Outcomes Framework indicators contains the following:
  • The practice can produce a register of patients: 1. Aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and 2. Aged 75 years and over with a record of a fragility fracture after 1 April 2012.
  • The percentage of patients aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone-sparing agent.
  • The percentage of patients aged 75 years and over with a fragility fracture, who are currently treated with an appropriate bone-sparing agent.

Definitions

A bone health assessment involves the generation of a skeletal risk score based upon the FRAX tool. However, the exact content of an assessment will depend on local clinical judgement.
In those people aged 75 years and older who have sustained a fragility fracture, a diagnosis of osteoporosis may be assumed if the responsible clinician considers a DXA scan to be clinically inappropriate or unfeasible. Pharmacological treatment may be offered without confirmation of osteoporosis using DXA scan.
NICE technology appraisal guidance 161 and NICE technology appraisal guidance 204 contain more information on pharmacological interventions for bone health.

Falls risk assessment

This quality statement is taken from the hip fracture quality standard. The quality standard defines clinical best practice in hip fracture care and should be read in full.

Quality statement

People with hip fracture are offered a multifactorial risk assessment to identify and address future falls risk, and are offered individualised intervention if appropriate.

Quality measure

Structure
Evidence of local arrangements to ensure people with hip fracture are offered a multifactorial risk assessment to identify and address future falls risk, and are offered individualised intervention if appropriate.
Process
a) Proportion of people with hip fracture who receive a multifactorial risk assessment of future falls risk.
Numerator: the number of people in the denominator who receive a multifactorial risk assessment of future falls risk.
Denominator: the number of people with hip fracture.
b) Proportion of people with hip fracture assessed to be at risk of falls who receive individualised intervention.
Numerator: the number of people in the denominator who receive individualised intervention.
Denominator: the number of people with hip fracture assessed to be at risk of falls.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with hip fracture to have a multifactorial risk assessment to identify and address future falls risk, and to have individualised intervention as appropriate.
Health and social care professionals offer people with hip fracture a multifactorial risk assessment to identify and address future falls risk, and offer individualised intervention as appropriate.
Commissioners ensure they commission services for people with hip fracture that provide a multifactorial risk assessment to identify and address future falls risk, and that provide individualised intervention as appropriate.
People with hip fracture are offered an assessment to identify their risk of falling in the future, and are offered help tailored to their circumstances to reduce these risks if needed.

Source clinical guideline references

NICE clinical guideline 21 recommendations 1.3.2 (key priority for implementation), 1.2.2 and 1.3.1.

Data source

Structure
Local data collection.
Process
a) The National Hip Fracture Database records specialist falls assessment criteria based on standard 4 in the 2007 British Orthopaedic Association and British Geriatrics Society 'The care of patients with fragility fracture ('blue book')':
Standard 4: All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls.
b) Local data collection.

Definitions

NICE clinical guideline 21 recommendation 1.2.2 states that multifactorial assessment may include the following:
  • identification of falls history
  • assessment of gait, balance and mobility, and muscle weakness
  • assessment of osteoporosis risk
  • assessment of the older person's perceived functional ability and fear relating to falling
  • assessment of visual impairment
  • assessment of cognitive impairment and neurological examination
  • assessment of urinary incontinence
  • assessment of home hazards
  • cardiovascular examination and medication review.
NICE clinical guideline 21 recommendation 1.3.1 states that the following components are common in successful multifactorial intervention programmes:
  • strength and balance training
  • home hazard assessment and intervention
  • vision assessment and referral
  • medication review with modification/withdrawal.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Information about hip fracture

Information about the NICE quality standard on hip fracture

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

22 April 2014 Links to the pressure ulcers pathway have been added.
21 March 2014 The recommendation in assess the patient in this pathway has been amended. This is to clarify how an occult fracture is identified and when an MRI scan should be done.
Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negative X-rays of the hip of an adequate standard. If MRI is not available within 24 hours or is contraindicated, consider computed tomography (CT).
25 February 2014 NICE technology appraisal 2 and NICE technology appraisal 44 removed from pathway because they have been updated by NICE technology appraisal 304, which has been added to related guidance.
14 May 2013 Minor maintenance updates
10 December 2012 Details about MHRA advice on the follow-up of people with metal on metal hip replacements added to the performing surgery node in the surgery path.
02 October 2012 Minor maintenance updates
7 August 2012 Changed navigation from Healthcare/Wounds and injuries to Healthcare/Wounds and injuries/Bone fracture.
7 August 2012 To coincide with publication of the osteoporosis pathway (August 2012), reading pane text for assess future fracture risk node has been updated.

Supporting information

Glossary

Non-steroidal anti-inflammatory drugs
Magnetic resonance imaging
Computed tomography
Fractures occurring between the edge of the femoral head and 5 cm below the lesser trochanter.
Fractures between the edge of the femoral head and insertion of the capsule of the hip joint. Also known as femoral neck fractures.
Fractures between the insertion of the capsule of the hip joint and a line 5 cm below the lesser trochanter.
A subgroup of the extracapsular group that includes inter- or pertrochanteric and reverse oblique fractures.
A subgroup of the extracapsular group where the fracture occurs below the lesser trochanter.
Dual-energy X-ray absorptiometry
Bone mineral density
Standard deviations

Person presents with suspected hip fracture

Person presents with suspected hip fracture

Assess the patient

Assess the patient

Assess the patient

Pain

Assess the patient's pain.
Offer immediate analgesia to patients with suspected hip fracture, including people with cognitive impairment.

Cognitive impairment

Actively look for cognitive impairment and keep reassessing patients to identify delirium. Offer individualised care in line with the NICE pathway on delirium.

Imaging

Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negative X-rays of the hip of an adequate standard. If MRI is not available within 24 hours or is contraindicated, consider computed tomography (CT).

Venous thromboembolism

For information on reducing the risk of venous thromboembolism in patients who have had a hip fracture, see the NICE pathway on venous thromboembolism.

Quality standards

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Implementation tools

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Source guidance

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Hip Fracture Programme

Hip Fracture Programme

Hip Fracture Programme

From admission, offer all patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme that includes all of the following:
  • orthogeriatric assessment
  • rapid optimisation of fitness for surgery
  • early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing
  • continued, coordinated, orthogeriatric and multidisciplinary review
  • liaison or integration with related services
  • clinical and service governance responsibility for all stages of the pathway of care and rehabilitation.

Quality standards

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Implementation tools

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Source guidance

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Patient information and support

Patient information and support

Patient information and support

Offer patients (or, as appropriate, their carer and/or family) verbal and printed information about treatment and care including:
  • diagnosis
  • choice of anaesthesia
  • choice of analgesia and other medications
  • surgical procedures
  • possible complications
  • postoperative care
  • rehabilitation programme
  • long-term outcomes
  • healthcare professionals involved.

Source guidance

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Multidisciplinary rehabilitation

Multidisciplinary rehabilitation

Multidisciplinary rehabilitation

Mobilisation strategies

Offer a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery.
Offer mobilisation at least once a day and ensure regular physiotherapy review.

Early supported discharge

Consider early supported discharge as part of the Hip Fracture Programme, provided the multidisciplinary team remains involved and the patient:
  • is medically stable and
  • has the mental ability to participate and
  • is able to transfer and mobilise short distances and
  • has not yet achieved their full rehabilitation potential.

Intermediate care

Only consider intermediate care (continued rehabilitation in a community hospital or residential care unit) if all the following criteria are met:
  • intermediate care is included in the Hip Fracture Programme and
  • the Hip Fracture Programme team retains the clinical lead, including patient selection, agreement of length of stay and ongoing objectives for intermediate care and
  • the Hip Fracture Programme team retains the managerial lead, ensuring that intermediate care is not resourced as a substitute for an effective acute hospital Programme.

Patients admitted from care or nursing homes

Patients admitted from care or nursing homes should not be excluded from a rehabilitation programme in the community or hospital, or as part of an early supported discharge programme.

Quality standards

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Implementation tools

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Source guidance

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Assess future fracture risk

Assess future fracture risk

Assess future fracture risk

For more information on assessing risk of fragility fracture, see the NICE osteoporosis pathway.

Quality standards

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Paths in this pathway

Pathway created: March 2012 Last updated: April 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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