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Hip fracture

About

What is covered

This interactive flowchart covers managing hip fracture in people aged 18 and over from admission to secondary care through to final return to the community and discharge from specific follow-up.

Updates

Updates to this interactive flowchart

15 May 2017 Update of hip fracture in adults (NICE quality standard 16) added.
9 May 2017 Recommendations on surgery to offer patients with displaced intracapsular hip fractures updated and footnote on reducing the risk from cemented hemiarthroplasty for hip fracture added to surgery.
24 November 2016 Update of hip fracture in adults (NICE quality standard 16) added.
31 March 2016 Structure revised and summarised recommendations replaced with full recommendations.
1 December 2014 Ultrasound-guided regional nerve block (NICE interventional procedures guidance 285) and CardioQ-ODM oesophageal doppler monitor (NICE medical technologies guidance 3) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing hip fracture in adults in an interactive flowchart

What is covered

This interactive flowchart covers managing hip fracture in people aged 18 and over from admission to secondary care through to final return to the community and discharge from specific follow-up.

Updates

Updates to this interactive flowchart

15 May 2017 Update of hip fracture in adults (NICE quality standard 16) added.
9 May 2017 Recommendations on surgery to offer patients with displaced intracapsular hip fractures updated and footnote on reducing the risk from cemented hemiarthroplasty for hip fracture added to surgery.
24 November 2016 Update of hip fracture in adults (NICE quality standard 16) added.
31 March 2016 Structure revised and summarised recommendations replaced with full recommendations.
1 December 2014 Ultrasound-guided regional nerve block (NICE interventional procedures guidance 285) and CardioQ-ODM oesophageal doppler monitor (NICE medical technologies guidance 3) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Hip fracture: management (2011 updated 2017) NICE guideline CG124
Ultrasound-guided regional nerve block (2009) NICE interventional procedures guidance 285
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technologies guidance 3
Hip fracture in adults (2012 updated 2017) NICE quality standard 16

Quality standards

Hip fracture in adults

These quality statements are taken from the hip fracture in adults quality standard. The quality standard defines clinical best practice for hip fracture care in adults and should be read in full.

Quality statements

Multidisciplinary management

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

Quality statement

Adults with hip fracture are cared for within a Hip Fracture Programme at every stage of the care pathway.

Rationale

People with hip fracture, including those cared for in the community, often have comorbidities and complex care needs. The multidisciplinary approach of a Hip Fracture Programme, with regular assessment and continuous rehabilitation, has been found to better meet those needs, and lead to improved functional outcomes and reduced mortality.

Quality measures

Structure
Evidence of local arrangements to ensure that people with hip fracture are cared for within a Hip Fracture Programme at every stage of the care pathway.
Data source: Local data collection.
Process
a) Proportion of presentations of hip fracture in which the person receives an orthogeriatric assessment prior to surgery.
Numerator – the number in the denominator in which the person receives an orthogeriatric assessment prior to surgery.
Denominator – the number of presentations of hip fracture.
Data source: Local data collection. The National Hip Fracture Database records access to orthogeriatric assessment.
b) Proportion of presentations of hip fracture in which the person has their goals for multidisciplinary rehabilitation identified.
Numerator – the number in the denominator in which the person has their goals for multidisciplinary rehabilitation identified.
Denominator – the number of people having surgery for hip fracture.
Data source: Local data collection.
Outcome
a) Mortality for people with hip fracture at discharge.
Data source: Local data collection.
b) Functional outcome at 1 year.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as hospitals) have systems in place to ensure that people with hip fracture are cared for within a Hip Fracture Programme at every stage of the care pathway.
Commissioners (such as clinical commissioning groups) ensure that they commission hip fracture services that provide care within a Hip Fracture Programme at every stage of the care pathway.
People with hip fracture are looked after within a programme of care, called a Hip Fracture Programme. This involves a team of healthcare professionals with different skills working together to provide care. Hip Fracture Programmes provide care at every stage, in hospital and at home, which includes regular assessment, and coordination of care and rehabilitation.

Source guidance

Hip fracture: management (2011) NICE guideline CG124, recommendation 1.8.1 (key priority for implementation)

Definitions of terms used in this quality statement

Hip Fracture Programme
A coordinated multidisciplinary approach ensuring continuity of care and responsibility across the clinical pathway. It covers care in all settings, including ambulances, A&E departments, radiology, operating theatres, wards and in the community and primary care, and at all stages, including diagnosis, treatment, recovery, discharge planning, rehabilitation, long-term after care and secondary prevention.
It involves 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.
It 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.
[Adapted from NICE’s guideline on hip fracture, recommendation 1.8.1 and expert consensus]

Timing and expertise for surgery

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

Quality statement

Adults with hip fracture have surgery on a planned trauma list on the day of, or the day after, admission.

Rationale

People with hip fracture can experience pain and anxiety while waiting for an operation. Delays in surgery are associated with negative outcomes for mortality and return to mobility. Therefore, it is important to avoid any unnecessary delays for people who are assessed as fit for surgery. A planned trauma list includes specific healthcare professionals with the expertise required for hip surgery. Senior staff supervision can help to reduce the risk of complications during the surgery.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people with hip fracture have surgery on a planned trauma list.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people with hip fracture have surgery on the day of, or the day after, admission.
Data source: Local data collection.
Process
a) Proportion of operations for hip fracture that are performed on a planned trauma list.
Numerator – the number in the denominator that are performed on a planned trauma list.
Denominator – the number of operations for hip fracture.
Data source: Local data collection. The National Hip Fracture Database records the time of the operation in relation to the admission.
b) Proportion of operations for hip fracture that are performed on the day of, or the day after, admission.
Numerator – the number in the denominator that are performed on the day of, or the day after, admission.
Denominator – the number of operations for hip fracture.
Data source: Local data collection. The NHS Digital Compendium of Clinical and Health Indicators records emergency hospital admissions and timely surgery: fractured proximal femur. The National Hip Fracture Database records the time of the operation in relation to the admission.
Outcome
a) Postoperative complications for people with hip fracture.
Data source: Local data collection.
b) Length of hospital stay for people with hip fracture.
Data source: Local data collection.
c) Mortality for people having hip fracture surgery.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (hospitals) ensure that systems are in place for people with hip fracture to have surgery on a planned trauma list on the day of, or the day after, admission.
Healthcare professionals (such as specialists, orthogeriatricians and anaesthetists) perform hip fracture surgery on a planned trauma list on the day of, or the day after, admission.
Commissioners (such as clinical commissioning groups) ensure that they commission services that have sufficient capacity for people with hip fracture to have surgery on a planned trauma list on the day of, or the day after, admission.
People with hip fracture have an operation carried out by a team of senior specialists on the day they are admitted to hospital or the next day.

Source guidance

Hip fracture: management (2011) NICE guideline CG124, recommendations 1.2.1 (key priority for implementation) and 1.5.1

Definitions of terms used in this quality statement

Planned trauma list
A planned trauma list is one with a rostered senior anaesthetist, senior surgeon and dedicated theatre time.
[NICE’s guideline on hip fracture, full guideline]

Intracapsular fracture

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

Quality statement

Adults with displaced intracapsular hip fracture have a total hip replacement if clinically eligible, rather than hemiarthroplasty.

Rationale

Many people with hip fracture are concerned with recovery and getting back to usual activity. Total hip replacement is associated with improved functional status compared with hemiarthroplasty, if the patient was active before the fracture, is not cognitively impaired and is medically fit for the procedure.

Quality measures

Structure
Evidence of local arrangements to perform total hip replacement if people with displaced intracapsular fracture are clinically eligible, rather than hemiarthroplasty.
Data source: Local data collection.
Process
Proportion of people with displaced intracapsular fracture and eligible for total hip replacement who receive total hip replacement.
Numerator – the number in the denominator who receive total hip replacement.
Denominator – the number of people with displaced intracapsular fracture and eligible for total hip replacement.
Data source: Local data collection. The National Hip Fracture Database records procedure type for intracapsular displaced fracture and cementing of arthroplasties.
Outcome
Functional status at 1 and 5 years after total hip replacement for displaced intracapsular fracture.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (hospitals) ensure that total hip replacement is performed for displaced intracapsular fracture, rather than hemiarthroplasty, if the person is assessed as clinically eligible.
Healthcare professionals (orthopaedic surgeons) treat displaced intracapsular fracture using total hip replacement, rather than hemiarthroplasty, if the person is assessed as clinically eligible.
Commissioners (clinical commissioning groups) ensure that orthopaedic services perform total hip replacement, rather than hemiarthroplasty, to treat displaced intracapsular fracture in people who are clinically eligible.
People with a fracture inside the socket of their hip joint and where the bones have moved out of position (called a displaced intracapsular fracture) who were fit and active before the fracture have both parts of the hip joint (the ball and socket) replaced with artificial parts (called a total hip replacement).

Source guidance

Hip fracture: management (2011) NICE guideline CG124, recommendations 1.6.2 and 1.6.3 (key priorities for implementation)

Definitions of terms used in this quality statement

Intracapsular fractures
Fractures above the insertion of the capsular attachment of the hip joint are called intracapsular.
[NICE’s guideline on hip fracture, full guideline]
Clinical eligibility for total hip replacement
Patients with a displaced intracapsular fracture who:
  • 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.
[NICE’s guideline on hip fracture, recommendation 1.6.3]

Trochanteric fracture

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

Quality statement

Adults with trochanteric fractures above and including the lesser trochanter receive extramedullary implants.

Rationale

Extramedullary implants, such as sliding hip screws, have similar clinical outcomes to intramedullary devices. However, some studies have shown that intramedullary implants have a higher reoperation rate because of periprosthetic fracture. In addition, extramedullary implants are less expensive than intramedullary implants. Therefore, extramedullary implants are recommended in preference to intramedullary nails for the treatment of trochanteric fractures.

Quality measures

Structure
Evidence of local arrangements to ensure that people with trochanteric fractures above and including the lesser trochanter receive extramedullary implants.
Data source: Local data collection.
Process
Proportion of presentations of trochanteric fractures above and including the lesser trochanter in which the person receives extramedullary implants.
Numerator – the number in the denominator in which the person receives extramedullary implants.
Denominator – the number of presentations of trochanteric fractures above and including the lesser trochanter.
Data source: Local data collection. The National Hip Fracture Database records procedure type for trochanteric fracture.
Outcome
Reoperation rates for people with trochanteric fractures.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (hospitals) ensure that systems are in place for people with trochanteric fractures above and including the lesser trochanter to receive extramedullary implants in preference to intramedullary nails.
Healthcare professionals (orthopaedic surgeons) ensure that people with trochanteric fractures above and including the lesser trochanter receive extramedullary implants in preference to intramedullary nails.
Commissioners (such as clinical commissioning groups) ensure that they commission services where people with trochanteric fractures above and including the lesser trochanter receive extramedullary implants in preference to intramedullary nails.
People with a fracture outside the socket of their hip joint and near the top of the thigh bone (called a trochanteric fracture) have an operation to reposition the broken bone and hold it in place while it heals. This is done using one or more special screws inserted into the bone and attached to a metal plate (called an extramedullary implant).

Source guidance

Hip fracture: management (2011) NICE guideline CG124, recommendation 1.6.7 (key priorities for implementation)

Definitions of terms used in this quality statement

Trochanteric fractures
Fractures that occur outside or distal to the hip joint capsule, which can be two-part fractures (stable) or multi-fragmentary (unstable).
[NICE’s guideline on hip fracture, full guideline]
Extramedullary implants
A screw that is attached to a plate on the outside of the femoral head and neck.
[NICE’s guideline on hip fracture, full guideline]

Subtrochanteric fracture

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

Quality statement

Adults with subtrochanteric fracture are treated with an intramedullary nail.

Rationale

Using an intramedullary device can provide mechanical protection to a potentially diseased bone. Intramedullary fixation is the treatment of choice for subtrochanteric fractures because it allows splinting of the whole of the femoral shaft. Although intramedullary nails are more expensive than extramedullary implants, they lead to fewer patients with non-union of fracture needing reoperation.

Quality measures

Structure
Evidence of local arrangements to ensure that people with subtrochanteric fracture are treated with an intramedullary nail.
Data source: Local data collection.
Process
Proportion of presentations of subtrochanteric fractures treated with an intramedullary nail.
Numerator – the number in the denominator that are treated with an intramedullary nail.
Denominator – the number of presentations of subtrochanteric fractures.
Data source: Local data collection.
Outcome
a) Number of people with non-union of fracture.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (hospitals) ensure that systems are in place for people with subtrochanteric fractures to be treated with an intramedullary nail.
Healthcare professionals (orthopaedic surgeons) perform surgery on people with subtrochanteric fractures using an intramedullary nail.
Commissioners (such as clinical commissioning groups) ensure that they commission services where people with subtrochanteric fractures are treated with an intramedullary nail.
People with a fracture outside the socket of their hip joint and a small way down the thigh bone (called a subtrochanteric fracture) have an operation to reposition the broken bone and hold it in place while it heals. This is done using a metal rod, called an intramedullary nail, which is inserted into the bone.

Source guidance

Hip fracture: management (2011) NICE guideline CG124, recommendation 1.6.8

Definitions of terms used in this quality statement

Subtrochanteric fracture
The fracture is predominantly in the 5 cm of bone immediately distal to the lesser trochanter.
[NICE’s guideline on hip fracture, full guideline]
Intramedullary nail
A metal rod, which is inserted down the middle of the femoral shaft.
[NICE’s guideline on hip fracture, full guideline]

Rehabilitation after surgery

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

Quality statement

Adults with hip fracture start rehabilitation at least once a day, no later than the day after surgery.

Rationale

Early restoration of mobility after hip fracture surgery can be beneficial for the person because it can reduce the length of hospital stay and avoid the complications of prolonged bed confinement. Rehabilitation at least once a day has potential benefits of improved mobility, increased independence, and reduced need for institutional care. A physiotherapist assessment is needed before the rehabilitation starts. People should be offered support with rehabilitation every day while in hospital, which can be given by members of the multidisciplinary team when the physiotherapist is not present. This support should continue after discharge from hospital.

Quality measures

Structure
Evidence of local arrangements to ensure that people with hip fracture start rehabilitation at least once a day, no later than the day after surgery.
Data source: Local data collection.
Process
a) Proportion of hip fracture operations after which the person starts rehabilitation no later than the day after surgery.
Numerator – the number in the denominator after which the person starts rehabilitation no later than the day after surgery.
Denominator – the number of hip fracture operations.
Data source: Local data collection. The National Hip Fracture Database records if the patient was mobilised on the day after surgery.
b) Proportion of hip fracture operations after which the person has rehabilitation at least once a day.
Numerator – the number in the denominator after which the person has rehabilitation at least once a day.
Denominator – the number of hip fracture operations.
Data source: Local data collection.
Outcome
a) Length of hospital stay for people with hip fracture.
Data source: Local data collection.
b) Return to the pre-hip fracture place of residence.
Data source: Local data collection.
c) Return to the pre-hip fracture level of mobility.
Data source: Local data collection. The National Hip Fracture Database records the routine follow-up of hip fracture patients.

What the quality statement means for different audiences

Service providers (such as hospitals) ensure that systems are in place for people with hip fracture to start rehabilitation at least once a day, no later than the day after surgery.
Healthcare professionals (such as physiotherapists and nurses) offer rehabilitation at least once a day to people with hip fracture, starting no later than the day after surgery.
Commissioners (such as clinical commissioning groups) ensure that they commission services in which people with hip fracture start rehabilitation at least once a day, no later than the day after surgery.
People who have had an operation for hip fracture are offered rehabilitation at least once a day to help them recover. Rehabilitation should be started by the day after their operation (unless there is a medical or surgical reason not to). Rehabilitation after a hip fracture operation includes support with sitting and standing and keeping an upright posture to improve movement and strength, and help with their recovery.

Source guidance

Hip fracture: management (2011) NICE guideline CG124, recommendations 1.7.1 and 1.7.2

Definitions of terms used in this quality statement

Rehabilitation
Rehabilitation is the process of re-establishing the ability to move between postures (for example, from sitting to standing), maintain an upright posture and to ambulate with increasing levels of complexity (speed, changes of direction, dual and multi-tasking).
[Adapted from NICE’s guideline on hip fracture, full guideline and expert input]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

Bispectral Index
electroencephalography
non-steroidal anti-inflammatory drugs
standard deviations

Paths in this pathway

Pathway created: March 2012 Last updated: September 2017

© NICE 2017

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