Patients should be offered a formal, acute orthogeriatric or orthopaedic ward-based Hip Fracture Programme, in line with NICE recommendations, says Dr Sally Hope

Management of hip fracture can vary considerably across the UK. Some hospitals have dedicated orthogeriatricians and specialist consultant anaesthetists working with orthopaedic surgeons, while others fit patients into emergency lists on an ‘as and when’ basis. Evidence shows that improved outcomes, with lower mortality and morbidity, and faster discharge can be achieved if:1

  • a dedicated senior multidisciplinary team is in place and
  • the patient is stabilised and operated on the same day as hospital admission or the day after.

Impact of hip fracture

Hip fracture is a very serious event for the person and their family, with enormous costs to the NHS and social service. There are over 70,000 new hip-fracture cases a year in the UK, with an annual cost (including medical and social care) of approximately £2 billion.1–3 Around 10% of people with a hip fracture die within 1 month and one-third within 12 months. Most of the deaths result from associated co-morbidities rather than the fracture itself; this is a reflection of the vulnerability of the mostly (but not exclusively) older patient group, which is often associated with a complex medical history and a long-term chronic disease co-morbidity list.1–3

Remit of the guideline

The NICE guideline on the management of hip fracture (Clinical Guideline 124) highlights the requirement for a skilled specialist medical, surgical, and anaesthetic multidisciplinary team in the care of patients with this condition.1–3 There is also an emphasis on providing patient-centred and continuous care across all disciplines and organisational boundaries, as such patients often cross specialties.1–3 A dedicated orthogeriatrician can be the ideal person to coordinate care throughout a patient’s hospital stay, and their skills are useful to all people with hip fracture. Treatment and care must take into account a patient’s individual needs and preferences. Good communication is essential, and it should be supported by evidence-based information, to allow patients and their carers, where appropriate, to reach informed decisions about their care.1–3

The NICE guideline covers the management of patients with hip fracture, from entering the accident and emergency department to the final return to the community setting after rehabilitation.1–3 The recommendations do not cover fracture prevention, but stress its importance through linkage to separate NICE guidance on osteoporosis.4–6 With the recent announcement of the new quality and outcomes framework (QOF) indicators on osteoporosis for 2012/13,7 GPs will be even more attentive to patients with hip fracture.

Types of hip fracture

A fracture of the hip can be divided into the following types (see Figure 1):

  • Intracapsular fractures occur between the edge of the femoral head and insertion of the capsule of the hip joint; they are also known as femoral neck fractures
  • Extracapsular fractures occur between the insertion of the capsule of the hip joint and a line 5 cm below the lesser trochanter:
  • Trochanteric fractures include inter- or per-trochanteric and reverse oblique fractures
  • Subtrochanteric fractures occur below the lesser trochanter.

Figure 1: Regions where hip fracture occurs3

graph

National Institute for Health and Care Excellence (NICE) (2011) CG124. Hip fracture: the management of hip fracture. Clinical Guideline 124. London: NICE. Reproduced with permission. Available at: www.nice.org.uk/guidance/CG124

Imaging options

Sometimes a hip fracture cannot be detected with standard anteroposterior pelvis and lateral hip X-rays. In such cases of continued clinical suspicion (about 3%–4%) magnetic resonance imaging (MRI) should be performed. Computed tomography (CT) should be considered if an MRI is not available within 24 hours or is contraindicated.1–3

Key priorities for implementation

The key priorities from the NICE guideline cover:

  • timing of surgery
  • the trauma team and what technical approaches they could employ
  • care of the patient in terms of analgesia and medical optimisation
  • mobilisation strategies
  • the role of the multidisciplinary team throughout the care process.

Timing of surgery

Surgery should be performed on the day of, or the day after, hospital admission (see Figure 2). This recommendation is broadly in line with the ‘payment by results’ (PbR) hip-fracture tariff currently operating in the NHS.8 The role of the multidisciplinary team starts as soon as the patient is admitted—to identify and treat correctable co-morbidities and plan care—so that surgery is not delayed. Surgery should be scheduled on a planned trauma list.1–3

Surgical procedures

Internal fixation of undisplaced intracapsular fractures is taken as read, and not the subject of a specific recommendation. Replacement arthroplasty is recommended for patients with a displaced intracapsular fracture. This should be a total hip replacement (versus a hemiarthroplasty) in people who:1–3

  • are able to walk independently outside with no more than the use of a stick and
  • are not cognitively impaired and
  • are medically fit for anaesthesia and the more extensive operation.

Extramedullary implants, such as a sliding hip screw, should be offered in preference to an intramedullary nail for patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2).1–3

Mobilisation strategies

Prompt mobilisation is the key to successful rehabilitation: patients should be offered a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery. This should be provided under regular physiotherapy review and at least once a day.1–3

Multidisciplinary management

From admission, patients should be offered a formal, acute orthogeriatric or orthopaedic ward-based Hip Fracture Programme (HFP). This is a defined structured entity, based in the acute hospital either on the trauma ward or an acute orthogeriatric unit. It includes all of the following:1–3

  • 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.

As part of the HFP, some patients may be assessed to see if they are suitable for early discharge, providing the HFP multidisciplinary team remains involved throughout. Patients must:1–3

  • be medically stable and
  • have the mental ability to participate in continued rehabilitation and
  • be able to transfer and mobilise short distances and
  • still be able to achieve their full rehabilitation potential, as discussed with the patient, their family, and/or carers.

It is essential to look actively for cognitive impairment when patients first present and to continue reassessing individuals during their admission. If delirium is detected, individualised care should be offered in line with the NICE guideline on this condition (Clinical Guideline 103).1–3,9

Hip fracture may complicate or precipitate a terminal illness. If this is the case, then the role of surgery and other interventions must be considered as part of a palliative-care approach that minimises pain and other symptoms, establishes each individual’s own priorities for rehabilitation, and his or her wishes about end-of-life care.1–3

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.1–3

Intermediate care (continued rehabilitation in a community hospital or residential care unit) should only be considered if it is included in the HFP and the HFP team retains the clinical and managerial lead.

Analgesia

NICE has developed an algorithm on the provision of analgesia for patients admitted to hospital with hip fracture (see Figure 3).

On initial presentation at hospital, patients with hip fracture should receive an immediate assessment of pain. Analgesia should be offered to patients, taking into account any cognitive impairment or other difficulty that might prevent the individual from expressing their distress. Pain should be reassessed within 30 minutes of administering initial analgesia, and then hourly until settled on the ward. Pain requirements must be reassessed regularly as part of routine nursing observations throughout admission.1–3

Analgesia must be sufficient to allow the necessary movements for investigations, nursing care, and rehabilitation. Non-steroidal anti-inflammatory drugs are not recommended,1–3 because of the availability of safer and more effective alternatives in this situation (e.g. paracetamol) and because of the high risk of impairing renal function and major gastric bleeds, particularly in the elderly.

Figure 2: Surgical pathway for hip fracture3

graph

Patient information

Patients (or, as appropriate, their carer and/or family) should be given verbal and written information about treatment and their care, which includes:1–3

  • diagnosis
  • choice of anaesthesia
  • choice of analgesia and other medications
  • surgical procedures
  • possible complications
  • post-operative care
  • rehabilitation programme
  • likely long-term outcome
  • healthcare professionals involved.

General practitioners need to be kept informed about past and future management for patients with hip fracture. Good communication between secondary and primary care is the key to making sure these individuals thrive when transferred back into the community. A full bone health and falls assessment should have been performed as part of the Multidisciplinary Team remit when the person was an inpatient. If this assessment did not happen, the GP should ensure that it occurs as an outpatient procedure and the patient’s medication should be adjusted accordingly. This information must all be Read coded and acted upon to fulfil the new QOF indicators in osteoporosis.

Where appropriate, the correct way to take bisphosphonates should be discussed and demonstrated with the patient and/or their carer to improve concordance.

Figure 3: Providing analgesia for hip fracture3

graph

Bracketed numbers refer to the relevant recommendation from National Institute for Healthand Clinical Excellence. Hip fracture: the management of hip fracture. Clinical Guideline 124. London: NICE, 2011. Reproduced with permission.

Conclusion

Until now patients with hip fracture have experienced variable treatment, with mortality rates higher than people having a heart attack. The NICE guideline on the management of hip fracture aims to improve all hospital care to the best practice standard, with a dedicated multidisciplinary team caring for these most complex of medical patients throughout their hospital stay.

All patients should be offered a falls and bone health assessment while they are inpatients, to help lower the risk of future fractures, and GPs can also achieve the new QOF targets for osteoporosis by prescribing the appropriate bone strengthening medication after assessment, if appropriate.

Implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 124 on Hip fracture: management of hip fracture. The tools are now available to download from the NICE website: www.nice.org.uk/CG124

Baseline assessment tool

The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Clinical audit tools

Audit tools aim to assist organisations with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. They consist of audit criteria and data collection tool(s) and can be edited or adapted for local use.

Costing report

Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Costing template

Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Electronic audit tools

Electronic audit tools are developed to assist organisations with clinical audit and to ensure that practice is in line with the NICE recommendations.

Implementation advice

This advice tool considers implementation issues that are specific to the guideline on hip fracture.

Slide set

The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.

Online educational tool

Educational modules are also available online.

Guideline Development Group members

Professor Cameron Swift (Chair), Emeritus Professor of Health Care of the Elderly; Mr Tim Chesser, Consultant Trauma and Orthopaedic Surgeon; Mr Anthony Field, patient representative; Dr Richard Griffiths, Consultant Anaesthetist; Mr Robert Handley, Consultant Trauma and Orthopaedic Surgeon; Mrs Karen Hertz, Advanced Nurse Practitioner Locomotor Directorate; Dr Sally Hope, General Practitioner; Dr Antony Johansen, Consultant Orthogeriatrician; Professor Sarah (Sallie) Lamb, Professor of Rehabilitation, Director of Warwick Clinical Trials Unit, Professor of Trauma Rehabilitation; Professor Opinder Sahota, Consultant Physician; Mrs Tessa Somerville, patient representative; Mrs Heather Towndrow, Clinical Manager, Day Rehabilitation and Falls Prevention; and Mr Martin Wiese, Consultant in Emergency Medicine.

National Clinical Guideline Centre staff members

Dr Saoussen Ftouh, Senior Research Fellow/Project Manager; Ms Joanna Ashe, Information Scientist; Miss Elisabetta Fenu, Senior Health Economist; Dr Jennifer Hill, Operations Director; Dr Antonia Morga, Health Economist; Dr Sarah Riley, Research Fellow; and Mr Carlos Sharpin, Senior Information Scientist/Research Fellow.

  1. National Clinical Guideline Centre. Hip fracture: the management of hip fracture. Clinical Guideline 124. London: NCGC, 2011. Available at: www.nice.org.uk/guidance/CG124/Guidance/pdf/English
  2. National Institute for Health and Care Excellence. Hip fracture: the management of hip fracture. Clinical Guideline 124. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG124/NICEGuidance/pdf/English
  3. National Institute for Health and Care Excellence. Hip fracture: the management of hip fracture. Quick reference guide. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG124/QuickRefGuide/pdf/English
  4. National Institute for Health and Care Excellence. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 160. London: NICE, 2008. Available at: www.nice.org.uk/Guidance/TA160
  5. National Institute for Health and Care Excellence. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 161. London: NICE, 2008. Available at: www.nice.org.uk/Guidance/TA161
  6. National Institute for Health and Care Excellence. Denosumab for the prevention of osteoporotic fractures in postmenopausal women. Technology Appraisal 204. London: NICE, 2010. Available at: www.nice.org.uk/guidance/TA204/
  7. NHS Employers website. Contract changes 2012/13. www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/GMSContractChanges/Pages/Contractchanges201213.aspx (accessed 12 December 2011).
  8. Department of Health website. Payment by results. www.dh.gov.uk/pbr (accessed 12 December 2011)
  9. National Institute for Health and Care Excellence. Delirium: delirium—diagnosis, prevention and management. Clinical Guideline 103. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG103/NICEGuidance/pdf/EnglishG