The Management of Hip fractures in the older person at Northwick Park Hospital 2009-2010

An audit of British Orthopaedic Association Standards for Trauma: Guidelineson the Management of Hip fractures in the older person at Northwick Park Hospital 2009/2010

Caesar Wek, Hani Abdul-Jabar, Nadine Hachach Haram, Amna Suliman, Ian Holloway.

Department of Orthopaedic Surgery, Northwick Park Hospital, Harrow HA1 3UJ


Introduction

In the United Kingdom, 70 - 75,000 hip fractures (proximal femur) occur annually in patient's over 60 years of age. The incidence is increasing by 2% annually and this may be attributed to our aging population.

Currently, neck of femur fractures account for greater than 20% of Orthopaedic bed occupancy. The annual medical and social cost for the care required amounts to 2 billion GBP with an average of 7,000-12,000 GBP per patient-fracture. A quarter of patient's with NOF# are admitted from institutional care and of those admitted from home, 10-20% ultimately move to institutional care.

The mortality rate from NOF# is high, with studies reporting this as 10% within the first month and 30% within the first year. It should be noted that fewer than half of these deaths are directly attributed to the fracture due the prevalence of co-morbidities in these patients.

The majority of hospital expenditure and morbidities in patients with NOF# are associated with the length of hospital stay. In 2008, the British Orthopaedic Association published guidelines on the management of hip fractures in the older person.

Aim

We have conducted two prospective audit cycles from1 st October 2009 to 6 th June 2010 to investigate and measure the standards of the Orthopaedic department at Northwick Park Hospital against national guidelines.


Methods

We prospectively analysed all of the patients who sustained neck of femur fractures from 01/10/2010. The first cycle of the audit was conducted between 01/10/2009 - 15/01/2010. The second cycle of the audit was conducted between 12/04/2010 - 15/06/2010.

As per the British Orthopaedic Association guidelines, we included all patients above the age of 60 and excluded all patients with imminently terminal disease.

The data was collected from a variety of sources including: Morning trauma meetings, A&E CAS sheets, Northwick Park fracture protocol, Drug charts, Operative Notes and Care of the Elderly Team input.


The following criteria were audited:

Surgical intervention within 48hrs admission

Pre-operative:fluids, bloods and ECG

The prescription of antibiotic prophylaxis in accordance with local guidelines

The prescription of anti-resorptive therapy

 

With the inclusion of two further criterions during the second cycle:

Transfer to appropriate ward within 4hr

Involvement of Ortho-geriatric team in all aspects of care


  Results

1 st Cycle

50 patients were included in this audit (35 females, 15 males). The average age of the males was 82, and 83 for the females. The following interventions were performed: 22 Dynamic hip screws; 19 Hemiarthroplasty; 5 Intramedullary nails; 3 Cannulated screws; 1 Bi-polar.

Criterion

Number of Patients

Standard

Surgical fixation should not be delayed more than 48 hours from admission unless there are clear reversible medical conditions.

 

27/50

54%

100%

Pre-operative dehydration must be avoided; IV fluids should be administered and appropriate blood tests undertaken. An ECG is mandatory.

 

50/50

100%

100%

Antibiotic prophylaxis, theatre discipline and sterile technique are paramount, recognising the devastating consequences and high mortality associated with implant related sepsis.

 

50/50

100%

100%

Secondary prevention (anti-resorptive therapy) for osteoporosis and falls assessments are effective in reducing further fragility fractures and must be an integral part of the fracture care.

 

41/50

82%

100%


2 nd Cycle

21 patients were included in the second cycle (12 females, 9 males). The average age of the males was 75 and 77 for the females included.

Criterion

Number of Patients

Standard

Surgical fixation should not be delayed more than 48 hours from admission unless there are clear reversible medical conditions.

 

15/21

71%

100%

Pre-operative dehydration must be avoided; IV fluids should be administered and appropriate blood tests undertaken. An ECG is mandatory.

 

21/21

100%

100%

Antibiotic prophylaxis, theatre discipline and sterile technique are paramount, recognising the devastating consequences and high mortality associated with implant related sepsis.

 

21/21

100%

100%

Secondary prevention (anti-resorptive therapy) for osteoporosis and falls assessments are effective in reducing further fragility fractures and must be an integral part of the fracture care.

 

19/21

90%

100%

Admission to an acute orthopaedic trauma ward within 4 hours of presentation

19/21

90%

100%

Managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission

21/21

100%

100%

Conclusion

Two of the four criterion audited during the first cycle met national standards whilst three of the six criterion audited during the second cycle met these. All patients audited received pre-op bloods, fluids, ECG, antibiotics and orthogeriatric input. During the first cycle, 54% of patients were operated on within 48hrs and this increased to 71% in the second cycle. There were many reasons for delay which were categorised as Medical, Surgical, and Anaesthetic as per the National Hip fracture database. Medical reasons included: anticoagulants (two patients were on Warfarin, seven on Clopidogrel); one patient had pneumonia; three were awaiting diagnostics and one was diagnosed late after admission under a medical team.

The use of secondary preventative measures such as anti-resorptive medication increased from 82% from the first cycle to 90% during the second cycle. The second cycle also reported that 90% of patients were admitted to the appropriate orthopaedic ward area.

The results of this audit suggest an improvement from the first to second cycle after increasing the awareness of the British Orthopaedic Association guidelines through lectures and teaching sessions for junior members of the Orthopaedic team. However, standards for operative fixation, the prescription of anti-resorptive medications and the admission of patients to appropriate ward areas have still not been met. In light of these findings, we have made the following recommendations:


Recommendations

Increase prioritization of femoral neck fractures when preparing theatre lists

Realistic Trauma List submissions to prevent delay and cancellation of cases

Include Guidelines in departmental induction

A3 laminated guideline visible in the relevant clinical areas as a reminder for assessing physician

Teaching session re: role of anti-resorptivetherapy for Orthopaedic Junior doctors as part of the induction.

 

 

 



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