The National Hip Fracture Database
In the previous step, we considered emergency general surgery and protocols being used to improve outcomes. A major group to consider separately from this are elderly patients with a fractured hip. In this step we will learn more about the National Hip Fracture Database (NHFD) and the excellent work they do to improve care in this area.
In 2007, orthopaedic surgeons, geriatricians and nurses set up the NHFD to collect information about hip fracture care in England, Wales and Northern Ireland. It is now a part of the Falls and Fragility Fracture Audit Programme at the Royal College of Physicians. The NHFD team publishes the best practice against which hospitals are assessed and each year releases an annual report. All the information in this article is from the 2018 report (data for 2017). 
Why is there a need for a dedicated hip fracture service?
The age and fragility of hip fracture patients means that up to a third of people die within a year of their injury. Only half of deaths that occur within a few months of the injury can be directly attributed to the fracture and surgery. However, the impact of the fracture is often recognised as precipitating the patient’s final illness. Since the NHFD’s inception in 2007, 30-day mortality has fallen from 10.9% to 8.5% in 2011 and 6.7% in 2016. . The table below is taken from the 2018 report, with the black line showing a decreasing trend in 30 day mortality.
The statistically typical patient presenting with a hip fracture is an 83-year-old woman with at least one significant comorbidity. Delirium is the most common complication of a hip fracture. The significance of delirium, perioperative cognitive disorders, frailty and multimorbidity in the elderly will be covered in detail in week 4. It is clear though that most hip fracture patients have a decreased physiological reserve which reduces their ability to cope with the stress of a fall, admission to an unfamiliar environment, surgery, anaesthesia and rehabilitation.
A hip fracture is the most common serious injury in older people. Hip fracture patients take up 1.5million hospital bed days each year and cost the NHS and social care £1billion. A hip fracture programme can deliver improved, streamlined care for patients as well as reducing cost to healthcare providers.
What should a hip fracture programme include?
Details of specific pathways used in UK hospitals can be found in the patient pathway section on the NHFD website. A general pathway should include:
- Orthogeriatric assessment
- Rapid optimisation of fitness for surgery
- Early identifications of individual goals for rehabilitations to recover mobility and independence
- Continued coordinated orthogeriatric review post-surgery
- Falls prevention
- Bone health assessment
- Liaison with primary care and social services
The NHFD audits hospital’s adherence to guidelines laid out by the National Institute for Health and Care Excellence (NICE). Any hip fracture programme should aim to improve care by increasing the compliance laid out by these guidelines which are summarised below. 
Timing of surgery and planning the theatre team
- Surgery should be performed on the day of, or the day after admission
- Hip fracture surgery should be scheduled on a planned trauma list
- Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams
- Patient’s pain should be assessed immediately on arrival at hospital, within 30 minutes of administering initial analgesia, hourly until settled on the ward and regularly as part of routine nursing observations throughout admission
- If paracetamol and opioids do not provide sufficient pain relief, then a nerve block should be administered. This could also be used to reduce opioid usage
- Patients should be offered a choice of general or spinal anaesthesia wherever possible with full discussion of risks and benefits
- All patients undergoing surgery should be considered for an intraoperative nerve block
- Unless medically contraindicated patients should be offered a physiotherapy session and mobilisation on the day after surgery
- On admission patients should be placed on an acute orthogeriatric or orthopaedic ward and started on a formal hip fracture pathway
- If the hip fracture complicates or precipitates a terminal illness then there should be consideration about the patients’ wishes for end-of-life care and consideration of surgery as part of a palliative care approach
- Coordinated work to consider early supported discharge
- Patients who are admitted from care homes should not be excluded from rehabilitation programmes
- All patients should be screened for malnutrition
- Patients should be offered detailed verbal and printed information about their care. The NHFD has produced an excellent patient information document for this purpose
- Care should be given to minimise the risk of delirium. This and other perioperative cognitive disorders will be discussed in week 4
- Falls prevention including multidisciplinary assessment with strength and balance training should be offered
- Bone protection with bisphosphonates should be considered for at risk groups
Key findings from the 2018 NHFD audit report
The key performance indicators and recommendations from the report are summarised below:
Prompt orthogeriatric assessment – Orthogeriatric assessment is central to NICE clinical guidelines, but still doesn’t occur for all patients (91.2% in 2017).
Prompt surgery – 70.2% of people underwent surgery within 36 hours of presentation – a further deterioration compared with national figures of 74.4% in 2015 and 73.0% in 2016 - with delays often due to lack of theatre space.
NICE compliant surgical approach – The surgical techniques appropriate to different types of hip fracture have been extensively examined by NICE in CG124 and QS16, however many sites are not following this guidance when selecting operative technique.
Prompt mobilisation after surgery - 79.4% of patients in England, 89.4% in Northern Ireland, only 62.2% of patients in Wales were able to be mobilised by the day after surgery. 9.4% of patients were unable to get up on the day after surgery as a result of pain or low blood pressure.
Not delirious when tested after operation – 62.3% of patients tested were found not to have delirium, but the figure ranged from 0% to over 90%.
Returned to original residence by 120 days - 67.5% of patients were known to have returned to their original residence by 120 days after hip fracture – a figure that is unchanged since 2016.
Key recommendations from the audit
Prompt orthogeriatric assessment – Continued Investment in orthogeriatrics continues to be incentivised by best practice tariff.
Prompt surgery – Monthly clinical governance meetings should review local NHFD data to identify and target common avoidable clinical and organisational reasons for delay in surgery.
NICE compliant surgical approach – Determine the reasons for failure to follow NICE guidance in their local area, and review their ability to deliver total hip replacement to appropriate patients.
Prompt mobilisation after surgery - Examine the reasons for delay in admission to beds where patients can receive coordinated multidisciplinary care from the hip fracture programme team who will be responsible for their whole stay.
Not delirious when tested after operation – Formal adoption of postoperative delirium testing has been encouraged via best practice tariff.
Returned to original residence by 120 days - Large variation may be explained by huge differences in how many patients are transferred to other trusts and units for rehabilitation. Teams will therefore need further information to identify whether this rehabilitation has been successful.
View the graphic on page 5 of the PDF.
Before moving on please reflect on the emergency care protocols you have read about in the previous two steps. Does the care described mirror that which you see in your own institutions? If not what do you think are the barriers which prevent you from providing this care?
- 2018 National Hip Fracture Database annual report
- Neuburger, J. et al. (2015). The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data. Med Care. Aug;53(8):686-91
- NICE clinical guidelines: Hip fracture management
© Material shared with permission from the Royal College of Physicians and the National Hip Fracture Network