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Guidance in brief

Managing proximal femoral fractures

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Guidance has been issued to improve the consistency of care for patients who have sustained a hip fracture

Introduction

Every year, approximately 77,000 hip fractures occur in the UK. These account for 1.5 million bed days, at an inpatient cost of £785m. Most hip fractures occur in patients over the age of 60 years, with 75% occurring in females. More than 98% of fractures are repaired surgically.
Hip fractures present unique challenges for anaesthetics departments, as they involve perioperative care for large numbers of older patients with significant comorbidities. Despite guidance being issued on best practice management for these patients since the early 1990s there is considerable variation in models of peri-operative care, rehabilitation and orthogeriatric input. The guidelines are also inconclusive about either the involvement of anaesthetics or the provision of anaesthesia for patients sustaining hip fracture.

Latest guidance

A group of organisations, including the Association of Anaesthetists of Great Britain and Ireland and the British Orthopaedic Association, has issued new guidance for managing proximal femoral fractures (Griffiths et al, 2012). The guidance includes a 10-point plan aimed at ensuring consistency of care for all patients who have sustained a hip fracture (Box 1).
According to the authors of the guidance, at one in five hospitals some patients with hip problems wait longer than two days before procedures, risking complications such as pressure ulcers and pneumonia (Griffiths et al, 2012).
The authors recommend that all patients with hip fracture are operated on within 48 hours of admission to minimise the risk of complications occurring while in hospital.
As most patients with hip fracture are admitted via an emergency department, a planned care package should be initiated promptly. Using a care pathway proforma focuses patient care and ensures basic quality standards are met, the authors suggest. They also recommend that continuous tracking or live-data systems that regularly update patient and logistical data may improve the management of hip fractures by identifying patients’ location, delays in treatment and relevant clinical information. These systems might also be used to help clinical audit.

BOX 1. THE 10-POINT ACTION PLAN

  1. There should be protocol-driven, fast-track admission of patients with hip fractures through the emergency department
  2. Patients with hip fractures require multidisciplinary care, led by orthogeriatricians
  3. Surgery is the best analgesic for hip fractures
  4. Surgical repair of hip fractures should occur within 48 hours of hospital admission
  5. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists
  6. There must be high-quality communication between clinicians and allied health professionals
  7. Early mobilisation is a key part of managing patients with hip fractures
  8. Preoperative management should take into consideration plans for the patient’s discharge from hospital
  9. Measures should be taken to prevent secondary falls
  10. Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture

Source: Griffiths et al (2012)

Rehabilitation of patients

As well as “fast-tracking” the care of patients who have sustained a hip fracture, the guideline recommends that rehabilitation of patients - ideally coordinated by orthogeriatricians - be aimed at providing a patient-centred package of care. This should be designed with the aim of returning patients to levels of activity similar to those they had before fracturing their hip.
Steps to reduce the likelihood of future falls should be considered in the early postoperative period.
Up to 60% of patients with hip fracture are clinically malnourished on admission to hospital. Mortality, and possibly length of hospital stay, may be reduced by providing patients with nutritional supplementation.
The authors stress the importance of using a multidisciplinary approach to caring for hip fracture patients with good communication between team members. They also recommend that hospitals produce written information leaflets or booklets to inform patients about hip fractures. Involving patients and relatives in this care process is essential.

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