Hip fracture

1. Hip fracture Implementing NICE guidance 2nd edition - March 2012 NICE clinical guideline 124

2. What this presentation covers • Background • Scope • Key priorities for implementation • Other recommendations • Costs and savings • Discussion • NICE Quality Standard • NICE Pathways • NHS Evidence • Find out more

3. Background • Hip fracture: fracture occurring in the area between the edge of the femoral head and 5 cm below the lesser trochanter. • Types: intracapsular (includes subcapital or femoral neck fractures), trochanteric and subtrochanteric fractures. • Not exclusively a surgical concern: a multidisciplinary approach is required for management.

4. Epidemiology • Hip fracture is a major public health issue. • 70,000 to 75,000 hip fractures occur each year in the UK. • Projections this will rise to 101,000 in 2020. • 10% of people with a hip fracture die within 1 month and about one-third within 12 months.

5. Scope • Management of hip fracture from secondary care admission through to final return to the community and discharge from specific follow-up • Adults presenting to the health service with a clinical diagnosis of fracture of the hip.

6. Key priorities for implementation • Timing of surgery • Planning the theatre team • Surgical procedures • Mobilisation strategies • Multidisciplinary management.

7. Timing of surgery and planning the theatre team • Perform surgery on the day of, or the day after, admission. • Identify and treat correctable comorbidities immediately so that surgery is not delayed. • Schedule hip fracture surgery on a planned trauma list.

8. Surgical procedures • Perform replacement arthroplasty in patients with displaced intracapsular fracture. • Offer THR to patients with displaced intracapsular fracture who meet defined criteria. • Use extramedullary implants in preference to an intramedullary nail in patients with trochantericfractures above and including the lesser trochanter. A B C

9. Mobilisation strategies • Offer patients a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery. • Offer patients mobilisation at least once a day and ensure regular physiotherapy. Insert image

10. Multidisciplinary management (1) • From admission, offer patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme that includes: • orthogeriatric assessment • rapid optimisation of fitness for surgery • early identification of individual goals for multidisciplinary rehabilitation • continued, coordinated, orthogeriatric and multidisciplinary review • liaison or integration with related services • clinical and service governance responsibility for all stages of the pathway of care.

11. Multidisciplinary management (2) • Consider early supported discharge provided the Hip Fracture Programme multidisciplinary team remains involved, and the patient: • is medically stable and • has the mental ability to participate in rehabilitation and • is able to transfer and mobilise short distances and • has not yet achieved their full rehabilitation potential, as discussed with the patient, carer and family.

12. Other recommendations • Imaging options in occult hip fracture – when to offer MRI • Analgesia – assessment and management of pain • Anaesthesia – offer spinal or general anaesthesia and consider intraoperative nerve blocks • Patient and carer information – offer verbal and printed information about treatment and care.

13. Summary of costs and savings per 100,000 population Costs correct at June 2011. Costs not updated for 2nd edition

14. Costs per 100,000 population Costs correct at June 2011. Costs not updated for 2nd edition

15. Savings per 100,000 population Costs correct at June 2011. Costs not updated for 2nd edition

16. Discussion • What are the key local issues in developing the Hip Fracture Programme? • How can we ensure all hip fracture patients receive orthogeriatric assessment and continued and coordinated orthogeriatric and multidisciplinary review? • How can we ensure all eligible patients admitted with hip fracture receive surgery on the day of, or the day after, admission? • Who do we need to work with to ensure hip fracture surgery is scheduled on a planned trauma list?

17. Quality standard for hip fracture • Covers the management and secondary prevention of hip fracture in adults (only fragility fracture) • Describes markers of high-quality, cost effective care which should improve the effectiveness, safety and experience of care for people with hip fracture • It requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole hip fracture care pathway • Integrated approach to provision of services is fundamental Click here for NICE quality standards

18. NICE Pathways • NICE Pathways provide quick and easy access, topic by topic to the range of guidance from NICE Click here to go to NICE Pathways

19. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects on Hip fracture Click here to go to the NHS Evidence website

20. Find out more • Visit www.nice.org.uk/guidance/CG124 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and costing statement • audit support and baseline assessment tool • Hip Fracture Programme implementation advice. • online educational tools from BMJ Learning and Nursing Times

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