Hip Fracture from audit into action

Transcription

1 Hip Fracture from audit into action Antony Johansen Orthogeriatrician Trauma Unit University Hospital of Wales, Cardiff National Hip Fracture Database Royal College of Physicians, London

2 Global projections thousands of hip fractures per year Adapted from Cooper C et al, Osteoporosis Int, 1992;2:

3 treat the patient and let the fracture go Astley Cooper, Lancet 1894 the surgical procedure must never be considered to be the whole treatment, but merely an incident in the general rehabilitation of the patient Devas, BMJ 1974

4 Length of stay profile for Trauma Unit Age profile of patients in the Trauma Unit

5 Key recommendation Offer all patients a formal, acute orthogeriatric or orthopaedic ward based Hip Fracture Programme that includes all of the following: 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 well-being continued coordinated orthogeriatric and multidisciplinary review communication with the primary care team

6 NICE economic model 11,793 6,294 Overall saving to health services of an HFP 60,000 5,499 NOK

7 Best Practice Tariff = 12,500NOK 1,330 Hip fracture surgery < 36 hours Geriatrician review < 72 hours Mental test score on arrival Joint assessment protocol Ortho-geriatric shared care Post-op. geriatrician-led MDT Falls and bone health assessment Nutritional risk assessment Post-op. delirium screen Physio assessment day 1 post-op.

8 Variation in provision of orthogeriatrician support Mean = 4 hours / patient NHFD annual report 2015

9 Adjusted 30-day mortality

10 Fitted trends in All adjusted hospitals 30-day morality - before and after launch of NHFD Participation in NHFD 6.7% 2016 Neuburger et al. Medical Care 2015;53:

11 All hospitals unadjusted 30 day mortality - accessed March 2018

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13 Cost-effectiveness of internal fixation compared to hemiarthroplasty or total hip replacement for displaced intracapsular hip fracture Hip fracture update 2017

14 THR if eligible as defined by NICE CG124 Displaced intracapsular fracture Medically fit for anaesthetic Normal cognition Walks outdoors (with a walking stick)

15 Perry et al. BMJ 2016

16 Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2) White et al. Anaesthesia 2016 doi: /anae.13415

17 Hip fracture after inpatient fall New pressure ulcer

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19 Two thirds (68.4%) of all patients got out of bed by the day after surgery but some hospitals managed this for less than half of patients Nearly one in ten patients were unable to get up as a result of pain, hypotension, or both but the best units have multidisciplinary routines that anticipate and address these problems

20 Bellelli et al. Age Ageing 2014; 43:

21 Alertness Markedly drowsy/sleepy (persisting for >10 seconds after attempting to wake them with speech or gentle touch), or agitated/hyperactive AMT Age Date of birth Current year Current place Time to the nearest hour Two person recognition Year of First World War Name of present monarch Count back from 20 to 0 Address recall Attention Tell me the months of the year in backwards order, starting at December, perhaps prompt What is the month before December? Acute change Change or fluctuation in alertness, cognition, paranoia or hallucinations, arising over the last 2 weeks and still evident in the last 24 hours

22 Reducing delirium after hip fracture: a randomized trial Marcantonio et al. J Am Geriatrics Soc 2001; 49: Geriatrician assessment and daily visits - ensure adequate CNS oxygen delivery - optimise fluid/electrolyte balance - treatment of severe pain - elimination of unnecessary medications - regulation of bowel/bladder function - adequate nutritional intake - early mobilization and rehabilitation - prevent, detect, and treat complications - appropriate environmental stimuli - treatment of agitated delirium

23 Using national hip fracture registries and audit databases to develop an international perspective Antony Johansen David Golding Louise Brent Jacqueline Close Jan-Erik Gjertsen Graeme Holt Ami Hommel Alma B. Pedersen Niels Dieter Rock Karl-Göran Thorngren

24 Johansen et al. doi: /j.injury