Orthopaedic Unit. Fractured Neck of Femur Clerking Proforma

Transcription

1 Orthopaedic Unit Fractured Neck of Femur Clerking Proforma Patient Details Admission details Date: Time: Time of arrival to A&E: Time of diagnosis if IP: Or Notes on how to complete this proforma: 1. All patients diagnosed with a neck of femur fracture must have a clerking proforma commenced, even if currently an inpatient. 2. It is the responsibility of the admitting doctor to ensure that the medical clerking proforma is commenced. 3. All boxes should be completed or marked N/A. 4. Once a patient has been clerked, the patient details must be added to both the on-call handover sheet and onto the trauma board on ward 10.

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3 HISTORY Prodromal symptoms? Chest pain Y N SOB Y N Dizziness Y N Weakness Y N Any other injuries? If yes, details Prolonged time on floor? Y N If yes, roughly how many hours Consider AKI and rhabdomyolysis PAST MEDICAL HISTORY Any previous fractures Y N Details Recent hospital admission Y N Details Recurrent falls Y N Details Community DNAR Y N Details

4 DRUG HISTORY Allergies: Admitted on bone protection? Y N Length of time on bisphosphonates yrs SOCIAL HISTORY Normal mobility Walks independently with no mobility aids Walks with one stick/crutch Walks with two sticks/crutches/frame Furniture walks indoors only Wheelchair bound Hoisted or requires assistance for all transfers Bed bound AMTS Score /10 1. Age 2. DoB 3. Time 4. Year 5. Place 6. Address for recall 7. Prime minister 8. 2-person recognition 9. Year WWI or WWII began 10. Count backwards from 20 to 1 History of cognitive impairment? Y N Accommodation House with stairs Bungalow/flat Residential home Nursing home Activities of daily living Fully independent Has care calls during the day ( /day) Requires full assistance with all ADLs Exercise tolerance Able to climb flight of stairs without stopping Able to walk on the flat comfortably SOB / CP / fatigue on minimal exertion Smoking Current smoker packs/day for yrs Ex-smoker yrs since giving up Alcohol No alcohol Infrequent alcohol Previous EtOH excess Current EtOH excess Units/week

5 EXAMINATION T HR BP RR Sats Cardiovascular Respiratory Evidence of heart failure? Gastrointestinal Musculoskeletal Neurovascular status of injured limb: Any ulcers/wounds on legs: Any other injuries? INVESTIGATIONS - Imaging CXR Y N Findings: If not done and clinically indicated, request CXR prior to leaving ED. Indications for CXR include fall, SOB, history of confusion, sepsis, history of malignancy. Pelvis/Hip XR Findings: If previous/current history of malignant and/or suspicion of pathological fracture, ensure full femur views have been done prior to leaving ED.

6 INVESTIGATIONS - Imaging (cont) Details of any other relevant imaging (e.g. CT CAP, Doppler US etc) INVESTIGATIONS - Blood tests Haematology Previous (date ) Group & Save Hb Hb WCC Plts WCC Plts Please ensure that a G&S has been taken INR INR Biochemistry Previous Na CCa Na CCa K Phos K Phos U Alb U Alb Cr Bili Cr Bili egfr ALT egfr ALT CK ALP CK ALP Details of any other relevant blood tests ECG Findings: Consider MI as a cause for fall if any abnormal ECG findings. D/W medics as appropriate. All patients must have an ECG reviewed and documented prior to leaving ED.

7 NOTTINGHAM HIP SCORE Score Criteria Explanation notes 3 points Age yrs 4 points Age > 86 yrs 1 point Male 1 point Admission Hb 10 g/dl 1 point Admission AMTS 6 1 point Number of comorbidities 2 1 point Living in an institution 1 point Malignancy within last 20 yrs Comordities include MI, angina, AF, valvular heart disease or hypertension, CVA/TIA, COPD/asthma, diabetes ore pre-existing renal failure (not AKI). Respite care, nursing homes and residential homes count as institutions. Living with relatives, carers or in warden controlled accommodation does not. Non-invasive skin cancer is not counted and can be excluded from the NHS. Total score /10 Score Risk 0.7% 1.1% 1.7% 2.7% 4.4% 6.9% 11% 16% 24% 34% 45% 30-day mortality risk % The Nottingham Hip Score should be considered when discussing with relatives and patient during clerking. If relatives are present in the ED, a DNAR should be discussed if appropriate. DIAGNOSIS 1. Fractured neck of femur type: BEFORE LEAVING THE EMERGENCY DEPARTMENT Please ensure that the following have been done prior to the patient leaving the ED Drug chart, including analgesia and regular medications VTE ECG G&S sample Blood results documented & actioned (please see management guidelines overleaf) D/W relatives if present In addition, the admitting doctor must update the handover sheet and trauma board.

8 GUIDE TO MANAGEMENT OF PRE-OPERATIVE ABNORMALITIES IN PATIENTS WITH PROXIMAL FEMORAL FRACTURES General principles Patients with a fractured neck of femur should undergo surgery within 36 hours of admission if possible. These patients often have medical issues, and medical optimisation should begin as soon as they are admitted. Minor abnormalities need not necessarily delay surgery, as optimisation and surgery can proceed simultaneously. Major abnormalities may delay surgery and require a higher level of early intervention, including advice as appropriate from, e.g. an anaesthetist (1st on-call or CEPOD/Trauma consultant), orthogeriatric consultant, medical registrar, or critical care outreach team. Such advice should be sought as soon as possible after admission. Minor abnormality Major abnormality Action Blood pressure Systolic BP > 180 mmhg Diastolic BP > 110 mmhg Systolic BP < 90 mmhg Look for cause Start 500ml Hartmanns IV stat, reassess after 30 mins Advice: anaesthetist, orthogeriatrician, medical registrar Heart rate and rhythm HR bpm or > 120 with no other ECG abnormality HR with atrial flutter or fibrillation HR < 45 bpm or complete heart block HR >120 bpm with atrial fibrillation/flutter or other ECG problem Review medication (?beta blockers) May need medical pacemaker Advice: anaesthetist, medical reg Treat as per trust protocols Advice: anaesthetist, orthogeriatrician, medical registrar, cardiac outreach team Ischaemic heart disease Stable angina +/- chronic ischaemic ECG changes Evidence of new MI Unstable angina Advice: anaesthetist, orthogeriatrician, medical registrar Give O2, consider transfer to CCU for monitoring cardiovascular instability May need HDU post-op Heart failure History of previous heart failure, now treated Clinical signs of heart failure Signs of failure on CXR pulmonary oedema, pleural effusion without consolidation Give O2, IV frusemide Caution with IV fluids Advice: anaesthetist, orthogeriatrician, medical registrar May need HDU post-op Respiratory failure SaO2 90%; and po2 8 kpa; and pco kpa SaO2 < 90%; or po2 < 8 kpa; and pco2 7.4 kpa Take ABG Give O2 (24% or 28% if history of COPD) Repeat ABG Advice: anaesthetist, orthogeriatrician, medical registrar Surgery should proceed without delay. In addition: Initiate appropriate treatment for above conditions Correct fluid resuscitation is particularly important Optimise analgesia and maintain usual medication unless contraindicated Discuss with anaesthetist as soon as possible after trauma meeting Be proactive if the patient is not fit: Inform Trauma Nurse Co-ordinator Document why surgery should be delayed Document a plant for optimisation Write your contact details in the notes

9 Cardiac murmurs and echocardiography Older people with hip fracture do not require routine echocardiography prior to surgery. History and physical examination is important and ideally the need for echocardiography should be confirmed by an experienced physician (consultant or registrar). Check for a previous echocardiogram there is unlikely to be a significant change if one has been done in the last 2 years. Echocardiography should be performed immediately prior to surgery if aortic stenosis is suspected, i.e. a systolic murmur radiating to the neck particularly if there are 2 or more of the following symptoms: angina on exertion, unexplained syncope or near syncope, slow rising pulse, absent 2nd heart sound, LVH on ECG without hypertension. A diagnosis of aortic stenosis should not delay surgery; patients may require additional invasive monitoring and a period of management on HDU post-operatively. This decision should be made by the consultant anaesthetist responsible for the trauma list and a plan made for when surgery can proceed. Minor abnormality Major abnormality Action < 35ºC Rewarm as per Trust policy Temp < 38ºC regardless of site of infection 38ºC Look for underlying cause Septic screen then treat as per Trust policy Advice: microbiologist, orthogeriatrician, medical registrar, orthopaedic surgeon Any patient on warfarin, give Vitamin K 10 mg IV stat, no need to check INR first. Recheck INR 6 hrs later. Warfarin INR 1.4 is acceptable for spinal anaesthesia INR > 1.5 Give second dose of Vit K 5mg IV Repeat INR in 6 hrs If INR > 1.6 consider FFP Advice: haematologist, trauma anaesthetist Clopidogrel Do not stop clopidogrel on admission. Relative contraindication to spinal anaesthesia (balance of risks). Cross match blood to be available for theatre. Electrolytes Na or mmol/l Na mmol/l Na + > 150 mmol/l Request medical review Stop thiazide/loop diuretics Check urine osmolality Consider fluid restriction Usually due to dehydration Slow correction with Hartmanns or Plasmalyte K or mmol/l K + < 2.8 mmol/l K mmol/l Refer to Trust hypokalaemia guidelines Refer to Trust hyperkalaemia guidelines Glucose mmol/l > 20 mmol/l Consider sliding scale Advice: medical registrar, orthogeriatrician Renal CKD stage 1-3 AKI stage 1-2 CKD stage 4 and 5 AKI stage 3 Avoid nephrotoxic drugs, see Trust policy Advice medical registrar, orthogeriatrician Anaemia Hb g/dl Hb 80 g/dl Check haemotinics then transfuse No delay to surgery Consider cell salvage in theatre Surgery should proceed without delay. In addition: Initiate appropriate treatment for above conditions Correct fluid resuscitation is particularly important Optimise analgesia and maintain usual medication unless contraindicated Discuss with anaesthetist as soon as possible after trauma meeting Be proactive if the patient is not fit: Inform Trauma Nurse Co-ordinator Document why surgery should be delayed Document a plant for optimisation Write your contact details in the notes

10 PLAN Admit under orthopaedics. If not, details NBM midnight If patient has arrived during normal working hours, is starved and is otherwise well, check with the orthopaedic registrar if space on trauma list prior to feeding Calorie drinks up until 6 am All patients should be allowed to have preoperative clear calorie drinks up until 6 am. These are available on the orthopaedic ward. Analgesia [paracetamol 1 qds IV/po, Oxynorm liquid (oxycodone immediate release) 1.25 mg po qds, Oxynorm liquid (oxycodone immediate release mg po 4-6 hourly prn]. Subcutaneous oxycodone can be used in those patients unable to take oral analgesia. Seek advice from the Acute Pain Service if necessary. If a patient s weight is < 50 kg then the dose of IV paracetamol should be reduced to 15mg/kg Anti-emetics (cyclizine 50 mg slow IV 8 hourly prn and ondansetron 4 mg in 100ml 0.9% sodium chloride IV over 20 minutes 8 hourly prn) Docusate sodium 200 mg orally bd Senna mg orally nocte IV fluid - standard Rx 100 ml/hr of crystalloid unless otherwise indicated. Hartmann s should be first line therapy rather than saline or 5% dextrose. With-hold antihypertensives apart from beta-blockers for 72 hours. Beta-blockers should be given on the day of surgery. Consent and mark Catheter For comfort and to allow nursing care, consider catheterisation in the pre-operative patient. Remember, particularly in female patients, that using a bedpan will be uncomfortable. Warfarin reversal ensure that it has actually been given to patient within 30 mins of prescription Consider block if pain poorly controlled with oral analgesia Recheck investigations needed: Test: at (time) Result: Test: at (time) Result: Test: at (time) Result: Other instructions: Clerked by: Signature: Grade: Bleep:

11 Date: Time: TRAUMA WARD ROUND Neck of femur fracture type: Undisplaced intracapsular Displaced intracapsular Intertrochanteric Subtrochanteric Consultant: Planned operation: Hip hemiarthroplasty Total hip replacement DHS IM nail Ward round notes: Please place post-take dictation here Fit for theatre Y N If no, details Requires medical stabilisation Requires further investigation Raised INR Outstanding jobs to be done prior to theatre Signed by Signature: Grade: Bleep:

12 Date: Time: ORTHOGERIATRICIAN REVIEW (continued) Bone protection To continue Start bisphosphonate & calcium supplement Change current bone protection to Requires DEXA scan prior to starting Rx Not required Falls assessment Low risk of falls High risk of falls Requires follow up in clinic No follow up required Signed by Signature: Grade: Bleep:

13 Date: Anaesthetic Start Time: Operation Start Time: OPERATION NOTE Responsible Cons: Surgeon Name/Grade: Assistant Name/Grade: Orthopaedic consultant present? Y N Anaesthetist Name/Grade: Anaesthetic consultant present? Y N WHO checklist completed? Y N Anaesthetic: GA Spinal Block given: Y N Antibiotics given: Y N Specimens sent: Y N Intraoperative imaging: Y N PROCEDURE: HEMIARTHROPLASTY THR DHS IM FEMORAL NAIL LEFT RIGHT INDICATION: Intracapsular NOF # Extracapsular NOF # Subtrochanteric / reverse oblique NOF # POSITION: Lateral Modified Hardinge Other HEMIARTHROPLASTY DHS IM NAIL THR Head size: mm Plate size: holes Lag screw: mm Head size: mm Stem size: Lag screw: mm Nail diameter: mm Stem size: Collar size: mm Nail length: mm Collar size: mm Cemented: Y N Shell size: Cement restrictor: Cemented: Y N Cement restrictor:

14 Date: Anaesthetic Start Time: Operation Start Time: OPERATION NOTE (continued) Untoward intraoperative events: Y N Vascular injury Cement reaction Pressure injury Nerve injury Fracture Diathermy injury Other: CLOSURE Capsule/Muscle: Fascia lata: Subcut layer: Skin: VTE thromboprophylaxis 28 days tinzaparin Restart warfarin on day 1 Apixiban Nil MOBILISATION INSTRUCTIONS Mobilise FWB / PWB / TTWB / NWB (circle one) Hip precautions to be followed? Y N If not FWB, indicate length of WB status and if XR required prior to change: Patient will be mobilised without a check XR on day one unless otherwise indicated here ADDITIONAL POST-OP INSTRUCTIONS: Routine observations Check bloods tomorrow VTE thromboprophylaxis as above Mobilisation as above Check XR requested Follow up yes / no (circle one) in weeks in clinic If patient has been placed on restricted weightbearing a follow-up # clinic must be arranged Other instructions: Signed by Signature: Grade: Bleep:

15 Date: Time: ORTHOGERIATRICIAN REVIEW

16 Date: Time: ADDITIONAL PREOPERATIVE REVIEW Specialty: Additional continuation sheets are available on the orthopaedic ward Signed by Signature: Grade: Bleep:

17 POST-OP DAY 1 REVIEW Post op bloods Hb WCC Plts INR Na K U Cr egfr Post op check XR Not required Satisfactory Concern identified If concerns, please seek senior advice and clearly document if any change to WB status and timeline for review. Delay to theatre > 36 hrs post admission? Anaemia / biochemical abnormality Hb < 80, Na < 120 / > 150, K < 2.8 / > 6.0 Uncontrolled diabetes Correctable cardiac arrhythmia Chest infection with sepsis Reversible coagulopathy Y N Lack of theatre space Lack of surgeon Awaiting echo Minor electrolyte abnormalities Other

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19 Date: Tester: Post op day No: Time: 4 AT ASSESSMENT - Assessment test for delirium & cognitive impairment [1] ALERTNESS This includes patients who may be markedly drowsy (e.g. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. [2] AMT4 Normal (fully alert, but not agitated, throughout assessment 0 Mild sleepiness for < 10 seconds after waking, then normal 0 Clearly abnormal 4 Age, date of birth, place (name of the hospital or building), current year [3] ATTENTION No mistakes 0 1 mistake 1 2 or more mistakes/untestable 2 Ask the patient: Please tell me the months of the year in backwards order, starting at December. To assist initial understanding one prompt of what is the month before December? is permitted. Achieves 7 months or more correctly 0 Starts but scores <7 months / refuses to start 1 Untestable (cannot start because unwell, drowsy, inattentive) 2 [4] ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in alertness, cognition, other mental function (e.g. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24 hours No 0 Yes 4 4 or above: possible delirium +/- cognitive impairment 1-3: possible cognitive impairment 0: delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete) 4AT SCORE The 4AT is a screening instrument designed for rapid initial assessment of delirium and cognitive impairment. A score of 4 or more suggests delirium but is not diagnostic: more detailed assessment of mental status may be required to reach a diagnosis. A score of 1-3 suggests cognitive impairment and more detailed cognitive testing and informant history-taking are required. A score of 0 does not definitively exclude delirium or cognitive impairment: more detailed testing may be required depending on the clinical context. Items 1-3 are rated solely on observation of the patient at the time of assessment. Item 4 requires information from one or more source(s), eg. your own knowledge of the patient, other staff who know the patient (eg. ward nurses), GP letter, case notes, carers. The tester should take account of communication difficulties (hearing impairment, dysphasia, lack of common language) when carrying out the test and interpreting the score. Alertness: Altered level of alertness is very likely to be delirium in general hospital settings. If the patient shows significant altered alertness during the bedside assessment, score 4 for this item. AMT4: This score can be extracted from items in the AMT10 if the latter is done immediately before. Acute Change or Fluctuating Course: Fluctuation can occur without delirium in some cases of dementia, but marked fluctuation usually indicates delirium. To help elicit any hallucinations and/or paranoid thoughts ask the patient questions such as, Are you concerned about anything going on here? ; Do you feel frightened by anything or anyone? ; Have you been seeing or hearing anything unusual?

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23 Date: Post-op day: Time: MEDICALLY FIT FOR DISCHARGE Is the patient Medically stable? Orthopaedically fit? No longer requiring inpatient investigation or treatment? Can be managed in the community/intermediate care? Y N Y N Y N Y N If No has been ticked, but it is still felt that the patient should be discharged, please outline reasons or planned management below: Signed by Signature: Grade: Bleep: DELAY TO DISCHARGE If the patient is not discharged within 48 hrs of being declared medically fit for discharge, please tick all reasons that apply. If the patient becomes medically unfit, please fill in another Medically fit for discharge form when appropriate. Became medically unwell Funding problems (discharge destination) Awaiting residential / nursing home placement Awaiting residential / nursing home review Needs home visit with OT Please provide additional information if possible... Awaiting social services/package of care Awaiting IMC Needs further physiotherapy No suitable discharge destination Signed by Signature: Grade & bleep: Date:

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25 Date: Post-op day: Time: DISCHARGE SUMMARY Discharge destination Own home Residential home Nursing home Intermediate care Other: Follow up required No follow up needed # clinic in wks Cons clinic ( ) in wks Immediate / early postoperative complications Pressure ulcers Hospital acquired pneumonia UTI / urinary sepsis Sepsis other PE/DVT MI CVA / TIA C. difficile MRSA Other Ensure that if any actions are required by the GP that this is communicated clearly in the discharge letter. If patient requires repeat blood tests within a week, then consider contacting GP directly. If patient has been restarted on warfarin anticoagulation, ensure that their yellow book is filled in, clear instructions are given as to when a repeat INR is needed and that an anticoagulation clinic referral letter has been completed. Unless contraindicated, all patients should receive thromboprophylaxis for 28 days post-fracture. For patients unable to inject themselves, a pink community prescription form must be filled in. NOTE any patient that is not FWB on discharge MUST have a follow up appointment in an orthopaedic fracture clinic.

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