Hip Fracture (HFR) Measures Document HFR Version: 2 - covering patients discharged between 01/10/2017 and present. Programme Lead: Sam Doddridge Clinical Leads: Ms Phil Thorpe Dr John Tsang Number of Measures In Clinical Focus Area (CFA) Clinical Process Measures 8 Clinical Outcome Measures 3 Email: advancing.quality@nhs.net Website: http://www.advancingqualitynw.nhs.uk Produced on 23 June 2017
Introduction Hip fracture is a major public health issue due to an ever increasing ageing population. About 70,000 to 75,000 hip fractures occur each year and the annual cost (including medical and social care) for all UK hip fracture cases is about 2 billion.(nice 2011) About 10% of people with a hip fracture die within one month and about one-third within 12 months. Most are due to associated conditions and not to the fracture itself, reflecting the high prevalence of comorbidity. Because the occurrence of fall and fracture often signals underlying ill health, a comprehensive multidisciplinary approach is required from presentation to subsequent follow-up, including the transition from hospital to community.(nice 2011) The Advancing Quality Hip fracture measures have been chosen to enhance the care that patients receive following hip fracture and to improve the clinical outcomes. Page 2
Measures In Clinical Focus Area Measure Type Measure ID Clinical Process Measure HFR-01 HFR-02 HFR-03 HFR-04 HFR-05 HFR-06 HFR-07 HFR-08 Measure Name Validated pain score assessment and analgesia within 60 minutes of arrival Admission to an appropriate Orthopaedic or Orthogeriatric ward within four hours of arrival Jointly agreed protocol commenced within six hours of arrival Pressure ulcer assessment within six hours of arrival Consultant/senior clinician supervision during surgery Documentation in the post-operative notes that the patient should fully weight bear Physiotherapy assessment within 24 hours of surgery Nutritional Screen within 24 hours of arrival Page 3
Measure ID: HFR-01 Measure Name: Validated pain score assessment and analgesia within 60 minutes of arrival Unique Record Identifier: 10069900 Measure Description: Hip Fracture Patients should have a pain score assessment using a validated tool and receive analgesia within 60 minutes of arrival at hospital or diagnosis for inpatients. Measure Type: Clinical Process Measure Rationale: Pain relief is important for simple humanitarian reasons, but also improves the patient's well-being, reduces the risk of delirium, and facilitates the return to mobility and independence. (NICE 2011) Numerator Statement: Number of Hip Fracture Patients who have a pain score assessment using a validated tool and receive analgesia within 60 minutes of arrival at hospital or diagnosis for inpatients. Denominator Statement: Number of Hip Fracture patients eligible for pain score assessment using a validated tool and analgesia within 60 minutes of arrival at hospital or diagnosis for inpatients. Measure Reported As: The percentage of eligible patients who have had a pain score assessment using a validated tool and received analgesia within 60 minutes of arrival at hospital or diagnosis for inpatients. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Already in Hospital Analgesia and laxative - Administered Analgesia and laxative - Patient declined Analgesia and Laxative - reason Analgesia Date Analgesia Time Arrival Date Arrival Time Diagnosis Date Diagnosis Time Glasgow Coma Scale (GCS) Pain Score Assessment Measure Exclusions: Glasgow Coma Scale was <=7 There is documentation that the patient declined analgesia Documentation by a consultant (or person working as part of the consultant team) that there is a reason for not administering analgesia Page 4
Measure ID: Measure Name: HFR-02 Unique Record Identifier: 10070000 Measure Description: Admission to an appropriate Orthopaedic or Orthogeriatric ward within four hours of arrival Hip Fracture Patients should be admitted to an appropriate Orthopaedic or Orthogeriatric ward within four hours of hospital arrival or diagnosis for inpatients. Measure Type: Clinical Process Measure Rationale: Unnecessary delay in transfer to an appropriate ward increases risk of pressure sores, confusion and pain. Numerator Statement: Number of Hip Fracture Patients who are admitted to an appropriate Orthopaedic or Orthogeriatric ward within four hours of hospital arrival or diagnosis for inpatients. Denominator Statement: Number of Hip Fracture Patients eligible to be admitted to an appropriate orthopaedic ward within four hours of hospital arrival or diagnosis for inpatients. Measure Reported As: The percentage of eligible patients who are admitted to an appropriate Orthopaedic or Orthogeriatric ward within four hours of hospital arrival. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Already in Hospital Arrival Date Arrival Time Death - HFR Death date Death time Diagnosis Date Diagnosis Time Glasgow Coma Scale (GCS) Orthopaedic or Orthogeriatric Ward Orthopaedic or Orthogeriatric Ward Date Orthopaedic or Orthogeriatric Ward Time Orthopaedic or Othogeriatric Ward - reason Specialist Care Required - arrival Measure Exclusions: Glasgow Coma Scale was <=7 Documentation that the patient required care on specialised ward on arrival (at diagnosis) Documentation by a consultant (or person working as part of the consultant team) for not admitting the patient to an appropriate Orthopaedic or Orthogeriatric ward Patient died within four hours of arrival or diagnosis Page 5
Measure ID: Measure Name: HFR-03 Unique Record Identifier: 10070100 Measure Description: Jointly agreed protocol commenced within six hours of arrival Hip Fracture Patients should be commenced on the Trust Hip Fracture jointly agreed protocol within six hours of arrival at hospital or diagnosis for inpatients. Measure Type: Clinical Process Measure Rationale: Early assessment and commencing jointly agreed protocols enables rapid optimisation for surgery. The aim is reduced time to surgery (within 24 to 36 hours) reducing incidence of complications such as mortality, pneumonia, pressure sores, cognitive dysfunction. Numerator Statement: Number of Hip Fracture Patients commenced on the Trust Hip Fracture jointly agreed protocol within six hours of arrival at hospital or diagnosis for inpatients. Denominator Statement: Number of Hip Fracture Patients eligible to be commenced on the Trust Hip Fracture jointly agreed protocol within six hours of arrival at hospital or diagnosis for inpatients. Measure Reported As: The percentage of patients who are commenced on the Trust Hip Fracture jointly agreed protocol within six hours of arrival at hospital or diagnosis for inpatients. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Already in Hospital Arrival Date Arrival Time Death - HFR Death date Death time Diagnosis Date Diagnosis Time Glasgow Coma Scale (GCS) Jointly Agreed Protocol - commenced Jointly Agreed Protocol Date Jointly Agreed Protocol Time Measure Exclusions: Glasgow Coma Scale was <=7 Patient died within six hours of arrival or diagnosis Page 6
Measure ID: Measure Name: HFR-04 Pressure ulcer assessment within six hours of arrival Unique Record Identifier: 10070200 Measure Description: Hip Fracture Patients should have a pressure ulcer assessment within six hours of hospital arrival or diagnosis for inpatients. Measure Type: Clinical Process Measure Rationale: The majority of pressure sores can be prevented by anticipatory care, thus reducing associated morbidity and mortality. (SIGN 2009) Numerator Statement: Number of Hip Fracture Patients who have a pressure ulcer assessment within six hours of hospital arrival or diagnosis for inpatients. Denominator Statement: Number of Hip Fracture Patients eligible for pressure ulcer assessment within six hours of arrival at hospital or diagnosis for inpatients. Measure Reported As: The percentage of patients who have a pressure ulcer assessment within six hours of hospital arrival or diagnosis for inpatients. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Already in Hospital Arrival Date Arrival Time Death - HFR Death date Death time Diagnosis Date Diagnosis Time Pressure Ulcer Assessment - completed Pressure Ulcer Assessment Date Pressure Ulcer Assessment Time Measure Exclusions: Patient died within six hours of arrival or diagnosis Page 7
Measure ID: Measure Name: HFR-05 Consultant/senior clinician supervision during surgery Unique Record Identifier: 10070300 Measure Description: A consultant or senior clinician (Associate Specialist) should be present in theatre during surgery for all Hip Fracture patients. This is in reference to both the surgeon and the anaesthetist. Measure Type: Clinical Process Measure Rationale: The presence of a consultant/senior clinician in theatre during hip fracture surgery improves care and reduces reoperation rate. Numerator Statement: Number of Hip Fracture Patients who have their surgery supervised by a consultant or senior clinician. Denominator Statement: Number of Hip Fracture Patients who are eligible for surgery. Measure Reported As: The percentage of patients who have surgery and have their surgery supervised by a consultant or senior clinician. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Death - HFR Non-Operative Management Senior Anaesthetist Supervision Senior Surgeon Supervision Measure Exclusions: Patient died prior to surgery Patient had non-operative management Page 8
Measure ID: Measure Name: HFR-06 Unique Record Identifier: 10070400 Measure Description: Documentation in the post-operative notes that the patient should fully weight bear Hip Fracture Patients should have documentation in their post-operative notes that they should fully weight bear. Measure Type: Clinical Process Measure Rationale: Early mobilisation allows for early rehabilitation, reduced length of stay and reduced complications.(sign 2009) Numerator Statement: Number of Hip Fracture Patients who have documentation within the post-operative notes that they should fully weight bear. Denominator Statement: Number of Hip Fracture Patients eligible to fully weight bear. Measure Reported As: The percentage of patients who have documentation within the post-operative notes that they should fully weight bear. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Death - HFR Fully Weight Bear - documentation Non-Operative Management Measure Exclusions: Patient died prior to surgery Patient died during surgery Patient had non-operative management Page 9
Measure ID: Measure Name: HFR-07 Physiotherapy assessment within 24 hours of surgery Unique Record Identifier: 10070500 Measure Description: Hip Fracture Patients should have a physiotherapy assessment completed by a qualified physiotherapist within 24 hours of surgery end time or non-operative management decision. Measure Type: Clinical Process Measure Rationale: Early physiotherapy assessment allows for early rehabilitation, reduced length of stay and reduced complications. Numerator Statement: Number of Hip Fracture Patients who have a physiotherapy assessment completed by a qualified physiotherapist within 24 hours of surgery end time or non-operative management decision. Denominator Statement: Number of Hip Fracture Patients eligible to have a physiotherapy assessment completed by a qualified physiotherapist within 24 hours of surgery end time or non-operative management decision. Measure Reported As: The percentage of patients who have a physiotherapy assessment completed by a qualified physiotherapist within 24 hours of surgery end time or non-operative management decision. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Death - HFR Death date Death time Non-Operative Management Non-Operative Management Date Non-Operative Management Time Physiotherapy Assessment - completed Physiotherapy Assessment - reason Physiotherapy Date Physiotherapy Time Surgery End Date Surgery End Time Surgery Start Date Surgery Start Time Measure Exclusions: Patient died prior to surgery Patient died during surgery There is a reason documented why the patient should not have a physiotherapy assessment Patient died within 24 hours of non-operative management or surgery end time Page 10
Measure ID: Measure Name: HFR-08 Nutritional Screen within 24 hours of arrival Unique Record Identifier: 10070600 Measure Description: Hip Fracture Patients should have a nutritional screen within 24 hours of hospital arrival or diagnosis for inpatients. Measure Type: Clinical Process Measure Rationale: Early nutritional screening leads to reduced length of stay and reduced complications as it allows for early recognition of malnutrition. Numerator Statement: Number of Hip Fracture Patients who have a nutritional screen within 24 hours of hospital arrival or diagnosis for inpatients. Denominator Statement: Number of Hip Fracture Patients eligible for a nutritional screen within 24 hours of hospital arrival or diagnosis for inpatients. Measure Reported As: The percentage of patients who have a nutritional screen within 24 hours of hospital arrival or diagnosis for inpatients. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Already in Hospital Arrival Date Arrival Time Death - HFR Death date Death time Diagnosis Date Diagnosis Time Nutritional Screen - completed Nutritional Screen - risk Nutritional Screen Date Nutritional Screen Time Measure Exclusions: Patient died within 24 hours of arrival or diagnosis (if an inpatient) Page 11
Appendices I. Data Elements Required for Clinical Focus Area Data Element Definition Source Collected for Measures Already in Hospital Analgesia and laxative - Administered Analgesia and laxative - Patient declined Analgesia and Laxative - reason Analgesia Date Analgesia Time Arrival Date Arrival Time Death - HFR The patient was already an inpatient when the onset/awareness/diagnosis (as appropriate) of symptoms occurred. There is documentation that analgesia was administered. Documentation that the patient declined analgesia. There is a reason documented by a consultant (or person working as part of the consultant team) for not prescribing analgesia and/or laxatives on day of surgery. The earliest documented date (dd/mm/yyyy) the patient was administered analgesia. The earliest documented time (hh:mm) (24 hour clock) the patient received analgesia. The earliest documented date (dd/mm/yyyy) that the patient arrived at the hospital for this spell of care/treatment The earliest documented time (hh:mm) (24 hour clock) the patient arrived at the hospital Documentation in the medical record that the patient died in hospital: Prior to Surgery During Surgery Post Surgery Inpatient death (for patients non-operatively managed) Or was Discharged Alive Death date Documented date of death (dd/mm/yyyy) Death time Diagnosis Date Diagnosis Time Documented time of death (hh:mm) (24 hour clock) The date (dd/mm/yyyy) of onset/awareness/diagnosis (as appropriate). The time (hh:mm) (24 hour clock) of onset/awareness/diagnosis (as appropriate). Discharge Destination The place or setting to which the patient was discharged. Discharge Method ESD - available to patient SUS The method by which the patient was discharged. SUS Documentation that the patient has access to an ESD Service. For Trusts that cross more than one HFR-01, HFR-02, HFR-03, HFR-04, HFR-08 HFR-01 HFR-01 HFR-01 HFR-01 HFR-01 HFR-01, HFR-02, HFR-03, HFR-04, HFR-08 HFR-01, HFR-02, HFR-03, HFR-04, HFR-08 HFR-02, HFR-03, HFR-04, HFR-05, HFR-06, HFR-07, HFR-08 HFR-02, HFR-03, HFR-04, HFR-07, HFR-08 HFR-02, HFR-03, HFR-04, HFR-07, HFR-08 HFR-01, HFR-02, HFR-03, HFR-04, HFR-08 HFR-01, HFR-02, HFR-03, HFR-04, HFR-08 Page 12
Clinical Commissioning Group (CCG), early supported discharge may be commissioned for some patients but not others. ESD - patient declined Documentation that the patient declined referral to ESD. ESD - reason documented ESD - referral FLS - available to patient FLS - known Fracture - previous Fully Weight Bear - documentation Glasgow Coma Scale (GCS) Jointly Agreed Protocol - commenced Jointly Agreed Protocol Date Jointly Agreed Protocol Time Non-Operative Management Non-Operative Management Date Non-Operative Management Time Nutritional Screen - completed Nutritional Screen - risk Nutritional Screen Date Nutritional Screen Time Orthopaedic or Orthogeriatric Ward Documentation of the reason that the patient was not referrred to ESD. Documentation that the patient was referred to ESD. Patients should be offered the option to go home soon after their operation (if they are fit enough to be discharged from hospital) with ongoing support and involvement from the Hip Fracture Programme team to continue rehabilitation. Documentation that the patient has access to FLS. For Trusts that cross more than one Clinical Commissioning Group (CCG), an FLS may be commissioned for some patients but not others. Documentation that the patient was known to the FLS prior to admission. Documentation that the patient has had a previous fracture Documentation in the post-operative notes that the patient should fully weight bear. The patient's Glasgow Coma Scale (GCS) score is greater than 7 or less than or equal to 7. There is documentation that the jointly agreed protocol for Hip Fracture was commenced. The earliest documented date (dd/mm/yyyy) the patient had a jointly agreed protocol for Hip Fracture commenced. The earliest documented time (hh:mm) (24 hour clock) the patient had a jointly agreed protocol for Hip Fracture commenced. Documentation the patient had non-operative management and did not undergo a surgical procedure The earliest documented date (dd/mm/yyyy) the patient was for non-operative management The earliest documented time (hh:mm) (24 hour clock) the patient was for non-operative management Documentation in medical record that the patient had a completed nutritional screen using a validated tool. Documentation in medical record of the nutritional screen malnutrition risk. The earliest documented date (dd/mm/yyyy) the patient had a nutritional screen The earliest documented time (hh:mm) (24 hour clock) the patient had a nutritional screen There is documentation that the patient was admitted to an appropriate Orthopaedic or Orthogeriatric ward. HFR-06 HFR-01, HFR-02, HFR-03 HFR-03 HFR-03 HFR-03 HFR-05, HFR-06, HFR-07 HFR-07 HFR-07 HFR-08 HFR-08 HFR-08 HFR-08 HFR-02 Page 13
Orthopaedic or Orthogeriatric Ward Date Orthopaedic or Orthogeriatric Ward Time Orthopaedic or Othogeriatric Ward - reason Pain Score Assessment Physiotherapy Assessment - completed Physiotherapy Assessment - reason Physiotherapy Date Physiotherapy Time Pressure Ulcer Assessment - completed Pressure Ulcer Assessment Date Pressure Ulcer Assessment Time Senior Anaesthetist Supervision Senior Surgeon Supervision Specialist Care Required - arrival Surgery End Date Surgery End Time Surgery Start Date Surgery Start Time The earliest documented date (dd/mm/yyyy) the patient was admitted to an appropriate Orthopaedic or Orthogeriatric ward The earliest documented time (hh:mm) (24 hour clock) the patient was admitted to an appropriate Orthopaedic or Orthogeriatric ward There a reason documented by a consultant (or person working as part of the consultant team) for not admitting the patient to an appropriate Orthopaedic or Orthogeriatric ward. There is documentation that the patient's pain was assessed using a validated tool and pain score recorded. There is documentation that the patient had a physiotherapy assessment. Reason documented for not performing a physiotherapy assessment The earliest documented date (dd/mm/yyyy) the patient had a physiotherapy assessment The earliest documented time (hh:mm) (24 hour clock) the patient had a physiotherapy assessment Documentation that the patient had a pressure ulcer assessment completed using a validated tool. The earliest documented date (dd/mm/yyyy) the patient had a pressure ulcer assessment completed. The earliest documented time (hh:mm) (24 hour clock) the patient had a pressure ulcer assessment completed. There is documentation that a senior anaesthetist was performing anaesthesia during the surgery or was changed and present in theatre during surgery There is documentation that a senior surgeon was performing the surgery or was changed and present in theatre during surgery. Documentation by a consultant (or person working as part of the consultant team) that the patient required care on a specialist ward on arrival or on diagnosis (diagnostic imaging) for inpatients. The date (dd/mm/yyyy) the procedure was completed defined as closure. The earliest documented time (hh:mm) (24 hour clock) the procedure completed, defined as closure. The earliest documented date (dd/mm/yyyy) the procedure started The earliest documented time (hh:mm) (24 hour clock) the surgery started, defined as induction (start of anaesthesia) HFR-02 HFR-02 HFR-02 HFR-01 HFR-07 HFR-07 HFR-07 HFR-07 HFR-04 HFR-04 HFR-04 HFR-05 HFR-05 HFR-02 HFR-07 HFR-07 HFR-07 HFR-07 Page 14
III. References American Academy of Orthopedic Surgeons; Recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty; 2010 American College of Radiology; Acute hip pain - suspected fracture; 2013 American Geriatrics Society, British Geriatrics Society; AGS/BGS clinical practice guideline: prevention of falls in older persons; 2010 American Society of Health-System Pharmacists (ASHP), Infectious Diseases Society of America (IDSA), Surgical Infection Society (SIS), Society for Healthcare Epidemiology of America (SHEA); Clinical practice guidelines for antimicrobial prophylaxis in surgery; 2013 Association of Anaesthetists of Great Britain and Ireland; Management of proximal femoral fractures 2011; 2012 British Association of Parenteral and Enteral Nutrition, Association of Clinical Biochemistry, Association of Surgeons of Great Britain and Ireland and Society of Academic and Research Surgery, Renal Association and the Intensive Care Society; British consensus guidelines on intravenvous fluid therapy for adult surgical patients; 2011 British Geriatric Society and the British Pain Society; The assessment of pain in older people; 2007 British Orthopaedic Association; The care of patients with fragility fracture ( Blue book ); 2007 National Institute for Health and Care Excellence; Falls Assessment and prevention of falls in older people; 2013 National Institute for Health and Care Excellence; Intravenous fluid therapy in adults in hospital; 2013 National Institute for Health and Care Excellence; Technical Appraisal - Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (amended); 2008 (last modified: January 2011) National Institute for Health and Care Excellence; The management of hip fracture in adults; 2011 Royal College of Physicians; National Hip Fracture Database National report; 2013 Scottish Intercollegiate Guidelines Network; Management of hip fracture in older people; 2009 Page 15
IV. Algorithms Page 16
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Hip Fracture: Advancing Quality Data form Name: Hospital Number: DOB: / / NHS: Ethnicity: ARRIVAL AND DIAGNOSIS 1. Inpatient at time of fracture? Yes No If No, skip 2; If Yes, skip 3 2. Date and time of diagnosis (diagnostic imaging) / / : 3. Arrival date & time / / : EXCLUDES SOME 4. Glasgow Coma Scale (GCS)? <=7 >7 5. Patient Death Prior to surgery During surgery Post-surgery Inpatient death (for non-operatively managed) Discharged alive (if patient died skip 33-36) 6. Death date and time / / : PAIN ASSESSMENT 7. Pain assessed and pains score recorded Yes No 8. Patient declined analgesia? Yes No 9. Reason documented for not prescribing analgesia? Yes No 10. Analgesia administered? Yes No 11. Analgesia administration date & time / / : WARD ADMISSION 12. Patient required specialist care on arrival? Yes No If Yes, skip 13-15 13. Reason documented for not admitting to orthopaedic ward? Yes No If Yes, skip 14-15 14. Patient admitted to orthopaedic ward? Yes No If No, skip 15 15. Orthopaedic ward admission date & time / / : JOINTLY AGREED PROTOCOL 16. Jointly agreed protocol commenced? Yes No If No, skip 17 17. Jointly agreed protocol date & time / / : PRESSURE ULCER ASSESSMENT 18. Pressure ulcer assessment completed? Yes No If No, skip 19 19. Pressure ulcer assessment date & time / / : Source of Admission Admission Date & Time / / : Discharge Date / / Discharge Destination Discharge Method SURGERY 20. Patient non-operatively managed? Yes No If Yes, skip 22-25 21. Non operative management decision date & time / / : 22. Senior surgeon supervision Yes No 23. Senior anaesthetist supervision Yes No 24. Surgery start date & time / / : 25. Surgery end date & time / / : MOBILISATION 26. Documentation in post-operative notes that the patient should fully weight bear Yes No PHYSIOTHERAPY ASSESSMENT 27. Reason documented for not performing physiotherapy assessment? Yes No If Yes, skip 28 & 29 28. Physiotherapy assessment completed? Yes No If No, skip 29 29. Physiotherapy assessment date & time / / : NUTRITIONAL SCREEN 30. Nutritional screen completed? Yes No If No, skip 31 & 32 31. Nutritional screen date & time / / : 32. Malnutrition risk score VALIDATIONS Form completed by Designation Inputted by Date Inputted / / AQ Hip Fracture Data collection for v2.0 Published September 2017 Page 31