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Revolution in hip fracture care shows the way in improving treatment of older people

12 July 2011

A new report shows that national clinical audit, supportive networks and extra payments for hospitals have delivered high quality and continuing improvements in hip fracture care – at a time when care of the elderly in other areas has given rise to concern. The National Hip Fracture Database (NHFD) 2011 Report published today (Wednesday 13 July, 2011) shows that since its launch in 2007 the NHFD has supported and documented substantial improvements in the quality of care for patients with a common and serious injury sustained by around 70,000 older people in the UK each year. Doctors say this approach provides a practical and achievable model that should now be followed more widely.

The NHFD 2011 National Report covers more than 53,000 cases admitted between April 2010 and March 2011, and shows consistent improvements in compliance with the six clinical standards measured. Since the audit began more patients are being admitted promptly to orthopaedic wards; delays for operation have been reduced, with the great majority of patients now having surgery within 48 hours. Fewer patients develop pressure ulcers; and more have specialist pre-operative assessment by a care of elderly physician. Prevention of future fractures is being addressed too: 71 per cent of patients will receive both falls and bone health assessments before leaving hospital.

NHFD

Clinicians believe the expansion of the audit since 2007, and its success so far, reflect:

  • Information sharing, working together – The NHFD’s data, website and regional meetings promote good practice in clinical care, service development and evaluation. NHFD feedback informs clinician/management discussions about service problems and their solutions and closer working between orthopaedic surgeons and care of elderly specialists has demonstrably improved patient care and safety.
  • Proof of cost-effectiveness – The NHFD has demonstrated that ‘looking after hip fracture patients well is cheaper than looking after them badly’. Minimising unnecessary delay and providing good rehabilitation enables patients to recover more quickly and return home sooner – and reduces costs too.
  • New financial incentives for hospitals – The recent introduction by the Department of Health of the Best Practice Tariff (BPT) for hip fracture care – which rewards hospitals for each patient who receives the specified  BPT care standards as monitored by the NHFD.
  • A new approach to hip fracture care – With continuous feedback on the care quality, a wealth of information on clinical care and service improvement, an increasing recognition of the value of collaboration, and a new financial incentive, the care of hip fracture has been transformed. There has now emerged a critical mass of enthusiasm and expertise in the care of an injury which, though common, had not previously attracted the attention its seriousness merited.

The broad national trend towards improved care noted above is welcome. In addition, the Report includes recent examples of how individual hospitals have used the NHFD to support and monitor improvements in care:

  • In Wansbeck and North Tyneside hospitals, Northumbria, a quality improvement programme for hip fracture care began in October 2009. 90 per cent of patients in both hospitals now have surgery within 36 hours; all medically fit patients are mobilised on the day following surgery; and by March 2010 90 per cent of patients were meeting BPT care standards. In Wansbeck 30-day mortality has fallen from 11.7 per cent to 7.7 per cent.
  • In Kingston, London, the introduction in February 2010 of a full-time ortho-geriatrician, together with a multidisciplinary team initiative and closer collaboration between surgeons and anaesthetists, made improvements throughout the hip fracture care pathway. Mean time to surgery fell from 41 to 30 hours, and mean length of stay from 21 to 14 days; and 94 per cent of patients now have both falls assessments and osteoporosis care.
  • In Torbay, South Devon, a five-month project beginning in November 2010 worked to redesign the entire hip fracture clinical pathway in order to deliver prompt, patient-focused, cost-effective care.  Average time to theatre went down from 48 to 16 hrs; and acute length of stay from 10 to 7 days. Pain control was improved, complications were fewer, and substantial efficiency savings were achieved through reduced length of stay. Patient satisfaction with the care provided was high.

Despite such substantial national and local improvements, the report shows that there is still some way to go before every hip fracture patient can expect the best care, and significant variation persists across the country. Two percent of medically fit patients still wait more than four days for surgery – with serious implications for their recovery and survival; and detailed case mix-adjusted statistical analysis of 30-day mortality shows that a small number of hospitals have mortality rates that require detailed attention and further analysis.  Documentation of overall length of stay remains incomplete, and further work using Hospital Episodes Statistics (HES) data that measures overall (acute and post-acute) NHS length of stay will be undertaken. This is important, because patients want to return home as soon as it is safe to do so, and length of stay is the major determinant of the overall cost of hip fracture care.

Dr Colin Currie, consultant geriatrician and chair of the NHFD implementation group, said:

“This report shows how a national audit addressing the care of a serious common injury can make a difference on a national scale. The combination of reliable data, achievable standards, continuous feedback, and available know-how has attracted widespread clinical and managerial support, with real gains in both the quality and cost-effectiveness of hip fracture care. Clinical teams can look at their own data, spot problems, work together, make changes, and see measurable benefits resulting for the patients they look after.”

Peter Kay, President of the British Orthopaedic Association, said:

“The importance of this report cannot be over-stated. Not only does it demonstrate how we can improve the care of some of our frailest and most vulnerable patients, but it also highlights the enormous benefit of aligning NHS funding, as a driver of change, with best clinical practice.

The collaborative leadership between the British Geriatrics Society and the British Orthopaedic Association that created the NHFD has driven positive change at the clinical "sharp end". It has done this by empowering local multidisciplinary teams to deliver continuous improvement in care, and through the advent of innovative NHS funding models designed to incentivise "best practice". These models actively support local management in focusing resources to develop high quality services and drives out poor practice. This is a model of healthcare that has clear potential to be more widely adopted across the NHS.”

Professor Norman Williams, President of the Royal College of Surgeons, said:

“This report shows once again that transparent publicly reported clinical outcome measures lead to a better understanding of how to organise surgery and better results for patients. The Royal College of Surgeons would like to see this approach be made mandatory across surgery.”

The NHFD is a collaboration between the British Geriatric Society and British Orthopaedic Association with funding from the Healthcare Quality Improvement Partnership. From March 2012 the audit is set to merge with the Royal College of Physicians falls audit and expand to cover other forms of fracture suffered by elderly patients in a re-titled “Falls & Fragility Fractures Audit”. The full NHFD 2011 National Report will be available from: http://www.nhfd.co.uk/.


Notes to Editor
1. The Royal College of Surgeons of England is committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care. Registered charity number: 212808. For more information please visit www.rcseng.ac.uk

2. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices.  Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales.  HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Their purpose is to engage clinicians across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. The programme comprises 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions, including diabetes.     

3. If you have any queries please contact:
Matthew Worrall             – Email: mworrall@rcseng.ac.uk; T: 020 7869 6047
Elaine Towell                 – Email: etowell@rcseng.ac.uk; T: 020 7869 6045
Heather Casey               --Email: hcasey@rcseng.ac.uk T: 020 7869 6042
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