A Johansen

Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society.

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri‐operative period . The advice presented is based on previously published advice and clinical studies.

The National Hip Fracture Database (NHFD) – Using a national clinical audit to raise standards of nursing care

The National Hip Fracture Database (NHFD) is a key clinical governance programme for staff working in trauma wards across England, Wales and Northern Ireland. It uses prospectively collected information about the 65,000 people who present with hip fracture each year, and links these with information about the quality of care and outcome for each individual. The NHFD can, therefore, provide a picture of the care offered to frail older people with this injury - people who, between them, occupy nearly half of inpatient trauma beds. The NHFD uses its website (www.nhfd.co.uk) to feed back live information to each of the countries 180 trauma units - allowing them to bench mark their performance against national standards, and against that in other hospitals. This helps to develop a consensus over the best care for frail older people in areas where national guidance is not yet available. This article shows how the NHFD is contributing to four key aspects of patient safety and nursing care: the prevention of pressure ulcers and post-operative delirium, the monitoring of falls incidence across hospitals and nutritional assessment of patients with hip fracture.

Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database

Hip fracture is the most common reason for older patients to need emergency anaesthesia and surgery. Up to one‐third of patients die in the year after hip fracture, but this view of outcome may encourage therapeutic nihilism in peri‐operative decisions and discussions. We used a multicentre national dataset to examine relative and absolute mortality rates for patients presenting with hip fracture, stratified by ASA physical status. We analysed ASA physical status, dates of surgery, death and hospital discharge for 59,369 out of 64,864 patients in the 2015 National Hip Fracture Database; 3914 (6.6%) of whom died in hospital. Rates of death in hospital were 1.8% in ASA 1–2 patients compared with 16.5% in ASA 4 patients. Survival rates for ASA 4 patients on each of the first three postoperative days were: 98.8%, 99.1% and 99.1% (compared with figures of > 99.9% in ASA 1–2 patients over these days). Survival on postoperative day 6 was 99.4% for ASA 4 patients. Nearly half (48.6%) of the 1427 patients who did not have surgery died in hospital. Although technically sound, a focus on cumulative and relative risk of mortality may frame discussions in an unduly negative fashion, discouraging surgeons and anaesthetists from offering an operation, and deterring patients and their loved ones from agreeing to it. A more optimistic and pragmatic explanation that over 98% of ASA 4 patients survive both the day of surgery and the day after it, may be more appropriate.

Hip fracture presentations are less frequent at weekends

For many medical and surgical conditions the people presenting at the weekend will be different from those who are well enough to delay their presentation until the working week, or to be admitted electively for investigation and treatment when weekday services are available. As a result the question of a ‘weekend effect’ remains controversial, despite suggestions of poorer outcome for people who are admitted to hospital at the weekend [1]. Patients with hip fracture cannot delay their presentation in this way, so this condition may provide a more objective test of the differences between weekday and weekend care. The publication in Injury of a study taking just this approach in one hospital in the Netherlands [2] provides a useful addition to the recent UK study which examined data for 241,446 patients admitted to about 180 hospitals between 2011 and 2014 [3]. However, work by the National Hip Fracture Database (NHFD) has now identified an additional confounding factor that such studies should consider. The NHFD is a national clinical audit which collects data on all over 60 year olds with hip fracture in England, Wales and Northern Ireland including the day on which they first attended the emergency unit or presented to the inpatient orthopaedic team [4]. During 2015 the NHFD recorded a total of 64,848 patients (mean age 83 years; 72% women) presenting to 177 acute hospitals. In total 47,577 people presented on the five weekdays; 10.2% more than on the days of the weekend (8848 on Saturday and just 8432 on Sunday).