Colin Currie

Standardised Audit of Hip Fracture in Europe (SAHFE)

The Standardization Audit of Hip Fracture in Europe (SAHFE) project aims to encourage centres in Europe to participate in hip fracture audit. It defines a data set consisting of a core of 34 questions which includes outcome measures at 120 days from injury. In addition there is a larger number of optional questions. It is envisaged that each participating centre will collect and analyse its own data, with national centres to provide comparative data. Because the data is standardised, international comparisons can be made, thereby assisting in defining the optimal method of treatment and rehabilitation for this common condition.

Contribution from geriatric medicine within acute medical wards.

In 1977 a scheme of attachment to acute medical wards of consultants in geriatric medicine and associated junior medical staff was instituted in a large Edinburgh teaching hospital. The effect on admissions of patients aged 65 and over was examined for comparable periods before and during this arrangement. Mean and median stays were reduced for both sexes but more noticeably for women. The mean stay for all women aged over 65 was reduced from 25 to 16 days and for women aged over 85 from 50 to 19 days. The proportion staying under two weeks was significantly increased in both sexes, and the proportion discharged home also increased, correspondingly fewer patients being transferred to convalescent wards. These changes were not accompanied by increased transfers to the geriatric department, and probably the skills and extra resources available to the geriatric service were the factors mainly responsible for the changes in performance.

The Impact of a National Clinician-led Audit Initiative on Care and Mortality after Hip Fracture in England: An External Evaluation using Time Trends in Non-audit Data

Background:Hip fracture is the most common serious injury of older people. The UK National Hip Fracture Database (NHFD) was launched in 2007 as a national collaborative, clinician-led audit initiative to improve the quality of hip fracture care, but has not yet been externally evaluated. Methods:We used routinely collected data on 471,590 older people (aged 60 years and older) admitted with a hip fracture to National Health Service (NHS) hospitals in England between 2003 and 2011. The main variables of interest were the use of early surgery (on day of admission, or day after) and mortality at 30 days from admission. We compared time trends in the periods 2003–2007 and 2007–2011 (before and after the launch of the NHFD), using Poisson regression models to adjust for demographic changes. Findings:The number of hospitals participating in the NHFD increased from 11 in 2007 to 175 in 2011. From 2007 to 2011, the rate of early surgery increased from 54.5% to 71.3%, whereas the rate had remained stable over the period 2003–2007. Thirty-day mortality fell from 10.9% to 8.5%, compared with a small reduction from 11.5% to 10.9% previously. The annual relative reduction in adjusted 30-day mortality was 1.8% per year in the period 2003–2007, compared with 7.6% per year over 2007–2011 (P<0.001 for the difference). Interpretation:The launch of a national clinician-led audit initiative was associated with substantial improvements in care and survival of older people with hip fracture in England.

Hip fracture care: all change

Hip fracture is the most common serious consequence of falls in older people, with a mortality rate of 10% at 1 month, 20% at 4 months and 30% at 1 year [1]. Many of those who recover suffer a loss in mobility and independence: approximately half of those previously independent become partly dependent, while one-third become totally dependant [2]. Hip fracture accounts for more than 20% of orthopaedic bed occupancy in the United Kingdom, and 87% of the total cost of all fragility fractures, and is thus, by far the most expensive fracture associated with osteoporosis [3]. In 2005–06, the acute care of 68,416 hip fracture patients in England cost the NHS an estimated £ 781 million [4]. The average age of patients with fractured neck of the femur is 81 years, and 75% of these are female. Many are frail and have significant co-morbidities, which may lead to delay before surgery and slow functional recovery. The median superspell (total time in NHS care) is 28 days, although this varies considerably from trust to trust, ranging from 17 to 40 days. In the past year, one-third of trusts have seen rises in the superspell bed days of between 1 and 9 days [5]. The journey of care for patients with hip fracture is complex and challenging, involving many professionals and several clinical departments, and often crossing a number of service boundaries. These patients are among the most frail to be admitted to hospital, and their outcomes depend critically on how effectively their care pathway is managed. Avoidable delay, incomplete assessment and lack of attention to important details—such as co-morbidities, fluid balance and nutritional status, as well as the underlying cause(s) of the fall and subsequent management of their osteoporotic risk—will result in poorer outcomes. Pre-operative delays increase mortality and, in those who survive, prolongs postoperative stay. For every additional 8 h delay to surgery after the initial 48 h, an extra day in hospital results [6]. Current models of care fall far short of the ideal to provide optimal care. The three key strategic elements towards improving hip fracture care are:

Hip fracture rehabilitation -- a comparison of two centres.

The outcomes for 2005 consecutive patients aged 50 years or over admitted to two orthopaedic centres with a hip fracture were prospectively studied. All the patients were followed up to 1 year from injury. The mean orthopaedic ward stay was shorter in Edinburgh in comparison to Peterborough (20 versus 10 days), but the total hospital stay was shorter in Peterborough (34 versus 22 days). In Peterborough twice as many patients were discharged directly back from the orthopaedic ward to their place or origin (82 versus 41%). At 1 year from injury 34% of the patients had died. Factors associated with an increased mortality were increased age, male sex, pre-fracture place of residence and impaired mobility. For the survivors, the patients from Edinburgh had an increased mortality but were older, more likely to have impaired mobility and to come from more dependent residential accommodation. The different mortality between centres (30 versus 36%) was not statistically significant when adjusted for the possible confounding factors.

Improving the experience of hip fracture care: A multidisciplinary collaborative approach to implementing evidence-based, person-centred practice

BACKGROUND Hip fracture care is well supported by national guidelines and audit that provide evidence of safe interventions and an improved process. In the drive for organisational efficiency, complications have been reduced and length of stay shortened. Prioritising targets and performance alone can lead to poor multidisciplinary communication that potentially omits the psychosocial needs of older people recovering from hip fracture. AIM To explore a multidisciplinary collaborative approach to implementing evidence-based, person-centred hip fracture care. DESIGN Collaborative inquiry. METHODS Sixteen clinical leaders (n = 16) from different disciplines, working with older people with hip fracture at different stages of the care pathway participated in eight two-hourly facilitated action meetings. Data collection included strengths and limitations of the present service, values clarification, clinical stories, review of case records and reflections on the stories of three older people and two carers. RESULTS Hip fracture care was driven by service pressures, guidelines and audits. The care journey was divided into service delivery units. Professional groups worked independently resulting in poor communication. Time away from practice enabled collaboration and the sharing of different perspectives. CONCLUSIONS Working together improved communication and enhanced understanding of the whole care experience. IMPLICATIONS FOR PRACTICE Enabling teams to find evidence of safe, effective person-centred cultures requires facilitated time for reflective practice.

HipMod: Development of a Multi-Agent Audit-Based Computer Simulation of Hip Fracture Care

This paper describes the development of a computer simulation of the care of hip fracture, a common and serious injury with a complex journey of care. The project made use of a national, evidence-based guideline on hip fracture care, together with data from a national hip fracture audit and from service and research sources. To overcome the recognized limitations of such data in the modelling of care, clinicians from different specialties and disciplines working on hip fracture care participated by means of multi-agent-based modelling techniques. The model followed the journey of care (admission, surgery, rehabilitation, discharge or death), and, by incorporating the clinical reasoning of experienced practitioners, was developed to reflect the realities of day-to-day clinical decision-making. It was evaluated in terms of the credibility of its outputs with clinical participants, and by formal statistical comparisons of its outputs with real outcomes from comparable groups of patients in the national audit. The model was used to explore the impact of guideline compliance on care and resource use. Further modelling might serve to explore the implications of different service configurations for hip fracture care; to support service planning for demographic change; and to assist clinical training.

Devolution and the Scottish NHS.

Scotland, with a population of five million people, is in that respect comparable to an English health region. Thereafter, similarities fade. Responsibilities for the NHS in Scotland lie, not with a regional authority, but directly with a Scottish Office minister and his civil servants in St Andrews House, Edinburgh. Per capita spending on health is higher in Scotland than in England, yet many health indicators remain obstinately worse. And even the history of the NHS in Scotland is different; a separate piece of legislation–the National Health Service (Scotland) Act 1947–established different procedures for appointing consultants and greater participation by universities in the running of the service, and sought to ensure that “the special virtues of the Highlands and Islands Medical Service would be protected and extended to the nation as a whole.”1 More recent reforms, seen as driven by the problems and politics of England, have been generally less admired. Market led and quango based solutions, …