Improving hip fracture care: take the plunge

Trauma and Orthopaedic Consultant Bob Handley on improving quality of care for patients with fragility hip fractures.

Blog post

Published: 22/11/2013

A long time ago I worked in the Antarctic. Groups of penguins would gather on the edge of an ice floe, aware of the direction they needed to go, they jostled for position but did not advance.

One or two brave souls would set off, they may have fallen to predators or they may have survived, but the others waited and waited, then eventually something persuaded the majority to follow.

Whilst fragility hip fractures have increased in number, they have been a common problem for many years. Most involved with these patients have known that their care was far from ideal.

The surgery was often delayed, carried out by unsupervised juniors; the medical co-morbidities were managed (if at all) by juniors; rehabilitation was disjointed; prevention of further falls and bone health ignored.

A few doctors, like the penguins in the Antarctic vanguard, did forge ahead. By their individual effort they constructed a system around them to serve a local population but the majority did not follow.

So what has happened to persuade the majority to take the plunge?

The first and most important point is that deep down everyone involved did really know that the status quo was wrong. Surgeons, geriatricians, physios, nurses, occupational therapists, managers, GPs all knew. All the little pushes and nudges to better practice were there, waiting to be joined up.

Whilst people knew in general what they should do to improve care, this was given some form as it was codified into guidelines, suggesting standards of care put forward by professional bodies, the British Geriatrics Society and the British Orthopaedic Association.

The National Hip Fracture Database (NHFD) was initiated by others on a voluntary basis, recording the process of hip fracture management hospital by hospital. Then crucially Best Practice Tariffs (BPT) were introduced to oil the wheels.

The targeting of BPT on measures that clinicians instinctively knew made sense meant that managers and clinicians were working in synergy.

BPT included simple points such as surgery being provided within 36 hours of admission, having care directed to a plan jointly agreed by surgeons and orthogeriatricians, and assessing bone health.

The NHFD was then used as the official tool to monitor adherence to BPT and hence payment. This led to an increase in the volume and quality of data.

We felt we were doing better, we were demonstrably performing our process tasks better and we were all encouraging each other to do it.

Those who remember school biology will recognise this as a positive feedback system; that is, one which tends to lead to a change of state, such as blood clotting or generation of a nerve impulse. It is in contrast to a negative feedback system we are all too familiar with which maintains the status quo.

The starkest indicator of this change of state in the QualityWatch report is the 22.9% decrease in the 30-day mortality rate for hip fractures in 10 years. It is a tribute to those involved in the process. However, the effort is not over.

The penguins now sit on another ice floe, granted it is further forward; but they are jostling again. They need another prompt to move on.

They need to work to produce a ‘seamless junction’ between institutional and community care, to properly recognise that a hip fracture is not the only important fragility fracture and better monitor not just the process and mortality but also measures of the quality of outcome.

Bob Handley is a Trauma and Orthopaedic Consultant in Oxford. He is president elect of the Orthopaedic Trauma Society and also sat on the NICE hip fracture guideline development group. Please note that the views expressed in guest blogs on the QualityWatch website are the authors' own.