Quality and Safety Programme Fractured neck of femur. Case for change

Transcription

1 Quality and Safety Programme Fractured neck of femur Case for change February 2013

2 TABLE OF CONTENTS Foreword... 3 Executive Summary... 4 Key Messages Introduction Context Defining the scope of the review Fractured neck of femur best practice standards Variation in outcomes in London Poor outcomes and delays to operations Failing to achieve best practice Reasons for delay Variation in length of stay and emergency readmissions relating to hip fracture Patient experience Variation in service arrangements Lack of effective and immediate pain relief soon after admission Being admitted to an appropriate ward Poor utilisation of critical care resources Lack of consultant involvement Freed from all other clinical duties Decision to operate The recognition and management of co-morbidities Lack of consultant anaesthetist involvement Performing the operation Planned trauma lists Post-operative care and secondary prevention Lack of regular and consistent input from multi-disciplinary teams Secondary prevention Using the enhanced recovery programme Conclusion Glossary of terms Appendix 1: Membership of the emergency department fractured neck of femur pathway Appendix 2: Provider Codes

3 Foreword In London the number of people being admitted to hospital with a fractured neck of femur (fractured hip) is increasing. A large proportion of these admissions will be elderly and frail patients who, in an emergency, will have no choice about which hospital they will be admitted to. I am aware that patients expect a high level of quality care from every hospital within London, regardless of the day of the week or the time. Therefore, it is my expectation that all hospitals in London should be working to deliver the best quality of care for all fractured neck of femur patients. The British Orthopaedic Association and the British Geriatric Society highlighted in the Blue Book (2007) the importance of early involvement by orthopaedic surgeons, consultant orthogeriatricians and consultant anaesthetists, as well as delivering collaborative care for fractured neck of femur patients as key to delivering improved outcomes. Evidence from clinical bodies has shown that earlier surgery for hip fracture patients is associated with decreased mortality. Additionally, rehabilitation and secondary prevention of fractures is integral to aid patients to regain mobility as well as prevent a subsequent fracture. However, the evidence has shown there is a large variation in the waiting time for patients to have their surgery as well as the availability of rehabilitation services across London. Today in London there are significant differences in the delivery of care across London. Patient outcomes are impacted by both the hospital the patient presents in as well as the day of the week they are admitted. The existing variation in current services cannot be allowed to continue and all fractured neck of femur within London should be moving toward providing a consistent consultant-delivered, high quality and safe service seven days a week to optimise patient outcomes. This review explored the current services delivered to fractured neck of femur patients that presented to London Hospitals during weekdays and weekends by reviewing the availability of key staff, access to diagnostics as well as the rehabilitation services available. From the clinical guidelines, evidence and recommendations that have been reviewed, the fractured neck of femur clinical expert panel and I are firmly behind having a standardised approach to the delivery of fractured neck of femur services across London. On behalf of the fractured neck of femur clinical expert panel, I would like to extend my gratitude to all the individuals that contributed to the composition of the case for change which demands for improvements in the quality and safety of London s fractured neck of femur services. Mr Gavin Marsh Associate Medical Director and Consultant Orthopaedic Surgeon at Croydon Healthcare Service NHS Trust Chair of the Quality and Safety Programme fractured neck of femur clinical expert panel 3

4 Executive Summary This case for change sets out the context of the fractured neck of femur services review and summarises the key issues affecting the quality and safety of fractured neck of femur services provided in London. This case has identified variations in the service across London and will be used as the evidence base for setting London quality standards for the aforementioned service. It outlines: Delays to operations and the impact this has on mortality The variation of consultant presence within different specialities Access to multidisciplinary services and rehabilitation The British Orthopaedic Society has highlighted that consultant orthopaedic surgeons and consultant physicians provide the senior clinical leadership necessary to deliver improved outcomes for fractured neck of femur patients. Consultants need to review fractured neck of femur patients at the early stages of their pathway in order to make vital decisions that will impact their treatment plan. However, the variation in consultant orthopaedic surgeon, physician and anaesthetist presence in London hospitals, especially at weekends, creates a considerable deficiency in senior decision-making and supervision which impacts on patient care and outcomes. The availability of rehabilitation services and secondary prevention is also an integral component of an effective fractured neck of femur service to enable the enhanced recovery of the patient. In London, the varying levels of rehabilitation provision and the delivery of secondary prevention programmes within hospitals means that a number of patients will have increased lengths of hospital stays and increased risk of repeated fractures leading to high readmission rates. Key Messages Patients admitted as an emergency do not have time to choose their hospital destination. The vast majority of patients will attend their nearest hospital. This means that it is even more important to ensure that services are not only equitable, but also of a consistently high standard. Current variation in time to operation for fractured neck of femur patients in London is unacceptable. Timely operations have a significant impact upon mortality and complication rates and yet almost a third of hospitals in London are below the national average and have at least 20% of operations that take place over two days after admission. Scotland is currently out performing London by having 84% of all operations within 24 hours. Furthermore, patients in London who are admitted on a Friday or a Saturday are 18% more likely to have their operation carried out over two days after admission. Admitting patients onto the appropriate ward will decrease delays to time of operation, as well as ensuring that patients have access to the right clinical professionals and services. Currently, over a third of patients are not being admitted and managed on the appropriate wards in hospital sites across London. 4

5 Length of hospital stay, re-admission and/or re-operation rates are key indicators for quality and have a substantial impact on patient outcomes. Current variations in these indicators suggest that high quality care is not consistent for fractured neck of femur patients in London. Early pre-operative involvement of a consultant geriatrician or physician is vital to optimise patients for timely surgery and yet there is considerable variation across London in the availability of these consultants, particularly between the weekday and weekend with only 52% of patients undergoing preoperative assessment by a geriatrician 1 Consultant orthopaedic surgeon input into patient care is vital to improved patient outcomes. Over half of consultant orthopaedic surgeons in London sites are not free from other duties when on-take and are unable to review fractured neck of femur patients within twelve hours of admission, as recommended in best practice guidance. Lack of direct consultant orthopaedic surgeon involvement in performing operations has a negative effect on patient outcomes. Despite the fact that fractured neck of femur operations are procedures with high mortality rates, there is no site in London currently that has all fractured neck of femur operations carried out by a consultant orthopaedic surgeon; a quarter of hospitals having a consultant perform the operation only sometimes. Lack of consultant anaesthetist involvement in operations has a negative effect on patient outcomes. Currently the availability of consultant anaesthetists varies across hospitals in London, and even more so at weekends. The use of critical care for pre- and post- operative optimisation varies across London, despite clinical consensus that it would benefit fractured neck of femur patients. Multi-disciplinary input into patient care is a vital component of recovery and rehabilitation for patients and yet there is stark variation in the availability of therapy services between weekday and weekend. The key to ensuring patients have a positive patient experience is delivering a highquality service which involves prompt assessment and treatment, good clinical outcomes with effective communication and seamless coordination of services and care. Applying the enhanced recovery programme method in the rehabilitation of fractured neck of femur patients will enhance patient recovery while producing overall better outcomes. In London hospitals, the use and delivery of the enhanced recovery programme is inconsistent, resulting in variable outcomes for patients. Secondary prevention is a key component in preventing future fractures for patients and is recommended by NICE and the British Geriatric Society. In London, there is not an agreed delivery method for secondary prevention. This means that patients 1 National Hip Fracture Database (NHFD) The National Hip Fracture Database National Report NHFD. 5

6 in London will have varied levels of secondary prevention, which could result in repeated fractures and long-term re-admissions. 6

7 1. Introduction A patient presenting to hospital as an emergency with a fractured neck of femur (fractured hip) has little choice as to where or when they attend. With an average age of above 75 years and a one in ten chance of dying within one month, patients with a fractured neck of femur represent some of the frailest patients in London. It is vital that the organisation of care in place across London s providers is consistently safe and of high quality to ensure patients receive the best possible care and outcomes. The adult emergency services case for change demonstrated an increased likelihood of dying if admitted as an emergency patient at the weekend. This analysis included patients that were admitted as an emergency for a fractured neck of femur. If the weekend mortality rate in London was the same as the weekday rate there would be a minimum of 500 fewer deaths a year. Reduced service provision at weekends is associated with this higher mortality rate 2. For fractured neck of femur patients numerous reports continue to identify poor outcomes linked to a lack of senior involvement and organisational failings, such as the lack of effective multi-disciplinary collaboration, which are further depleted at weekends 3,4. A key early indicator of a patient s outcome is the time to operation from time of admission; best practice is for operations to be performed within 36 hours as a key marker of quality. As well as being detrimental to patient experience, delays in the time to operation have clear links to increased mortality rates. For this reason Scotland now mandate all patients to be operated on within 24 hours if medically fit. Data from 2011/12demonstrates clear variations in time to operation across London; just under a third of hospitals had over 20% of their operations carried out after two days of admission into hospital, which is far below what is now considered best practice and lags far behind performance in Scotland. Overall, the variation in service provision and outcomes for fractured neck of femur patients in London needs to be addressed. All fractured neck of femur patients should be medically optimised quickly for surgery to ensure operations are performed without delay; this requires early assessment and ongoing direct involvement in patient care from a range of consultants and this needs to be happening consistently across all seven days of the week, this is not currently happening across hospitals in the capital Context There are over 60,000 hip fractures every year in the UK 5 and around 7,000 of these were in London 6. Almost all hip fractures are admitted as an emergency; in London 2009/10 95% of hip fractures were emergency admissions 7. Surgery is the main treatment for a fractured hip with 98% of hip fractures treated in this way in 2010/11. A fractured neck of femur is a condition that primarily affects the elderly; in London the average age of a hip fracture patient is 76 (male) and 81 (female) 8. It is also an injury that primarily affects women with 70% of admissions were female in London London Health Programmes (2011) Adult emergency services: case for change. London Health Programmes. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2010) An age old problem? A review of the care received by elderly patients undergoing surgery. NCEPOD. Dr Foster (2011) Inside your hospital: Dr Foster hospital guide Dr Foster Intelligence. Bottle, A. and Aylin, P. (2006) Mortality associated with delay in operation after hip fracture: observational study. BMJ; 22 March Source: HES data 2009/10. Source: HES data 2009/10. Source: HES data 2009/10. 7

8 Mortality rates are high; one in ten people admitted will die within one month 9 and oneyear mortality rates are consistently around 30%. These elderly patients represent some of the frailest patients and will often present with complex co morbidities such as dementia and diabetes that require specialist management. Reflecting the age and complex needs of the patient, the lengths of stay in hospital are long: fourteen days is the average length of stay following a hip fracture 10 and in 2010/11 8% of hip fractures in London had hospital stays of over 30 days. As the elderly population is projected to increase it is important that robust systems are put in place so that care now and all future care is high quality and consistent across London to improve patient outcomes for this growing population Defining the scope of the review The scope of this review is patients admitted as an emergency to hospital with a fractured neck of femur covering a patient s assessment, treatment plan and subsequent care plan until they are discharged from hospital or to another specialist ward for treatment not directly related to the fractured neck of femur Fractured neck of femur best practice standards There are two key sets of standards that form the current basis for treatment of a fractured neck of femur. The British Orthopaedic Association published six blue book standards to reflect good practice at key stages of hip fracture care 13 : 1) All patients with a hip fracture should be admitted to an acute orthopaedic ward within four hours of presentation. 2) All patients with a hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours. 3) All patients with a hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer. 4) All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission. 5) All patients presenting with a fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures. 6) All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls. Building on this, in April 2011 the Department of Health introduced a best practice tariff (BPT) for hip fractures as a financial incentive to improve care, which was updated in 2012 to include cognitive screening. Hip fracture was chosen as a high volume clinical area National Institute of Health and Clinical Excellence (NIICE) (2011) The management of hip fracture in adults. NICE. Source: HES data 2009/10. Parker, M. and Johansen, A. (2006) Hip fracture. BMJ 2006; 333: World Health Organisation. Prevention and management of osteoporosis. EB11413, British Orthopaedic Association (BOA) & British Geriatric Society (BGS) (2007) The care of patients with fragility fracture. BOA. 8

9 with significant unexplained variation in quality of clinical practice and clear evidence of what constitutes best practice. The seven indicators to define best practice and to qualify for the best practice tariff are 14 : 1) The time to surgery is within 36 hours from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia. 2) Admitted under the joint care of a consultant geriatrician and a consultant orthopaedic surgeon. 3) Admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia. 4) Assessed by a geriatrician in the peri-operative period (defined as within 72 hours of admission). 5) Post-operative geriatrician-directed multi-professional rehabilitation team. 6) Fracture prevention assessments (falls and bone health). 7) Two Abbreviated Mental Health Tests (AMT) to be performed and all the scores recorded in the National Hip Fracture Database with the first test carried out prior to surgery and the second post-surgery but within the same spell. The case for change and any subsequent standards recognise the importance of these indicators as a benchmark for a quality service for fractured neck of femur patients in London. 14 Department of Health Payment by Results team (2010) Payment by Results guidance 2010/11. Department of Health. 9

10 2. Variation in outcomes in London Outcomes such as mortality, length of stay and emergency re-admission are key markers for quality of care for fractured neck of femur patients and considerable variation is found all between hospitals and further between weekdays and weekends. This shows that a patient s quality of care is dependent upon the hospital to which they are admitted and the day of the week they are admitted Poor outcomes and delays to operations One of the most crucial factors affecting outcomes and mortality following a hip fracture is how long the patient has to wait for surgery, with longer wait times associated with increased chances of dying 15,16,17 as well as increased lengths of stay 18,19 and additional complications 20. A recent review found that earlier surgery was associated with a 19% decreased chance of dying; a 41% decreased chance of developing pneumonia whilst in hospital and a 52% decreased chance of developing pressure sores 21. This is supported by an earlier review which found an operative delay of more than hours from the time of admission may increase the odds of death at 30 days by 44% and death at one-year after a fracture by 33% 22. Recent intelligence data confirmed a significant difference between the mortality rates of operations carried out within two days of admission (7.4%) compared with operations carried out over two days (10.1%) 23. Figure 1 shows the variation in operation waiting times in London. Nearly a third of acute providers in London failed to meet the national average and were unable to carry out at least 20% of operations within two days of admission; three of these providers were judged to have waiting times significantly above the national average Simunonvic, N. et al (2010) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. October 19, (15) Bottle, A. and Aylin, P. (2006) Mortality associated with delay in operation after hip fracture: observational study. BMJ; 22 March 2006 Siegmeth, A. W. et al (2005) Delays to surgery prolongs hospital stay in patients with fractures of the proximal femur. The journal of bone and joint surgery. Vol 87 B, No 8, August Khan, S. et al (2009) Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. Volume 40, Issue 7: , July 2009 Siegmeth, A. W. et al (2005) Delays to surgery prolongs hospital stay in patients with fractures of the proximal femur. The journal of bone and joint surgery. Vol 87 B, No 8, August Orisz, G. M. et al (2004) Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004; 291: Simunonvic, N. et al (2010) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. October 19, (15) Shiga, T. et al (2008) Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Canadian Journal of Anaesthesia. 55:3. March Dr Foster (2011) Inside your hospital: Dr Foster hospital guide Dr Foster Intelligence. 10

11 Figure 1: Percentage of hip fracture operations not carried out within two days (2010/11) Source: National Hip Fracture Database 2012 The report also found that the proportion of patients who waited for more than two days for an operation was significantly higher for those who were admitted on a Friday or Saturday compared with patients admitted on Sunday to Thursday. Figure 2 shows that in London hospitals, patients admitted on Friday and Saturday are 18% more likely to wait two days or longer for their operation compared to those admitted Sunday to Thursday. Figure 2: Percentage of hip fracture patients in London operated on after two days by day of the week admitted Source: HES 2010/11 11

12 This reinforces findings from earlier studies which have shown that patients admitted overnight or at a weekend were more likely to have to wait for an operation over two days 24. This suggests that historical working patterns which conform to normal Monday to Friday working hours, rather than medical reasons related to the patient, are the main drivers behind the delays 25. With delays so clearly linked to mortality rates, this is an unacceptable situation that cannot continue in London Failing to achieve best practice As early as 1989 the Royal College of Physicians recommended that all fractured neck of femur patients should be operated on within 24 hours 26. Later guidance from the British Orthopaedic Association recommended that hip fracture patients are operated on within 48 hours 27. The latest guidance from NICE (2011) recommends that surgery is performed on the day or the day after admission 28 and the current Department of Health Best Practice Tariff recommends that all hip fracture surgery is performed within 36 hours 29. The recommended best practice in Scotland is that all hip fracture operations are carried out within 24 hours. Scotland s latest figures suggest that, including those medically unfit for operation and those that were treated without surgery, 84% of patients are operated on within 24 hours. London and Scotland have similar numbers of admissions for fractured hips 30, however, as Figure 3 illustrates, London is lagging far behind Scotland in achieving this rate of operations within 24 hours. If London was to match Scotland s rate then the outcomes for thousands of patients could be improved Bryson, G. L. (2008) Waiting for hip fracture repair do outcomes and patients suffer? Canadian Journal of Anaesthesia. 55:3 March National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2010) An age old problem? A review of the care received by elderly patients undergoing surgery. NCEPOD. Royal College of Physicians (1989) Fractured neck of femur: prevention and management. Royal College of Physicians. British Orthopaedic Association (BOA) (2008) The care of patients with fragility fracture. BOA. National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE. Approximately 7,

13 Figure 3: Time to operation for hip fracture patients in London Source: National Hip Fracture Database 2012, Scottish Hip Fracture Audit Reasons for delay For a minority of patients there may be clinical reasons for delays to surgery, such as medical stabilisation and the treatment of co-morbidities. Delays that are related to a poorly functioning system should not be occurring 31. These include waiting for routine medical consultation 32, the unavailability of operating theatre or surgeon 33, 34, 35, 36, waiting for family discussion 37 or waiting for laboratory results Bottle, A. and Aylin, P. (2006) Mortality associated with delay in operation after hip fracture: observational study. BMJ; 22 March 2006 Orosz, G. M. et al (2002) Hip fracture in the older patient: reasons for delay in hospitalisation and timing of surgical repair. Journal of Geriatric Society. 2002; 50: Parker, M. J. and Pryor, G. A. (1992) The timing of surgery for proximal femoral fractures. Journal of Bone Joint Surgery. 1992; 74: Zuckerman, J. D. et al (1995) Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. Journal of Bone Joint Surgery. 1995; 77: Moran, C. G. et al (2005) Early mortality after hip fracture: is delay before surgery important? Journal of Bone Joint Surgery 2005; 87: Siegmeth, A. W. et al (2005) Delays to surgery prolongs hospital stay in patients with fractures of the proximal femur. The journal of bone and joint surgery. Vol 87 B, No 8, August Siegmeth, A. W. et al (2005) Delays to surgery prolongs hospital stay in patients with fractures of the proximal femur. The journal of bone and joint surgery. Vol 87 B, No 8, August

14 Figure 4 shows the reason for delays in operating on patients within 36 hours for London. It shows that a large majority of patients had delayed operations because of working arrangements and medical reasons, with 33% of patients waiting for medical review and 35% waiting for theatre space. Figure 4: Reason for no operation in 36 hours by London provider, 2011/12 Source: National Hip Fracture Database This only includes patients having surgery over 36 hours *Excluding London Key message None of the hospitals in London are able to operate on all their patients within two days and all are falling below current best practice recommendations and 24 hour operation performance in Scotland. This is unacceptable considering there are clear links between delays to operation and mortality rates. Furthermore patients in London who are admitted on a Friday or a Saturday are 18% more likely to have their operation carried out after two days due to unacceptable variations in working arrangements. 38 Siegmeth, A. W. et al (2005) Delays to surgery prolongs hospital stay in patients with fractures of the proximal femur. The journal of bone and joint surgery. Vol 87 B, No 8, August

15 2.4. Variation in length of stay and emergency readmissions relating to hip fracture Patient lengths of hospital stay as well as re-admission and/or re-operation rates are key indicators for quality and have substantial impact on patient outcomes. Higher re-operation rates and longer lengths of hospital stay are linked to higher mortality rates in patients with hip fractures 39. Figures 5 and 6 show these key indicators of quality for fractured neck of femur service delivery in London. It is clear that there is substantial and significant variation across London. Whilst some hospitals are better than the national average, there are hospitals which sit closer to or worse than the national average. The average length of stay for a hip fracture patient is about two weeks. Varying length of stay has many factors but can indicate variations in quality of care and service arrangements. It also emphasises the importance of joined up working with GPs and social services, which are important to facilitate swift discharge and follow up care and rehabilitation. Poor access to these services could increase length of stay for some patients. Figure 5: Variation in length of stay for hip fracture patients across London (2010/11) Source: National Hip Fracture Database National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE 15

16 An emergency re-admission relating to hip fracture is an indicator of variation in social services and support on discharge as well as inappropriate and/or inadequate care packages given to discharge patients. High numbers of emergency re-admissions that relate to hip fractures are an indication of an inadequate service. Figure 6 shows the variation in emergency re-admission ratio for fractured neck of femur patients in London. Figure 6: Variation in emergency re-admission relating to hip fracture within 28 days for London (2010/11) Source: Dr Foster Hospital Guide 2011 Key message: The length of hospital stay as well as re-admission and/or re-operation rates are key indicators for quality and have a substantial impact on patient outcomes. Almost half of London hospitals are above the national average for rates of re-admission within 28 days and over half have a length of stay above the national average. This level of variation is an indicator that high quality care is not consistent for fractured neck of femur patients in London. 16

17 2.5. Patient experience A high quality service is vital to ensure a positive experience for the patient and their family and carers. A patient s clinical outcome is key in determining their treatment experience. Patients having prompt pain relief, pressure sore prevention and the necessary intravenous fluids are all indicators of a quality service as set out in the Department of Health s care bundle approach 40 which seeks to have a positive impact on the patient s experience. Time to surgery is the most important factor in reducing morbidity and mortality 41 supporting the patient panel s endorsement with the clinical expert panel recommendation that operations should be carried out within 24 hours of admission. Delays to operation for patients can cause increased levels of discomfort and dissatisfaction due to waiting whilst in pain and because they often fasted in anticipation of earlier surgery. However, improving patient outcomes is not the only determinant for a positive patient experience. Good communications with patients and their families, the correct provision of information and appropriate surroundings should all be considered as important factors in creating a positive patient experience. Additionally effective coordination of the multi-disciplinary team will enable Hospitals to deliver the best model of care to the patient which will improve their recovery process, reducing the time spent in hospital and leading to a better quality of life. The patient panel consensus is that patient experience is vital and must therefore be considered in the context of quality standards. This was particularly clear around waiting times for operations and the swiftness of consultant review. Key message: The key to ensuring patients have a positive patient experience is delivering a high-quality service. This involves prompt assessment, minimal delays to surgery, good clinical outcomes with effective communication, and seamless coordination of services and care Royal College of Physicians (RCP) (2011) Falling standards, broken promises, London: RCP. D. Marsland, C. Chadwick (2009) Prospective study of surgical delay for hip fractures: impact of an orthogeriatrician and increased trauma capacity International Orthopaedics (SICOT) 34:

18 3. Variation in service arrangements 3.1. Lack of effective and immediate pain relief soon after admission Several studies have demonstrated that effective analgesia for a fractured neck of femur patient begins in the emergency department. The fascia iliaca compartment block (a localised anaesthetic nerve block) has been proven to provide efficient, safe and optimal pain relief for patients 42,43,44. This local anaesthetic nerve block should be performed by an experienced anaesthetist or an emergency physician or they should supervise delivery. The current use of such pain relief is variable across London. A fascia iliaca compartment block would also be a component of an enhanced recovery programme, designed to improve patient outcomes, patient satisfaction and enhanced recovery. Key message: An early fascia iliaca nerve block with local anaesthetic is proven to be beneficial to patient experience and outcomes by providing effective, dynamic analgesia, yet use of this in London is variable Being admitted to an appropriate ward To achieve the best standard of care for elderly hip fracture patients, they should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission 45. Being placed on the correct ward will increase the chances of seeing the orthogeriatrician - this will create a forum for early identification of any complications, easy access to appropriate services, as well as effective continuity of care. Figure 7 shows that one third of providers are unable to allocate patients with a fragility fracture including fractured neck of femur onto an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of the patients admission. Taking into account the benefit that could be derived from elderly fracture patients being placed on the appropriate ward, the level of providers in London not currently able to do so is unacceptable considering the ageing population in London Elkhodair, S. et al (2011) Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency departments: a pilot study. European Journal of Emergency Medicine 2011, 18: Dolan, J. et al (2008) Ultrasound guided fascia iliaca block: a comparison with the loss of resistance technique. Regular anesthesia and pain medicine, Vol 33, No 6, Foss, N. B. et al (2007) Fascia iliaca compartment blockade for acute pain control in hip fracture patients. Anesthesiology 2007; 106; British Orthopaedic Association (BOA) & British Geriatric Society (BGS) (2007) The care of patients with fragility fracture. BOA 18

19 Figure 7: Are all patients presenting with a fragility fracture managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission? Source: London Health Programmes audit 2012 Key message: Admitting patients onto the appropriate ward will decrease delays to time of operation, as well as ensuring that patients have access to the right clinical professionals and services. Currently, over one third of patients are not being admitted and managed on the appropriate wards in hospital sites across London Poor utilisation of critical care resources The benefits of pre- and post- operative optimisation by critical care for fractured neck of femur patients has been stated by the fractured neck of femur clinical expert panel as an aspiration for best practice. There is variation across London in the identification and use of critical care by different hospital pathways for fractured neck of femur pathways. With dedicated nursing for fragile patients, critical care has benefits to a patient s treatment and outcome that can not be delivered as consistently on a general ward 46. Key message: The use of critical care for pre- and post- operative optimisation varies across London despite clinical consensus that it would benefit fractured neck of femur patients. 46 British Orthopaedic Association (BOA) & British Geriatric Society (BGS) (2007) The care of patients with fragility fracture. BOA 19

20 4. Lack of consultant involvement All hip fracture patients should be assessed and prepped quickly for surgery and operations should be performed without delay. This requires early assessment and ongoing direct involvement in patient care from a range of consultants and needs to happen consistently across all seven days of the week, this is not currently happening across hospitals in the capital. The initial assessment of a patient is vital for confirming the diagnosis and ensuring that the patient is on the correct pathway within the hospital. It is important to recognise significant co-morbidities to ensure subsequent optimisation for timely surgery 47. This treatment planning and decision making requires senior input and swift consultant reviews. This is not always the case in London. Several major reports have identified a link with inadequate early consultant involvement and poor outcomes, including increased mortality 48, Freed from all other clinical duties Consultants should be available to deal with emergency admissions without undue delay and their job plans should include protected time for on-take commitments 50. However, job plans are not always arranged so that when on-take, consultants are released from other clinical duties (such as outpatient clinics and elective commitments) to focus on emergency admissions. Figure 8 shows that over half of orthopaedic surgeons are not completely free from elective duties when on-take. Figure 8: Orthopaedic surgeons that undertake elective duties when on call Source: London Health Programmes audit 2012 Key message: Consultant orthopaedic surgeon input into patient care is vital to improved patient outcomes. Yet over half of orthopaedic surgeons in London are not free from other duties when on-take National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2010). An age old problem? A review of the care received by elderly patients undergoing surgery. NCEPOD. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007). Emergency admissions: A step in the right direction, NCEPOD Royal College of Physicians (RCP) (2007). The right person in the right setting first time. RCP. 20

21 4.2. Decision to operate For very sick fractured neck of femur patients, the decision of whether or not to offer them an operation is very complex and significant. It is of paramount importance that decisions to operate are taken in agreement with a consultant as a senior, surgical decision maker 51 with input from anaesthesia and medicine, as well as the patient and/or their carer 52. The expertise and experience of an orthopaedic consultant is fundamental to assess the patient and ensure that the correct treatment plan is underway; a recent NCEPOD report identified 15% of cases where there had been a delay in consultant review for surgery 53. The report noted that the majority of patients have high ASA (American Society of Anaesthetist) grades; indicating high level of physical impairment which would need careful planning and management. Figure 9 and 10 shows that currently around 40% of hospital sites in London have consultant surgeon reviews very often within 12 hours during the week; one third of sites state that this will only be sometimes. At weekends over 10% of patients will rarely have a review by a consultant surgeon within 12 hours of admission. Figure 9: Are fractured neck of femur patients assessed by a consultant surgeon within 12 hours of admission Monday to Friday? Source: London Health Programmes audit ASGBI (2007). Op. cit McFarlane (2009) The Scottish Audit of Surgical Mortality: a review of areas of concern related to anaesthesia over 10 years. Anaesthesia 64: National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2010) An age old problem? A review of the care received by elderly patients undergoing surgery. NCEPOD 21

22 Figure 10: Are fractured neck of femur patients assessed by a consultant surgeon within 12 hours of admission Saturday-Sunday? Source: London Health Programmes audit 2012 Key message: For very sick fractured neck of femur patients, the decision of whether or not to offer them an operation is complex and significant. During weekdays in London only one third of hospitals consistently assess their patients within 12 hours of admission. This proportion drops by almost half during the weekend with only 18% of hospitals having consultant surgeon s assess their patients within 12 hours of admission. This level of variation for such a fundamental part of the patient pathway is unacceptable The recognition and management of co-morbidities The input of a physician or geriatrician, a consultant who specialises in medicine for the elderly, is essential to a fractured neck of femur patient s quality of care 54. There are considerable survival advantages of early optimisation for surgery and geriatrician input is key to this The recent NCEPOD review found that only 40% of cases were reviewed by a specialist consultant and that this was often only a weekly review. This means that the day on which a patient was admitted (a chance event) could mean that they were waiting for up to a week for the input of a specialist geriatric consultant. Patients should not be delayed for surgery because of awaiting routine tests whereby the results will not affect the surgical procedure 57, as delays increase the chances of medical complications and mortality, with reduced chances of effective rehabilitation National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE. NCEPOD (1999) Extremes of age. NCEPOD British Orthopaedic Association (BOA) & British Geriatric Society (BGS) (2007) The care of patients with fragility fracture. BOA National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE. 22

23 In 2007, the Scottish Hip Fracture Audit found that just 10 to15% of patients were unable to undergo surgery within 24 hours because they were not medically fit 58, resulting in 85% of all patients undergoing surgery within 24 hours. This shows that co-morbidities will present some complications for this group of patients but the percentage of medically unfit patients is small in comparison to the number of patients that will be medically fit to undergo surgery within 24 hours subject to the appropriate reviews and optimisation. London sites should therefore aim to perform surgery on all patients within 24 hours, with the small exception of those medically unfit, in order to achieve the best outcomes for this group of patients. Failure to recognise, and subsequently act upon the recognition of the high instances of delirium and dementia, has also had a significant impact on mortality for this group of patients. Recognising them in the pre-operative stage has a beneficial effect on patient outcomes. The expertise of a consultant physician is vital to this Yet the number of patients in London that are pre-operatively assessed by a physician or geriatrician varies considerably. The London Health Programmes Quality and Safety audit of acute hospitals 61 showed that only half of London hospital sites have a consultant geriatrician assess patients within 12 hours of admission and that for most sites this is reduced to only sometimes or rarely at the weekend. One fifth of London sites are never able to have a consultant see and assess their patients within 12 hours at the weekends. Figure 11 shows the percentage of patients in London that are pre-operatively assessed by a geriatrician varies considerably. Over half of London sites in London pre-operatively assess less than 50% of their patients, with five sites only assessing 15% or less of their patients Scottish Hip Fracture Audit (SHFA) (2007) The Scottish Hip Fracture Repot SHFA Robinson, T. N. et al (2009) Post operative delirium in the elderly. Annals of surgery 2009; 249: Inouke S. K. et al (2007) Risk factors for delirium at discharge. Development and validation of a predictive model. Archives of internal medicine 2007; 167: London Health Programmes (2012) Quality and Safety audit of acute hospitals. London Health Programmes. 23

24 Figure 11: Percentage of patients that are pre-operatively assessed by a geriatrician Source: National Hip Fracture Database 2012 The recent Quality and Safety audit of acute hospitals 62 found that there is a considerable difference in the number of hours a consultant geriatrician is required to be on site during weekdays and weekends. On average, a consultant geriatrician spends 6.5 hours a day more on the ward on weekdays than on the weekends. This is an enormous difference in geriatric presence on site which can lead to colossal consequences in medical services offered to the patient. Some hospital sites did not report an expected number of hours a consultant geriatrician is expected to be on site during the weekends. It could be perceived that this issue is not a matter of importance for their departments, resulting in consultant geriatric presence on the ward at weekends being left to randomised chance, which is unsatisfactory. Key message: Early pre-operative involvement of a consultant geriatrician or physician is vital to optimise patients for timely surgery. Although the London average for patients assessed preoperatively by a geriatrician is slightly higher than the national average of 52%, there are 14 hospitals that are below the national average. This variation in service is more apparent between weekdays and weekends, resulting in patients across London not receiving equitable care Lack of consultant anaesthetist involvement In London, not all fractured neck of femur patients have access to consultant anaesthetists, especially at weekends. This can cause delays in the time to surgery, as they are needed not only to administer anaesthetic but as also to assess a patient s fitness for surgery. Figure 12 illustrates the variation in consultant anaesthetist presence on weekdays compared to weekends. Currently there is marked variation across London in consultant anaesthetist presence between weekdays and weekends, with the average presence half of what it is for the weekday. 62 London Health Programmes (2012) Quality and Safety audit of acute hospitals. London Health Programmes. 24

25 Figure 12: Variation in consultant anaesthetist presence at weekdays compared to weekends Source: 2011 Survey of London acute trusts Key message: Lack of consultant anaesthetist involvement in the assessment of a patient s fitness for surgery and in the actual operation has an effect on patient surgical times and their outcomes. The London average consultant presence during weekdays is approximately 10 hours a day, which drops by half at the weekend. This level of variation will inevitably cause variations in operation delays, quality outcomes and the overall patient experience Performing the operation The presence of a consultant orthopaedic surgeon and a consultant anaesthetist in the operating theatre significantly improves patient care and outcomes 63, 64, 65. Research has found that poorer outcomes are associated with unsupervised non-consultants performing high risk surgery on emergency patients 66. Studies have demonstrated that there is a RCA (2009) Guidelines for the provision of anaesthetic services. Royal College of Anaesthetists. RCS (2004). Op. cit. ASGBI (2010) Emergency Surgery Survey Association of Surgeons of Great Britain and Ireland Newsletter Number 31; September 2010 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007) Emergency admissions: A step in the right direction, NCEPOD National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2010). An age old problem? A review of the care received by elderly patients undergoing surgery. NCEPOD. 25

26 significantly higher re-operation rate with unsupervised/junior orthopaedic surgeons with less than three years experience than senior more experienced surgeons 67. Equally, studies have demonstrated that one in five cases of anaesthesia related surgical mortality involved the grade of the anaesthetist being too junior, or the failure of junior staff to seek senior advice 68. In their review of fractured neck of femur patients NCEPOD found that only one third of operations were performed by a consultant orthopaedic surgeon. NICE recommends that consultant or senior staff should directly supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures 69. Figure 13 shows that no London hospital site currently has all of their operations performed by a consultant surgeon and just over a quarter have a consultant surgeon perform the operation only sometimes or rarely. Figure 13: Are fractured neck of femur operations carried out by a consultant orthopaedic surgeon? Source: London Health Programmes audit 2012 Key message: Currently, not one London hospital has all fractured neck of femur operations carried out by a consultant orthopaedic surgeon, which is worrying. The lack of direct consultant orthopaedic surgeon involvement in performing operations will have a negative effect on patient outcomes. Just over a quarter of sites having a consultant perform the operation only sometimes or rarely which is unacceptable National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE McFarlane (2009) The Scottish Audit of Surgical Mortality: a review of areas of concern related to anaesthesia over 10 years. Anaesthesia 2009, 64, National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE 26

27 4.6. Planned trauma lists It is expected that all fractured neck of femur patients should undergo surgery during normal (standard daytime) working hours 70, on planned trauma lists with experienced staff. Undertaking fractured neck of femur surgery on planned trauma lists indicates that a consultant orthopaedic surgeon and a consultant anaesthetist should be present in the theatre performing the necessary procedures, or closely supervising junior staff 71. The benefits of having fractured neck of femur patients on trauma lists includes better outcomes with lower re-admission rates which is linked with senior staff undertaking or closely supervising procedures rather than unsupervised junior staff 72. Figure 14 shows the percentage of hip fracture surgery that is undertaken on planned trauma lists. One fifth of sites in London do not perform all of their hip fracture surgery on a planned trauma list. This is not acceptable as it leaves 20% of all fractured neck of femur patients under the probability of undergoing surgery without all the necessary services and medical staff required to get the best possible outcome for the patient. Figure 14: Is all hip fracture surgery undertaken on planned trauma lists? Source: London Health Programmes audit 2012 Key message: It is expected that all fractured neck of femur patients should undergo surgery during normal (standard daytime) working hours on planned trauma lists with experienced staff. However, one fifth of patients in London are not having fractured neck of femur surgery on a planned trauma list which could lead to a poorer outcome British Orthopaedic Association (BOA) & British Geriatric Society (BGS) (2007) The care of patients with fragility fracture. BOA National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE 27

28 5. Post-operative care and secondary prevention 5.1. Lack of regular and consistent input from multi-disciplinary teams Good post-operative care planning includes the early identification of individual goals for multi-disciplinary rehabilitation to recover mobility and independence and long-term wellbeing 73. The role of multi-disciplinary teams in assessing a patient and developing a care plan is vital and the provision of early multi-disciplinary rehabilitation is a key standard set out by the British Orthopaedic Association. Early mobilisation is a key component of any enhanced recovery programme. This should include physiotherapy, occupational therapy, dietician and nursing involvement. However, results of the adult emergency services survey showed stark variation in the availability of therapy services between Monday to Friday and Saturday to Sunday. Whilst all hospitals ran at least a to service Monday to Friday, during the weekend this was reduced to 16% of hospitals running a regular service similar to during the week. Over 70% of hospitals were running an on-call service. This means that there is less availability to patients and therefore less input into their care. Currently, 7% of London providers are still unable to offer their patients mobilisation at least once a day, as well as not being able to offer regular input from occupational therapy as shown in figure 15. This means that patients treated at these sites will not have equitable mobilisation service access with the rest on London. The consequence of this is a longer recovery process for the patient extending their stay in hospital. Figure 15: percentage of patients offered mobilisation at least once a day (seven days a week) with regular physiotherapy and input from occupational therapists Source: London Health Programmes audit 2012 Key message: Multi-disciplinary input into patient care is a vital component of recovery and rehabilitation for patients. In London there is a stark variation in the availability of multi-disciplinary services including therapy, pharmacy and social services between weekdays and weekends, resulting in insufficient quality of rehabilitation care for the patient. 73 National Institute for Health and Clinical Excellence (NICE) (2011) The management of hip fracture in adults. NICE 28