Best practice tariff for fractured neck of femur: A completed audit from a busy district general hospital

Purpose – The hip fracture “best practice tariff” (BPT) came into effect in April 2010. It advocated two key improvements: surgery within 36hrs of arrival in the emergency department; and multi-disciplinary care directed by ortho-geriatrician from admission to discharge. The aim of this paper is to look at the 36 hours to operation target and its implications for orthopaedic department trauma service staff in a busy district general hospital, and to evaluate the measures implemented to meet the target. Design/methodology/approach – Trauma-list data, collected from a theatre management system, was compared with trauma patients placed on elective and emergency lists, before and after designated daily trauma lists were implemented. Findings – After a designated daily trauma list was introduced, a significant rise (from 56 per cent to 85 per cent) became evident in the proportion of patients operated on within 36hrs, between November 2010 to February 2011, while hip fracture cases managed on the elective list fell from 24 per cent to 17 per cent. Practical implications – Despite adding a half-day trauma list, the trauma service has insufficient capacity to achieve the new BPT for all hip fracture patients in the hospital. Therefore, there is a significant knock-on effect for managing patient overspill on elective services. Will the significant changes in service provision designed to achieve this BPT be cost effective? Originality/value – This paper aims to answer how busy department staff address an issue that professionals in every English hospital are facing.

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266 The Effect of the COVID-19 Pandemic on Emergency Theatre Mortality, Time to Intervention and Length of Stay in the First Phase of National Lockdown at a District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab259.448 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

W Luo ◽

R Limb ◽

A Aslam ◽

R Kattimani ◽

D Karthikappallil ◽

...

Keyword(s):

Length Of Stay ◽

General Hospital ◽

Postoperative Mortality ◽

District General Hospital ◽

Urgent Care ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Emergency Operations ◽

Significant Difference ◽

The Impact

Abstract Aim This study aimed to investigate the patient population requiring emergency surgery during the first phase of lockdown due to COVID-19 in the United Kingdom and compare it to the equivalent population in the same calendar period for 2019. Thus, we aimed to evaluate the impact of the pandemic on emergency operations. Method We retrospectively reviewed patients undergoing surgery in emergency theatres at our district general hospital between March 23rd and May 11th in 2019 and 2020. Data collected included demographics (age/gender), National Confidential Enquiry into Patient Outcome and Death (NCEPOD) category and operation. The primary outcome was 90-day post-operative mortality; secondary outcomes included time to intervention and length of inpatient stay. Results 132 (2020) versus 141 (2019) patients were included with no significant difference in age (p = 0.676) nor sex (p = 0.230). There was no difference in overall 90-day postoperative mortality (p = 0.196). Notably, time to intervention was faster for NCEPOD code 3 patients in 2020 than in 2019 (p = 0.027). Time to intervention in 2020 was longer for those dying within 90 days post-operatively compared to survivors (p = 0.02). There was no difference in length of stay between the years, both overall and when conducting subgroup analyses by NCEPOD category or procedures (fractured neck of femur (p = 0.776), laparoscopies (p = 0.866), laparotomies (p = 0.252)), except for upper limb trauma (p = 0.007). Conclusions Patients were appropriately prioritised with no overall change in mortality or length of stay. A national validation audit assessing outcomes of emergency operations during these challenging times would further elucidate risks posed to surgical patients requiring urgent care.

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Management of Warfarin Anticoagulation in Patients with Fractured Neck of Femur

ISRN Hematology ◽

10.5402/2011/294628 ◽

2011 ◽

Vol 2011 ◽

pp. 1-5 ◽

Cited By ~ 17

Author(s):

Feras Ashouri ◽

Wissam Al-Jundi ◽

Akash Patel ◽

Jitendra Mangwani

Keyword(s):

Vitamin K ◽

Hip Fractures ◽

National Policy ◽

District General Hospital ◽

Pharmacological Therapy ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Time To Surgery ◽

Group A ◽

Group B

Background. Most orthopaedic units do not have a policy for reversal of anticoagulation in patients with hip fractures. The aim of this study was to examine the current practice in a district general hospital and determine difference in the time to surgery, if any, with cessation of warfarin versus cessation and treatment with vitamin K. Methods. A retrospective review of the case notes between January 2005 and December 2008 identified 1797 patients with fracture neck of femur. Fifty seven (3.2%) patients were on warfarin at the time of admission. Patients were divided into 2 groups (A and B). Group A patients (16/57; 28%) were treated with cessation of warfarin only and group B patients (41; 72%) received pharmacological therapy in addition to stopping warfarin. Time to surgery between the two groups was compared. Results. The mean INR on admission was 2.9 (range 1.7–6.5) and prior to surgery 1.4 (range 1.0–2.1). Thirty eight patients received vitamin K only and 3 patients received fresh frozen plasma and vitamin K. The average time to surgery was 4.4 days in group A and 2.4 days in group B. The difference was statistically significant (P<.01). Conclusion. Reversal of high INR is important to avoid significant delay in surgery. There is a need for a national policy for reversing warfarin anticoagulation in patients with hip fractures requiring surgery. Vitamin K is safe and effective for anticoagulation reversal in hip fracture patients.

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22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur

Age and Ageing ◽

10.1093/ageing/afz183.22 ◽

2020 ◽

Vol 49 (Supplement_1) ◽

pp. i1-i8

Author(s):

J Kingdon ◽

H Aadan ◽

S Husain ◽

C Atkinson ◽

C Thomson ◽

...

Keyword(s):

Clinical Pathway ◽

Best Practice ◽

Nutritional Assessment ◽

Nutritional Supplements ◽

Alternative Methods ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Post Surgery ◽

Retrospective Audit ◽

Pdsa Cycle

Abstract Background Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality. Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016). Introduction Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support. Intervention A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time. Results Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate. PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%). PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%). Conclusions The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.

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Lean thinking: Can it improve the outcome of fracture neck of femur patients in a district general hospital?

Injury ◽

10.1016/j.injury.2010.11.024 ◽

2011 ◽

Vol 42 (11) ◽

pp. 1234-1237 ◽

Cited By ~ 40

Author(s):

T.A. Yousri ◽

Z. Khan ◽

D. Chakrabarti ◽

R. Fernandes ◽

K. Wahab

Keyword(s):

General Hospital ◽

District General Hospital ◽

Neck Of Femur ◽

Lean Thinking ◽

Fracture Neck Of Femur

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799 Do Not Attempt Cardiopulmonary Resuscitation Decisions in Neck of Femur Fractures – Is Documentation Adequate?

British Journal of Surgery ◽

10.1093/bjs/znab259.101 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

T Williamson ◽

K Hughes ◽

M Osborne-Grinter ◽

V Philip ◽

G Dall ◽

...

Keyword(s):

Cardiopulmonary Resuscitation ◽

District General Hospital ◽

Healthcare Team ◽

Power Of Attorney ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Care Plans ◽

Femur Fractures ◽

Senior Clinician ◽

Grade 3

Abstract Introduction ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation is essential to communicate decisions regarding ceilings of care for patients to the clinical team. Patients admitted to hospital with a fractured neck of femur (#NOF) are often elderly with multiple comorbidities, and so robust and clear anticipatory care plans are especially indicated. Method All patients admitted to a large district general hospital in Scotland with a #NOF over a three-week period between 23/10/2020 and 12/11/2020 were identified prospectively and included in this audit. Patients’ demographic information, DNACPR status and the quality of their DNACPR documentation was recorded. Results 20 patients (85% Female, 15% Male) were identified and included. Median ASA grade was 3, with 77.8% of patients ASA grade 3 or 4. 63.2% of patients had DNACPR documentation in place, all of which were ASA grade 3 or above. Most DNACPR documentation had patient information clearly identifiable (91.7%), was completed preoperatively (90.9%), and involved either the patient or appropriate relative or power of attorney (91.6%). However, only 75% of patients’ documentation had the rationale for the DNACPR decision documented and only 25% of DNACPR decisions were reviewed by a senior clinician within 72 hours. No DNACPR decisions were documented as having been communicated to the wider healthcare team. Conclusions DNACPR documentation is a crucial for anticipatory care planning in #NOF patients. This audit shows improvement is needed in documenting whether decisions have been reviewed by senior clinicians, and if they have been communicated to the wider healthcare team.

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The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0032 ◽

2019 ◽

Vol 101 (5) ◽

pp. 342-345

Author(s):

J Craik ◽

R Geleit ◽

J Hiddema ◽

E Bray ◽

R Hampton ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Length Of Stay ◽

Hip Arthroplasty ◽

Functional Outcomes ◽

Best Practice ◽

Complication Rates ◽

Delayed Presentation ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Total Hip

Introduction Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes. Methods All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours. Results Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health. Conclusions Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

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