Fracture NOF - guidelines - audit results

1. TRAUMA: FRACTURE NECK OF FEMUR
DR GEETANJALI S VERMA
SPECIALTY DOCTOR, ANAESTHETICS
NORTH CUMBRIA UNIVERSITY HOSPITAL, UK

2. • CONFLICT OF INTEREST: none
• DISCLOSURES :none

3. AREAS COVERED
• Background
• At risk groups
• NICE guidelines
• Do we follow it?

4. BACKGROUND
• Major public health issue
• 70,000 to 75,000 hip fractures annually in the UK
• Cost : £2 billion /yr
• Projected rise: 101,000 in 2020
• 1/4th of patients - admitted from institutional care, 10–20% of those
admitted from home ultimately move to institutional care.
• Average age (NHD): 84 years for men and 83 for women
• High mortality: 10% die within 1 month, 1/3rd within 12 months.

5. RISK FACTORS

6. NICE GUIDELINES: what, why, who, how?
Multidisciplinary Guideline Development Group (GDG)
• Purpose:
• make recommendations
• develop standards
• education and training
• informed decisions
• improve communication
STEPS involved:
• Guideline topic referral to NICE from the Department of Health
• Stakeholders register an interest The scope is prepared by the National Clinical
Guideline Centre (NCGC)
• The NCGC establishes a guideline development group
• Draft guideline production post assessment of available evidence

7. NICE GUIDELINES : # NOF
1. IMAGING
2. REVIEW
3. ANALGESIA
4. ANAESTHESIA
5. SURGERY AND SURGICAL OPTIONS
6. REHABILITATION

8. What this guideline does not cover:
1. POPULATION: a) < 18 years
b) Fractures 2° to specific pathologies other than osteoporosis or
osteopaenia
2. CLINICAL AREAS:
a) Prevention of fragility fracture
b) Pressure sores
c) VTE
d) Post op infection
e) Nutritional support
f) Prostheses for hip replacement.
g) Complementary and alternative therapies

9. GUIDELINE SUGGESTIONS
1. IMAGING: X ray > MRI > CT scan
2. TIMING OF SURGERY
• On the day or the day after, admission
• Treat correctable comorbidities immediately:
• anaemia
• anticoagulation
• volume depletion
• electrolyte imbalance
• uncontrolled diabetes
• uncontrolled heart failure
• correctable cardiac arrhythmia or ischaemia
• acute chest infection
• exacerbation of chronic chest conditions.

10. 3. ANALGESIA
• Assessment: immediately → 30 minutes → hourly →routinely
• Offer: immediate analgesia
• Sufficient analgesia: to allow movements necessary for investigations & for nursing care
and rehabilitation
• Options:
• Paracetamol Q6H
• Opioids
• Nerve blocks
• NSAIDs

11. 4. ANAESTHESIA
SAB / GA + Nerve blocks
5. PREPARATION FOR SURGERY
• Schedule on a planned trauma list
• Consultants / senior staff +/- trainee

12. 6. SURGERY
Aim: to allow full weight bearing (without restriction) in immediate postop period
- Replacement arthroplasty (hemiarthroplasty or total hip replacement) in patients with
displaced intracapsular fracture.
- THR in those able to walk independently, not cognitively impaired, medically fit
- Use of proven femoral stem design rather than Austin Moore or Thompson stems for
arthroplasties
- Use cemented implants in patients undergoing surgery with arthroplasty.
- Approach: Anterolateral > posterior in hemiarthroplasty.
- Extramedullary implants > intramedullary nail in patients with trochanteric fractures
- Intramedullary nail in subtrochanteric fracture.

13. 7. MOBILISATION STRATEGIES
• Physiotherapy assessment
• Mobilisation post op: day 1, atleast OD, regular review
8. MULTIDISCIPLINARY MGMT
• orthogeriatric assessment
• rapid optimisation of fitness for surgery
• early identification of individual goals for multidisciplinary rehabilitation
• continued review
• Integration with related services (mental health, falls prevention, bone health,
primary care and social services)
• clinical and service governance responsibility

14. LOCAL AUDIT
• Retrospective study
• Sample size: 50 patients, random selection
• Inclusion / exclusion criteria: NICE guidelines
• Collection & analysis: microsoft excel
• Registration with local audit team (NCUH)
Aim:
1. To assess % of patients in whom NICE guidelines for #NOF is followed in:
- timing of surgery
- analgesia
2. To analyse reasons for fall back

15. Results
• Population: age group: 60- 95 yrs; female> male
• Timing of surgery:
• within 36hrs: 40/50
• >36hrs: 10
• reason for delay: unfit, theatre over run
• Analgesia
• A&E: Nerve blocks: 30/50
Pain score: noted in 15
Reasons not given in A &E: inexperience, workload
Intra op: Nerve blocks: 44
Reasons not given in OT: inexperience in RA

16. Suggestions
• Developing nerve block skills / workshops
• Pain score form introduction (pre op & post op)
• Addressing concerns in delay: orthogeriatrician, early review, golden patient
concept
• Re audit in 4 months

17. • https://www.nice.org.uk/guidance/cg124/evidence/full-guideline-pdf-183081997
• Department of Health. (2007) Reference Costs 2006-07 Collection Guidance.
London: (Guideline Ref ID: DH2007)
• Department of Health. (2009) The national framework for NHS continuing
healthcare and NHS-funded nursing care. (Guideline Ref ID: DH2009)
• Department of Health. (2010) Prioritising need in the context of Putting People
First: a whole system approach to eligibility for social care - guidance on eligibility
criteria for adult social care, England 2010. (Guideline Ref ID: DH2010A)
• video: youtube (AFV)