AUDIT OF HIP FRACTURE MANAGEMENT – THE IMPACT OF A PROFORMA PATHWAY

Abstract

Aim: To assess the impact of a proforma pathway on the care of patients following fractured neck of femur at Maidstone General Hospital compared to the gold standard set out in the British Orthopaedic Association and British Geriatric Society Blue Book – The Care of Patients with a Fragility Fracture.

Objectives: Initial audit of care prior to the introduction of the Proforma

• Development of a multidisciplinary care pathway and proforma following BOA Standards for Trauma (BOAST) and National Hip Fracture Database (NHFD) guidelines

• Re-audit of care following implementation of the proforma

• Identification of areas for development to implement in the NHS (Institute for Innovation and Improvement) Rapid Improvement Program – Focus on Fractured Neck of Femur

Background: The recent publication of the BOA and BGS Blue Book guidelines for care of patients with fragility fractures has defined a gold standard for the care of these patients. This has highlighted the areas of care that are commonly suboptimal and defined the requirements of a department providing ideal care. Both this, and the introduction of the NHFD and the resultant requirements for data collection and monitoring led us to develop a proforma for management and data collection.

Methods: An initial audit of care was performed. Notes were reviewed retrospectively for 62 patients and results were compared to the gold standard.

In June 2008 the proforma was implemented and data collected for reaudit (n=48). Direct comparison and statistical analysis was performed for the two groups of patients

Results: Comparison of the two audit groups shows dramatic and highly statistically significant differences in a number of areas of patient care, notably: mortality rates; appropriate A& E investigation and treatment; documentation of correct diagnosis and social history; mental test scoring; time to ward admission; time to surgery and osteoporosis treatment.

Discussion: The lack of a ring fenced, dedicated trauma ward leads to patients being admitted to outlying wards following fractured neck of femur. These wards are less likely to be as well equipped to deal with the unique requirements of these patients, which may explain the consistent problems with pressure area care and delay in discharge.

A strong recommendation for gold standard care is the provision of an orthogeriatric service with regular medical review both pre- and post-operatively. Currently no such dedicated service exists at Maidstone and this affects both the treatment of acute medical problems and the provision of falls investigation and treatment.

The introduction of the pathway has clearly benefitted the management of this difficult problem. With the support of the Rapid Improvement Program, further beneficial changes can be made to the care of patients following fractured NOF.