Introduction Over 250 patients older than 50 years with fractured neck of femur (NOF) are treated annually at The Canberra Hospital (TCH). Our aim was to improve patient outcomes and reduce length of stay by developing a protocol driven approach to management of patients with NOF fractures, particularly focusing on efficient peri-operative assessment and management of fluid and electrolyte status.

Methods A prospective study of all patients over 50 years, admitted with a diagnosis of fractured neck of femur was carried out at TCH for a 12 month period. Baseline data was collected for a period of six months. We measured clinical factors including; time to theatre, pre-operative fluid resuscitation, length of stay and morbidity. A protocol was then introduced according to agreed best practice dealing with the issues identified in baseline data. Education of medical and nursing staff followed in the major treating areas: Emergency Department and orthopaedics ward. Following this a further six months data was collected to assess the effectiveness of the intervention.

Results Over the 12 month period prior to this study, the length of stay following fractured NOF at TCH was 15.39 days compared to the benchmark of 12.94 days. In the initial six month period 116 patients were admitted to the study. Baseline data demonstrated: average length of stay 12.75 days (from ED to discharge), average time to theatre 35 hours, variable fluid resuscitation for the first 24 hours averaging 1668.4 mls (range: 0 to 4000 mls). The in-hospital death rate in this patient group was 9.5%. In the second six month period, following protocol implementation, improvements were noted to be greatest in fluid resuscitation for the first 24 hours, averaging 3000 mls. Smaller improvements were seen in time to theatre, averaging 34 hours. The mortality rate and length of stay were not significantly different probably due to the higher anaesthetic risk score of the second cohort (p< 0.05).

Conclusions A program of outcomes assessment and evaluation in its first phase improved initial management of these patients and reduced length of stay. Further work is necessary to achieve timely assessment and early surgical intervention. Reducing the in-hospital death rate remains a problematic and complex issue.