Management of Proximal Femoral Fractures 2011 - aagbi

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Anaesthesia 2011Griffiths et al. | Guidelines: proximal hip fracturesNational Hip Fracture Database (NHFD)The NHFD is a collaboration between the British Orthopaedic Associationand the British Geriatrics Society, with the main aim ‘to focus attention onhip fracture both locally and nationally, benchmark its care across thecountry, and use continuous comparative data to create a drive for sustainedimprovements in clinical standards and cost effectiveness’ [48]. All eligiblehospitals in the UK (except Scotland) are registered, with regularcontributions of data from over 75% of eligible hospitals, concerning inexcess of 130 000 patients (2011). The NHFD has recently begun to collectdata about anaesthetic methods used for hip fracture surgery.Patient informationThe provision of good quality information for patients is a key componentof the consent process, and is fundamental to good practice as detailed bythe General Medical Council [49] and AAGBI [50].The Working Party recommends that each department produce awritten information leaflet or booklet. It is essential that patients andrelatives are involved in the process. Typically, such information wouldinclude basic surgical information about the injury with more detailedinformation the anaesthetic considerations. Anaesthetic options, includingintended benefits and risks, should be explained clearly. An alternative toan anaesthetic information leaflet might be a more comprehensivedocument developed with multidisciplinary input from nurses, surgeons,physiotherapist, occupational therapists, etc. The Working Party recommendsthat, where possible, information should be evidence-based.A specimen patient information sheet is freely available from theHFPN website [47], and may be edited to apply to the hip fracture carepathway of specific hospitals.Appendix 2 lists areas where information for patients can be found.TrainingThe elderly patient with a proximal femoral fracture offers multipleopportunities to learn and demonstrate specific core outcomes, knowledgeand skills within ‘units of training’ set out in the Royal College ofAnaesthetists’ 2010 curriculum [51].The Working Party recommends that basic level trainees (CT1-2)participate in the multidisciplinary peri-operative care of patients with hipfracture (e.g. through participation in orthogeriatric and acute pain wardrounds, and pre-operative assessment), as well as receiving training in the24 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland
Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011theory of intra-operative care of the elderly and practical experience ofrelevant nerve block and regional anaesthetic techniques.Intermediate level trainees (ST3-4) should be encouraged to becomemore independent in patient assessment, and should aim to manage themoderate- to high-risk patient with indirect local support only.Higher level trainees (ST5-7) should be encouraged to undertakeindependent trauma list planning, prioritisation and management, withsenior advice. This will, undoubtabley, reveal numerous potentialmanagement, teamwork and leadership opportunities; all essentialdomains of Common Competencies of Medical Practice. The traineemay also develop roles in teaching medical students and more juniortrainees.Advanced training ⁄ fellowship posts (ST6-7) undertaken in hospitals,for example specialising in regional anaesthesia or anaesthesia for theelderly, may provide the potential for a trainee for develop a specificinterest in the peri-operative care of older trauma patients. Higher leveltrainees should be encouraged to participate in audit and researchinvolving patients with hip fracture.AcknowledgementThe Working Party acknowledges the assistance of Prof. Opinder Sahotaand Dr Iain Moppett, Queen’s Medical Centre, Nottingham.Competing interestsRG and SW have advised both the National Institute for Health andClinical Excellence (during development of Clinical Guideline 124 (Themanagement of hip fracture in adults)) and the NHFD, and arerespectively, Lead Clinician and Research Co-ordinator for the HFPN.MJP has received honoraria from a number of commercial companies forgiving lectures on different aspects of hip fracture treatment and advisingon hip fracture treatments, and he has received royalties from BBraun Ltdrelated to the design and development of an implant used for the internalfixation of intracapsular hip fractures.References1. Scottish Intercollegiate Guidelines Network. Management of hip fracture in olderpeople. National clinical guideline 111. 2009. http://www.sign.ac.uk/pdf/sign111.pdf (accessed 30 ⁄ 08 ⁄ 2011).2. British Orthopaedic Association and British Geriatrics Society. The care of patients withfragility fracture. 2007. http://www.nhfd.co.uk/ (accessed 30 ⁄ 08 ⁄ 2011).Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 25
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