Management of Proximal Femoral Fractures 2011 - aagbi

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Anaesthesia 2011Griffiths et al. | Guidelines: proximal hip fracturesThese guidelines will mainly focus on the acute hospital episode,particularly the pre-operative period, intra-operative management andimmediate postoperative phase. Where evidence is limited, issues controversialor guidelines uninformative, the Working Party has providedpragmatic consensus opinions.In addition, these guidelines will describe the logistics of providing ahigh quality service for these patients, together with the importantrelationships that must be developed between departments to ensurequality care.This has been a multidisciplinary collaboration that has resulted inadvice for anaesthetists and other health-care professionals on how tocreate, develop and manage a service for patients with proximal femoralfracture.Facilities and services requiredOlder patients with hip fracture are at risk of significant morbidity andmortality, both of which can be reduced by prompt surgical fixation of thefracture and early, effective rehabilitation. This section outlines thestructures and processes required to expedite early surgery and achievehigh quality rehabilitation.The Department of Health has suggested the following targets forpatients with hip fracture [9]: (i) all patients should be admitted within4 h of arrival in the emergency department; and (ii) patients should beoperated on by an experienced clinical team within 24 h of a decisionthat the patient is fit for surgery. In addition, the British OrthopaedicAssociation Standards for Trauma (BOAST) guidelines [10] stipulate thatwithin 4 h of hospital arrival, hip fracture patients should be admitted toan appropriate clinical ward area with nursing, orthogeriatric medicineand surgical expertise appropriate for this often frail patient group;further, that surgical fixation should not be delayed more than 48 h fromadmission unless there are clear reversible medical conditions (seebelow).For many hospitals, achievement of these standards may requireservice re-organisation, incorporating the following components.Multidisciplinary hip fracture management groupThis involves a broad collective of stakeholder personnel who meetregularly in order to discuss and improve the quality and efficiency of hipfracture care appropriate to a particular hospital. The group may includetrauma co-ordinators, general practitioners, community ⁄ falls assessment4 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland
Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011nurses, emergency staff, bed managers, orthopaedic nursing staff andsurgeons, anaesthetists, orthogeriatricians, physio- and occupationaltherapists, social workers and rehabilitation services. Trauma coordinatorshave a pivotal role, in reducing pre-operative delays, facilitatinginterdisciplinary communication and instituting early dischargeplanning.Communication between this group and the hospital’s theatremanagement group improves integration of system changes into generaltheatre service provision.Fast-track admission pathwayMost patients with hip fracture are admitted via an emergency department,where a planned care package should be initiated promptly. The useof a care pathway proforma focuses patient care and ensures basic qualitystandards are met; a number of these exist, which can be tailored toindividual hospitals.Continuous tracking ⁄ live data systems that regularly update patientand logistical data may improve management by identifying patients’location, delays in treatment and relevant clinical information, and may beused to facilitate clinical audit and business planning.Trauma listsProtected trauma lists, separate from general emergency operating lists,improve the efficiency of trauma service provision. These should beprovided daily, including weekends and bank holidays, and be staffed byappropriately experienced senior medical and theatre staff. Unless life orlimb-threatening trauma intervenes, the Working Party suggests that hipfracture surgery is prioritised within operating lists, overriding theparticular subspecialist interest of the senior surgeon assigned to the list.Multidisciplinary trauma meetingsDaily multidisciplinary trauma meetings, convened before the start ofoperating lists, offer excellent opportunities to communicate issuesrelating to recent admissions and to plan operative lists and equipmentrequired for the day ⁄ next day, as well as providing regular teaching andfeedback. Trauma meetings may involve the same staff as above, includingtheir trainees. Members of the trauma team may change on a daily basis,so handover of information is a key element. Communication of clinicalinformation should always involve accurate documentation in patients’notes in addition to verbal handover.Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 5
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