South West Falls, Bone Health and Hip Fracture Review

Tim ChesserConsultant Orthopaedic and Trauma Surgeon

North Bristol

Regional Advocacy Groups• The National Osteoporosis Society • National Hip Fracture Database Executive Committee• British Geriatrics Society • British Orthopaedic Association, • with the support of Help the Aged,

to establish of a set of regional clinical advocacy groups for fragility fracture issues.

general practitioners and public health doctorsmetabolic bone doctorssurgeonsorthogeriatriciansfalls prevention specialistspatient representatives National Osteoporosis Society regional managers

Goals

• Hip fracture care: Universal participation in the National Hip Fracture Database offers all Trauma Units synergy between evidence-based standards of care and audit-based continuous feedback in the context of national benchmarking

• Fragility fracture prevention: NICE guidance on secondary fracture prevention can be delivered through Fracture Liaison Services for patients presenting to hospital with new fractures and pro-active case finding in primary care of unassessed prior fracture patients

• Integrated falls and osteoporosis assessment: Secondary fracture prevention will be optimised by seamless integration of post-fracture falls risk assessment and osteoporosis management as advocated by the BOA – BGS Blue Book on care of patients with fragility fracture

South West Ambitions by March 2010

• 95% of ALL fractures operated on within 24 hours of admission or fit for surgery

• # NoFs length of stay will in in top 25%

• Reduce emergency admissions as a result of fall by 30% through effective falls and bone health prevention programmes

A systematic approach to falls and fracture prevention

South West Team Leads

• Karen Tanner - Associate Director,SW SHA• Nye Harris – SW SHA, Regional Change Agent, DoH• Anne Thurston - National Osteoporosis Society• Tim Chesser – clinical lead• Karen Harding - clinical lead• Trevor Eardley – Project Manager, Organi Associates• Heather Eardley Project Manager, Organi Associates

Methodology• clarity on the current commissioning and provision ofFalls servicesHip fracture services Bone health services in the 14 health and social care communities, across the South West

• provision of an independent peer review baseline of the strengths and areas for development for falls, hip fracture and bone health services in each community

Methodology• collection of a set of core metrics

• included quantitative and qualitative information provided by each of the local health and social care commissioning leads and based on priority themes and benchmarks set out by the Department of Health

• review visit took place over a period of one day to enable the review team to meet with managers, practitioners, clinicians, service users, carers and lead commissioners

Review teams• approximately 40 review team members, identified by chief officers or

volunteers, to ensure a cross-agency, multi-disciplinary approach from a range of primary and secondary care, social care and other backgrounds

• consultant orthopaedics, orthogeriatricians, rheumatologists;• nurses;• allied health professionals;• adult social care representatives;• public health;• National Osteoporosis Society;• South West Seniors Network;• primary care and secondary care• service and senior managers

• a peer review and not an inspection

• allowed local champions to voice either their praise or concern of the service they provided

• South West Seniors Network were commissioned to gather service user

feedback from local groups in each community

• Hip fracture services• Fragility fracture services• Falls services

Process

Core Metrics

Review

Draft Report

Report

Action Plan

Hip Fractures

• ~ 8,000 per annum in South West(or so we think!)

• Numbers not readily available • Length of acute stay not always available• Length of superspell -unknown

What we know

• ED management efficient• Always better with pathway

• Time to op – unclear data, different data collected• More efficient when on dedicated trauma lists• All felt 24 hour target unachievable

• Orthogeriatric involvement – when present excellent service but coverage sporadic

Results• Multidisciplinary rehabilitation – universal

• Falls and bone health – dependent on orthogeriatrician

• Length of stay – difficult to measure

• National Hip Fracture Database – nothing like a review to change practice!! (12 / 16 submitting), needs resource

• Commissioning of hip fractures - ???

Observations• Still a wide variation in service• Really difficult problem• Rehabilitation pathways dependent on Historylocal geographylocal infrastructureavailability of community bedslocal prioritiesBenchmarking with acute LOS impossible

Data set• patients admitted to hip fracture unit within 4 hours;• hip fractures operated on within 36 hours of admission or

diagnosis;• hip fracture patients entered onto the National Hip Fracture

Database including 30 day and 120 day follow up;• patients receiving preoperative orthogeriatric care, involving

Medical Staff grade ST3 and above;• patients receiving post -operative orthogeriatric care, involving

Medical Staff grade ST3 and above;• patients receiving a multi-disciplinary assessment;• length of stay (both acute and superspell) to be measured

Recommendations• Commissioning guidance for PCTs• NHFD has to be properly supported by Trusts• Clinical lead for hip fractures• Pathway for hip fractures• More orthogeriatricians• Planned consultant led trauma lists• Measure performance• Change 24 hour target to 36 hours (BPT)

Opportunity• Multidisciplinary team working

• Communication

• Learn from each other

• Set baselines and help units to progress

• Put it on the agenda

• It is our opportunity to make a difference

Thank you

• hip fracture length of stay to be accurately recorded as both the acute spell and the super spell, which includes time spent in any NHS inpatient facility for rehabilitation or awaiting care placement

• reduction in emergency admissions; however, the data around falls admissions is currently so poor that measuring a reduction may not be realistic. In order to achieve this, measures to improve data collection in emergency departments and Ambulance NHS Trusts

• fractures requiring surgery within 24hours - a key issue is that the Best Practice Tariff from the Department of Health recommends 36 hours as the qualification towards the Best Practice Tariff premium; the clinical pathway group may therefore wish to reconsider this standard and must be measured accurately from time of diagnosis