Introduction

The management of patients with hip fracture is complex and involves a wide multidisciplinary approach across many different boundaries. It tests the integration of services from ambulance services into the emergency department, the acute services including operating surgeries, rehabilitation services, end-of-life care, health services in the community, social services and the provision of local council services for the elderly. Excellence in outcomes in this condition may be an indicator of overarching performance, and as such, hip fracture is a key condition for National Health Service (NHS) England and the Department of Health.

Patients with hip fracture

Our knowledge about patients with hip fracture in the UK has been strengthened over the past 5 years since the introduction of the National Hip Fracture Database and publication of their annual report . Two-thirds of patients are aged over 80 and almost a quarter over 90. More than half required a stick or a frame to mobilise prior to their fracture. Three quarters live at home, many requiring support from formal or often informal carers.

Using the American Society of Anaesthesiology (ASA) grading system, two-thirds are assessed as ASA grade three or above indicating severe systemic disease that limits activity. One in eight is deemed ASA grade four indicating incapacitating systemic disease that is constantly life threatening .

The 5-year follow-up data from well-established orthogeriatric units demonstrate that mortality is about 6.9–8.4% at 30 days, 22–33% at 1 year and about 66% at 5 years .

Those who were admitted from home and were well enough to return home had a mean survival rate of 5.2 years, whilst those who required institutional care had a mean survival of 1.3 years.

Some patients are relatively fit and well, but a significant proportion can be considered frail and elderly. Frailty is difficult to define but can be described as a loss of physiological reserve such that systems fail with minor stress. There may be a loss of muscle, collagen, bone and brain with homoeostatic instability, immune deficiency and a vulnerability to disease . Frailty is not always obvious from the end of the bed, but requires a detailed understanding of co-morbidities and their impact on the individual.

Many patients presenting with hip fracture do so as a result of frailty and as such require comprehensive geriatric assessment by senior experienced professionals in addition to the anaesthetic and surgical aspects of their care. It is no longer acceptable for them to be managed purely by orthopaedic teams without the expertise in geriatric medicine.

Patients with hip fracture

Our knowledge about patients with hip fracture in the UK has been strengthened over the past 5 years since the introduction of the National Hip Fracture Database and publication of their annual report . Two-thirds of patients are aged over 80 and almost a quarter over 90. More than half required a stick or a frame to mobilise prior to their fracture. Three quarters live at home, many requiring support from formal or often informal carers.

Using the American Society of Anaesthesiology (ASA) grading system, two-thirds are assessed as ASA grade three or above indicating severe systemic disease that limits activity. One in eight is deemed ASA grade four indicating incapacitating systemic disease that is constantly life threatening .

The 5-year follow-up data from well-established orthogeriatric units demonstrate that mortality is about 6.9–8.4% at 30 days, 22–33% at 1 year and about 66% at 5 years .

Those who were admitted from home and were well enough to return home had a mean survival rate of 5.2 years, whilst those who required institutional care had a mean survival of 1.3 years.

Some patients are relatively fit and well, but a significant proportion can be considered frail and elderly. Frailty is difficult to define but can be described as a loss of physiological reserve such that systems fail with minor stress. There may be a loss of muscle, collagen, bone and brain with homoeostatic instability, immune deficiency and a vulnerability to disease . Frailty is not always obvious from the end of the bed, but requires a detailed understanding of co-morbidities and their impact on the individual.

Many patients presenting with hip fracture do so as a result of frailty and as such require comprehensive geriatric assessment by senior experienced professionals in addition to the anaesthetic and surgical aspects of their care. It is no longer acceptable for them to be managed purely by orthopaedic teams without the expertise in geriatric medicine.

Multidisciplinary Care and the Hip Fracture Programme

The National Institute for Health and Care Excellence (NICE) guidelines on the management of patients with hip fracture were published in 2011 and they outline the requirement for these patients to be managed by a multidisciplinary team (MDT) from the point of admission to the point of discharge into the community, once they have reached their full rehabilitation potential . The guidelines refer to the concept of ‘a hip fracture programme’ that includes

orthogeriatric assessment, rapid optimisation of fitness for surgery, early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence.

This requires continued, coordinated orthogeriatric and multidisciplinary review of patients throughout their journey. The hip fracture programme should involve close collaboration between orthopaedic surgeons, anaesthetists, orthogeriatricians and nursing and therapy teams with a named clinician from each of the above specialities responsible for developing and maintaining the hip fracture services.

Organisation of services

In recent years, many hospitals have reviewed and developed their hip fracture programme. The NHS Institute of Innovation and Improvement worked with 10 trusts across the UK to pilot rapid improvement programmes and published recommendations in their report, ‘Focus on: Fractured neck of Femur in 2006’ . This work has more recently been incorporated in the Enhanced Recovery Programme for musculoskeletal pathways alongside the work of the National Hip Fracture Database.

The institute introduced the concept of lean methodology into NHS service improvement. This methodology, using five principles to improve flow and eliminate waste, was initially described by Womack and Jones in reviewing the manufacturing systems of the Toyota Corporation of Japan .

The NHS Institute has defined lean thinking as

a philosophy that has been used widely in manufacturing industries, but is also very applicable to healthcare. It is essentially about simplifying processes, identifying which parts of a process add value to patient care, enabling care to flow more effectively and eliminating waste .

As such, the clinical MDT requires support from non-clinical departments including service improvement, informatics, audit, finance and commissioning.

Service improvement in the hip fracture pathway requires clinicians from the emergency department, anaesthetics, orthopaedics, geriatrics, nursing and therapy to join forces with social services and managers to work together towards an agreed vision for a hip fracture pathway that meets the standards set out by national guidelines including the Blue Book, Association of Anaesthetists of Great Britain and Ireland (AAGBI) and NICE . These standards promote early surgery, orthogeriatric review, a multidisciplinary approach including falls and bone health assessment. All departments must be represented by a senior decision-maker who will ‘champion’ change within their speciality area.

The hip fracture programme must continue to meet regularly to evaluate and review the service, particularly focussing on where defined standards have not been met in addition to reviewing 30-day mortality, adverse events and length of stay as part of ongoing clinical governance.

It is essential that all members of the hip fracture programme are aware of the many steps that contribute to best possible care and remain engaged with local and national networks to keep abreast of new developments.

Early management

There is a need for speed in the management of patients presenting with hip fracture as pain and immobility quickly lead to complications in the frail elderly. Restoration of previous levels of independence and mobility becomes more unlikely with each day of bed rest because of a rapid loss of muscle strength, increasing pain and stiffness from underlying arthritis and loss of confidence. Constipation, pressure sores, poor nutrition, retained chest secretions and thromboembolic disease are all well-recognised additional risks.

The emergency department

Most patients with hip fracture are admitted through the emergency department. Triage is overseen by advanced nurse practitioners who will prioritise and arrange urgent X-rays for patients with suspected hip fracture. Some hospitals have successfully introduced an alert bleep that is put out when a patient in the emergency department has a hip fracture confirmed on X-ray. Many patients will be fast-tracked to a hip fracture unit, but a brief assessment by a senior doctor in the emergency department is required to recognise and treat unstable medical conditions that may have contributed to the fall, such as dehydration, sepsis, gastrointestinal haemorrhage, stroke or a cardiac event.

Analgesia

Pain should be measured using a validated score immediately upon presentation at hospital, within 30 min of administering initial analgesia and hourly until the patient is settled in the ward . Pain should continue to be reviewed and documented regularly as part of routine nursing observations, medical ward rounds and physiotherapy assessments.

Early adequate analgesia to allow toileting and nursing care is essential. However, many analgesic drugs have significant unwanted side effects in this population. Intravenous paracetamol should be standard and has been shown to be as effective as morphine for patients with acute traumatic limb pain .

Increasingly, patients with hip fracture are receiving early fascia iliaca compartment blocks in the preoperative period. This is a low-skill, inexpensive method to provide analgesia for patients with hip fracture. The fascia iliaca compartment is a potential space that allows the deposition of local anaesthetic in sufficient volume to spread to at least two of the three major nerves (the femoral nerve and lateral femoral cutaneous nerve) that supply the medial, anterior and lateral aspects of the thigh in a single injection. It can also block the obturator nerve with some limited efficacy.

This has been shown in a double-blind randomised controlled trial to reduce the need for opiate analgesia in patients with hip fracture . This procedure can be performed by trained individuals including non-physician practitioners as outlined in a position statement by the AAGBI .

Opiate analgesia is often required, but should be used with caution and in low dose as side effects including nausea, urinary retention, constipation, respiratory depression and delirium are common.

Codeine, Tramadol and other opioids should be avoided, as they are poorly tolerated in the frail elderly. Non-steroidal anti-inflammatory drugs are contraindicated because of high side-effect profile with significant risks of renal impairment and peptic ulcer disease in the peri-operative period .

The most effective method of reducing pain for patients with a hip fracture is to undergo early surgical intervention.

Post-operative analgesia varies but should be standardised with a unit. Poor post-operative pain control leads to increased hospital length of stay, delayed ambulation and long-term functional impairment . Achieving adequate pain control requires good communication between the patient, nurses, physiotherapists and doctors.

Hydration and nutrition

Complex fractures may bleed significantly at the fracture site and resuscitation with intravenous fluids and/or blood transfusion should be commenced immediately. Most patients, unless in decompensated heart failure or with fluid overload from other co-morbidities, require intravenous fluids pre-operatively ensuring that electrolytes are measured and corrected where necessary.

An early orthopaedic assessment to confirm the diagnosis and a likely plan for surgery ensures that patients are not kept nil by mouth for prolonged periods of time. Patients should be encouraged to eat until 6 h pre-surgery. Evidence suggests that clear fluids are safe until 2–3 h pre-surgery . The use of oral carbohydrate-loading drinks until up to 2 h pre-operatively is well established in elective colorectal surgery and is used in other elective surgery as part of the enhanced recovery programme. Carbohydrate-loading drinks may be used in patients with hip fracture but care needs to be taken in encouraging the frail elderly to drink large quantities pre-operatively, particularly if they have been given opiates, which slow stomach emptying.

Malnutrition is common in the frail elderly leading to an increased risk of poor wound healing, pressure sores, sepsis and general decline with apathy and depression. Everything possible should be done to recognise this and a care plan instituted. NICE guidelines recommend use of the Malnutrition Universal Screening Tool (MUST) tool to monitor nutritional status in hospitalised patients. Red tray systems and nutritional supplements may be beneficial and there should be liaison with the dieticians where necessary .

Skin integrity

Early assessment of skin integrity and risk factors for pressure sores should be undertaken and a low threshold for an appropriate mattress employed. With a proactive collaborative approach, the incidence of pressure ulcers can be significantly reduced .

Clerking and initial management

A standardised clerking pro forma helps to guide junior doctors through the assessment of a patient with a hip fracture, prompting them to record necessary information, to complete a basic examination that should include an assessment of cognition and to ensure appropriate initial management. The AAGBI has produced clear and concise guidelines for the management of proximal femoral fractures with consensus agreement by the working party on acceptable and unacceptable reasons for delaying surgery . These guidelines should be incorporated into accessible local guidelines to support all junior doctors and anaesthetists in managing patients with hip fracture.

Pre-operative medical assessment

Pre-operative medical assessment can be done by any senior doctor with dedicated time in their job plan, who has an interest and experience in this area. In some hospitals, this will be an emergency physician, an orthopaedic physician or an anaesthetist. More commonly, this role is being undertaken by an orthogeriatrician as many of the ongoing issues in the peri-operative period will require a ward-based multidisciplinary approach with clear leadership.

Interest and knowledge in the area of pre-operative assessment and anaesthesia for the elderly are growing. The Age Anaesthesia Association run an annual scientific meeting with specialist interest groups in hip fracture and emergency laparotomy, attracting membership from an increasing number of geriatricians and other specialists. These educational opportunities encourage networking and closer working relationships between different disciplines.

The number of orthogeriatricians has increased significantly in the UK since the introduction of best practice tariff with half of patients now seen pre-operatively by a senior geriatrician . The move towards a model of joint care between orthopaedic surgeons and geriatricians ensures that appropriate senior decision-makers are involved from the outset, setting realistic expectations for the patient, their relatives and the whole team.

A thorough holistic geriatric medicine review ensures the early recognition of medical co-morbidities and the likely impact of these on the peri-operative period. Experience reduces the need for further investigations and specialist opinions pre-operatively, because often, there is little that can be done by way of optimisation that justifies delaying surgery.

Medication review

Pharmacy technicians can usually obtain an up-to-date record of the patient’s prescription from the general practitioner (GP) on admission. Their assistance with medication reconciliation for patients on complex drug regimens is vital, particularly in patients with Parkinson’s disease. A thorough medication review pre-operatively is essential. This can often provide significant information about the presence and severity of co-morbidities. However, care should be taken not to draw incorrect conclusions; a patient on sodium valproate may be epileptic but this may be also used to augment treatment of depression, and a patient on a dopamine agonist may have Parkinson’s disease or it may be used for restless legs syndrome. Clarity about each drug, why it was started and whether it is still indicated, allows alleviation of the pill burden for patients and reduces unwanted side effects, future hospital admissions and mortality . Screening Tool of Older People’s potentially inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to the Right Treatment (START) criteria offer some helpful advice about inappropriate medication and also about underprescribing .

Anti-hypertensives

Anti-hypertensives should be reviewed pre-operatively, and diuretics and angiotensin-converting enzyme (ACE) inhibitors withheld as they may contribute to intraoperative hypotension and subsequent renal impairment. Beta-blockers should usually be continued, particularly in those with known ischaemic heart disease or tacharrythmias, but with caution in patients with hypotension.

The Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) study showed a lower mortality in elective patients with suspected ischaemic heart disease who were started on beta-blockers 4 weeks pre-operatively, although this study and its author have been widely criticised . For non-elective patients such as those with hip fracture, starting beta-blockers on the day of surgery was investigated in the Perioperative Ischemic Evaluation Study (POISE) study . This provided conflicting evidence suggesting a reduction in ischaemic events but an increase in the incidence of hypotension and peri-operative stroke and therefore is not recommended .

The need for restarting anti-hypertensive medication should be reviewed once the patient is euvolaemic, eating and drinking and has started mobilising.

Diabetic medication

Management of diabetes in the peri-operative period is important as poor glycaemic control leads to an increased risk of sepsis and poor wound healing. Prolonged periods without oral intake can lead to problems; thus, it is important to know the time of surgery and for careful anaesthesia to prevent post-operative nausea so that the patient can start to eat and drink immediately post-operatively. Oral hypoglycaemics are usually omitted on the day of surgery. Metformin should be withheld for 48 h as there is an association with lactic acidosis . Those on insulin are usually started on an insulin-sliding scale. It is important to try to withdraw this as soon as possible post-operatively to avoid fluid overload and electrolyte disturbance.

Anti-platelets and anticoagulants

Anti-platelet drugs have in the past caused concern and it is recommended that they be discontinued for elective patients 7 days pre-operatively. However, recent studies have shown no evidence to suggest that prompt surgical treatment of hip fracture in patients taking clopidogrel compromises peri-operative outcomes .

Warfarin is one of the most common reasons for delay towards surgery. Early reversal with vitamin K is usually effective. For resistant international normalised ratios (INRs), prothrombin complex concentrate (PCC) (Beriplex) is effective for emergency reversal of anticoagulation although its use in this circumstance is off licence . The concern about increased thrombotic risk post-operatively has not been studied in this population.

Novel oral anti-coagulants (NOAC) have been the newest challenge in emergency surgery. These are recommended for use in patients with atrial fibrillation with a contraindication or intolerance to vitamin K agonists such as warfarin. However, unlike warfarin, some of these drugs are not quickly reversed by vitamin K, fresh frozen plasma or by PCC. The European Society of Cardiology suggests that if emergency surgery is required, the NOAC should be discontinued. A small study suggests that rivaroxiban is reversed by PCC but dabigatran is not .

Surgery should be deferred, if possible until at least 12 h and ideally, 24 h after the last dose or even longer if there is renal impairment .