Care of patients with fragility fracture (Blue Book)

Osteoporosis: a new epidemic

• Osteoporosis is the most common disease of bone and its incidence is rising rapidly as the population ages. Though treatable, it is often left untreated.
• Organisation of the relevant services is poor, with little recognition of the nature of osteoporosis as a long-term condition.
• Better coordinated services – offering early diagnosis and bone protection, optimal fracture care and secondary prevention – would improve quality of life for patients and reduce the burden on services of fracture care.

Fragility fractures in an ageing society

• Over 300,000 patients present to hospitals in the UK with fragility fractures each year, with medical and social care costs – most of which relate to hip fracture care – at around £2 billion.
• The care and rehabilitation of patients with hip fracture is the central challenge for UK trauma services, but the quality and cost effectiveness of such care varies considerably across the country.
• Current projections suggest that, in the UK, hip fracture incidence will rise from the current figure of c. 70,000 per year to 91,500 in 2015 and 101,000 in 2020.

Improving fracture services

The evidence-base for hip fracture care is improving rapidly and, in general terms, shows that prompt, effective, multidisciplinary management can improve quality and at the same time reduce costs.

Key elements of good care include:

• Prompt admission to orthopaedic care.
• Rapid comprehensive assessment – medical, surgical and anaesthetic.
• Minimal delay to surgery.
• Accurate and well-performed surgery.
• Prompt mobilisation.
• Early multidisciplinary rehabilitation.
• Early supported discharge and ongoing community rehabilitation.
• Secondary prevention, combining bone protection and falls assessment.

Many elderly fracture patients are frail and have complex medical problems. Their needs for specialist medical care and early rehabilitation are best addressed when an orthogeriatrician – a care of the elderly physician with an interest in fracture care – is fully integrated in the work of the fracture service.

Advantages of such collaborative care include:

• Overall improvement in standards of medical care.
• Minimal delay to surgery caused by medical problems.
• Improved management of perioperative medical complications.
• Better coordination of multidisciplinary team work.
• Improved communication with patients and relatives.
• Reduction in adverse events.

Secondary prevention of fragility fractures

• Sustaining a fragility fracture at least doubles the risk of future fractures and, although secondary prevention in the form of bone protection and falls assessment is of proven value, only a minority of patients currently benefit from such interventions.
• Older patients presenting with fractures should be offered assessment for osteoporosis by axial bone densitometry. In patients with osteoporosis, the risk of further fracture can be halved by anti-resorptive therapy.
• Most fractures result from a fall, and interventions to reduce the risk of falls can be effective in preventing further such events. However, fewer than half of patients currently admitted with fracture are routinely offered such an assessment.
• Ideally, comprehensive secondary prevention should consist of osteoporosis assessment and treatment together with a falls risk assessment, in a ‘one-stop shop’ setting. The challenge of organising such services and integrating them across acute and primary care is considerable.
• A Fracture Liaison Service, delivered by a Nurse Specialist, is a proven approach to the identification, assessment and treatment of fracture risk, and this model should be considered in all units.

Using audit, standards and feedback to improve care and secondary prevention

The National Hip Fracture Database (NHFD) is a web-based audit that builds on the work of a number of a number of large scale hip fracture audits across the UK and is supported by the National Clinical Audit Support Programme (NCASP). Its aim is to promote best practice in the care and secondary prevention of hip fracture. NHFD will:

• Collect data on patient casemix, care, outcomes and secondary prevention.
• Allow casemix-adjusted outcome assessment to promote transparency of inter-hospital comparisons.
• Enable hospitals to compare care and outcomes against national benchmarks and quality standards.
• Monitor performance over time.
• Measure the impact of changes in clinical care and service organisation.
• Support large-scale research on aspects of hip fracture care, through the use of ‘sprint audits’ and casemix-adjusted outcomes.

Six standards for hip fracture care

These standards reflect good practice at key stages of hip fracture care. Widespread compliance with them would improve the quality and outcomes of care and also reduce its costs. The rationale for them is set out in the Blue Book, and compliance – and progress towards compliance – can be continuously monitored by participation in NHFD.

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation.
2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours.
3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer.
4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission.
5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures.
6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls.