Updated hip fracture standard released

The Australian Commission on Safety and Quality in Health Care (the Commission) has launched the updated national clinical care standard for hip fracture at the binational Hip Fest 2023 conference, hosted by the Australian & New Zealand Hip Fracture Registry (ANZHFR).

The launch coincides with the release of the ANZHFR Annual Report 2023, which includes over 16,000 hip fracture records on care outcomes from 97 participating hospitals.

Hip fracture is a leading cause of death and morbidity in older people, with one in four people dying within the first year after a hip fracture injury^[i]. Many people with a hip fracture wait longer than is optimal for surgery — despite some hospitals making a dramatic improvement in time to surgery in the past few years.

Faster recovery

The revised Hip Fracture Clinical Care Standard (2023) offers guidance on pain management, time to surgery, mobilisation and prevention of future fractures. A key change is the reduction in the maximum time to surgery from 48 hours to 36 hours, regardless of where a patient presents for medical care. For the first time, this explicitly includes patients who need to be transferred to a hospital that can perform the surgery.

First released in 2016, the binational standard was developed by the Commission to improve how people with a hip fracture are assessed and managed.

The Commission’s Acting Chief Medical Officer, emergency physician Associate Professor Carolyn Hullick, said there was an urgent need for health services to offer better care for people with a hip fracture, using the framework in the updated standard.

“Anyone who has seen someone live through a hip fracture knows it’s much more than a broken bone. People with a hip fracture tend to be older, frail and more vulnerable, so it is critical the fracture is repaired quickly to reduce pain and get them on the road to recovery back to independence,” she said.

“The data is sobering, as an Australian with a hip fracture is almost four times more likely to die within a year than someone of the same age who isn’t injured. This has an immense personal toll on individuals and families, in addition to the burden on our health system of around $600 million each year.”^[ii]

Not letting the sun set twice before repair

Much has improved since the Hip Fracture Clinical Care Standard was introduced in 2016, according to ANZHFR annual reports. The ANZHFR contains around 90,000 records, with 91% of hospitals performing hip fracture surgery in Australia participating to help improve their hip fracture care.

While some hospitals have substantially reduced their time to surgery, there is still marked variation. In 2022, the average time to surgery ranged from 16 to 92 hours,^[ii] with the longest waiting times for people being transferred for surgery. 78% of patients had surgery within 48 hours.

Geriatrician Professor Jacqueline Close, Co-Chair of the ANZHFR and Co-Chair of the expert advisory group for the standard, knows first-hand the value of high-quality care for hip fractures and believes the updated standard will be a lever for change.

“The Hip Fracture Clinical Care Standard sets expectations for how every patient should be cared for, while allowing for treatment to be tailored to the individual,” she said.

“The adage ‘don’t let the sun set twice before hip fracture repair’ has merit for several reasons. Firstly, no-one wants to see their mum or dad fasting and in pain waiting for surgery; and shorter time to surgery is associated with fewer complications, better recovery and survival.

“It is also more cost-efficient to manage these patients well. Every day surgery is delayed, two days are added to the length of stay. The sooner you operate, the quicker patients can get walking and go home.”

Improving outcomes

Close said the registry data shows Australia can do better in several key areas of hip fracture care. “The evidence tells us the sooner you are supported to get out of bed, the better your functional recovery. Last year, fewer than half (45%) of patients walked on the first day after hip fracture surgery.

“Also, only one-third (32%) of patients leave hospital on bone protection medication for osteoporosis to prevent another fracture. We absolutely can and should do better,” she said.

Hullick added, “Older people can have complex needs, and research shows the best results come when specialists from both orthopaedic surgery and geriatric medicine work together on a patient’s care — known as an orthogeriatric model of care.

“This means that as well as repairing the bone, we are managing the person’s other medical conditions, their cognitive function, their mobility and reducing the risk of more falls and fractures. This has been a focus since the standard was first introduced, with many hospitals now having orthogeriatric teams.

“The standard has already been a catalyst for change. By updating it and addressing the gaps, care will continue to improve. It will be fantastic to see a solid boost to patient outcomes as hospitals embed these latest changes.”

^{[i] Australian and New Zealand Hip Fracture Registry. ANZHFR Annual Report 2023
[ii] Australian Institute of Health and Welfare. Disease expenditure in Australia 2019–20}

Image credit: iStockphoto.com/Zinkevych