Acting now on hip fractures will pay off later

Conjoint Associate Professor Carolyn Hullick* FACEM, Emergency Physician and Chief Medical Officer at the Australian Commission on Safety and Quality in Health Care, explains what needs to change to improve patient outcomes after a hip fracture injury.

It is a startling truth that one in four people in Australia die within 12 months of having a hip fracture. Even to those of us who work on the frontline, this fact is staggering. The question is, what can our health system do to turn this around?

The Hip Fracture Clinical Care Standard has already shown itself to be a key lever to motivate systemic changes in hospitals across Australia. The recent update, released by the Australian Commission on Safety and Quality in Health Care (the Commission) on 11 September 2023 aims to further improve the care for this potentially life-changing injury.

Each year in Australia 19,000 people fracture their hip, and that figure is expected to climb with our aging population. Of those who survive, many cannot return to their former lives or level of independence — with about 15% entering residential aged care after the injury.

We know that hip fractures are associated with high mortality, morbidity and disability. Apart from the high personal cost, hip fractures are an increasing burden on our health system, costing almost $600 million each year.ⁱ

Given the numerous issues facing older people and the aged care sector, it’s important we tackle this problem now.

Building on achievements

Firstly, we should recognise the concerted efforts to address this serious and complex problem over the past seven years, which have led to significant changes in hip fracture care. The first Hip Fracture Clinical Care Standard introduced in 2016 set national expectations for the evidence-based care that people with this injury should receive. We have come a long way since then to improve care for people with a hip fracture.

The updated standard comprises seven evidence-based quality statements to ensure that a patient with a hip fracture receives optimal treatment from presentation to hospital to the completion of treatment in hospital (see Box 1). The new standard:

• Reduces the recommended maximum time to surgery from 48 to 36 hours.
• Emphasises a coordinated multidisciplinary approach to identify and address malnutrition, frailty and delirium.
• Renews the focus on the early initiation of a tailored care plan aimed at restoring movement and function, and minimising the risk of another fracture when patients are discharged.
   

This last point is crucial — the Commission is aware that transitions of care are often a weak link in the system, even when high-quality care has been provided in the acute phase. Effective communication of ongoing care needs with patients, their families and ongoing service providers is so important to ensure the patient’s recovery is optimised after the acute phase of care.

Registry data tracks performance

Outcomes over the past eight years have been tracked by the Australian and New Zealand Hip Fracture Registry (ANZHFR), based at Neuroscience Research Australia, which reports facility and patient level data against the standard and its indicators each year.

Since its inception in 2015, the number of Australian public hospitals participating in the ANZHFR has increased from 20 to 76 in 2022. This represents 84% of hospitals performing hip fracture surgery in Australia who participate to help improve their hip fracture care.

With data on more than 90,000 hip fractures collected over the past eight years, the registry is critically important for healthcare services delivering hip fracture care, as well as for policymakers, and has been instrumental in informing the updated version of the standard.

In 2022ⁱⁱ, 89% of participating hospitals in Australia and New Zealand had a hip fracture pathway in place. Preoperative assessment of cognition, delirium and pain continue to improve. Last year in Australia, 77% of patients ≥65 years had their preoperative cognition assessed and 40% were found to be impaired. Surgery within 48 hours was achieved for 78% of patients. Pain management has improved overall, with 66% of patients in 2022 having a pain assessment within 30 minutes of presentation — up from 54% in 2017.

Nerve blocks as part of pain management are now common before people arrive at the operating theatre, more older people are being seen by a geriatrician during their acute hospital stay and a growing proportion of patients are leaving hospital on bone protection medication.

These are all remarkable achievements — but it’s time to do more.

While there had been little change in average time to surgery in the three years prior to 2022 — with an average wait time of 34 hours — the ANZHFR Annual Report 2023 shows an increase to 37 hours last year, reflecting the ongoing challenges relating to the impact of COVID-19. The report also highlights ongoing wide variation in hospitals’ average time to surgery, ranging from 16 to 92 hours.

Also, first day walking remains low, with just 45% of patients taking a step the day after surgery, despite most people (91%) being offered the opportunity. We need to focus on actually getting people on their feet, since the evidence tells us the sooner people get out of bed, the better their functional recovery.

Adjusting to reduced time to surgery

Prompt hip fracture surgery reduces morbidity, hastens functional recovery and reduces length of stay. These reasons underlie the reduced maximum time to surgery of 36 hours for all patients, regardless of whether they first present at a hospital able to conduct the surgery or not.

While this further reduction will require adjustments on the part of health services, it is widely supported given the evidence that surgery within this timeframe leads to better outcomes for patients and reduces hospital length of stay.

This is clearly explained by ANZHFR Co-Chair Associate Professor Catherine McDougall, who is an Orthopaedic Surgeon in Brisbane and Chief Medical Officer of Queensland Health. “The challenge is that time to surgery is a systems-level issue,” she said. “The shift to reduce time to surgery to 36 hours requires facilities and organisations to re-think how hip fracture patients are managed and to identify ways they can get access to theatres which may be occupied with elective surgery as well as other emergencies.”

McDougall added: “We know that setting 48 hours in the 2016 standard has already resulted in huge improvements simply by setting a timeframe — although progress has been slow in the last few years. While it may be challenging to achieve 36 hours for every patient, we need to strive for this. Having this benchmark in the standard means that we need to consider as a system how we can achieve this.”

Time to surgery is also important as an equity marker for how we manage people with hip fracture in rural, regional and remote locations, McDougall emphasised. “Often the first hospital presentation is not where people are able to get their surgical management, so we will need to overcome some challenges to be able to meet the target in some areas.”

Equity of access to health care wherever people live is a priority for the Commission. I agree with McDougall that it won’t be easy for every hospital to achieve this immediately, although we are both confident it can be done.

As an ED physician in a small NSW hospital, I know first-hand that it’s possible in many instances to transfer a patient to a larger hospital and do hip fracture surgery within 36 hours — when the system is set up the right way. Much of it is about building relationships between our smaller and larger hospitals to expedite the process.

The question is how we work together to meet this challenge.

Addressing the whole patient

We know that many people who break their hip are older and often have complex care needs. Older patients tend to be, on average, frail, may have poor nutrition and are at risk of delirium by virtue of their older age and complexity, particularly if they have existing cognitive impairment.

Awareness and assessment of frailty, delirium and nutritional needs are significant components of multidisciplinary care under an orthogeriatric model of care, and are a stronger focus in this standard.

Frailty is associated with a longer length of stay and complications, and using a validated assessment tool can help to optimise treatment before and after surgery, remembering that frailty is not just about body weight and that people who are overweight can also be frail.

Malnutrition may be present on admission, and if so, it’s important to address this and to ensure optimal nutrition during hospital admission for all patients. The standard recommends addressing individual nutritional needs for all hip fracture patients in line with international dietary guidance and includes a new indicator to capture provision of oral nutritional supplements.

I encourage health services to look at the revised standard and the guidance provided in the quality statements for clinicians and healthcare services. The indicators have also been revised, and those that are new will be included in the ANZHFR for ongoing quality assurance by health services.

We have made great strides with hip fracture care, and just as we have improved care for stroke and acute coronary syndromes, it’s about setting the standards and building the right systems to meet those standards. How services do that may differ state to state and region to region, but we all belong to a much bigger system, and everyone has their part to play.

I’m confident this updated Hip Fracture Clinical Care Standard will raise the bar on how we work together to look after people with this life-changing injury.

Hip Fracture Clinical Care Standard — Quality statements Care at presentation Pain management Orthogeriatric model of care Timing of surgery Mobilisation and weight bearing Minimising risk of another fracture Transition from hospital care

Box 1.

Read the full quality statements at safetyandquality.gov.au/hipfracture-ccs.

Find out more: safetyandquality.gov.au/hipfracture-ccs.

This article was developed with Christina Lane and Alice Bhasale from the Commission’s Clinical Care Standards team.

*Conjoint Associate Professor Carolyn Hullick FACEM is Chief Medical Officer at the Australian Commission on Safety and Quality in Health Care and has geriatric leadership roles with the Australasian College and the International Federation for Emergency Medicine. At the Commission, she is also associated with projects focused on aged care, transitions of care and the appropriate use of anti-psychotics. In addition, Hullick is an Emergency Physician in Newcastle, New South Wales, and has expertise in geriatric emergency medicine.

^{[i] Australian Institute of Health and Welfare. Disease expenditure in Australia 2019–20, AIHW, Australian Government, accessed 02 December 2022.}

^{[ii] Australian and New Zealand Hip Fracture Registry. ANZHFR Annual Report 2023}

Graphics and image courtesy of ACSQHC.