Meeting the NICE Quality Standard for Hip Fracture ICO Conference Centre, London 10th October 2012 Progress in hip fracture care: audit and standards in

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Meeting the NICE Quality Standard for Hip FractureMeeting the NICE Quality Standard for Hip Fracture

ICO Conference Centre, LondonICO Conference Centre, London

10th October 201210th October 2012

Progress in hip fracture care: audit and Progress in hip fracture care: audit and standards in the UKstandards in the UK

Colin CurrieColin Currie

Clinical Lead (Geriatric Medicine) Clinical Lead (Geriatric Medicine)

National Hip Fracture DatabaseNational Hip Fracture Database

OutlineOutline

• Hip fracture: the tracer condition for the current Hip fracture: the tracer condition for the current epidemic of fragility fracturesepidemic of fragility fractures

• UK progress in hip fracture care: The National UK progress in hip fracture care: The National Hip Fracture Database and the Blue BookHip Fracture Database and the Blue Book

• Audit and standards working together? Audit and standards working together? – The NHFD and the NICE hip fracture quality The NHFD and the NICE hip fracture quality

standardsstandards

The fragility fracture careerThe fragility fracture careerThe fragility fracture careerThe fragility fracture career

Morbidity

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age

No fractures – increasing morbidity due to ageing alone

Added morbidity from fractures

AgeAdapted from Kanis JA, Johnell O; 1999

Hip fractureHip fracture

““The most common serious – The most common serious – and the most serious and the most serious common – injury of older common – injury of older people”people”

The tracer condition for the The tracer condition for the current epidemic of fragility current epidemic of fragility fracturesfractures

Hip fracture – the patient experienceHip fracture – the patient experience

• A major life-eventA major life-event

• Recovery of mobility often limitedRecovery of mobility often limited

• Mortality highMortality high

• Loss of home much dreaded – and fairly Loss of home much dreaded – and fairly common common

Hip fracture – the patient experienceHip fracture – the patient experience

f r om

Hospital 16 (n= 444)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 11 21 31 41 51 61 71 81 91 101 111

120 days post admission

home

Residential Care

Long Term Care

other

ger rehab

Acute Ward

Orthopaedic Department

Died

Hip fracture – service implicationsHip fracture – service implications

• 30 years ago – an unwelcome and 30 years ago – an unwelcome and burdensome caseloadburdensome caseload

• Now a major surgical, medical and Now a major surgical, medical and rehabilitation challengerehabilitation challenge

• Resource-intensive – amid growing Resource-intensive – amid growing service pressuresservice pressures

• Service response much improved!Service response much improved!

PhysiotherapyPhysiotherapy Primary CarePrimary Care

NursingNursing A&EA&E RadiologyRadiology

Supported DischargeSupported Discharge OccupationalOccupational TherapyTherapy

Geriatric MedicineGeriatric Medicine AnaestheticsAnaesthetics

Social Social Management Management RehabilitationRehabilitation

ServicesServicesG.P.G.P.

Labs PorteringPortering

Orthopaedic SurgeryOrthopaedic Surgery

Hip fracture care – who’s involved?Hip fracture care – who’s involved?Hip fracture care – who’s involved?Hip fracture care – who’s involved?

CarersCarers

Projected hip fractures worldwideProjected hip fractures worldwideProjected hip fractures worldwideProjected hip fractures worldwide

Adapted from Cooper C et Adapted from Cooper C et al, Osteoporosis Int, al, Osteoporosis Int, 1992;2:285-91992;2:285-9

Projected to reach 3.250 million in Asia by 2050

1990 2050

600

3250

1990 2050

668

400

1990 205074

2

378

1990 2050

100

629

Total number ofTotal number ofhip fractures:hip fractures:1990 = 1.66 million 1990 = 1.66 million 2050 = 6.26 million2050 = 6.26 million

Hip fracture – a suitable case for audit?Hip fracture – a suitable case for audit?

• Common, serious, Common, serious, well-definedwell-defined injury injury• Good evidence base for care – and preventionGood evidence base for care – and prevention• Care is complex and costly Care is complex and costly • Care, outcomes – and costs – vary Care, outcomes – and costs – vary • Numbers rising as populations ageNumbers rising as populations age

• Hip fracture care the central challenge of Hip fracture care the central challenge of current global fragility fracture epidemiccurrent global fragility fracture epidemic

Hip fracture audit: a brief historyHip fracture audit: a brief history

• 1980’s onwards: 1980’s onwards: ‘Rikshoft’‘Rikshoft’ (Sweden) (Sweden)– European bilaterals European bilaterals – Scottish Hip Fracture AuditScottish Hip Fracture Audit (1993-2010) (1993-2010)– Standardised Audit of Hip Fracture in Europe (SAHFE)Standardised Audit of Hip Fracture in Europe (SAHFE)– Growing numbers of single-centre auditsGrowing numbers of single-centre audits

• 2007 2007 UK National Hip Fracture Database UK National Hip Fracture Database (NHFD)(NHFD)– using the synergy of audit, standards and using the synergy of audit, standards and

benchmarked feedback to improve care and benchmarked feedback to improve care and outcomesoutcomes

• 2011/12 2011/12 International interest – and action! (Australia, International interest – and action! (Australia, NZ, Ireland, Canada)NZ, Ireland, Canada)

National Clinical Governance for Hip Fracture Care: ScotlandNational Clinical Governance for Hip Fracture Care: Scotland

The National Hip Fracture DatabaseThe National Hip Fracture Database

• A clinically-led, web-based, continuous audit of A clinically-led, web-based, continuous audit of hip fracture care and secondary prevention in hip fracture care and secondary prevention in England, Wales, and Northern IrelandEngland, Wales, and Northern Ireland

• Using the synergy of audit, standards and Using the synergy of audit, standards and feedback to improve care and outcomesfeedback to improve care and outcomes

• Valued by clinicians and managers, and by the Valued by clinicians and managers, and by the Departments of HealthDepartments of Health

• Successive national reports show improvements Successive national reports show improvements in care and secondary preventionin care and secondary prevention

www.nhfd.co.uk

Development: 2004-2007Development: 2004-2007

• Strategic vision and ruthless acquisitionStrategic vision and ruthless acquisition• Dataset from Rikshoft, SHFA, etcDataset from Rikshoft, SHFA, etc• IT from Myocardial Infarction National Audit Project (MINAP)IT from Myocardial Infarction National Audit Project (MINAP)

• Soft money and hard workSoft money and hard work• Industry funding (via national organisations) 2004-2009Industry funding (via national organisations) 2004-2009

• Committees large and smallCommittees large and small• To consult – and implementTo consult – and implement

• Making friends and influencing peopleMaking friends and influencing people• Media, meetings, lobbying, etcMedia, meetings, lobbying, etc

Blue Book and NHFD: launched together in 2007Blue Book and NHFD: launched together in 2007

Progress: the NHFD 2007-2012Progress: the NHFD 2007-2012

• NHFD launched – Sept. 2007NHFD launched – Sept. 2007• Recognised by NCAAG in 2009 for funding by Recognised by NCAAG in 2009 for funding by

HQIP as a national clinical auditHQIP as a national clinical audit• Steady growth towards national coverageSteady growth towards national coverage• National reports: 2009, 2010, 2011, 2012National reports: 2009, 2010, 2011, 2012• Growing impact on care and outcomesGrowing impact on care and outcomes• International interest – and acton!International interest – and acton!


A recurrent dilemma in clinical audit…A recurrent dilemma in clinical audit…

Simplicity vs. Complexity?Simplicity vs. Complexity?

(e.g. SAHFE…)(e.g. SAHFE…)



A recurrent dilemma in clinical audit…A recurrent dilemma in clinical audit…

Simplicity vs. Complexity?Simplicity vs. Complexity?

For Blue Book Standards and NHFD For Blue Book Standards and NHFD dataset: dataset:

Simplicity preferred!Simplicity preferred!

Six Blue Book standards – monitored by NHFDSix Blue Book standards – monitored by 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, during normal working hours

3. All patients with hip fracture should be assessed and cared for with a view to minimising the 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 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

Six Blue Book standards – why comply?Six Blue Book standards – why comply?

• Compliance with these standardsCompliance with these standards– raises quality in hip fracture careraises quality in hip fracture care– and reduces its costs!and reduces its costs!

• Cost and quality not in conflictCost and quality not in conflict

• ‘‘Looking after hip fracture patients Looking after hip fracture patients well is cheaper than looking after them well is cheaper than looking after them badly’badly’

NHFD Reports: 2008-2011NHFD Reports: 2008-2011

12,983 records from 64 hospitals






NHFD National Report 2012NHFD National Report 2012

NHFD coverage: September 2012NHFD coverage: September 2012

• 188/188 (100%) of eligible hospitals registered188/188 (100%) of eligible hospitals registered

• 186/188 (99%) submitted data in the last three 186/188 (99%) submitted data in the last three monthsmonths

• 220,000+ records submitted since launch220,000+ records submitted since launch

• c. 5000 records submitted per month (c. 95+% of c. 5000 records submitted per month (c. 95+% of all eligible hip fractures – based on c. 65,000 p.a.)all eligible hip fractures – based on c. 65,000 p.a.)

Audit and changeAudit and change

• Improving compliance with Blue Book Improving compliance with Blue Book standardsstandards

• Local use of audit for service changeLocal use of audit for service change

• Trend data: 28 hospitals, 2008 – Trend data: 28 hospitals, 2008 – 20112011

• Implementing Best Practice TariffImplementing Best Practice Tariff

Compliance with Blue Book standards: 2009-12Compliance with Blue Book standards: 2009-12

StandardStandard 20092009 20102010 20112011 201220121. Admission to orthopaedic ward 1. Admission to orthopaedic ward within 4 hourswithin 4 hours

N/AN/A 55%55% 56%56% 52%52%

2. Surgery within 48 hours and during 2. Surgery within 48 hours and during working hoursworking hours

75%75% 80%80% 87%87% 83%83%

3. Patients developing pressure 3. Patients developing pressure ulcersulcers

N/AN/A 6%6% 3.7% 3.7% 3.7%3.7%

4. Pre-operative assessment by an 4. Pre-operative assessment by an orthogeriatricianorthogeriatrician

24%24% 31%31% 37%37% 43%43%

5. Discharged on bone protection 5. Discharged on bone protection medicationmedication

N/AN/A 57% 57% 66%66% 69%69%

6. Received a falls assessment prior 6. Received a falls assessment prior to dischargeto discharge

44%44% 63%63% 81%81% 92%92%

NHFD: audit and change locallyNHFD: audit and change locally

Hospital-level initiatives Hospital-level initiatives

• NHFD offers NHFD offers current, credible local datacurrent, credible local data on workload and on workload and service performance service performance

• Such data Such data can prompt and monitor local initiativescan prompt and monitor local initiatives agreed by clinicians and managersagreed by clinicians and managers

• Many substantial improvements: e.g. reduced time to Many substantial improvements: e.g. reduced time to theatre, length of stay, mortality and service coststheatre, length of stay, mortality and service costs

Wansbeck and N. TynesideWansbeck and N. Tyneside

• Quality improvement programme: NHFD data; Quality improvement programme: NHFD data; Kings Fund support – addressing whole care Kings Fund support – addressing whole care pathway pathway

– Pain control improved (79% of patients get Pain control improved (79% of patients get nerve block on admission)nerve block on admission)

– 95% have surgery within 36 hours95% have surgery within 36 hours– 100% mobilise on first post-op day if medically 100% mobilise on first post-op day if medically

fitfit– Systematic feedback from patients and Systematic feedback from patients and

families consistently averages >9.3/10families consistently averages >9.3/10

St Peters Hospital, ChertseySt Peters Hospital, Chertsey

• Two ortho-geriatricians appointed; quality initiative on hip Two ortho-geriatricians appointed; quality initiative on hip fracture care pathway (2010)fracture care pathway (2010)

• In 2012, 60% of patients have surgery within 24 hours, In 2012, 60% of patients have surgery within 24 hours, 80% within 36 hours80% within 36 hours

• Length of stay reduced from 25 to 22 days, with Length of stay reduced from 25 to 22 days, with considerable efficiency savingsconsiderable efficiency savings

• 60% of patients discharged to original residence within 60% of patients discharged to original residence within 25 days, compared with 44% within 30 days in 201025 days, compared with 44% within 30 days in 2010

Chelsea and Westminster HospitalChelsea and Westminster Hospital

• Meeting in May 2011 recognises hip fracture care Meeting in May 2011 recognises hip fracture care as sub-optimalas sub-optimal

• Changes include dedicated trauma theatre Changes include dedicated trauma theatre sessions, thrice-weekly ortho-geriatrician Ward sessions, thrice-weekly ortho-geriatrician Ward rounds, and weekly discharge planning roundsrounds, and weekly discharge planning rounds

• In-patient mortality reduced from 11% to 9%In-patient mortality reduced from 11% to 9%

• Average acute length of stay down from 24 to Average acute length of stay down from 24 to 19.5 days, with estimated savings of £91,00019.5 days, with estimated savings of £91,000

Trend data: 2008-2011Trend data: 2008-2011

• 28 hospitals28 hospitals– Early and sustained NHFD participationEarly and sustained NHFD participation– Good case ascertainment, data Good case ascertainment, data

completenesscompleteness– 30,022 cases (130,022 cases (1stst April 2008 to 31 April 2008 to 31ststMarch March

2011)2011)– Time to theatre, orthogeriatrician Time to theatre, orthogeriatrician

involvement, secondary prevention, involvement, secondary prevention, mortalitymortality



The Best Practice Tariff for hip fracture The Best Practice Tariff for hip fracture carecare

• A DoH initiative, based on NHFD participationA DoH initiative, based on NHFD participation• Enhanced case-by-case payment if clinically Enhanced case-by-case payment if clinically

determined care standards metdetermined care standards met– Surgery within 36 hoursSurgery within 36 hours– Joint care, joint protocol: surgeon, anaesthetist, Joint care, joint protocol: surgeon, anaesthetist,

orthogeriatrician orthogeriatrician – Early involvement of orthogeriatrician in careEarly involvement of orthogeriatrician in care– Multi-disciplinary rehabilitationMulti-disciplinary rehabilitation– Bone health, falls assessments Bone health, falls assessments

Audit and change: how does it work?Audit and change: how does it work?

• NHFD offers:NHFD offers:

– the synergy of audit, standards and feedback the synergy of audit, standards and feedback – a website providing key documents and literature databasea website providing key documents and literature database– helpdesk and supportive central staff helpdesk and supportive central staff – regional meetings regional meetings – national reportsnational reports

• ‘‘Together, these measures have succeeded in creating Together, these measures have succeeded in creating a critical mass of enthusiasm and expertisea critical mass of enthusiasm and expertise in hip in hip fracture care…’*fracture care…’*

**NHFD 2011 Summary Report on NHFD 2011 Summary Report on www.nhfd.co.uk

Progress in hip fracture care?Progress in hip fracture care?

• NHFD and the Blue BookNHFD and the Blue Book– the synergy of audit, feedback and standardsthe synergy of audit, feedback and standards

• National-level evidence of:National-level evidence of:– rising care standardsrising care standards

• Large-series evidence of:Large-series evidence of:– lower mortalitylower mortality– associated with orthogeriatric care? associated with orthogeriatric care?

Progress in hip fracture care?Progress in hip fracture care?

• Local evidence of:Local evidence of:– better care and outcomesbetter care and outcomes– lower costs toolower costs too

• BPT a recent and effective incentiveBPT a recent and effective incentive– with double effect?with double effect?

• ‘‘Looking after hip fracture patients well is Looking after hip fracture patients well is cheaper than looking after them badly’cheaper than looking after them badly’

(Blue Book on the care of patients with fragility (Blue Book on the care of patients with fragility fracture)fracture)

More effort required?More effort required?

• Better documentation of long-term care & Better documentation of long-term care & outcomesoutcomes– post-acute carepost-acute care– mobilitymobility– place of residence place of residence

• Sprint auditsSprint audits– ASAP in developmentASAP in development– other?other?

• Health economicsHealth economics– cost-effective care?cost-effective care?

More progress in hip fracture care?More progress in hip fracture care?

• Without audit, clinical standards are simply Without audit, clinical standards are simply aspirationalaspirational

• As a national clinical audit of hip fracture care, As a national clinical audit of hip fracture care, the NHFD has demonstrated the synergy of the NHFD has demonstrated the synergy of audit and standards in improving careaudit and standards in improving care

• NHFD has the potential to monitor NHFD has the potential to monitor compliance with the NICE Quality compliance with the NICE Quality StandardsStandards

NHFD & the NICE Quality Standards for Hip FractureNHFD & the NICE Quality Standards for Hip Fracture




• NHFD has the potential to monitor NHFD has the potential to monitor compliance with (some of) the NICE compliance with (some of) the NICE Quality Standards… Quality Standards…

… …and measure any impact on care and and measure any impact on care and outcomes?outcomes?

AcknowledgementsAcknowledgements

• Prof K-G Thorngren & RikshoftProf K-G Thorngren & Rikshoft• SHFA colleaguesSHFA colleagues• Dave Marsh, Professor of Orthopaedic Surgery, RNOH, Chair/Co-chair, Dave Marsh, Professor of Orthopaedic Surgery, RNOH, Chair/Co-chair,

NHFD; Finbarr Martin, Co-chair, NHFD; Rob Wakeman, Lead Clinician, NHFD; Finbarr Martin, Co-chair, NHFD; Rob Wakeman, Lead Clinician, Orthopaedic Surgery, NHFD; Maggie Partridge, Project Manager, NHFD; Orthopaedic Surgery, NHFD; Maggie Partridge, Project Manager, NHFD; NHFD Project CoordinatorsNHFD Project Coordinators

• NHFD Steering Group, Dataset Sub-group, & Scientific and Publications NHFD Steering Group, Dataset Sub-group, & Scientific and Publications CommitteeCommittee

• BOA & BGS BOA & BGS • Dept of Health and HQIP Dept of Health and HQIP • Blue Book Authorship GroupBlue Book Authorship Group• Colleagues in NCASP/CCAD/NHS ICColleagues in NCASP/CCAD/NHS IC• Quantics Consultancy Quantics Consultancy • Patients & staff in participating hospitalsPatients & staff in participating hospitals

www.nhfd.co.ukwww.nhfd.co.uk

Documents

Meeting the NICE Quality Standard for Hip Fracture ICO Conference Centre, London 10th October 2012 Progress in hip fracture care: audit and standards in