Fractured Hip Surgery in the

Elderly

Bronwyn Shumack Manager Patient Safety

December 2012

The Clinical Excellence Commission

and its role in Patient Safety in NSW

• 2001 – Institute for Clinical Excellence established

by a small committed group with focus on ‘better

systems, better training, better research’• 2004 (NSW) – Camden/Campbelltown � CEC

‘should be responsible for investigating and making

recommendations with respect to systems issues that

have the potential to have an area or Statewide

significance’

• 2011 – CEC ‘...will take responsibility for quality and

safety and providing leadership in clinical governance

with LHDs’

INCIDENTS

UNREPORTED ERRORS

Loukopoulos/Dismukes, 2002, NASA

ACCIDENTS

Our drivers1,500,000 patient admissions for around

6,000,000 bed days each year. A further

2,000,000 non-admitted ED presentations

and many more people treated in the

community. In most cases, care goes well.

Around 140,000 clinical incidents reported

annually (representing 8.0 percent of all

admissions). 600 of these rated as

serious. 400 were associated with patient

deaths.

The Patient Safety Team oversees and

analyses the clinical incidents reported

in “IIMS” and to the Ministry

So what do we do with all this “bad news”?

• Aggregated analysis in collaboration with clinicians

• Use IIMS, RCA and clinician input to determine how and

where to drive change

• Provide system and public feedback

• Provide education in patient safety, RCA/incident

investigation and basic “human factors”

We rely heavily on cake, jelly snakes, coffee and black humour

• “In health care we are learning slowly and

painfully that safety is a tough intractable

problem that will take much more than

reporting to resolve”

Charles Vincent 2008

Serious incident reported RCA

conducted

Report reviewed &

endorsed by CE

NSW Ministry of

Health (MoH)

Relevant health service

managers allocated

responsibility for

implementing

recommendations.

Implementation

overseen by senior

managers and Director

Clinical GovernanceOther MoHdirectorates/state bodies for action as appropriate

CECRCA review committees

CEC undertakes aggregated analysis of issues identified in RCA

and IIMS reports; develops and distributes

reports to Minister, public, LHDs – including

Clinical Focus Reports and Patient

Safety Reports

Ongoing monitoring and improvement

cycles

Open disclosure & support processes

commence Report provided to

patient, family & relevant staff

In 2011 that included ….

http://www.cec.health.nsw.gov.au/__documents/programs/patient-

safety/patient-safety-report-hip-fractures-1.pdf

Developed in conjunction

with SCIDUA, CHASM and

in consultation with ACI

A long time ago in this fair city...

a request was made …

From Wikipedia, the free encyclopedia Securiger 23 Feb 2005

http://www.innomed.net/hip_tools_other.htm

A lot has changed since 1972

Improved technology, but still a major intervention for the patient

• The length of stay in acute wards for patients admitted to hospital

with a hip fracture has fallen by an average of one day—to just

over 20 days—over the past year, concludes the latest report

from the national hip fracture database for England, Wales,

Northern Ireland, and the Channel Islands. BMJ 2012;345:e5940

• Compared with expected stay of 8 days for elective THR

http://healthtopics.hcf.com.au/TotalHipReplacement.aspx

This is a highly complex patient group.

There is strong evidence that early, comprehensive treatment

greatly increases the likelihood of a good outcome

Case 1• Patient brought to ED with #hip, reviewed by ED &

orthopaedic registrars

• Anaemic, left-sided consolidation and effusion on

CXR, no evidence that this was followed up.

• Senior clinician on call was contacted and patient

transferred to a ward to await surgery the next day.

• ED registrar documented that a review by the

medical registrar was required. Again – not followed

up - did not occur.

• Next day patient had decreased UO - reviewed by

intern, managed with oral fluids.

• Surgery postponed due to OT load

Case 1 (cont’d)

• Later review by orthopaedic registrar - no evidence

that poor renal function was recognised by team or

communicated to the orthopaedic surgeon.

• Pre-anaesthetic review occurred the same evening.

• Documentation did not reflect patient assessment or

any discussion with the anaesthetist about

anaesthetic risks.

• The next day a different anaesthetic registrar was

allocated to administer the patient’s anaesthetic. This

registrar did not review the patient on the morning of

surgery as the patient had been assessed the night

before.

Case 1 (cont’d)

• The patient underwent surgical fixation of the

fractured hip under spinal anaesthesia and sedation.

• Uneventful but hypotension both intra-operatively

and in recovery, managed by a senior anaesthetist.

• Once stable, the patient was transferred to an

orthopaedic ward. A few hours later it was noted

that the patient had no urinary output despite IV

fluids. Fluid boluses were given.

• Continued hypotension, transiently unresponsive

and reviewed by the anaesthetist and intern.

?cardiac event.

• No evidence of escalation to a senior clinician. The

patient died.

Case 2

An elderly patient requiring surgery for a fractured

femur (category 4 requiring surgery within 24 hour)

had the surgery postponed twice. On the first

occasion other emergencies took precedence and on

the second, the elective lists took precedence as no

surgeon was available. When the patient was finally

booked for surgery, it was cancelled by the

anaesthetist as the patient was assessed as no

longer fit. A cardiology review was required prior to

the surgery proceeding.

A recent RCA

Described a very similar story

• A patient arrived in ED after falling a breaking her hip

at the hostel where she lived

• Her comorbidities included AMI, for which she was

taking Clopidogrel, COPD and chronic renal failure.

• Accepted by ortho team and listed for surgery

• Anaesthetist reviewed her and said “leave for a

week”.

A recent RCA (cont)• During the week - several calls for review due to low

BP, O2, ↑RR, HR, but only seen by ortho team. Later

given transfusion (Hb 85)

• ORIF under spinal completed 9 days after admission.

She died six days after surgery

• The RCA team found: the patient had comorbidities

which may have been managed earlier if the

specialist medical team were consulted at the time of

admission and the expectations for treatment and

follow-on care made clear to the consulting team.

Back to the report:

the scope of the review

Report Type Date range Number identified in initial search

Number used in analysis

IIMS incident reports

- SAC1 (RCA reports)

- SAC2

- SAC3

- SAC4

January 2010 – December 2010

April 2003 - December 2010

January 2010 - January 2011

April 2010 - January 2011

26

337

1,000

1,000

26

79

CHASM summary reports 2007 - 2010 23 15

SCIDUA summary reports 2005 - 2011 43 20

2,429 140

Age of patients in SAC 2-4 incidents

Clinical management sub-classification

for the RCAs reviewed (n=26)

indicates a fall during inpatient stay

73% of cases reviewed

Clinical risks identified in the RCAs

“System” factors which may have

contributed to the incidents

Very

human

factors

System factors (cont)

Inadequate care planning and coordination were the

most common system issue identified.

• Care plans were:

• not developed at all

• not documented and/or communicated

appropriately

• inadequate for the patient’s complex needs

System factors (cont)

• Care coordination was:

• poor or fragmented between specialties, teams

and/or clinicians;

• unclear in regard to which clinician had primary

responsibility for overseeing the patient’s care;

or

• there was no evidence of effective teamwork,

including lack of involvement of a senior

clinician/consultant.

Issues identified during the review

• Hip fracture surgery is often undertaken after hours

and on emergency lists, reducing the availability of

necessary support services.

• Optimisation of patients prior to hip surgery is a less

than a robust process in some facilities. Co-

management (joint responsibility) of high risk

patients is not evident.

• Time to surgery (including access) is not

standardised or monitored. The patient’s state of

readiness for surgery is not the deciding factor on

when surgery occurs.

Issues identified (cont)

• Senior clinician input to post-operative care is less

than optimal. Patients deemed ASA 4 or 5 are not

always seen by a senior clinician prior to

anaesthesia.

• The appropriateness of high risk elderly patients

undergoing major hip surgery in facilities which

have no ICU/HDU must be considered.

• Although guidelines promoting an orthogeriatric

model of care are available they appear not to be

widely known and/or applied.

Recommendation 1.8.1 in the NICE

clinical guideline on hip fracture

States that people with hip fracture are offered from

admission access to a formal, acute orthogeriatric or

orthopaedic ward-based Hip Fracture Programme

(HFP) that includes all of the following:

• 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 and long-term

wellbeing

NICE clinical guideline (cont)

• continued, coordinated, orthogeriatric and

multidisciplinary review

• liaison or integration with related services, particularly

mental health, falls prevention, bone health, primary care

and social services

• clinical and service governance responsibility for all

stages of the pathway of care and rehabilitation, including

those delivered in the community

Best Practices for Elderly Hip Fracture

Patients (a Canadian review)Consistent evidence of benefit for use of:

• spinal anesthesia pressure-relieving mattresses

• perioperative antibiotics deep vein thromboses prophylaxes

Routine preoperative traction was not associated with any benefits and should be

abandoned

Types of surgical management, postoperative wound drainage, and even

‘‘multidisciplinary’’ care, lacked sufficient evidence to determine either benefit

or harm.

There was little evidence to either determine best subacute rehabilitation practices

or to direct ongoing medical issues (e.g., nutrition ). Studies conducted during

the subacute recovery period were heterogeneous in terms of treatment

settings, interventions, and outcomes studied and had no clear evidence for

best treatment practices. Beaupre LA, Jones A et al

How important

are these

elements if

patient is unfit for

surgery?

UK National Confidential Enquiry

Report into Patient Outcomes and

Death (2009) Caring to the End?

• “half the patients dying within four days of admission in

the UK lacked input from senior doctors”. Expert

reviewers assessed patient records found that

consultants were not involved in making a diagnosis in

just over half (53 per cent) of cases.

• There was evidence of poor decision-making and lack of

senior input, particularly in the evenings and at night.

• Other findings indicated a clinically important delay in the

first review by a consultant in 25 per cent of cases, poor

communication between/within teams in 13.5 per cent of

cases and nearly 22 per cent of ‘Do Not Attempt

Resuscitation’ (DNAR) orders were signed by very junior

staff.

Length of stay and outcome

• UK review of costing

http://www.nice.org.uk/nicemedia/live/13489/54928/54928.pdf

• Estimated that if all strategies introduced LOS would

be reduced by two days – saving millions of pounds

• NHFD report 2011

http://www.hqip.org.uk/assets/National-Team-Uploads/NHFD-National-

Report-2011Final.pdf

..and significant ongoing benefit for the patient – less

likely to be “de-conditioned”, confused or suffering

complications/exacerbation of comorbidities

Benefits of the UK model

Since the audit began more patients are being admitted

promptly to orthopaedic wards; delays for operation have been

reduced, with the great majority of patients now having surgery

within 48 hours. Fewer patients develop pressure ulcers; and

more have specialist pre-operative assessment by a care of

elderly physician. Prevention of future fractures is being

addressed too: 71 per cent of patients will receive both falls

and bone health assessments before leaving hospital.

The CEC report found far too many patients who did not get to

theatre for several days

Recommendations based on

evidence and discussions with ACI

• All elderly patients with hip fracture must be admitted

under a co-admission process with joint

responsibility (orthogeriatrician, geriatrician or

general physician and surgeon)...

• ...access to surgery within 48 hours of admission and

high dependency care in the immediate post

operative phase if the patient is deemed ASA 4 or 5.

• ACI Orthogeriatric Model of Care Clinical Practice

Guide 2010...be implemented across NSW.

Recommendations (cont)

• Implementation will require the establishment of

support structures at state and local health districts

level including changes to patient flow and admission

processes, access to operating suite, management of

elective surgery waiting lists.

• In consultation with orthopaedic services state wide

key performance indicators be developed related to

the care processes of elderly patients, who sustain hip

fractures. This should include the establishment of

state wide benchmarks for the management of hip

fractures in both the metropolitan and rural sector.

Recommendations (cont)

• A state wide process for the monitoring of these

agreed key performance indicators be established.

This should include monitoring of patient outcomes,

variation in care and actions taken when none

compliance/variation occurs.

• A full economic evaluation be conducted to identify

the financial impact of the above recommendations.

In summary

CEC would like to see:

• Orthogeriatric models, such as the ACI

model in NSW implemented

• Supported by good quality data collection

and feedback

• Improved outcomes for elderly patients

undergoing hip surgery – as in UK report

QUESTIONS???

bronwyn.shumack@cec.health.nsw.gov.au