When a patient suffers a hip fracture it is an ACUTE EMERGENCY.
Management of this severe injury requires a co-ordinated emergency approach to recognition and early treatment.
The mortality rate at 1 year following a hip fracture is approximately 25%. In addition hip fractures result in significant morbidity. 50% of patients may not be able to walk independently and 25% not return to their own home after sustaining a hip fracture.
This would compare similarly with such conditions as severe sepsis, major trauma and stroke. Hence it should be treated in the same manner as these time dependent conditions.
Delays to treatment are associated with further increased morbidity such as delirium and longer hospital stays.
Typical symptoms suggestive of a hip fracture are groin/hip pain following a fall and subsequently being unable to weight bearing on the affected limb. The affected limb may be shortened and rotated. However the absence of external rotation and limb shortening obviously does not negate the presence of a fracture.
As per national guidelines we have 4 HOURS to transfer this patient from ED registration to the orthopaedic ward bed. This is the only condition we manage whereby the “money follows the patient” and the hospital receives a stipend when this target is met. Getting the patient to the ward within 4 hours benefits the patient and hospital.
The recognition of a hip fracture should start at the pre-hospital phase. If suspected by EMS, ambulance control should contact MMUH ED and pre-alerted to the transfer.
The pre-alert should trigger a response of:
· Vocera Alert – “URGENT BROADCAST – HIP FRACTURE PATHWAY” and then the details of the case eg 89 year old female, suspected left hip fracture, going to blue zone room 1
· Hip fracture proforma and methoxyflurane as analgesia available.
· ED X-ray will be aware of the need for urgent XR following Vocera broadcast
On arrival to ED, bed to bed transfers should be limited. Ideally they should have only one transfer; from ambulance trolley to ED trolley. If hip fracture is clinically suspected XRs should be ordered as soon as possible and Radiology porter informed.
Follow the patient to the ED X-ray room and take a picture of the XR for posting on Siilo – this saves time and earlier identification.
A checklist of appropriate investigations is available on the hip fracture proforma. (see below)
ED Hip Fracture checklist
X-Ray – AP pelvis and lateral hip
CT if x-ray not definitive or if significant concerns from EM or FIT team regarding occult hip fracture
Laboratory and Point of Care Blood Tests,
The following are suggested
Group and Hold
Renal profile (U&E)
Other laboratory blood tests as dictated by patient history and condition
CK - if long lie
TNI - if cardiac cause for fall/collapse suspected
IF CLINICALLY STABLE DO NOT WAIT FOR RESULTS BEFORE REFERRAL/ADMISSION
Analgesia (IV Paracetamol, +/- Penthrox, +/- IV Opioids)
FICB - see overleaf
MMUH hip fracture admission document
IV fluids and diet*
Siilo referral and contact orthopaedic team on call
Inform ED CNM of # and request bed
Premorbid Clinical Frailty scale
Identify and treat immediately correctable co-morbidities **
Most hip fracture are readily identified on plain film XRs. Occasionally cross sectional imaging may be needed to identify a fracture. This is more common in severe osteoporosis or impacted fractures. This should be expedited from the ED team through the radiology service. This should not delay a patient getting to the hip fracture bed. An opinion should be sought from the orthopaedic team if an occult fracture is suspected (ie normal XR but clinically suspected hip fracture) via Siilo application.
Contact the EM consultant if there is a delay in access to necessary imaging studies.
Once a hip fracture is identified, inform:
· CNM2 ED
· Siilo hip fracture group
· Patient flow/Site nurse manager (out of hours)
· Patient flow/Site nurse manager should contact St Anges’ ward where a hip fracture bed is available.
· Commence the Hip fracture proforma document, available on patient centre, on the navigator tab under Trauma Documents.
This document can be filled in electronically. Please save after you’ve inputted details but do not verify as complete, to allow for further details to be inputted later. Inform the orthopaedic team that this document has been commenced.
These are vital steps in ensuring the patient gets to the bed in time. All delays, even small, add up.
An FICB should be performed on all patients once consent obtained as per the FICB protocol on page 2 of the hip fracture proforma. Please document the times of the block and dose of LA administered. Occasionally patients may need a subsequent block and this information is very important. Following the block, patients should be monitored for LAST for 30 minutes in a monitored area on a continuous cardiac monitor.
Inform the duty ED CNM what time the transfer can occur at. Ensure that portering staff aware of transfer.
If other cross sectional imaging is required (eg Head/C-Spine CT) ensure that this is performed urgently to avoid delay to transfer to the hip bed.
If medically unstable do not fast track patient to orthopaedic bed. Stabilise patient in ED until suitable for transfer. This is based on assessment of senior ED staff. If medically stable but a medical review is required, inform the medical registrar on call who can review that patient on the ward.
Bloods should be sent including group and screen, ECG and CXR performed. CXR is performed not as a “pre-op” but as part of their clinical assessment in clinically frail older patients following trauma.
Once medically stable, patients with a hip fracture should be transferred to the hip fracture bed within 4 hours. Transfer should not be delayed for blood results if not clinically important. If there is a delay in the time for orthopaedic SHO to see the patient in ED the patient should be transferred and the formal admission note, proforma, kardex and consent completed on the orthopaedic ward.
Ensure that the patient is fed unless for OT within 12 hours or requested to fast.
Hip fracture patients require coordinated emergent medical care for a high risk condition
If a patient is suspected of suffering a hip fracture inform staff via Vocera Urgent broadcast group
Expedite imaging and diagnosis – inform the Hip fracture Sillo group
Avoid opiates in pain management – methoxyflurane, paracetamol, local anaesthesia blocks as soon as possible
Transfer the patient to the hip fracture bed as soon as clinically possible
Hip Fracture Governance committee MMUH