Information for Healthcare Services - Hip Fracture Clinical Care Standard

What the standard says

A patient presenting to hospital with a suspected hip fracture receives care guided by timely assessment and management of medical conditions, including cognition, pain, nutritional status and frailty. Arrangements are made according to a locally endorsed hip fracture pathway.

What this means for you

Ensure systems are in place to support clinicians to provide timely and effective assessment and management based on a locally endorsed hip fracture pathway. Systems should include transfer protocols including consideration of straight to ward arrangements for inter-hospital transfers.

For hospitals that do not perform hip fracture surgery, ensure that the pathway is commenced with attention to stabilising medical conditions.

For hospitals receiving transfer patients with hip fracture, ensure both hospitals are using the same pathway and that the expectations for referral and receiving of patients are clear.

What the standard says

A patient with a hip fracture is assessed for pain at the time of presentation to the emergency department and regularly throughout their acute admission. Pain management includes appropriate multimodal analgesia, and incorporates peripheral nerve blocks unless contraindicated.

What this means for you

Ensure pain management protocols are in place to provide pain assessment and management for patients with a hip fracture that:

• Align with current guidelines
• Support the appropriate use of multimodal analgesia and nerve blocks
• Support appropriate prescribing of opioid analgesics in accordance with the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.

Ensure systems are in place to monitor appropriate adherence and regularly evaluate effectiveness of acute pain management.

What the standard says

A patient with a hip fracture is offered treatment based on an orthogeriatric model of care as defined in the Australian and New Zealand Guideline for Hip Fracture Care. Coordinated orthogeriatric and multidisciplinary review includes assessment and management of malnutrition, frailty, cognitive impairment and delirium.

What this means for you

Ensure systems are in place to offer patients with a hip fracture treatment that is based on an orthogeriatric model of care as recommended in the Australian and New Zealand Guideline for Hip Fracture Care. For hospitals that do not have a geriatric medicine service available, care should be shared between an orthopaedic surgeon and an anaesthetist with a physician, using the orthogeriatric model of care.

For hospitals that do not perform hip fracture surgery, it is important that the orthogeriatric model of care is commenced while patients await transfer.

What the standard says

A patient with a hip fracture receives surgery within 36 hours of first presentation to hospital.

What this means for you

Ensure systems are in place for clinicians to perform hip fracture surgery within 36 hours of presentation. 

For health service organisations covering some remote areas, networks and systems should be in place to ensure coordinated inter-facility transfer of patients who sustain a hip fracture, to facilitate surgery within 36 hours of the first clinical presentation. 

Ensure that there is a palliative pathway available for patients with a hip fracture that complicates or precipitates a terminal illness.

What the standard says

A patient with a hip fracture is mobilised without restrictions on weight bearing starting the day of, or the day after surgery, and at least once a day, according to the patient’s clinical condition and agreed goals of care.

What this means for you

Ensure systems and protocols are in place for:

• Patients to be mobilised the day of, or the day after hip fracture surgery and at least once a day thereafter, unless contraindicated
• Pressure injury prevention and wound management, consistent with best-practice guidelines.

Ensure that equipment and devices are available to enable mobilisation, and decrease the risk of pressure injuries.

What the standard says

Before a patient leaves hospital after a hip fracture, they receive a falls and bone health assessment and management plan, with appropriate referral for secondary fracture prevention.

What this means for you

Ensure systems are in place for routine assessment of patients’ fracture risk and follow-up for secondary fracture prevention. This includes:

• Education to address modifiable risk factors including patient education materials (such as for reducing falls risk and specific exercises to improve muscle strength and balance)
• Prescribing or administering bone protection medicines prior to discharge where possible
• Referral where appropriate. 

Where a FLS exists within the health service, establish processes to systematically identify patients after a fracture and arrange follow up, as described in the Clinical Standards for Fracture Liaison Services in New Zealand. Where no FLS exists, a model of care should include systems and resources to:

• Identify at risk patients
• Conduct investigations
• Assess and manage future fracture risk
• Refer to the appropriate treatment provider(s) for secondary fracture prevention care that cannot be provided during the hospital stay.

In Australia, this may involve liaison with Primary Health Networks to develop appropriate models of care.

What the standard says

Before leaving hospital, an individualised care plan is developed in discussion with the patient and their family or support person, that describes their goals of care and ongoing care needs. The plan includes mobilisation activities and expected function post-injury, wound care, pain management, nutrition, fracture prevention strategies, changed or new medicines and specific rehabilitation services and equipment. This plan is provided to the patient, and communicated with the patient’s general practice and other ongoing clinicians and care providers on discharge.

What this means for you

Ensure systems are in place to support clinicians to develop an individualised care plan with patients prior to discharge, and refer patients to the relevant services as required.

Ensure clinical information systems support clinicians in providing the plan to the patient, and communicating the content to their general practitioner, ongoing clinical providers, or community providers responsible for the patient clinical care (such as Aged Care Homes). Where local clinical information systems allow, upload information into the patient’s My Health Record. Sharing information on the care provided in hospital is particularly important if the patient is discharged to interim care (rehabilitation hospital or respite aged care) before returning home or consulting their usual general practitioner.