Information for clinicians - 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

Use a locally endorsed hip fracture pathway to guide the comprehensive clinical assessment and management of patients with a suspected hip fracture including: 

• Screening for malnutrition, frailty, cognitive impairment and risk factors for delirium
• Identifying comorbidity and medicines that may impact on time to surgery or readiness for surgery
• Providing pain relief
• Assessing for underlying acute and chronic medical conditions precipitating the fall, 
• Excluding other injuries 
• Conducting relevant diagnostic imaging and pathology. 

Put in place interventions to prevent or manage delirium, in accordance with the Delirium Clinical Care Standard. Document the frailty assessment and use the results to guide care planning.

Ensure the patient knows what is happening and what to expect from their treatment and recovery, and identify a substitute decision maker. Document and communicate processes as part of the patient’s comprehensive care plan to ensure effective management and clinical handover. 

For hospitals that do not provide hip fracture surgery, organise prompt transfer and initiate the care pathway locally to optimise the patient’s pre-operative condition. There is an expectation that all patients will receive surgery within 36 hours, no matter the hospital where they first present.

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

Many patients with a hip fracture will have received analgesics in the ambulance. Assess and document the patient’s pain:

• Immediately upon presentation to hospital
• Within 30 minutes of administering initial analgesia
• Hourly until the patient is settled and pain is managed
• Regularly as part of routine nursing and other clinicians’ observations throughout the admission.

Provide appropriate pain management including multimodal analgesia, and local nerve blocks as part of peri-operative pain management. A nerve block has the potential to reduce opioid dose requirements and their unwanted side effects (such as sedation, respiratory complications and delirium).

For hospitals that do not provide hip fracture surgery, arrange appropriate analgesia and if suitable, administer a nerve block prior to transfer.

Include the use of a standardised pain assessment system that:

• Includes functional assessment for pain
• Specifically addresses the assessment of pain for patients with cognitive impairment or those unable to communicate pain.

If opioid analgesics are used:

• Prescribe immediate-release formulations at the lowest appropriate dose for a limited duration in accordance with the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard
• Plan for appropriate opioid analgesic use at the transfer of care when a patient is first prescribed, supplied or administered an opioid analgesic

Follow a weaning and cessation protocol guided by assessing the patient’s functional activity and pain scores.

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

From the time of admission, offer patients with a hip fracture a formal orthogeriatric model of care that includes:

• Regular orthogeriatrician assessment including medication review
• Managing patient comorbidities
• Optimisation for surgery
• Early identification of goals of care, in discussion with the patient and their family or support people and documented in the comprehensive care plan
• Early assessment of the patient’s nutritional status using a validated assessment tool, reassessed during the course of the admission with individualised interventions when required including offering oral nutritional supplements postoperatively 
• Management based on initial assessment for frailty, cognitive impairment and delirium
• Ongoing orthogeriatric and multidisciplinary review including reassessment of cognition, delirium and malnutrition after surgery
• Assessment for venous thromboembolism (VTE) risk to determine the need for VTE prophylaxis
• Discharge planning liaison with primary care, including falls prevention and secondary fracture prevention
• Coordination of care to provide multidisciplinary rehabilitation aimed at increasing mobility and independence, facilitating return to pre-fracture residence and supporting long‑term wellbeing, if appropriate and clinically indicated
• Early identification of most appropriate service to deliver rehabilitation, if indicated. 

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

Discuss treatment options with the patient. Explain the goals, benefits, risks and limitations of treatment options, taking into account the patient’s medical conditions, goals of care and prior level of function. If a hip fracture complicates or precipitates a terminal illness, consider the role of surgery as part of a palliative care approach to alleviate symptoms and minimise suffering.

If clinically indicated and in accordance with patient preferences, surgery should be performed within 36 hours of the patient’s first presentation to hospital. If a patient sustains a fracture in hospital, surgery should be performed within 36 hours of the fracture occurring. Prescribe surgical antibiotic prophylaxis and thromboprophylaxis according to current guidelines.

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

Improving mobility outcomes after hip fracture is key to recovery. Mobilise patients the day of, or the after hip fracture surgery, and at least once a day thereafter unless contraindicated. Mobilised means the patient manages to stand and step transfer out of bed onto a chair/commode or walk. Allow patients to bear weight as tolerated, but avoid weight‑bearing if there is a clinical concern about the fracture, the fixation or the likelihood of healing. 

Additional exercises, such as training of gait, balance and functional tasks can further improve patient outcomes. For patients with conditions preventing mobilisation, arrange for tailored advice from a physiotherapist or occupational therapist.

For patients at risk of pressure injuries, conduct comprehensive skin inspections and provide pressure injury prevention and care in accordance with best-practice guidelines.

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

Assess patients with a hip fracture for their risk of another fracture. Educate them by discussing risk factors for falls and providing written information on specific exercises to improve muscle strength and balance. Where clinically indicated, discuss the need for bone protection medicines and initiate treatment prior to discharge. Where appropriate, refer to an established fracture liaison service (FLS). Ensure the management plan is included in the patient’s discharge summary and care plan.

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

Develop an individualised care plan with the patient before they leave hospital (for example the ANZHFR My Hip Fracture or NZHQSC Recovering from a Hip Fracture booklets). The individualised care plan is separate to a clinical discharge summary and should:

• Identify any changes in medicines, any new medicines or ongoing pain management
• Identify equipment and contact details for rehabilitation services and refer as required 
• Describe mobilisation activities, wound care and function post-injury
• Provide information and recommendations for secondary fracture prevention including contact details for services, where appropriate
• Recommend bone protection medicines to the patient and their GP if they have not been started in the hospital.

Provide the care plan to the patient before they leave hospital. Include an overview of the care discussed within the discharge care summary and provide to their general practice, and other regular clinicians and care providers on discharge.