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Evidence to Improve Care

Hip Fracture

Care for People With Fragility Fractures

Click below to see a list of brief quality statements and scroll down for more information.


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.


Quality Statement 1: Emergency Department Management
Patients with suspected hip fracture are diagnosed within 1 hour of arriving at hospital. Preparation for surgery is initiated, and patients are admitted and transferred to a bed in an inpatient ward within 8 hours of arriving at hospital.


Quality Statement 2: Surgery Within 48 Hours
Patients with hip fracture receive surgery as soon as possible, within 48 hours of their first arrival at any hospital (including any time spent in anonsurgical hospital).


Quality Statement 3: Multimodal Analgesia
Patients with suspected hip fracture have their pain assessed within 30 minutes of arriving at hospital and managed using a multimodal approach, including consideration of non-opioid systemic analgesics and peripheral nerve blocks.


Quality Statement 4: Surgery for Stable Intertrochanteric Fractures
Patients diagnosed with a stable intertrochanteric fracture are treated surgically with sliding hip screws.


Quality Statement 5: Surgery for Subtrochanteric or Unstable Intertrochanteric Fractures
Patients diagnosed with a subtrochanteric fracture or unstable intertrochanteric fracture are treated surgically with intramedullary nails.


Quality Statement 6: Surgery for Displaced Intracapsular Fractures
Patients diagnosed with a displaced intracapsular hip fracture are treated surgically with arthroplasty.


Quality Statement 7: Postoperative Blood Transfusions
Patients with hip fracture do not receive blood transfusions if they are asymptomatic and have a postoperative hemoglobin level equal to or higher than 80 g/L.


Quality Statement 8: Weight-Bearing as Tolerated
Patients with hip fracture are mobilized to weight-bearing as tolerated within 24 hours following surgery.


Quality Statement 9: Daily Mobilization
After surgery, patients with hip fracture are mobilized on a daily basis to increase their functional tolerance.


Quality Statement 10: Screening for and Managing Delirium
Patients with hip fracture are screened for delirium using a validated tool as part of their initial assessment and then at least once every 12 hours while in hospital, after transitions between settings, and after any change in medical status. Patients receive interventions to prevent delirium and to promote recovery if delirium is present.


Quality Statement 11: Postoperative Management
Patients with hip fracture receive postoperative care from an interdisciplinary team in accordance with principles of geriatric care.


Quality Statement 12: Patient, Family, and Caregiver Information
Patients with hip fracture and/or their family and caregivers are given information on patient care that is tailored to meet the patient’s needs and delivered at appropriate times in the care continuum.


Quality Statement 13: Rehabilitation
Patients with hip fracture participate in an interdisciplinary rehabilitation program (in an inpatient setting, a community setting, or a combination of both) with the goal of returning to their pre-fracture functional status.


Quality Statement 14: Osteoporosis Management
While in hospital, patients with hip fracture undergo an osteoporosis assessment from a clinician with osteoporosis expertise and, when appropriate, are offered pharmacologic therapy for osteoporosis.


Quality Statement 15: Follow-Up Care
Patients with hip fracture are discharged from inpatient care with a scheduled follow-up appointment with a primary care provider within 2 weeks of returning home and a scheduled follow-up appointment with the orthopaedic service within 12 weeks of their surgery.

Summary

This quality standard addresses care for adults aged 50 years and older undergoing surgery for fragility hip fractures. Fragility fractures are fractures caused by low-energy trauma, such as falls from a standing height.


This quality standard includes 15 quality statements addressing areas identified by Health Quality Ontario’s Hip Fracture Quality Standard Advisory Committee as having high potential for improving the quality of hip fracture care in Ontario.

This quality standard focuses on adults aged 50 years and older undergoing surgery for fragility hip fractures and the care delivered from the point at which they present to the emergency department until three months following surgery. Fragility hip fractures are fractures of the femur caused by low-energy trauma, such as falls from a standing height. This quality standard does not apply to people with hip fractures resulting from high-energy trauma or people with fragility fractures who are not candidates for surgery.

People who experience fragility hip fractures are typically elderly and living with osteoporosis and a variety of other comorbidities. For these frail individuals, a hip fracture can be a catastrophic event that precipitates a steep decline in health and independence.

About 13,000 people living in Ontario experience a hip fracture every year. Roughly 20% of these people will die within a year of their fracture, another 20% who had been independent before their fracture will be admitted to long-term care, and less than half of those who had previously been living independently will be able to walk without aids following the fracture. The health care expenditures associated with hip fracture are substantial, accounting for nearly $500 million of health care spending per year in Ontario.

There is considerable variation in the quality of hip fracture care in Ontario. In the 2014/15 fiscal year, about 20% of patients presenting with hip fracture in Ontario waited longer than the recommended 48 hours for surgery (this ranged from 2% to 45% across hospitals in Ontario). Patient outcomes also varied widely, with risk-adjusted 30-day mortality rates in 2014/15 ranging from 3% to 17% across hospitals (Discharge Abstract Database and National Ambulatory Care Reporting System, April 2016).

 

This quality standard is informed by Health Quality Ontario and the Ministry of Health and Long-Term Care’s 2013 Quality-Based Procedures Clinical Handbook for Hip Fracture, in addition to other guidance sources. This quality standard does not attempt to provide guidance for all the topic areas addressed in the 2013 Clinical Handbook; the quality statements in this standard focus on areas that have been prioritized for having the greatest opportunity for improvement in how hip fracture care in Ontario is currently provided.

It should also be noted that this quality standard does not contain guidance related to the hospital funding component of the 2013 Clinical Handbook; the scope and statements of this quality standard focus on clinical practice.

This quality standard is underpinned by the principles of respect and equity.

People with hip fractures receive services that are respectful of their rights and dignity and that promote self-determination.

People with hip fractures are provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious background), and disability.

A high-quality health system is one that provides good access, experience, and outcomes for all Ontarians no matter where they live, what they have, or who they are.

A limited number of overarching objectives are set for this quality standard; these objectives have been mapped to performance indicators to measure the success of this quality standard as a whole:

  • Percentage of patients who undergo surgery for hip fracture who die within 30 days or within 90 days of surgery

  • Percentage of patients who undergo surgery for hip fracture who achieve weight-bearing as tolerated within 24 hours of surgery

  • Percentage of patients who undergo surgery for hip fracture who return to pre-fracture functional status within 90 days or by 6 months following surgery

  • Percentage of patients who undergo surgery for hip fracture who are readmitted to hospital within 30 days or within 90 days of surgery

  • Percentage of previously community-dwelling patients who undergo surgery for hip fracture who return to the community

In addition, each quality statement within this quality standard is accompanied by one or more indicators to measure the successful implementation of the statement.

In 2011/12 fiscal year, there were 12,860 hospital admissions for hip fractures in Ontario. For an elderly individual, a hip Fracture can result in morbidity, permanent disability and loss of independence, and for many, premature mortality. About 20% of people die within a year of a hip fracture with risk of mortality higher for men, people of more advanced age, and for those living in nursing homes.

Despite this high burden of illness, researchers around the world have highlighted that best practices for management of hip fracture are frequently inconsistently applied, and that outcomes for hip fracture patients could be improved through closer adherence to evidence-based best practices1,2. In Ontario, the wide regional variation observed on a number of measures hints at the opportunities to improve. For example, the percentage of hip fracture patients receiving surgery within the recommended 48 hours ranged from 67% to 94% across the 14 Local Health Integration Networks (LHINs), mean acute care length of stay (LOS) ranged from 8 to 13 days and the percentage of patients discharged from acute care to LTC ranged from 11% to 24%3. This extraordinary variation found within the same publicly funded health system suggests room for improvement by implementing consistent standards of practice.

Figure 1

The percent of hip fracture patients who underwent surgery within 48 hours of first presentation to the hospital varied across the LHIN regions from 70.2% to 91.6%.

graph


Data Source: Discharge Abstract Database (DAD), National Ambulatory Care Reporting System. (NACRS), provided by the MOHLTC.


1 Koval KJ, Skovron ML, Aharonoff GB, Zuckerman JD. Predictors of functional recovery after hip fracture in the elderly. Clin Orthop Relat Res. 1998;(348):22-8.

2Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly. Arch Phys Med Rehabil. 2009;90(2):246-62.

3 Discharge Abstract Database (DAD), National Ambulatory Care Reporting System. (NACRS), provided by the MOHLTC.

"I am grateful for my treatment, but two questions remain. First, having arrived at the emergency at ten o’clock in the evening after a fall, no orthopedic surgeon was available or called until the next morning. Since I did not get to see a surgeon promptly, I was told I would develop avascular necrosis. I received a hemiarthroplasty instead of the usage of surgical screws. So I have a device in me for life to deal with. Second, between hospital and community rehab care transition, a gap of physiotherapy direction or daily care exists in which I think the patient goes backwards in strength and recovery. Never have I felt as weak or useless as in this stage of my life. This gap needs to be minimized or eliminated."

Norman Ferguson, Hip Fracture Quality Standard Advisory Committee Panel Member

"Sometimes, individuals in different areas of an organization only have pieces of knowledge and information on how to proceed with patients with hip fractures. I think this quality standard will help providers to put all those pieces together while working together on standardizing care. For example, the hospital where I work implemented a new pathway to make sure patients with hip fractures receive surgery within 48 hours. When a patient with a hip fracture comes into the hospital now, there are certain things that happen automatically. Previously, even though everybody knew that surgery should happen within 48 hours, this wasn’t always prioritized. I think this example speaks to the utility of standardization. I hope that the hip fracture quality standard will improve the quality of care for patients because anytime we can standardize care based on the best evidence, this usually leads to improved outcomes."

Dr. Sarah Ward, Hip Fracture Quality Standard Advisory Panel member

This quality standard was completed in September 2017.

For more information, contact QualityStandards@HQOntario.ca.

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