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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.

11

Postoperative Management

Patients with hip fracture receive postoperative care from an interdisciplinary team in accordance with principles of geriatric care.


Care for hip fracture patients should be guided by an orthopaedic surgeon in collaboration with a clinician familiar with geriatric principles. For example, an orthopaedic surgeon may partner with a geriatrician, clinical nurse specialist, nurse practitioner, hospitalist, or internal medicine practitioner to coordinate care for a hip fracture patient. This care partnership ensures that geriatric considerations regarding surgical and medical decisions are addressed from the time of admission throughout the continuum of care.

For Patients

You should receive care from a team of health care professionals who understand the health needs of older adults.


For Clinicians

Following hip fracture surgery, ensure your patient continues to receive care from a surgical–medical partnership that takes into consideration the unique needs of geriatric patients. While the patient is still in hospital recovering from surgery, encourage appropriate nutritional intake and hydration, closely monitor and address the patient’s risk of developing pressure injuries, and ensure proper venous thromboembolism prophylaxis.


For Health Services

Ensure that appropriate human resources are in place such that a medical–surgical partnership is possible for the care of hip fracture patients. Additional resources may include protocols, hip fracture pathways, medical directives, and standardized order sets to facilitate the implementation of principles of geriatric care.

Process Indicator

Percentage of hip fracture patients who are managed by both an orthopaedic surgeon and a clinician with geriatric expertise

  • Denominator: total number of adults admitted to hospital with a primary diagnosis of fragility hip fracture who undergo surgery for hip fracture

  • Numerator: number of people in the denominator who are seen by an orthopaedic surgeon and a clinician with geriatric expertise

  • Data source: local data collection

Percentage of hip fracture patients who receive venous thromboembolism prophylaxis while in hospital

  • Denominator: total number of adults admitted to hospital with a primary diagnosis of fragility hip fracture who undergo surgery for hip fracture

  • Numerator: number of people in the denominator who receive venous thromboembolism prophylaxis while in hospital

  • Data source: local data collection

Percentage of hip fracture patients who receive an indwelling catheter postoperatively

  • Denominator: total number of adults admitted to hospital with a primary diagnosis of fragility hip fracture who undergo surgery for hip fracture

  • Numerator: number of people in the denominator who receive an indwelling catheter postoperatively

  • Data source: local data collection


Structural Indicator

Percentage of hospitals with access to a clinician with geriatric expertise

  • Data source: Regional and/or provincial data collection method would need to be developed

Postoperative care from an interdisciplinary team

Management for hip fracture patients should include, at a minimum, the following clinical interventions and senior-friendly considerations:

  • Nutritional intake should be assessed and protein and high-energy supplements provided if required

  • Risk assessment for pressure injuries should be performed using the Braden Scale or another validated instrument.8Precautions should be taken, including proper turning and repositioning, to prevent the development of pressure injuries

  • If postoperative catheterization is necessary, an intermittent catheter should be used rather than an indwelling catheter

  • Appropriate hydration should be provided to help prevent delirium while carefully balancing the risk of fluid overload; for example,with intravascular or oral fluids

  • Venous thromboembolisms should be prevented using medical rather than mechanical strategies (unless medications are contraindicated)

  • A fall risk assessment should be performed

  • A comprehensive medication review and reconciliation should be performed

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Claude Lurette and Kowsiya Vijayartnam, Health Quality Ontario Patient, Family and Caregiver Advisors Council Co-Chairs

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