The management of patients who have suffered a neck of femur fracture requires the input not only by surgeons but also the medical doctors. This has given rise to a nationally agreed standard that all hospitals must adhere to by rewarding trusts via a ‘Best Practice Tariff’ System.
Patients who suffer a neck of femur fracture are treated via a complex clinical pathway involving an array of specialists to best manage their condition. This has given rise to a nationally agreed standard that all hospitals must adhere to by rewarding trusts via a ‘Best Practice Tariff’ System.
East Sussex Healthcare Trust aims to ensure these standards are met and tariffs achieved through its Neck of Femur Integrated Pathway to improve care. We looked at how these standards have been affected since the implementation of the new Neck of Femur Pathway brought in 2016, and whether this, alongside a Junior Doctor Handover Intervention, have improved standards of care.
Osteoporosis is one of the most common conditions affecting those over the age of 65, and with an ageing population, is only set to increase in prevalence. Because of such demographic trends, once such derivative increase in the population will be the incidence of neck of femur (NOF) fractures. These numbers have increased by 25% between 1990 and 2000, and now represent a higher lifetime risk in certain female populations than that of breast cancer.1,2
Osteoporosis is a condition characterised by the reduction of bone mineral density, leading to the weakening of bones, and the increased susceptibility to fractures. Although osteoporosis is a common cause of fractures of the vertebrae, humerus and distal forearm, it is the burden associated with the hip that represents the biggest problem for patients and economy.1
Following a hip fracture, 40% of people will never regain fully independent mobility and over 20% of those previously living in the community will require long-term nursing homes.3,4 In addition to this, there remains a 5-10% risk of sustaining a recurrent hip fracture, contributing to the 80,000 hip fractures that are now treated every year in the UK, costing over £2 billion in direct costs alone.5
To curb the increasing cost of hip fractures, a range of specialty teams, agencies and departments are required to ensure the impact of a hip fracture is kept minimal, according to evidence-based treatment guidelines. NICE has thus recommended a formal hip fracture program (FHFP) to ensure all aspects of hip fracture care are met.6,7 However, just the presence of such a programme does not guarantee adherence to all its parts.
|TABLE 1 PATIENT DEMOGRAPHICS|
|June – August (%)||September – November (%)|
|Gender||Male||37 (24%)||41 (31%)|
|Female||118 (76%)||92 (69%)|
|Age||Over 65||154 (99%)||126 (95%)|
|Under 65||1 (1%)||7 (5%)|
|Type of fracture||Intracapsular||95 (61%)||80 (60%)|
|Intertrochanteric||49 (32%)||45 (34%)|
|Sub trochanteric||11 (7%)||8 (6%)|
|Side of fracture||Left||79 (51%)||68 (51%)|
|Right||76 (49%)||65 (49%)|
|ASA grade||1||2 (1%)||4 (3%)|
|2||40 (26%)||36 (27%)|
|3||97 (63%)||85 (64%)|
|4||15 (10%)||7 (5%)|
|Not recorded||1 (1%)||1 (1%)|
|Residence before admission||Own home / SA*||121 (78%)||107 (80%)|
|Residential care||17 (11%)||13 (10%)|
|Nursing home||17 (11%)||13 (10%)|
|Pre-fracture mobility||Freely mobile||58 (37%)||58 (44%)|
|Impaired mobility||97 (63%)||75 (56%)|
|* = Sheltered accommodation|
The aim of our audit was to assess adherence to the local guidelines following a NOF fracture using the current NOF pathway used in the East Sussex Healthcare trust.
East Sussex employs a Neck of Femur Integrated Pathway to ensure all patients with a suspected NOF fracture are clerked on an all-inclusive pro forma encompassing all aspects of hip fracture management, produced through evidence-based research. East Sussex Healthcare trust includes both the Eastbourne District General Hospital and Conquest Hospital, with all acute orthopaedic treatment carried out in the latter hospital.
Hip fracture care is based on best practice tariffs.8,9 These are nationally agreed standards of care that ensure that known best practice is adhered to. In the case of hip fractures, the National Hip Fracture Database (NHFD) has identified several metrics that need to be met for the provider (East Sussex Healthcare) to be reimbursed financially for the care they have provided. These are in line with Guidance and Quality Standards from NICE.8,9
The seven metrics outlined by the NHFD are as follows:
- Being clerked on the correct integrated care pathway
- Having an operation within 36 hours of A&E admission
- An ortho-geri review (ST3+ or higher) within 72 hours of A&E admission
- Falls assessment
- Pre-op Abbreviated Mental Test Score (AMTS)
- Post-op AMTS
- Bone protection prescribed (or valid reason for the omission).
Thus, the latest edition of the NOF pathway produced in early August 2016 was designed to help prompt the completion of the metrics, such as by having a separate ortho-geriatric page, and having boxes for falls assessments. If all seven metrics are achieved successfully, the trust is paid best practice tariff of £1,335 for each patient successfully managed and the knowledge that patients have been treated in the optimal manner as laid out by evidence-based research.
Most trusts in the UK continually submit data to the National Hip Fracture Database (NHFD) so that areas of strength and weakness can be easily identified both regionally and nationally. Our aim was to see what impact the new proforma had on local performance data submitted to NHFD, and to identify any shortcomings that could be improved. If there was room for improvement, our aim was to employ an intervention that could be used to help reach the best practice targets laid out by NHFD, and in doing so, improve both health and economic outcomes for the trust.
|TABLE 2 NATIONAL HIP FRACTURE DATABASE BEST PRACTICE METRICS|
|June – August (%)||September – November (%)|
|Clerked on correct ICP||Yes||155 (100%)||133 (100%)|
|No||0 (0%)||0 (0%)|
|Operation within 36 hours of A&E admission+||Yes||115 (74%)||103 (77%)|
|Ortho-Geri review* within 72hrs of A&E admission||Yes||148 (96%)||125 (94%)|
|No||7 (5%)||8 (6%)|
|Falls assessment||Yes||149 (96%)||132 (99%)|
|No||6 (4%)||1 (1%)|
|Pre-op AMTS||Yes||153 (99%)||130 (98%)|
|No||2 (1%)||3 (2%)|
|Post-op AMTS||Yes||143 (92%)||123 (93%)|
|No||12 (8%)||10 (7%)|
|Bone protection prescribed†||Yes||145 (94%)||130 (98%)|
|No||10 (6%)||3 (2%)|
|+ = or diagnosis of fracture
* = ST3+ or higher
† = or valid reason for omission
All patients admitted with a neck of femur fracture have their hospital care assessed by the Trust’s Neck of Femur Fracture Pathway coordinator, who collates all the data from their stay relevant to NHFD guidelines. This data was then organised into two three-monthly periods:
- June-August (2016)
- This three-month period looks at the run up to the new integrated pathway, overlapping with the first month of its implementation.
- September-November (2016)
- This three-month period looks at the first three full months of using the new integrated pathway.
Following the analysis of data collected in the six months, an intervention was made to improve outcomes of the seven metrics necessary to achieve best practice by NHFD. This was implemented in early December 2016, and following the switch over of junior doctors between rotations, was re-audited from January 2017. This will later be referred to as the ‘third period’ or ‘second cycle.’
- January-March (2017)
- This three-month period audits the first full three-month period following the introduction of an intervention made to improve adherence to NICE and NHFD recommendations.
|TABLE 3 OVERALL NUMBER OF MISSED TARIFFS PER TIME PERIOD|
|June – August (%)||September – November (%)|
|Missed tariffs||60 (38.7%)||45 (33.8%)|
First audit results
Between June and August 2016, 155 patients with neck of femur fractures were admitted to the Conquest, either directly, or from Eastbourne District General Hospital. Table 1 highlights the pattern of demographics between the two periods. Table 2 highlights adherence to each metric needed to meet the Best Practice Tariff in the two periods. Table 3 highlights the overall number of missed tariffs between the two periods. Table 4 highlights the percentage change in the seven metrics required for best practice NHFD payment between the two three-monthly periods.
The data obtained between the two three-month periods highlights a reduction in the overall percentage of ‘breached’ neck of femur patients, in turn highlighting those patients for whom best practice guidelines were missed, and loss of best practice tariff for the Trust.
This is shown in Table 3, whereby there were 38.7% of patients missing out on optimal treatment between June and August, and 33.8% of patients missing out between September and November. This equates to a £80,100 and £60,075 best practice income loss to the trust respectively between the two data sets.
Although this does suggest an overall improvement in adherence to recommended guidelines and in turn successful implementation of the new integrated neck of femur fracture pathway, analysis of the data suggests there are areas in which clear improvements can be made. Table 2 shows the success rate of completion for each metric in the two periods. Almost all areas showed a positive ‘% change’ except in two metrics.
The metrics required to attain completeness can be split into those of the orthopaedic and orthogeriatric team respectively.
For the orthopaedic team it was:
- Clerking on the correct proforma
- Conducting the operation within 36 hours
For the orthogeriatric team: it was
- Orthogeriatric review
- Falls assessment
- Pre-op AMTS
- Post Op AMTS
- Bone protection
The only two areas that showed worsening data were the metrics ‘Pre-Op AMTS’ and ‘Ortho-Geri Review <72 hours’ with a 1.57% and 0.98% difference between the two data sets respectively.
|TABLE 4 COMPARATIVE METRIC SHORTFALLS BETWEEN THE TWO DATA SETS|
|June – August (%)||September – November (%)||% change|
|Clerked on correct ICP||100||100||0.00%|
|Ortho-Geri review <72hrs||95.483870||93.984962||-1.57%|
|Bone protection prescribed||93.548387||97.744361||4.19%|
Much of the orthogeriatric management of patients within the East Sussex Healthcare Trust is carried out by the foundation doctors, who are based solely on the trauma wards in which the neck of femur patients are based. Aside from their on call responsibilities, they represent the continuity for the management of patients on the ward, and thus for orthogeriatric standards to be improved, it would be they who would be at the forefront.
Within East Sussex, an orthogeriatric team involving a consultant, registrar, senior house officers and foundation year doctor manage the pre-and post-operative care of neck of femur fracture patients. All patients clerked on the NOF pathway are assigned to one of two 32-bed orthopaedic wards managed by these teams. Despite such a large team, the only constant on the wards are the foundation doctors, as they have no theatre responsibilities (as is the case with the senior house officers) and no geriatric responsibilities on other wards (as is the case with the registrars and consultant). Thus, it has become reasonable to accept that many of the day-to-day orthogeriatric responsibilities have become assigned to the foundation doctors.
Foundation doctors rotate between different departments over four-monthly cycles, and can often take time to adjust to different departments and the types of patients needing to be managed on the wards. However, between departments and between teams, a doctor’s ‘list’ keeps vital track of patient information and actions or ‘jobs’ on the ward needing to be completed. Updated daily by the most junior members of the team, the list, no matter what department or hospital, ensures the team can keep track of any outstanding jobs.
A table was formed that could be easily copied into onto doctors’ lists for each NOF patient.
With a list circulated amongst all members of the team and updated at the end of each day, it would ensure that all aspects of NOF management had been carried out by ‘ticking ()’, and if any had not been, could be easily picked up by other members of the team and completed at the next available opportunity. Not only would this ensure all orthogeriatric tasks had been completed, but also save team members time going through to all 64 patients to work out which were NOF’s and what NOF specific tasks had not been completed
|TABLE 5 NATIONAL HIP FRACTURE DATABASE BEST PRACTICE METRICS|
|June – August (%)||September – November (%)||January – March 2017 (%)|
|Clerked on correct ICP||Yes||155 (100%)||133 (100%)||145 (100%)|
|No||0 (0%)||0 (0%)||0 (0%)|
|Operation within 36 hours of A&E admission+||Yes||115 (74%)||103 (77%)||130 (89.7%)|
|No||40 (26%)||30 (23%)||15 (10.3%)|
|Ortho-Geri review* within 72hrs of A&E admission||Yes||148 (96%)||125 (94%)||144 (99.3%)|
|No||7 (5%)||8 (6%)||1 (0.7%)|
|Falls assessment||Yes||149 (96%)||132 (99%)||143 (98.6%)|
|No||6 (4%)||1 (1%)||2 (1.4%)|
|Pre-op AMTS||Yes||153 (99%)||130 (98%)||145 (100%)|
|No||2 (1%)||3 (2%)||0 (0%)|
|Post-op AMTS||Yes||143 (92%)||123 (93%)||138 (95.2%)|
|No||12 (8%)||10 (7%)||7 (4.8%)|
|Bone protection prescribed†||Yes||145 (94%)||130 (98%)||144 (99.3%)|
|No||10 (6%)||3 (2%)||1 (0.7%)|
|+ = or diagnosis of fracture
* = ST3+ or higher
† = or valid reason for omission
Between January and March 2017, 145 patients were admitted with a NOF. Table 6 highlights adherence to the seven metrics required for achieving Best Practice Tariff in the three periods. Table 6 highlights the overall number of missed tariffs between the two periods. Table 7 highlights the percentage change in the seven metrics required for best practice NHFD payment between the second period (September-November 2016) and the third period (January-March 2017).
Re-audit data analysis (following re-audit)
|TABLE 6 OVERALL NUMBER OF MISSED TARIFFS PER TIME PERIOD|
|June – August (%)||September – November (%)||January - March (2017) (%)|
|Missed tariffs||60 (38.7%)||45 (33.8%)||22 (15%)|
Tables 5, 6 and 7 highlight the findings after re-audit and implementation of the handover table (Table 5), with each showing a distinct improvement in meeting best practice tariffs.
Table 5 looks at the key areas in the three data periods. January-March 2017 is shown in the far-right column and highlights the success of the handover intervention, as all but one of the metrics needed for meeting best practice tariffs were achieved. The only area that did not show any improvement was in falls assessment, where there was a very slight decline in adherence to guidelines (-0.06%, shown in Table 7). Looking at the figures from Table 5, this equates to just two patients missing out on a falls assessment. It is worth noting that when looking back at the original hospital data, one of these two patients later died in hospital, which could perhaps be a cause for the lack of a documented falls assessment.
Despite the shortfall in fall assessment, all the five metrics highlighted as ‘orthogeriatric responsibilities’ achieved an adherence of 95% or greater, reflecting a significant improvement in orthogeriatric-team clinical practice. The far-right column of Table 7 shows an up to 12.22% improvement in certain best practice metrics and up to 5.33% in orthogeriatric metrics.
Overall improvement can be seen when looking at the total number of missed tariffs. In the second cycle, between January 2017 and March 2017, just 22 patients (15%) missed out on one or more metrics. This equates to the reduction of best practice income loss to the trust of just £29,370, compared to £60,075 and £80,100 in the previous two three-month periods.
|TABLE 7 COMPARATIVE METRIC SHORTFALLS BETWEEN THE TWO DATA SETS|
|June – August (%)||September – November (%)||January – March (2017)||% change|
|Clerked on correct ICP||100||100||100||0.00%|
|Ortho-Geri review <72hrs||95.483870||93.984962||99.3103||5.33%|
|Bone protection prescribed||93.548387||97.744361||99.3103||1.57%|
The data collected shows evidence of a clear improvement in the orthogeriatric care, but it is difficult to solely attribute this to the implementation of the pathway and the handover table. The findings assume that the competence of the junior doctors remained the same throughout all the cycles, despite the doctors working in orthogeriatric changing over in August 2016 and again in December 2016. In addition, in the latter part of 2016, the trust employed an additional orthogeriatric consultant to work solely on the trauma wards where the NOF patients were situated, and this could have also led to an improvement in meeting standards.
The management of patients who have suffered a neck of femur fracture requires the input not only by surgeons but also the medical doctors. Ortho- geriatricians ensure patients who have suffered this life-threatening injury not only get back as near to their baseline as possible, but also aim to reduce the risk of such injuries occurring again. Although such risk can never be eliminated, adhering as closely as possible to evidence-based guidelines provided by the NHFD will ensure that standards are met.
Unique clerking proformas and improving the quality of handover documentation has shown to significantly improve the adherence to NHFD best practice tariffs and in turn NICE guidance. Not only does this ensure that the trust is receiving financial reward for providing high quality care, it also ensures all patients receive the optimal care needed following a hip fracture.10
These small interventions have demonstrated very clear improved results; therefore, it is possible that other conditions that employ best practice tariffs such as chronic obstructive pulmonary disease and myocardial infarction could also benefit from such similar interventions.11
Dr Nimlan Shanmugathas, Foundation Year 1, Conquest Hospital, St Leonards-on- Sea, East Sussex
Dr Kalon Hewage, Core Surgical Trainee, Conquest Hospital, St Leonards-on- Sea, East Sussex
Rahmani MJH, Consultant Physician, Department of Health and Ageing, Conquest Hospital, The Ridge, St Leonards on Sea, East Sussex Healthcare Trust
Conflict of interest: none declared
6. NICE Hip Fracture Management (2011) https://www.nice.org.uk/guidance/cg124 Accessed June 2017
7. NICE Quality Statements (2012) https://www.nice.org.uk/guidance/qs16/chapter/Quality-statements Accessed June 2017
8. National Hip Fracture Database Annual Report (2015) http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf
9. Gershlick (2016) - Best Practice Tariffs Country United Kingdom (England) The Health Foundation April 2016. https://www.oecd.org/els/health-systems/Better-Ways-to-Pay-for-Health-Care-Background-Note-England-Best-practice-tariffs.pdf
11. NHS improvement: Best Practice Tariff Proposals (2016) https://improvement.nhs.uk/uploads/documents/BPT_Additional_Information_-_FINAL_WITH_IRB.pdf Accessed June 2017