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Meeting the NICE Quality Standard for Hip Fracture

Meeting the NICE Quality Standard for Hip Fracture. ICO Conference Centre, London 10th October 2012 Progress in hip fracture care: audit and standards in the UK Colin Currie Clinical Lead (Geriatric Medicine) National Hip Fracture Database.

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Meeting the NICE Quality Standard for Hip Fracture

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  1. Meeting the NICE Quality Standard for Hip Fracture ICO Conference Centre, London 10th October 2012 Progress in hip fracture care: audit and standards in the UK Colin Currie Clinical Lead (Geriatric Medicine) National Hip Fracture Database

  2. Hip fracture: the tracer condition for the current epidemic of fragility fractures UK progress in hip fracture care: The National Hip Fracture Database and the Blue Book Audit and standards working together? The NHFD and the NICE hip fracture quality standards Outline

  3. The fragility fracture career Morbidity Hip fracture Added morbidity from fractures Vertebral fracture Colles' fracture No fractures – increasing morbidity due to ageing alone Age 50 60 70 80 90 Age Adapted from Kanis JA, Johnell O; 1999

  4. “The most common serious – and the most serious common – injury of older people” The tracer condition for the current epidemic of fragility fractures Hip fracture

  5. Hip fracture – the patient experience • A major life-event • Recovery of mobility often limited • Mortality high • Loss of home much dreaded – and fairly common

  6. Hip fracture – the patient experience

  7. Hip fracture – service implications • 30 years ago – an unwelcome and burdensome caseload • Now a major surgical, medical and rehabilitation challenge • Resource-intensive – amid growing service pressures • Service response much improved!

  8. Hip fracture care – who’s involved? Physiotherapy Primary Care NursingA&ERadiology Supported DischargeOccupational Therapy Geriatric MedicineAnaesthetics Social Management Rehabilitation Services G.P. LabsPortering Orthopaedic Surgery Carers

  9. 3250 Projected hip fractures worldwide Projected to reach 3.250 million in Asia by 2050 668 400 600 629 1990 1990 1990 1990 2050 2050 2050 2050 100 742 Total number ofhip fractures:1990 = 1.66 million 2050 = 6.26 million 378 Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-9

  10. Hip fracture – a suitable case for audit? • Common, serious, well-defined injury • Good evidence base for care – and prevention • Care is complex and costly • Care, outcomes – and costs – vary • Numbers rising as populations age • Hip fracture care the central challenge of current global fragility fracture epidemic

  11. Hip fracture audit: a brief history • 1980’s onwards: ‘Rikshoft’ (Sweden) • European bilaterals • Scottish Hip Fracture Audit (1993-2010) • Standardised Audit of Hip Fracture in Europe (SAHFE) • Growing numbers of single-centre audits • 2007 UK National Hip Fracture Database (NHFD) • using the synergy of audit, standards and benchmarked feedback to improve care and outcomes • 2011/12 International interest – and action! (Australia, NZ, Ireland, Canada)

  12. National Clinical Governance for Hip Fracture Care: Scotland

  13. The National Hip Fracture Database • A clinically-led, web-based, continuous audit of hip fracture care and secondary prevention in England, Wales, and Northern Ireland • Using the synergy of audit, standards and feedback to improve care and outcomes • Valued by clinicians and managers, and by the Departments of Health • Successive national reports show improvements in care and secondary prevention www.nhfd.co.uk

  14. Development: 2004-2007 • Strategic vision and ruthless acquisition • Dataset from Rikshoft, SHFA, etc • IT from Myocardial Infarction National Audit Project (MINAP) • Soft money and hard work • Industry funding (via national organisations) 2004-2009 • Committees large and small • To consult – and implement • Making friends and influencing people • Media, meetings, lobbying, etc

  15. Blue Book and NHFD: launched together in 2007

  16. Progress: the NHFD 2007-2012 • NHFD launched – Sept. 2007 • Recognised by NCAAG in 2009 for funding by HQIP as a national clinical audit • Steady growth towards national coverage • National reports: 2009, 2010, 2011, 2012 • Growing impact on care and outcomes • International interest – and acton!

  17. The National Hip Fracture Database A recurrent dilemma in clinical audit… Simplicity vs. Complexity? (e.g. SAHFE…)

  18. The National Hip Fracture Database A recurrent dilemma in clinical audit… Simplicity vs. Complexity? For Blue Book Standards and NHFD dataset: Simplicity preferred!

  19. Six Blue Book standards – monitored by NHFD • All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation • All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours • All patients with hip fracture should be assessed and cared for with a view to minimising the risk of developing a pressure ulcer • All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission • All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures • All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls

  20. Six Blue Book standards – why comply? • Compliance with these standards • raises quality in hip fracture care • and reduces its costs! • Cost and quality not in conflict • ‘Looking after hip fracture patients well is cheaper than looking after them badly’

  21. NHFD Reports: 2008-2011 12,983 records from 64 hospitals 36,556 records from 129 hospitals 53,443 records from 176 hospitals

  22. NHFD National Report 2012 53,443 records from 176 hospitals 53,443 records from 176 hospitals 59,635 records from 180 hospitals

  23. NHFD coverage: September 2012 188/188 (100%) of eligible hospitals registered 186/188 (99%) submitted data in the last three months 220,000+ records submitted since launch c. 5000 records submitted per month (c. 95+% of all eligible hip fractures – based on c. 65,000 p.a.)

  24. Audit and change • Improving compliance with Blue Book standards • Local use of audit for service change • Trend data: 28 hospitals, 2008 – 2011 • Implementing Best Practice Tariff

  25. Compliance with Blue Book standards: 2009-12

  26. NHFD: audit and change locally Hospital-level initiatives • NHFD offers current, credible local data on workload and service performance • Such data can prompt and monitor local initiatives agreed by clinicians and managers • Many substantial improvements: e.g. reduced time to theatre, length of stay, mortality and service costs

  27. Wansbeck and N. Tyneside • Quality improvement programme: NHFD data; Kings Fund support – addressing whole care pathway • Pain control improved (79% of patients get nerve block on admission) • 95% have surgery within 36 hours • 100% mobilise on first post-op day if medically fit • Systematic feedback from patients and families consistently averages >9.3/10

  28. St Peters Hospital, Chertsey • Two ortho-geriatricians appointed; quality initiative on hip fracture care pathway (2010) • In 2012, 60% of patients have surgery within 24 hours, 80% within 36 hours • Length of stay reduced from 25 to 22 days, with considerable efficiency savings • 60% of patients discharged to original residence within 25 days, compared with 44% within 30 days in 2010

  29. Chelsea and Westminster Hospital • Meeting in May 2011 recognises hip fracture care as sub-optimal • Changes include dedicated trauma theatre sessions, thrice-weekly ortho-geriatrician Ward rounds, and weekly discharge planning rounds • In-patient mortality reduced from 11% to 9% • Average acute length of stay down from 24 to 19.5 days, with estimated savings of £91,000

  30. Trend data: 2008-2011 • 28 hospitals • Early and sustained NHFD participation • Good case ascertainment, data completeness • 30,022 cases (1st April 2008 to 31stMarch 2011) • Time to theatre, orthogeriatrician involvement, secondary prevention, mortality

  31. Trend data: 2008-2011

  32. Trend data: 2008-2011

  33. The Best Practice Tariff for hip fracture care • A DoH initiative, based on NHFD participation • Enhanced case-by-case payment if clinically determined care standards met • Surgery within 36 hours • Joint care, joint protocol: surgeon, anaesthetist, orthogeriatrician • Early involvement of orthogeriatrician in care • Multi-disciplinary rehabilitation • Bone health, falls assessments

  34. Audit and change: how does it work? • NHFD offers: • the synergy of audit, standards and feedback • a website providing key documents and literature database • helpdesk and supportive central staff • regional meetings • national reports • ‘Together, these measures have succeeded in creating a critical mass of enthusiasm and expertise in hip fracture care…’* *NHFD 2011 Summary Report on www.nhfd.co.uk

  35. Progress in hip fracture care? • NHFD and the Blue Book • the synergy of audit, feedback and standards • National-level evidence of: • rising care standards • Large-series evidence of: • lower mortality • associated with orthogeriatric care?

  36. Progress in hip fracture care? • Local evidence of: • better care and outcomes • lower costs too • BPT a recent and effective incentive • with double effect? • ‘Looking after hip fracture patients well is cheaper than looking after them badly’ (Blue Book on the care of patients with fragility fracture)

  37. More effort required? • Better documentation of long-term care & outcomes • post-acute care • mobility • place of residence • Sprint audits • ASAP in development • other? • Health economics • cost-effective care?

  38. More progress in hip fracture care? • Without audit, clinical standards are simply aspirational • As a national clinical audit of hip fracture care, the NHFD has demonstrated the synergy of audit and standards in improving care • NHFD has the potential to monitor compliance with the NICE Quality Standards

  39. NHFD & the NICE Quality Standards for Hip Fracture

  40. NHFD & the NICE Quality Standards for Hip Fracture

  41. NHFD & the NICE Quality Standards for Hip Fracture

  42. NHFD & the NICE Quality Standards for Hip Fracture • NHFD has the potential to monitor compliance with (some of) the NICE Quality Standards… …and measure any impact on care and outcomes?

  43. Acknowledgements • Prof K-G Thorngren & Rikshoft • SHFA colleagues • Dave Marsh, Professor of Orthopaedic Surgery, RNOH, Chair/Co-chair, NHFD; Finbarr Martin, Co-chair, NHFD; Rob Wakeman, Lead Clinician, Orthopaedic Surgery, NHFD; Maggie Partridge, Project Manager, NHFD; NHFD Project Coordinators • NHFD Steering Group, Dataset Sub-group, & Scientific and Publications Committee • BOA & BGS • Dept of Health and HQIP • Blue Book Authorship Group • Colleagues in NCASP/CCAD/NHS IC • Quantics Consultancy • Patients & staff in participating hospitals www.nhfd.co.uk

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