A systematic approach to hip fracture care and prevention
A toolkit for securing resources
1. Hip fracture care
National Hip Fracture Database participation by fracture units
This document aims to provide lead clinicians in fracture units with the necessary materials
to efficiently assemble a business case to support the employment of personnel who can
enter data on the unit’s hip fracture patients into the National Hip Fracture Database. It is
distributed electronically so that the various modules can be modified to fit the local
situation.
The sequence of argument suggested is the following:
•
Hip fracture presents a massive burden of cost both to the patient and the NHS. The
incidence is rising rapidly
•
Good practice can both improve quality and reduce costs
•
Participation in the NHFD is an effective mechanism for establishing best practice, will
improve quality and will be at least self-funding because of:
-
•
Reduced length of stay
More accurate coding
Reduced impact of hip fractures on elective work and achievement of 18 week
targets
In (add in your Trust’s) fracture unit, the best model for NHFD data collection is to make
it one of the duties of a (add role)
2. Hip fracture prevention
Fracture Liaison Services to deliver secondary fracture prevention
Half of hip fracture patients have suffered a prior fragility fracture that could and should have
served as a trigger for secondary fracture prevention. Fracture Liaison Services provide a
proven mechanism to ensure that patients presenting with fragility fractures receive
secondary preventative care to reduce their risk of subsequent hip fracture. FLS have been
implemented within 30% of NHS Trusts across the UK to deliver NICE TA87 and SIGN71.
FLS has been endorsed by the Department of Health and the Royal College of Physicians
as an example of best practice to deliver secondary fracture prevention. The rationale to
inform a business case is provided for NHS Trusts that are yet to implement an FLS.
1
The following documents are in word format to allow you to insert identifiers and figures
relevant to your own organisation.
2
1. Hip fracture care
The National Hip Fracture Database:
Rationale for (add in your Trust) participation
The burden of hip fracture on patients and (your Trust)
Hip fracture is the most common cause of acute orthopaedic admission for older people. During
2006/7, in excess of 70,000 hip fractures occurred in the UK which translates to 300-400
presentations per year to an acute hospital serving a population of 300,000. Hip fracture incidence
has been projected to increase by 50% by 2020 because of the ageing population. (1)
Hip fracture is associated with substantial morbidity and mortality. Up to 20% of patients admitted
from home will be moved into residential or nursing care homes as a result of the hip fracture. (2)
Elderly patients are profoundly fearful of suffering a hip fracture; a published survey of elderly
women found that 80% would prefer to die rather than move into a nursing home as a result of
suffering a “bad hip fracture”. (3) Mortality is 5-10% after one month and about 30% after one year. (4)
Hip fracture exerts an enormous burden upon NHS budgets. The current hospital costs of treating
hip fractures have been estimated at £12,000 per case (5); three-quarters of this expenditure is
attributable to the acute stay. Accordingly, the average District General Hospital spends £3.6 - £4.8
million per year on the acute management of hip fractures. Hip fracture care represents one of the
more expensive tariffs for acute care at a median cost of £5,523 (HRG version 3.5, H82 to H99) in
comparison to the average hospital tariff of around £1,250. (6) However, clearly a major disparity
exists between the standard costs incurred by hospitals caring for hip fracture patients relative to the
reimbursement received from Primary Care Trusts through the Payment by Results system. For a
large English trauma unit that serves a population of 685,000, admission of 750 patients with hip
fractures annually has been estimated to result in an annual PbR deficit of £3 million per year for the
NHS Trust. (7)
Burden of hip fracture on (your Trust)
The burden placed upon orthopaedic and geriatric service provision by (your Trust) can be put into
context by collation of the following data:
- Annual number of patients admitted with hip fracture
- Length of Stay (average, range and total number of bed days for hip fracture patients)
- Acute care costs (average, range and total incurred by [your Trust] for 2006/7)
- Total PbR reimbursement from local Primary Care Trusts for acute hip fracture care
The National Hip Fracture Database: Reducing costs through improving quality
Hip fracture has a substantial impact on elderly patients’ quality of life and local NHS budgets.
Accordingly, all NHS Trusts that provide services for patients with hip fracture should consider
participation in NHFD. The aim of NHFD participation is to improve the quality of hip fracture care,
and at the same time improve its efficiency. The NHFD has been modelled upon the highly
successful MINAP database (Myocardial Infarction National Audit Project) which has contributed to
significant improvements nationally in the management of patients with acute coronary syndromes.
(8)
Participation in NHFD, including advice and data analyses, is free; but data collection is a local
responsibility. Arrangements for data collection will depend on case volume and local service
3
structures; and effective participation will depend heavily on the degree of commitment and support
offered by key stakeholders.
The National Hip Fracture Database:
Underpinning effective ortho-geriatric care
The multi-factorial nature of the problems facing hip fracture patients, and the healthcare
professionals responsible for their care, necessitates a multi-disciplinary approach. Most UK
hospitals have implemented one of a range of systems to ensure geriatrician involvement in the
medical management of hip fracture patients. Indeed, the National Service Framework for Older
People advocates that “at least one general ward in an acute hospital should be developed as a
centre of excellence for ortho-geriatric practice.” The NHFD provides hospitals with a mechanism to
underpin a cycle of continuous audit and quality improvement of hip fracture care and as such
provides a central component of good ortho-geriatric service provision aligned with national policy.
To ensure that all stakeholders in the locality are fully engaged in the process of NHFD participation
at (your Trust); a multi-disciplinary stakeholder group should be established from the outset. This
group will likely include:
- NHFD Lead Clinician (most likely to be an Orthopaedic Surgeon or Ortho-geriatrician)
- Consultant Orthopaedic Surgeon
- Consultant Geriatrician or Ortho-geriatrician
- Consultant Anaesthetist
- Lead Clinician in Osteoporosis for (your Trust)
- Relevant specialist nurses, physiotherapists and other AHPs
- Personnel responsible for NHFD data entry (when identified/appointed)
- Representative from hospital IT Department
- Representative from hospital Finance or Coding Department re: PbR coding issues
- Representative from local Primary Care Trusts
The National Hip Fracture Database: Spend to save
Participation in the National Hip Fracture Database will be self-funding and is likely to result in a
significant reduction in the cost of hip fracture care to (your Trust).
Hospital stay accounts for 80% of the current £12,000 average cost incurred by NHS hospitals for
each hip fracture admission. (5) Long-term hip fracture audit in Nottingham has demonstrated that a
1 day pre-operative delay leads to a 2.5 day increased length of stay post-op. The Scottish Hip
Fracture Audit has been associated with reductions in length of stay. NHFD participation will provide
(your Trust) with a new capability to:
1. Scrutinise length of stay: NHFD participation enables NHS Trusts to focus on the process of
care for hip fracture patients and so identify which steps in the pathway could be improved and lead
to consequent reductions in acute care costs. For example, in an average District General Hospital
(300 hip fracture patients per year treated):
- An early result of effective NHFD participation - quantifying, addressing, and reducing
preoperative delay - might shorten acute LoS by 1 day, and total LoS by more
- Assuming an acute orthopaedic bed costs £200 per day and data collection £70 per patient
the efficiency gain over a year could amount to around £40,000 for the orthopaedic unit
alone
4
2. Focus on accurate PbR coding: The 2007/8 tariff for fractured neck of femur is in the range
£4,518 to £7,936. The importance of accurate coding practice has been highlighted by a recent audit
of a UK hospital suggesting that a £318,300 - £424,400 annual loss of income could be directly
attributed to inaccurate PbR coding for hip fracture for an average DGH. (6)
3. Deliver the 18 week patient pathway: An October 2007 publication from the 18 weeks
Orthopaedic Co-ordinating Group has highlighted the potential for service transformation of hip
fracture care to support local delivery of the 18 week target for elective work. (9)
Models for National Hip Fracture Database data collection
The optimal model for participation in NHFD by (your Trust) will be determined by local case volume
and service structures. As an illustration of how colleagues throughout the NHS have addressed the
issue of local data collection, examples of how NHFD data collection has been incorporated into a
range of NHS job descriptions are included as Appendices. These appendices are provided to the
(your Trust) stakeholder group to illustrate potential local solutions:
- Appendix 1: Elderly Trauma Nurse Co-ordinator - example Job Description
- Appendix 2: Trauma Audit Coordinator - example Job Description
- Appendix 3: Trauma Co-ordinator - example Job Description
Regarding post 1 and 3 above - if an organisation is considering one of these posts, an
amalgamation of the job descriptions may best suit the service and that this would be appropriate. A
trauma co-ordinator’s role is a good management strategy for total patient care in all trauma; but
there should be an emphasis on providing excellent hip fracture (and trauma) care to older people.
.
The business plan for NHFD participation by (your Trust) will likely consider the following:
- Aims and objectives of NHFD participation
- Burden of hip fracture care on Anywhere NHS Trust
• Annual number of patients admitted with hip fracture
• Length of Stay (average, range and total number of bed days)
• Acute care costs (average, range and total incurred in 2006/7)
• Total PbR reimbursement from local PCTs for acute hip fracture care
- Critical appraisal of actual/perceived strengths/weaknesses of current care
- Review of performance indicators versus national averages e.g. 30 day mortality
- Identification of opportunities for audit-based clinical/service change
- Start-up costs for establishing NHFD data collection at (your Trust)
- Plan for using NHFD outputs to benchmark and improve care
• Stakeholder group constitution, remit and membership
• Proposed reporting arrangements
- Accountability and clinical governance issues
- Draft job description of individual responsible for NHFD data entry
How to register with NHFD
The lead clinician sends an email to their Project Manager/Coordinator at Maggie@nhfd.co.uk
(London) fay@nhfd.co.uk Midlands and The North or Andy@nhfd.co.uk The South, Northern Ireland
and Wales (from an NHS email address) to request access to the database. The minimum
information required to register each person must include the following:
- Name and job title
5
- Full address of hospital(s)
- Email address
- Contact telephone number
After registration, a username will be emailed directly to the lead clinician with a request to contact
the NCASP helpdesk for issue of a personal password. Then, go to www.nhfd.co.uk, click on the
NHFD ‘Log In’ where you will be asked to enter your username and password.
NHFD Facilities audit
This allows the NHFD to understand your hospital's facilities. This needs to be completed at time of
registration and annually. The components of the facilities audit are provided in Appendix 6. The
data needs to be completed 'on-line’ by entering website > Database Records > Records [on left of
page] > Facilities Audit > save as ‘complete’. This will enable the data analysts to gain a clear
picture of the nature of your unit and see how differences in structure are related to differences in
function, so please be as accurate as possible.
The NHFD audit tool is provided in Appendix 7.
A generic version of a patient information leaflet describing NHFD is provided in Appendix 8.
6
2. Hip fracture prevention
Fracture Liaison Services:
Rationale for implementation at (add in your Trust)
The case for secondary fracture prevention
Osteoporosis is the most common bone disease in humans affecting both women and men (10); the
clinical manifestation of this disease is fragility fracture. An illustration of the consequences of
unchecked osteoporosis amongst elderly patients is provided in figure 1. As with other chronic
diseases such as hypertension or hyperlipidaemia, osteoporosis sufferers experience an
asymptomatic disease phase prior to the occurrence of end-organ damage. Fragility fractures
usually result from a fall in older patients that have compromised bone strength. Hip fracture is all
too often the final destination of a thirty year journey fuelled by decreasing bone strength and
increasing falls risk.
Figure 1. Fracture and quality of life over the life span
Morbidity
Hip fracture
Vertebral fracture
Colles' fracture
Morbidity
attributable to
ageing alone
50
60
70
80
90 Age
Adapted from J Endo Investigation 1999 Kanis JA & Johnell O
Half of hip fracture patients have suffered a prior fragility fracture that could and should have served
as a trigger for secondary fracture prevention. (11-14) In January 2005, NICE published Technology
Appraisal 87 (15) which mandated osteoporosis assessment for all post-menopausal female fragility
fracture patients. Targeting all older patients who present with fragility fractures at any skeletal site
for anti-fracture therapy provides a means to intervene in up to a half of all future hip fracture cases.
A comprehensive meta-analysis of the principle agents licensed for the treatment of osteoporosis
suggests that a 50% reduction in fracture incidence can be achieved during three years of
pharmacotherapy. (16)
The current management gap in the UK
Many UK studies have established that routine provision of secondary fracture prevention is
occurring for a maximum of 30% of fragility fracture patients in the absence of a systematic
approach to healthcare delivery. (17-27) In August 2007, the first UK national evaluation of standards
of care for osteoporosis and falls in primary care was commissioned. (28) This study established that
NICE TA87 was not implemented for the majority of fragility fracture patients. A subsequent national
audit commissioned by the Healthcare Commission into standards of care for patients presenting to
hospital with a new fragility fracture found similar shortcomings. (29) Given that 50% of all future hip
fracture patients are likely to have suffered a prior fragility fracture, a lack of implementation of NICE
7
secondary prevention guidance will result in a continued escalation of the burden of hip fracture on
patients, orthopaedic trauma units and NHS budgets.
8
Fracture Liaison Services
A systematic approach to secondary fracture prevention
Osteoporosis care of the fragility fracture patient has been characterised as a Bermuda Triangle
comprised of osteoporosis experts, orthopaedic surgeons and primary care physicians into which
the fracture patient disappears. (30) Sub-optimal care has been attributed in part to a lack of clarity
regarding which speciality should take responsibility for the medical management of patients with
fragility fractures. (31) Fracture Liaison Services (FLS) have been demonstrated within the UK NHS
and healthcare systems in other countries to provide a reliable mechanism to close this ubiquitous
management gap.
The FLS model was originally developed within the Glasgow University Teaching Hospitals and has
been described in detail in 2 peer-reviewed publications. (32, 33) In summary, the FLS relies upon a
dedicated nurse specialist working within the orthopaedic environment under the guidance of an
expert in metabolic bone disease. Usually the “Lead Clinician in Osteoporosis” will be a geriatrician,
orthopaedic surgeon, rheumatologist or endocrinologist. The specialist nurse is responsible for
establishing systems of care in the particular hospital to ensure that every fracture patient over 50
years (excluding high trauma and road traffic accidents) receives a “one-stop-shop” osteoporosis
assessment, with DEXA where appropriate, by the nurse working to protocols devised by clinicians.
The FLS will integrate with local falls services and other agencies as described in the 2007 edition of
the BOA-BGS Blue Book on the care of patients with fragility fracture. (1)
The Fracture Liaison Service model has been recognised by the Department of Health (34) and the
BOA-BGS (1) as an example of best practice to implement NICE TA87. The 2006 National audit of
the organisation of services for falls and bone health for older people found that only 27% of
hospitals in England had established an FLS.
Establishing a Fracture Liaison Service in (add in your Trust)
Establishing a Fracture Liaison Service at (your Trust) will implement a systematic approach to
secondary fracture prevention with potential to intervene in half of all future hip fracture cases
The 2007 BOA-BGS Blue Book on care of patients with fragility fracture (1) states “…the most
practical option available to the NHS to attenuate the rising incidence of hip fractures is to ensure
that every patient presenting today with any fragility fracture receives effective secondary
preventative care”. The Blue Book advocates establishment of an FLS in every UK hospital as the
means to achieve this objective.
In the event that your hospital is yet to establish a Fracture Liaison Service resources follow to
support you and your colleagues to construct an FLS business case. For hospitals in England,
financial support for the FLS is likely to come from a commissioning arrangement with local PCTs.
To ensure that all stakeholders in the locality are fully engaged in the establishment of FLS
participation at (your Trust), a multi-disciplinary stakeholder group should be established from the
outset. This group will likely include:
- Osteoporosis Lead Clinician (geriatrician, orthopaedist, rheumatologist or endocrinologist)
- Consultant Orthopaedic Surgeon
- Consultant Geriatrician or Ortho-geriatrician
- NHFD Lead Clinician for (your Trust)
- Relevant specialist nurses, physiotherapists and other AHPs
- Personnel responsible for development/installation of FLS database
- Representatives from hospital and primary care medicines management
- Representative from local PCT and/or PBC groups
9
- Representative from local general practice
- Representative from local Public Health
Service design for FLS in (your Trust)
The optimal model for establishing an FLS in (your Trust) will be determined by local case volume
and service structures. Illustrations of how colleagues have staffed their services are provided as
appendices to the stakeholder group at (your Trust) to illustrate potential local solutions:
- Appendix 4: Fracture Liaison Specialist Nurse – example Job Description
- Appendix 5: A&E Falls and Comprehensive Geriatric Assessment Practitioner - JD
Consideration of a published cost-effectiveness analysis of an FLS established overseas (35) may be
useful to Lead-Clinicians at project out-set. The business plan will probably consider the following:
- Aims and objectives of the Fracture Liaison Service
- Burden of fragility fracture care on Anywhere NHS Trust
• Annual number of patients admitted with hip fracture and other fragility fractures
• Length of Stay (average, range and total number of bed days)
• Acute care costs (average, range and total incurred in 2006/7)
• Total PbR reimbursement from local PCTs for acute fracture care
- Critical appraisal of actual/perceived strengths/weaknesses of current care
- Plan for communication between secondary and primary care
- Plan for set-up of an FLS database to enable reporting to GPs and audit
- Identification of opportunities for audit-based clinical/service change
- Start-up costs for establishing the Fracture Liaison Service
- Accountability and clinical governance issues
- Draft job description of clinicians and allied healthcare professionals involved in FLS
Several UK-based Fracture Liaison Service teams have published work on the set-up, audit and
outcomes of their services:
- Glasgow (32, 33, 36, 37)
- Ipswich (38)
- Peterborough (39)
- Belfast (40)
10
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Salkeld G et al. Quality of life related to fear of falling and hip fracture in older women: a
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Gallagher J et al Epidemiology of fractures of the proximal femur in Rochester, Minnesota.
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Content G et al. Osteoporosis screening and education following distal radial fracture: An
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Appendix 1
Example Job Description: Elderly Trauma Nurse Co-ordinator
Post:
Location:
Reports to:
Grade:
Elderly Trauma Nurse Co-ordinator
Surgical Directorate
Managerially: To be completed locally
Professionally: To be completed locally
Band 7
Job summary
1. To assist in developing a culture that understands and meets the specialist and complex
needs of hip fracture patients, whilst ensuring that performance targets such as decreased
length of stay are met.
2. Physically assess all hip Fracture patients, ensuring effective patient management plans are
created and carried out in a timely manner.
3. To identify and meet the training needs of all staff caring for hip fracture patients.
4. To work as part of the multi-disciplinary team, acting as a liaison between Orthopaedic
Consultants and ward staff/A & E/Rehabilitation and Community Staff.
5. To manage own case load.
6. To provide a quality service to patients suffering from hip fracture and ensure all patient’s data
are included in the National Hip Fracture Database(NHFD)
Core responsibilities
1. To attend daily trauma meetings and trauma ward rounds involving the orthopaedic consultants
and team.
2. To monitor and advise in the care of all patients with hip fracture, ensuring appropriate
treatment and nursing care is provided from 'decision to admit', by regularly monitoring A & E
and identifying hip fracture patients who are not admitted into direct access bed.
3. To ensure that theatre space is used effectively and prevents unnecessary pre-op fasting of
patients with fractured neck of femur.
4. Audit the progress of all hip fracture patients and complete NHFD audit tool with attention to
detail and accuracy and produce reports as requested and present at Directorate Audit
meetings.
5. Ensure effective liaison within the multi-disciplinary team.
6. To request appropriate investigations for all fractured neck of femur patients to ensure patients
are in their optimum physical condition prior to theatre.
7. To ensure continuity of care, specialist advice, training and liaison within the clinical area
(including Consultants and GP’s), in order to provide a high standard of patient care.
8. To be a contact for discharged hip fracture patients if advice regarding their injury is required.
9. To ensure that all patients and their relatives are fully informed, psychologically prepared for
theatre and educated about their injuries, the intended management and discharge plans.
10. To run a nurse-led clinic for fractured neck of femur patients requiring post-op monitoring.
11. Apply current research findings to clinical care and actively disseminate these findings.
12. To regularly provide structured teaching sessions to A & E, ITU and ward staff on the role of the
Hip Fracture Nurse Specialist and the needs of hip fracture patients.
13
13.
14.
15.
16.
To ensure maximum effectiveness of the service within the resources available.
A willingness to undertake research projects with an aim to publish results.
To ensure compliance with all Trust policies and those procedures relevant to the area of work.
At all times maintain high levels of confidentiality and information security complying with the
relevant legislation such as the Data Protection Act and the Computer Misuse Act.
17. Where any processing of information takes place (paper records or electronically) ensure that
the data is of good quality, accurate and relevant for purpose.
This job description should be regarded only as a guide to the duties required and is not intended to be definitive.
Person specification – Elderly Trauma Nurse Co-ordinator
Requirements
Education and
Qualifications
Job related
Experience
Skills /
Attributes
Personal
qualities
Essential
RGN Level 1- UKCC Registered
ENB 998 or City & Guilds 998 or equivalent
Health Assessment Skills – level 4, or willingness
to work towards
At least 2 years at Band 6
At least 2 years experience working within Older
person, trauma specialty or A/E areas
Ability to manage own workload and prioritise
Excellent interpersonal and negotiation skills
Communication skills of tact and diplomacy.
Ability to communicate with all clinical groups of
staff to achieve patient care of a high standard.
Presentation skills
Proven good line-management skills
Adept at working in multi-disciplinary teams
Ability to work flexibly
Ability to meet the demands/hours.
Good team player
Enthusiastic and motivated
Desirable
Evidence of management
experience
ENB 219/ONC/A&E course
Evidence of extended role activity.
IV cannulation, ECG trained,
ALERT Course.
Experience in caring for acutely ill
older people.
Audit awareness / use of
spreadsheets
Budgetary awareness
Computer literacy
Previous project work
14
Appendix 2
Example Job Description: Trauma Audit Co-ordinator
Job title:
Location:
Responsible to:
Grade:
Trauma Audit Coordinator
Surgical Directorate
Managerially: To be completed locally
Professionally: To be completed locally
A & C Grade 5, Hours per week to be specified
JOB SUMMARY:
To coordinate data collection across the Trust and to facilitate trauma audit as part of the
development of high quality clinical practice. To support the development of an initiative which aims
to improve the quality of trauma services and the sharing of good practice.
CORE RESPONSIBILITIES: Injuries in the Elderly Patient Audit
1.
To support and promote trauma audit at the Trust, liaising closely with clinical staff and clinical
audit and information staff to ensure that good quality data is available
2. To collect and coordinate accurate, reliable and timely data. To maintain the audit database
3. To liaise with other cooperating centres and research unit staff working with the elderly
4. To organise regular trauma audit reports and events for the Trust and to support educational
events
5. To develop effective networks and channels of communication across multi-professional
groups to facilitate trauma audit
6. To assist clinicians and hospital staff in the interpretation of information and in identifying
areas requiring further audit, change or research
7. To make presentations to educational meetings, seminars and symposia as required
8. To participate in individual performance appraisal arrangements
9. Any other allied duties as requested by the line-manager
10. To cross cover core data collection/identification for the parallel audit in injuries in the Critically
Injured Patients during periods of leave
This job description should be regarded only as a guide to the duties required and is not intended to be definitive.
15
Person specification - Trauma Audit Co-coordinator
Specification
Education /
Training
Occupational
Special skills /
aptitudes
Personal
Qualities
Circumstances
Essential
Trained in the use of PCs with Windows operating systems,
Word, Excel, email and Access
Experience of clinical terminology in trauma care
Experience of SPSS or other statistical application
Retrieval and refiling training for ORH notes
Extraction of data from hospital notes
Ability to interact with clinical staff to clarify data
Ability to manipulate databases to produce summary statistics
Ability to statistically analyse data
Knowledge of data protection and security
Presentation skills
Ability to work with multidisciplinary teams to effect practice
change based on audit
Contribution to the development of improved methods for data
collection and handling in Critical Care
Great attention to detail and thoroughness in data retrieval and
entry.
Ability to work in partnership with other data team members
and their audits
Willingness to attend specific audit training courses/sessions at
other hospitals e.g. initially and for regular updates
Working collaboratively with partner Critical Care Audit staff to
maintain core data collection for all audit projects during
periods of leave.
Flexibility in working hours to ensure live data capture in this
emergency field, over either 4 or 5 days per week
Desirable
Research
qualification or
experience
Ability to create
and enhance
databases
16
Appendix 3
Example Job Description – Trauma Co-ordinator
Job title:
Trauma Co-ordinator
Location:
Surgical Directorate
Responsible to:
Managerially: To be completed locally
Professionally: To be completed locally
Grade:
Band 7
Job Summary
1. To comprehensively assess trauma patients, assist and co-ordinate trauma activity with the
Directorate, liaising with various healthcare professionals to ensure that each patient’s hospital
episode is managed in the most effective and efficient way, in line with the Trust strategies on
nursing, midwifery and patient centred care.
2. To improve the scheduling of surgery for trauma patients, reduce cancelled operations and
reduce pre-operative starvation. To assist in the data collection pertaining to these issues by
means of quantative/qualitative audit, on-going monitoring and general feedback.
3. Maintaining close liaison with patients, relatives/carers, medical teams ward nursing teams,
anaesthetic and operating department staff.
CORE RESPONSIBILITES
1. Patient management
 Physically assess all trauma patients, ensuring effective patient management plans are
created and carried out in a timely manner.
 Undertake autonomous lead role in the appropriate prioritisation of the trauma list, taking into
account the clinical needs of the patients.
 Participation in the consultant led trauma ward round and lead a cohesive and streamline
service formulating a specific management plan for each trauma patient.
 Assessing the patient and liaison with any necessary parties to facilitate operative
management, including physical examinations, history taking and documentation as
necessary.
 To ensure that patients admitted onto the Trauma Unit/Wards are appropriately assessed and
to ensure that all pertinent tests, specialist investigations and clerking are completed and
available. Liaising and ensure these have been undertaken buy all disciplines involved in
patient care.
 To discuss individual patients with appropriate consultants and/or their medical team to ensure
that theatre lists reflect patients’ priorities, matching complexity of the patient’s surgery against
the availability of surgeons and anaesthetists.
 Communication and documentation with patients, surgeons, anaesthetists, ward nursing
teams, operating department teams, junior medical staff and all professionals allied to
medicine.
 To ensure that all procedures within the unit are carried out according to established standards
within the Trust.
 Liaising with relevant disciplines to ensure a holistic approach to patient care.
2. Communication
17









To report the unit’s activity to the medical teams to enable the co-ordination of junior doctors
input for trauma management.
To develop collaborative partnerships and effective working relationships with clinical staff and
in particular Clinical Area Leads both within the Division and the Trust to influence the
management, planning and development of the service.
To liaise with theatre staff to ensure that theatre availability and equipment meets the demands
of patients requiring trauma surgery and that all orthopaedic operating sessions are fully
utilised.
To communicate with the Nurse Manager for Orthopaedics, the Bed Management team, A & E
staff and the Orthopaedic Outpatients to ensure that optimum bed usage is provided at all
times.
To participate in clinical audit (including the National Hip fracture Database- NHFD) and
research. Ensure that there is a local strategy is in place to support collection of NHFD data
and web input on ALL hip fracture patients. To collect agreed data on trauma activity to enable
theatre utilisation remains effective and efficient.
After the consultant led trauma round, close liaison must then take place with the Operating
Department, giving them as much information about their patients and their surgical
management to facilitate the smooth running of the day’s list.
Re-planning and trouble shooting throughout the day. To monitor activity within the unit and
identify and minimise potential problems through pro-active working practices.
To facilitate cross Divisional communication networks and develop strategies to ensure that
each patient’s hospital episode is managed individually and in the most effective and efficient
way.
Complete a formal handover taking place at the end of the day with the Consultant on call and
other disciplines. This meeting informs and updates the Consultant on call team and prioritise
the workload for the following day.
This job description should be regarded only as a guide to the duties required and is not intended to be definitive.
Person specification – Trauma Co-ordinator
Requirements
Essential
Education
and
Qualifications
RGN Level 1- UKCC Registered
ENB 998 or City & Guilds 998 or equivalent
ENB 219/ONC/A&E course preferred
Health Assessment Skills – level 4, or willingness to
work towards
At least 2 years at Band 6
At least 2 years experience working within Trauma or A/E
areas
Job related
Experience
Skills /
Attributes
Personal
qualities
Ability to manage own workload and prioritise
Excellent interpersonal and negotiation skills
Communication skills of tact and diplomacy.
Ability to communicate with all clinical groups of staff to
achieve patient care of a high standard.
Presentation skills
Proven good line-management skills
Adept at working in multi-disciplinary teams
Ability to work flexibly
Ability to meet the demands/hours.
Good team player
Enthusiastic and motivated
Desirable
Evidence of
management
experience
Evidence of extended
role activity. IV
cannulation, ECG
trained, ALERT Course.
Audit awareness / use
of spreadsheets
Budgetary awareness
Computer literacy
Previous project work
18
Appendix 4:
Example Job Description: Fracture Liaison Specialist Nurse
Job title:
Fracture Liaison Specialist Nurse
Location:
Surgical Directorate
Responsible to:
Managerially: To be completed locally
Professionally: To be completed locally
Grade:
Dependant on specifics of post
JOB SUMMARY
1. To co-ordinate and be responsible for the development of the Fracture Liaison Service for
location.
2. To be aware of the Osteoporosis Guidelines for location involved in the Osteoporosis initiative.
3. To develop links and communication between the orthopaedic services and metabolic bone unit.
4. To develop appropriate referrals and pathways of care for patients admitted with fragility
fractures that may have osteoporosis.
5. To be autonomous and be prepared to make decisions where appropriate, manage own time
and workload and work individually as well as contributing to the team when necessary.
6. To assist in the establishment of a multidisciplinary unit for the diagnosis and management of
bone disorders principally osteoporosis.
7. To act as a link person enhancing co-ordination and communication between the various
members of the orthopaedic and medical teams, to the metabolic bone team as well as other
areas that refer patients to the unit.
8. To help establish educational and health promotion programs for patients attending the unit and
those seen at other sites.
9. To perform audit of the unit the developing service and associated bone densitometry screening
programs.
10. To be aware of time constraints and financial implications of developing the service projects.
11. To be responsible for accurate data entry and of data associated with research and be proficient
in appropriate computer packages.
12. To identify any areas of opportunity within the unit for development of research, and assist in
their evolution. To be involved in the submission of ethics proposals, grant applications and the
setting up of research and audit.
CORE RESPONSIBILITIES
1. To ensure an efficient and effective service is given to patients who may have osteoporosis who
are admitted with fragility fracture.
2. To liaise with all members of the team to ensure smooth running of the referral service and unit.
3. To develop and maintain accurate data collection and storage using computer skills.
4. To be skilled in patient assessment techniques such as taking histories and clinical skills
including venepuncture for patients needing investigations.
5. To be a source of knowledge and provide educational support concerning osteoporosis and
identification of research areas.
19
6. To be involved in the development of proposals, ethical requirements and implementation of
research within the unit.
7. To maintain and update own knowledge and clinical skills of bone disorders to enable education
and advice to be given to patients and their families.
8. To maintain and develop own personal and professional development according to UKCC
guidelines.
9. To liaise with all members of the team to ensure smooth running of the unit.
This job description should be regarded only as a guide to the duties required and is not intended to be definitive.
Person specification – Fracture Liaison Specialist Nurse
Requirements
Essential
Education
and
Qualifications
RGN Level 1- UKCC Registered
ENB 998 or City & Guilds 998 or equivalent
ENB 219/ONC/A&E course preferred
Health Assessment Skills – level 4, or willingness to
work towards
Job related
Experience
At least 2 years at Band 6
At least 2 years experience working within Trauma or A/E
areas
Ability to manage own workload and prioritise
Excellent interpersonal and negotiation skills
Communication skills of tact and diplomacy.
Ability to communicate with all clinical groups of staff to
achieve patient care of a high standard.
Presentation skills
Proven good line-management skills
Adept at working in multi-disciplinary teams
Ability to work flexibly
Ability to meet the demands/hours.
Good team player
Enthusiastic and motivated
Skills /
Attributes
Personal
qualities
Desirable
Evidence of
management
experience /
counselling
advantageous
Audit and research
awareness / use of
spreadsheets
Computer literacy
Previous project work
20
Appendix 5:
Example Job Description: A+E Falls and Comprehensive Geriatric Assessment Practitioner
Job title:
Location:
Responsible to:
Grade:
A+E Falls and Comprehensive Geriatric Assessment Practitioner
Surgical Directorate
Managerially: To be completed locally
Professionally: To be completed locally
Band 7
Job Summary
The A&E Falls and Comprehensive Geriatric Assessment (CGA) Practitioner post has been
developed to improve the comprehensive assessment of older people (aged 65+) presenting to
A+E. The A+E Falls & CGA Practitioner will specifically focus on patients presenting with a fall. The
post holder will assess fallers and appropriately refer to other services with streamlining of referrals
to the Falls Clinic and community services. They will also apply CGA methods in assessing older
people in A&E and the Clinical Decision Unit (CDU). An important aspect of the post will be to
embed this assessment approach into routine practice by nurses and junior medical staff working in
A&E and the CDU.
The post holder would ensure that older people who have presented in A+E with a fall or other
geriatric syndrome (confusion, reduced mobility, incontinence, frailty) are assessed and referred to
appropriate teams/agencies for further assessment and treatment. The nurse will be responsible for
assessing fallers when they present at ED using a structured proforma and identifying the
appropriate referrals. The nurse will also be responsible for triaging out of hours attendees and
ensuring appropriate follow up care.
Core responsibilities
1. To work closely with A+E staff to ensure that older people presenting with falls and other issues
have access to an appropriate level of assessment and intervention and/or with appropriate
onward referral.
2. To ensure that people who have fallen are assessed using an identified proforma with a view to
identifying risk factors for both falls and osteoporosis
3. Demonstrate good CGA assessment skills using a structured approach to a holistic assessment
of the older person incorporating environmental issues. This will include embedding a brief
structured CGA proforma into routine A&E practice.
4. Support carers and patients during their attendance in ED and providing explicit details of and
follow-up care.
5. Ensure patients and carers are involved in decision making process and give valid consent to all
treatment of referrals.
6. Using ED consultation information and telephone follow-up to assess the need of the patient in a
proactive manner to ensure appropriate follow up care.
7. To actively identify, assess and intervene in people at risk of osteoporosis and fractures.
8. Key role at primary/secondary health care interface. Facilitating the safe discharge of people
who fall and ensuring follow-up with appropriate members of the multidisciplinary team. Close
working and integration with SLIPS project to streamline ED into Falls ICP.
9. Link with existing improvement programmes in the specialist area: SLIPS project, OPAL, TACT,
Day Hospital and Intermediate care centres.
10. Work closely with POPS (proactive management of older people requiring surgery) in relation to
patients with hip fractures.
11. To engage in clinical audit activity and maintain the falls database.
12. Implement and evaluate innovations in clinical practice
13. Practice and further develop advanced clinical skills
21
14. Lead nursing input in A+E decision-making
15. Participate in quality assessment of the project on an ongoing basis with quarterly reports on the
impact of service and quality of care
16. Participate in the formalisation of assessment forms, standards of care and policies for patients
who have presented with a fall.
17. Optimise appropriate post-operative discharge from hospital by working with the other clinical
members of the team and other agencies such supportive discharge and other intermediate care
provision, and linking with voluntary organisations and groups.
18. Review, maintain and develop agreed standards of documentation and electronic record
keeping.
Teaching and Staff Development
1. To meet patients information needs. Advice will be given with respect to diet, exercise, vision,
and footcare through the patient assessment and consultation with patients.
2. To provide A+E staff with information on falls management through regular teaching and
education support fro all staff within ED. Medicine and Primary Care.
3. Together with ED staff to identify training, educational sessions and discussions and provide
recommendations to meet these with training needs and secure plans to address needs.
4. To identify, provide and develop required literature for patients about falls and ensure that all
fallers are given this information on discharge.
5. To communicate all developments, Day Hospital steering group.
6. Develop and maintain effective lines of communication with relevant hospital Clinicians, Nursing
Staff and across the Primary/Secondary Care interface.
7. To collect and record patient data as required and to take appropriate actions as indicated.
8. Provide support and advice to all staff involved in the care of patients who have fallen.
9. To keep abreast of professional and managerial developments
10. To organise and participate in regular meetings with the Clinical Nurse Manager and Day
Hospital Manager.
11. To attend the Day Hospital Operational Meetings and keep informed of other elderly care activity
e.g. falls clinic, POPS etc.
22
This job description should be regarded only as a guide to the duties required and is not intended to be definitive.
Person specification - A+E Falls and Comprehensive Geriatric Assessment Practitioner
Requirements
Education
and
Qualifications
Job related
Experience
Skills /
Attributes
Personal
qualities
Essential
RGN Level 1- UKCC Registered
ENB 998 or City & Guilds 998 or equivalent
Degree or willingness to work towards
At least 18 months at Band 6
At least 5 years post registration experience, preferably within a hospital
setting and with elderly patients
Management of change both personally and as a facilitator
Sound Knowledge of current issues in the profession and practice of
nursing
Understanding of health and social care policy especially the NSF of
Older People
Ability to manage own workload and prioritise
Excellent interpersonal and negotiation skills
Ability to communicate with all clinical groups of staff to achieve patient
care of a high standard.
Presentation skills
Proven good line-management skills
Adept at working in multi-disciplinary teams
Able to work under pressure and achieve deadlines
Proficient in the use of IT applications including word and Excel
Interest in promoting improved care for the older person
Ability to work flexibly and meet the hours/demands of the post
Good team player
Enthusiastic, innovative and self motivated
Diplomatic, flexible and politically sensitive
Commitment to personal development and professional effectiveness
Desirable
Evidence of management
experience / counselling
Audit and research
awareness / use of
spreadsheets
Computer literacy
Previous project work
23
Appendix 6, NHFD Facilities Audit
Headings
Your Information
Comments/Options
Hospital
Trauma catchment population (DGH workload)
Number of hip fracture cases each year
Trauma service description
DGH/Tertiary/both
Acute admission
Hip# ward / any ortho bed /Older person ward
/ any ward
Best description of hip fracture service
All pts > acute ortho then transferred to Medicine
for Older People Ward / community Hospital bed at
Day 5 post op
Hours of designated trauma list /per week
Number of WTE orthopaedic consultants
Number of WTE orthopaedic middle grades
Number of hours per week worked by orthogeriatric
consultants in orthopaedic department
Number of hours per week orthogeriatric middle grades
work in orthopaedic department
Number of OG ward rounds a week
Number of clinical nurse practitioner WTE specialising in
fragility fracture patients
Number of WTE fracture liaison nurses
Falls clinic
None / Consultant led / nurse led
Dexa on site
Axial / peripheral / none
(If you have axial & peripheral just put axial)
Dexa Since
E.g. since 2001
Who predominantly collects and enters data?
nurses, doctors or audit staff
Do you use local audit software, if so what is it called
Access/Excel/ Teleform / other (please state)
Rehabilitated
In admission ward / GORU
Characteristics of
hospital
Free text – comment on unique aspects of your
hospital - e.g. pts transferred > other hospital post
op
24
Appendix 7, National Hip Fracture Database – Audit Tool 5.0
Patient Information
First Name
Surname
Date of Birth
M
NHS / CHI Number
Gender
M
BM
Patient’s Post Code
M
__ __ /__ __ /__ __ __ __
Patient ID / Hospital number
K
Admission
First Presenting Hospital
Admitted from
M
l
Note: Holiday residence/respite care = Own home/sheltered housing
Admission via A & E
Date & time of admission to A & E
__ __ / __ __ / __ __ __ __
BM
__ __:__ __hrs
Note: Use presentation to trauma team if not admitted via A&E
Date & time left A & E
Type of ward admitted to
__ __ / __ __ / __ __ __ __
– Medicine for older people
__ __:__ __hrs
Date & time of admission to orthopaedic ward
__ __ / __ __ / __ __ __ __
M
Consultant Code
__ __:__ __hrs
Note: This is for your hospital use only.
Orthopaedic GMC number
BM
Geriatrician GMC number
__ __ __ __ __ __ __ __
BM
__ __ __ __ __ __ __ __
Admitted using jointly agreed assessment protocol
B
Assessment
Walking ability indoors pre-admission
M
Walking ability outdoors pre-admission
own
M
or bedbound
Accompanied to walk indoors pre-admission
M
Abbreviated Mental Test Score (AMTS) on admission
Accompanied to walk outdoors pre admission
M
Pathological
M
__ __ / 10
Note: Yes only if primary or secondary malignancy present at the fracture site
Side of fracture
K
Pre-op medical assessment
M
Type of fracture
– displaced
– undisplaced
M
Note: Basal/basicervical #s are to be classed as Intertrochanteric
25
Treatment
ASA grade
Date & time of primary surgery
__ __ / __ __ / __ __ __ __
B
__ __:__ __hrs
Reason if delay > 36hours
M
- surgery < 36hrs
–awaiting orthopaedic diagnosis/investigation
– awaiting medical review/investigation or stabilisation
- awaiting inpatient or high dependency bed
– awaiting space on theatre list
/logistic – problem with theatre /equipment
- problem with theatre/surgical/anaesthetic staff
cover
- Cancelled due to theatre over-run
Note: Delay is calculated from time of admission in A&E
Pressure ulcers
Operation Performed
Internal fixation – SHS
Internal fixation – Screws
Internal fixation - IM nail (long)
Internal fixation - IM nail (short)
Arthroplasty - Unipolar hemi (uncementeduncoated)
Arthroplasty - Unipolar hemi (uncemented- HA
coated)
Arthroplasty - Unipolar hemi (cemented)
Arthroplasty - Bipolar hemi (uncemented - uncoated)
Arthroplasty - Bipolar hemi (uncemented – HA
coated)
Arthroplasty - Bipolar hemi (cemented)
Arthroplasty - THR (uncemented - uncoated)
Arthroplasty - THR (uncemented – HA coated)
Arthroplasty - THR (cemented)
Other
No operation performed
Reason if delay > 48hours
- surgery < 48hrs
–awaiting orthopaedic
diagnosis/investigation
– awaiting medical
review/investigation or stabilisation
- awaiting inpatient or high
dependency bed
tive/logistic – awaiting space on theatre
list
– problem with theatre
/equipment
- problem with
theatre/surgical/anaesthetic staff cover
- Cancelled due to theatre
over-run
her
Note: Delay is calculated from time of admission in A&E
M
Note: Grade 2 + above during acute admission
Re-operation within 30 days
Reduction of dislocated prosthesis
Washout or debridement
Implant removal
Revision of internal fixation
Conversion to Hemiarthroplasty
Conversion to THR
Girdlestone/excision arthroplasty
Surgery for periprosthetic fracture
Note: Most significant procedure only
Date & Time assessed by Geriatrician
__ __ / __ __ / __ __ __ __
BM
Geriatrician grade
Consultant
SAS
ST3+
B
BM
Bone protection medication
Started on this admission
Continued from pre-admission
Awaits DXA scan
Awaits bone clinic assessment
Assessed – no bone protection medication
needed/appropriate
ent or action taken
B
__ __:__ __hrs
Specialist falls assessment
- performed on this admission
- awaits falls clinic assessment
- further intervention not appropriate
Multidisciplinary rehabilitation team assessment
BM
26
Discharge
Date & time of discharge from acute Orthopaedic ward
__ __ / __ __ / __ __ __ __
__ __:__ __hrs
Date & time of final discharge from Trust
__ __ / __ __ / __ __ __ __
__ __:__ __hrs
Discharge date/time of final discharge from NHS care
__ __ / __ __ / __ __ __ __
M
__ __:__ __hrs
M
Discharge destination from acute Orthopaedic ward
Own home/sheltered housing
Residential care/nursing home/LTC hospital
Rehabilitation unit
Acute hospital
Dead
Other
Discharge destination from Trust
Own home/sheltered housing
Residential care/nursing home/LTC hospital
Rehabilitation unit
Acute hospital
Dead
Other
Unknown
Discharge destination from NHS care
Own home/sheltered housing
Residential care/nursing home/LTC hospital
Rehabilitation unit
Acute hospital
Dead
Other
Unknown
M
M
Follow Up
Residential
status
30 days
120 days
1 year
Date.............................
Date...................................
Date...............................
Own home/sheltered housing
Residential care / nursing home / LTC
hospital
Rehabilitation unit
Acute hospital
Dead
Other
Unknown
Own home/sheltered housing
Residential care / nursing home /LTC
hospital
Rehabilitation unit
Acute hospital
Dead
Other
Unknown
Own home/sheltered
housing
Residential care /
nursing home / LTC
hospital
Rehabilitation unit
Acute hospital
Dead
Other
Unknown
Walking
Ability
indoors
without aids
wheelchair or bedbound
one aid
ed with
two aids or frame
Walking
ability
outdoors
lked without aids
without aids
one aid
two aids or frame
c buggy
Accompanied
to walk
indoors
nknown
nknown
nknown
Accompanied
to walk
outdoors
nknown
nknown
nknown
Bone
protection
medication
o
nknown
nknown
nknown
K= key fields. If missing or invalid data entered, the record will be rejected.
M = mandatory fields. If missing or invalid data entered, the record will remain in draft form.
We would strongly encourage you to collect data in all other fields (but if missing, the record will still be considered complete)
B = Required for Best Practice Tariff. If missing or invalid data entered BPT will not be available
27
Appendix 8
Why a National Hip Fracture Database?
~ why information about your care is important.
Hip fracture is a common injury, and caring for patients with hip fracture is an
important part of the work of the NHS.
This hospital takes part in the National Hip Fracture Database (NHFD), which
has been set up to improve the care of patients who have broken a hip.
Information gathered about care in hospital and about recovery afterwards
enables us to measure the quality of that care and helps us to improve the
services we provide.
Reports based on NHFD data are made to our clinical staff to assist them in
improving care here. NHFD national reports show how different hospitals
compare, thus helping to improve standards of care nationally.
So, information about your care and progress is important, and will be
collected during your hospital stay. And, because your progress after you
leave hospital matters to us, you may be contacted later about how you are
getting on.
All information collected is confidential, and no information is ever made public
about you or about any other patient. All NHFD information is stored,
transferred and analysed securely – both in this hospital and within the
national database – in keeping with the provisions of the Data Protection Act
(1998). Participation is, of course, voluntary; and you are free, if you so wish,
not to take part - tell your doctor if you do not wish to participate. However, the
more people take part, the more helpful NHFD will be in improving care.
NHFD is supported by the National Clinical Audit Support Programme, a
division of the Information Centre for Health and Social Care.
More details are available at www.nhfd.co.uk
28