Improved Standards to Increase Hip Fracture Survival

The data was decribed as “sobering” taking an immense toll on individuals and families while “burdening” the health system with $600 million yearly.

Ambulances arrive at St Vincent's Hospital in Sydney, Australia, on Dec. 28, 2021. Jenny Evans/Getty Images

The maximum time to hip fracture surgery was reduced from 48 hours to 36 hours after a health care commission found one in four older people died within 12 months of a hip injury, a considerably increased death risk.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) launched the updated national Hip Fracture Clinical Care Standard (pdf) at the binational Hip Fest 2023 conference hosted by the Australian & New Zealand Hip Fracture Registry (ANZHFR) on Sept.11.

The updated standard also included other improved care management statements, and ACSQHC said it could drive meaningful change as hospitals establish protocols to meet them.

ACSQHC Acting Chief Medical Officer Carolyn Hullick said it comes after an urgent need for health services to offer better care, and “anyone who has seen someone live through a hip fracture knows it’s much more than a broken bone. People with a hip fracture tend to be older, frail and more vulnerable, so the fracture must be repaired quickly to reduce pain and get them on the road to recovery, back to independence.”

Further urgency was needed after ACSQHC found that 19,000 people fracture their hip annually in Australia, usually after a fall.

Most hip fractures happen to people over 65 years and are often life-changing. Many older people who survive a hip fracture injury lose their ability to live independently or return to their former lifestyle.

Ms. Hullick said the data was “sobering” and has an immense personal toll on individuals and families while “burdening” the health system with approximately $600 million yearly.

Health System Buckling Under Pressure

Australian health system challenges further include an ageing population with an increasing demand for hip services, which could continue in the coming decades, according to the Department of Health and Aged Care (DHAC).

Further, DHAC said the health system would need a flexible and well-trained workforce nationwide to meet demand for the older population requiring different health services.

Meanwhile, ACSQHC said time-to-surgery varied nationwide, and many people with hip fractures waited longer than optimal. However, some hospitals have substantially reduced this.

A doctor speaks with a patient during triage at the St George Hospital in Sydney, Australia, on May 15, 2020. Lisa Maree Williams/Getty Images

For example, data showed the average time to surgery ranged from 16 to 92 hours in 2022, with the most extended waiting times for people being transferred. Seventy-eight percent of patients had surgery within 48 hours.

The data also saw a change for the first time with the updated time for hip fracture surgery explicitly including patients who need to be transferred to hospitals that can perform the surgery.

ANZHFR Co-chair Jacqueline Close believes this would be a lever for change and has merit for several reasons.

“Firstly, no one wants to see their mum or dad fasting and in pain waiting for surgery, and a shorter time to surgery is associated with fewer complications, better recovery and survival,” Ms. Close said.

“It is also more cost-efficient to manage these patients well. Every day surgery is delayed, two days are added to the length of stay. The sooner you operate, the quicker patients can get walking and go home.”

Evidence showed better functional recovery resulted from patients returning home quickly after surgery. In 2022, fewer than half (45 percent) of patients walked on the first day after hip fracture surgery, according to ANZHFR.

“Also, only one-third (32 percent) of patients leave the hospital on bone protection medication for osteoporosis to prevent another fracture. We absolutely can and should do better,” Ms. Close said.

Better improvements for care were also outlined in the updated Hip Fracture Clinical Care Standard to ensure hip fracture patients are offered treatment based on an orthogeriatric model of care as defined in the Australian and New Zealand Guideline for Hip Fracture Care.

Improving Lives: Orthogeriatric Model of Care

“Older people can have complex needs, and research shows the best results come when specialists from orthopaedic surgery and geriatric medicine work together on a patient’s care – known as an orthogeriatric model of care,” Ms. Hullick said.

An orthogeriatric model of care is a coordinated multidisciplinary approach to identify and manage malnutrition, frailty, cognitive impairment and delirium.

She said the model of care meant that while repairing the hip bone, “we are managing the person’s other medical conditions, their cognitive function, their mobility and reducing the risk of more falls and fractures.”

The care model has been a hospital focus since the Hip Fracture Clinical Care Standard was first introduced in 2016, with many hospitals now having orthogeriatric teams.

Evidence shows the model leads to improved mortality, complications, functional outcomes, medication management and cost-effectiveness compared with an alternative ‘usual care’ model in which geriatric consultation is only provided ‘as needed’ and at the surgeon’s request, according to the Agency for Clinical Innovation NSW.

ACSQHC said the updated standard has already been a catalyst for change, and by addressing the gaps, care will continue to improve. Further, seeing a solid boost in patient outcomes “will be fantastic” as hospitals embed these latest changes.