We thank the correspondents for their constructive comments on our recent editorial  in which we sought to promote the inclusion of transthoracic echocardiography (TTE) for investigation of previously undiagnosed heart murmurs in the package of care provided to hip fracture patients without causing delay to surgery.
Our recommendation was based on evidence from the 2001 Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) , the management and outcome of the 272 hip fracture patients with a previously undiagnosed murmur and echocardiographically proven aortic stenosis admitted from 2001–2005 in our hospital following adoption of the NCEPOD recommendations , and the publication by Canty et al. which prompted our editorial and which indicated a beneficial effect on 30-day and 1-year mortality for hip fracture patients at risk of cardiac disease who underwent pre-operative TTE compared with those who did not .
Whether the TTE performed is comprehensive or focused, whether it is performed by a technician or a doctor, and whether it is performed at the bedside or in the laboratory, depends on local circumstances and expertise. The essential element is that the service is provided and does not cause a delay to surgery.
The suggested option of not investigating patients with previously undiagnosed murmurs denies healthcare workers access to information that may be used in optimisation, risk assessment and subsequent medical, surgical and anaesthetic management. Canty et al. discuss how this information enables proactive management of reduced cardiac function that may result in improved outcomes . This information may also enable judicious use of spinal anaesthesia whether or not significant aortic stenosis is present.
We acknowledge that auscultation of the heart using current traditional methods by non-cardiologists will not detect all cases of significant aortic stenosis, as demonstrated by Loxdale et al. , although the experience of the doctor performing auscultation was not included in their results. Improvements in detecting murmurs may be possible using computer-aided auscultation and electronic stethoscopes, and it is perhaps surprising that this technology has not received greater attention.
Excellence in hip fracture management, as in all areas of medicine, is determined by the sum of all the individual elements of care provided. We stand by our comments that current best-practice tariff criteria in England, despite improving process, are limited in their pursuit of excellence in performance with their focus on orthogeriatric involvement and time to theatre of less than 36 hours. We agree with Sneyd that comparison of adjusted 30-day mortality rates between hospitals should be encouraged. The 2011 National Hip Fracture Database Report  shows a funnel plot of 30-day mortality rates for the contributing hospitals, with the Royal Victoria Hospital, Belfast remaining two standard deviations below the average rate (8.7%) with a value of 5.9%. We continue with our policy of continuous improvement using ‘performance by the aggregation of marginal gains’ and we encourage others to join us in this quest.