Fractured neck of femur: guidelines and beyond

Authors

  • W. Ummenhofer,

  • N. Suhm


Society has aged dramatically, and fall-related injuries in the elderly have become one of the major public health issues for many countries [1, 2]. Falls are the leading cause of injury-related admissions to emergency departments in patients over 65 years [3]. These fragility fractures are age- and sex-related [4], and are accompanied by short- and long-term functional impairment and reduced of quality of life [5]. Despite expanding healthcare consumption, fragility hip fractures in older adults are still not always taken seriously, and as treatment and management of individual cases, including rehabilitation and social reintegration, are organised piecemeal, the major consequences of the problem at the population level are obscured by other priorities. In many institutions, hip fractures are often managed randomly and patients get into the operating room when virtually nothing else is on the list. In this issue of Anaesthesia, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) introduces a new guideline: Management of Proximal Femoral Fractures 2011 [6].

Guidelines have a certain tradition within our community. Initial efforts by the American Society of Anesthesiologists to establish consensus guidelines for specific aspects of our daily practice began in the early 1990s, with recommendations for pulmonary artery catheterisation being the first, and those for management of the difficult airway the best known [7]. In a recent commentary, guidelines are described as a constructive response to the reality that the physician requires assistance to assimilate and apply the exponentially expanding and often contradictory body of medical knowledge [8]. Unfortunately, the body of guidelines is growing at a similar rate – though for assimilation and application by a practitioner, guidelines should aim for clearness and feasibility. The German guideline for management of the multiply-injured patient is a 445-page document [9], and the US-National Guideline Clearinghouse shows a list of over 2600 guidelines produced by more than 280 organisations [10]. The aim of an anaesthesia guideline is to improve the quality of anaesthesia care by using the latest evidence-based medical knowledge, and this may include simplifying and/or eliminating unnecessary steps [11]. But elimination of unnecessary steps should also refer to a guideline itself: “By definition, one of the goals of guidelines is to eliminate unnecessary employment of resources and build a more efficient and cost-effective healthcare system” [11]; following this path could have resulted in a more concentrated and abbreviated version than the one presented here.

Rather than focus purely on efficiency and cost-effectiveness, the new AAGBI guideline [6] defines a clinical pathway concerning a specific group of patients and is aimed at increasing interdisciplinary collaboration of the involved caregivers of various specialities, thereby shortening hospital stay and improving allocation of resources. But, first of all, quality of care for each individual patient must be increased. Due to pre-existing co-morbidities and related loss of function and mobility, many of these patients are bordering on an unstable equilibrium already, ahead of their injury. Following the fragility fracture, these patients are at high risk of losing their independence if pre-fracture function cannot be fully restored. Previously, a relevant percentage of elderly hip fracture patients has missed this goal [12]. There is a clear opportunity for improvement.

Hip fractures challenge our healthcare systems. Because these patients are complex and have a high risk of complications, it is not sufficient to address only the broken bone. Instead, an interdisciplinary approach is needed in order to co-ordinate efforts [13]. There is growing acceptance that clinical pathways need to be implemented in order to guide geriatric hip fracture patients from their admission to the emergency department until discharge back home [14]. Such treatment follows standard protocols developed and agreed upon by the interdisciplinary treatment team. This is the moment when a Geriatric Fracture Unit is born! It is the process of treatment, not the type of implant or specific type of surgical approach, that makes the difference in outcome for these patients [15]. By means of treatment protocols, a huge amount of routine care can be formulated, based on current evidence, without having to reinvent the wheel every time. Furthermore, this approach prevents inappropriate ‘creativity’ in the treatment of these patients.

In everyday clinical practice, protocols can help to ensure a smooth treatment process, balancing proper pre-operative evaluation against too many pre-operative investigations in a frail elderly population, which can result in a delay to surgery without further benefit. For the emergency physician, protocols can aid decisions on which medication to continue and how much fluid to administer in order to keep the patient stable. In addition, anaesthesiologists, geriatricians, orthopaedic surgeons, bone specialists and nutritionists contribute to the interdisciplinary team, each adding to the comprehensive treatment approach. Standards of care can help to identify patients at risk, e.g. for postoperative delirium [16] or subsequent fractures due to osteoporosis [17], or repetitive falls [18]. Having passed through the acute treatment phase, standards of care help the rehabilitation specialist to rate the patient’s rehabilitation potential in order to identify those at risk of missing the treatment goal. In these cases, additional physiotherapy can be important [19].

In order to describe the outcomes correctly, we need to agree on the outcome parameters and on the assessment tools to measure them [20]. Such an agreement should be achieved at an international level, because the same problems occur over and over again in every healthcare system. Furthermore, such an agreement would allow for better comparison and quality control amongst the different healthcare systems in the future. The AO Foundation’s ‘Fracture Fixation in Osteoporotic Bone’ programme is an example of such an international quality assurance initiative (see http://www.aofoundation.org/research/exploratory-applied-research/aotrauma/fracture-fixation-osteoporotic-bone/Pages/fracture-fixation-osteoporotic-bone.aspx).

Despite the international aspects, treatment protocols need national input and adaptation. The solutions to general problems very much depend on the specific type of healthcare system we are in and especially on the mode of payment. A process-oriented approach for better control of the treatment process has been described recently [21], but, as we all know, a guideline in a journal does not automatically include implementation of new strategies into everyday clinical practice [22].

To reiterate, anaesthesia is a community with a long tradition and certain adherence to guidelines and recommendations. Overall, we are happy to see the new AAGBI guideline on hip fracture – although this one is more of a clinical pathway than a traditional guideline – even more so because the topic is of increasing importance. We do, though, have some specific comments about the new guideline. Given the plethora of guideline activities we currently encounter, should a new guideline dealing with a specific issue not try to avoid most (if not all) paragraphs of general relevance, and concentrate rather on the specific problems and solutions? For example, there is a newly published ‘continent-wide’ guideline dealing with the pre-operative evaluation of adult patients undergoing non-cardiac surgery [23]. The pre-operative assessment part of the AAGBI guideline could have been restricted to the specific complications of fragility hip fracture patients, instead of a rather long and non-specific paragraph on preoperative assessment; reiterating aspects covered elsewhere risks losing the focus on our original aim. Similarly, we would have liked to see coverage of pain control more focused on the particular injury (including a stronger recommendation for femoral blockade as something that ‘must’ be done, rather than a statement that it ‘may’ be used) and other, more general recommendations suited to the elderly population. Stating that opioids ‘should be used) with caution’ implies that strong analgesics will be prescribed very reluctantly. But many of these patients are in considerable pain; paracetamol will be too weak; and in most cases emergency staff will be present to monitor the patients and their treatment for pain. Regarding intra-operative management, if there is little evidence to support regional vs general anaesthesia, is it necessary to discuss the respective advantages or disadvantages? Is this ongoing discussion not very dependent on the specific patient’s condition and the provider’s preference?

If, as mentioned above, guidelines should be more specific and less general in nature, perhaps predisposing and precipitating factors for postoperative delirium should be addressed in more detail, since elderly patients with hip fractures are among the most affected groups of patients. Strategies either to identify individuals at specific risk or to improve physiological homeostasis for the patients are well described [24, 25]. Further, the potential 48-hour wait with an unrepaired fracture, including transfers for diagnostic procedures and to the operating room, could be significantly reduced. In addition, if the purpose of this pathway is to advise us on how to create, develop and/or manage a service, should we really accept the reasons for delaying surgery for hip fracture as considered acceptable by the Working Party and summarised in Table 2 [6]? Again, we note that the authors declare these are reasons that ‘may’ be acceptable, not that they ‘are’ necessarily acceptable. We see no reason why most (if not all) of these acceptable causes for delay should not be resolved or at least be attenuated within 36–48 hours, and would have preferred relabelling them instead as ‘problems to be resolved in advance’.

Apart from criticism of some of its finer points, we consider Management of Proximal Femoral Fractures 2011 to be a noteworthy addition to resources for increasing interdisciplinary communication and networking for the benefit of an important group of patients and possibly a starting point for other clinical pathways. The anaesthesiologist is just one of the necessary team members, and even if hard to admit, our surgical colleagues occupy the ‘pole position’, at least for the final part, the good operative results. Help your hip fracture patients to be fast walkers again, and they will be more likely to survive [26].

Competing interests

No external funding and no competing interests declared.

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