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Management of older people with hip fractures in Belfast has continuously developed and improved since the inception of our orthogeriatric service in 1997, using ‘performance by the aggregation of marginal gains’ as our focus, to borrow the mantra of British Cycling’s Perforance Director David Brailsford [1]. One of the earliest issues we addressed with this approach was the management of previously undiagnosed heart murmurs. Patients with hip fractures were often subjected to long pre-operative delays for various reasons. Often a murmur was detected on admission but a transthoracic echocardiogram (TTE) was not requested. Further delays were then added following pre-operative assessment by the anaesthetic team and a request for a TTE when surgery was eventually scheduled.

In 2001, we adopted a policy that a TTE should be obtained for all patients with hip fractures and previously undiagnosed murmurs detected on auscultation. We did so in order to comply with the two recommendations for older people with aortic stenosis made in the Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) published that year [2]. These were: (i) whenever possible the anaesthetist of a patient with aortic stenosis should obtain a pre-operative echocardiogram of the aortic valve; and (ii) the availability of the echocardiography service for patients pre-operatively should be accorded an appropriate priority in the funding and development plans of hospitals.

From 2001 to 2005, a TTE to investigate an undiagnosed heart murmur was requested in 908 out of 3997 (23%) consecutive patients with hip fractures in our unit [3]. Our ability to obtain these investigations was initially facilitated by long delays to theatre, but with communication, feedback and service development we now have access to a rapid bedside echocardiography service. In an analysis of the 272 patients in whom the TTE detected aortic stenosis, we found significant trends towards general anaesthesia over spinal anaesthesia, and use of invasive monitoring of intra-operative blood pressure, as the severity of the aortic stenosis increased, with no significant trend towards a higher 30-day mortality [3].

Over the past decade, management of hip fracture has been improved by national guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) and the British Orthopaedic Association/British Geriatrics Society that have been published on the basis of national audits of hip fracture management in Scotland (Scotttish Hip Fracture Audit) and the rest of the UK (National Hip Fracture Database (NHFD)), respectively [4–6]. These guidelines focus on optimising the management of older patients with hip fractures while minimising delays to theatre. Guidelines have also been produced by the National Institute for Health and Clinical Excellence (NICE) [7].

As delays to theatre have been markedly reduced, controversy surrounding the necessity for TTE has emerged since such a request may lead to a delay to operative fixation of the fracture. This may now be perceived as being extremely costly in England as any delay to surgery beyond 36 hours from admission will deny the treating hospital the Best Practice Tariff (BPT) for hip fractures, which now equates to £1335 (€1706; $2102) above base tariff for each patient whose care meets BPT criteria defined by the NHFD.

What evidence is there to suggest that hip fracture units should ensure that patients with previously undiagnosed murmurs should have a TTE performed before surgery? Should this be available in all hip fracture units?

The decision to perform any pre-operative investigation must be based upon the premise that the information obtained will enable: (i) correction or optimisation of any abnormalities detected; (ii) quantification of risk for the medical teams and the patient; and/or (iii) modification of anaesthetic, surgical and/or medical management. Various factors modify the decision to pursue an investigation, including the costs involved, the availability of the service, the risks of performing the investigation itself, whether the investigation can be obtained in the time available for urgent or emergency surgery, and the complexity and risks of the surgery involved.

Correction or optimisation of any abnormalities detected

  1. Top of page
  2. Correction or optimisation of any abnormalities detected
  3. Quantification of risk for the medical teams and the patient
  4. Modification of anaesthetic, surgical and/or medical management
  5. Competing interests
  6. References

If severe aortic stenosis is detected, it is unlikely that traditional valve replacement will be considered before hip fracture fixation. Trans-catheter aortic valve implantation before surgery may be considered in the future when greater expertise has been obtained in the technique, but if not, either of these interventions may be appropriate once wound healing has occurred.

Quantification of risk for the medical teams and the patient

  1. Top of page
  2. Correction or optimisation of any abnormalities detected
  3. Quantification of risk for the medical teams and the patient
  4. Modification of anaesthetic, surgical and/or medical management
  5. Competing interests
  6. References

Aortic stenosis was identified as an operative risk factor by Goldman in 1977 [8] but has since been removed from the Revised Cardiac Risk Index published by Lee et al. in 1999 [9], largely because only five of the 4315 patients in their study used to develop this index had critical aortic stenosis, preventing statistical significance being attached to the outcomes measured. The critical question when considering TTE for assessing murmurs in patients with hip fractures is not whether known significant aortic stenosis affects morbidity and mortality, since measures can be taken to minimise risk, but whether unknown significant valvular disease is a potential risk factor. As it is not ethical to withhold such critical information in a blinded study of ‘unknown’ aortic stenosis versus a control group, this question will remain unanswered, but it would not be unreasonable to assume that unknown moderate or severe aortic stenosis is a significant risk factor for morbidity and mortality following a hip fracture, at any stage of the patient’s hospital admission.

Guidelines have been produced for cardiac risk assessment and investigation by the American College of Cardiology/American Heart Association in 1997 and by the European Society of Cardiology in 2009 [10, 11]. Both guidelines recommend that patients with severe valvular heart disease should undergo clinical and echocardiographic evaluation before non-cardiac surgery. This is in agreement with the 2001 NCEPOD recommendations [2].

Unfortunately, the recent NICE guidelines on management of hip fracture did not discuss echocardiography [7]. The SIGN guidelines in 2009 suggested that echocardiography “should be performed if aortic stenosis is suspected, to allow confirmation of diagnosis, risk stratification and any future cardiac management” [4]. However, they state that the need for echocardiography “should not delay surgery unduly” and that if delays are to be avoided, “rapid access to an echocardiography service is recommended” [4].

The recent Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines Management of Proximal Femoral Fractures 2011 recognise that “echocardiography may be indicated …. to investigate the severity of an ejection systolic murmur heard in the aortic area” [12]. However, the practical difficulties in auscultating murmurs in older patients in a trauma unit can be immense. The environment tends to be noisy and patients’ cooperation can be limited by co-morbid conditions such as delirium or dementia. Manoeuvres used to elicit murmurs, such as lying patients on their side or sitting them forward, are often inappropriate with a recent fracture. It is also not possible to use classical symptoms and signs as reliable assessment tools because many older patients will be asymptomatic due to immobility from other causes, they may not be competent to report symptoms, and the signs have a low sensitivity for determining severity of the stenosis [13]. The 2001 NCEPOD report included the warning that an asymptomatic murmur in patients with aortic stenosis may still indicate significant cardiac disease [2].

Modification of anaesthetic, surgical and/or medical management

  1. Top of page
  2. Correction or optimisation of any abnormalities detected
  3. Quantification of risk for the medical teams and the patient
  4. Modification of anaesthetic, surgical and/or medical management
  5. Competing interests
  6. References

Although spinal anaesthesia is not absolutely contraindicated for patients with aortic stenosis, these patients are more susceptible to the potential hazard of sudden hypotension as a result of the reduced systemic vascular resistance caused by the sympathetic blockade. The critical issue is not whether a regional or general anaesthetic technique is used, but how the technique is administered in order to avoid precipitous falls in blood pressure. One essential element to prevent this is the use of invasive arterial monitoring in order to provide beat-to-beat measurement and enable rapid correction of hypotension. The more severe the aortic stenosis, the more critical it is to maintain cardiovascular stability, hence the increased use of invasive arterial pressure monitoring seen with increasing severity of aortic stenosis that we observed [3]. This again is in keeping with the recommendation from the 2001 NCEPOD report [2].

The echocardiographic findings in patients with previously undiagnosed aortic stenosis may also have implications for surgical management. A recent review of the bone cement implantation syndrome suggested that uncemented prostheses should be used in patients at high risk of developing the syndrome, including older patients with impaired cardiopulmonary function [14]. The information revealed by a pre-operative echocardiogram may help in making this decision.

For medical management, an echocardiogram can be very helpful in rationalising medications in the peri-operative period. End-of-life decision-making may also be facilitated. In order to qualify for BPT, an orthogeriatric falls assessment must be performed. For any patient with a previously undiagnosed murmur this should involve a TTE. Obtaining this valuable information after the critical peri-operative period would appear to be illogical.

How might hip fracture units re-organise to deal with the uncertainty posed by patients with previously undiagnosed murmurs, without causing delays to surgery? One option is to proceed without an echocardiogram using general anaesthesia and invasive monitoring, as proposed by the AAGBI hip fracture guidelines. This approach was only supported by 1.1% of trauma anaesthetists in the UK who took part in the national postal survey by Sandby-Thomas et al. [15]. In contrast, Loxdale et al. recently described how they routinely perform TTE on all hip fracture patients admitted to their unit, with the finding that of those patients investigated, 6% had moderate and 2% had severe aortic stenosis [16]. No published guidelines currently support this untargeted approach.

For those hip fracture units currently without access to rapid TTE, options available include dialogue with existing cardiology services within their hospitals to work towards either its availability in dedicated slots or when required, or developing a focused TTE service without the need for initial cardiology input. Focused TTE has not been universally defined but according to a recent review by Cowie [17] it should minimally include:

  •  a qualitative assessment of left and right ventricular function;
  •  an estimate of aortic valve gradient;
  •  an estimate of right ventricular systolic pressure;
  •  an assessment of volume status.

As its name suggests, focused TTE does not set out to replace a standard comprehensive examination carried out by a trained technician. There are many devices on the market, varying in their degree of miniturisation and portability. Focused echocardiography has been increasingly used in recent years in settings such as critical care and emergency departments. Consensus statements have been produced in this area by the American Society of Echocardiography and American College of Emergency Physicians [18].

A number of recent papers in this journal have added to the evidence base surrounding focused echocardiography. Although numbers were small, it does appear that focused TTE can provide meaningful reliable data that can change management plans [19, 20], and possibly affect outcomes, as suggested by Canty et al. in this issue of Anaesthesia [21]. Experienced anaesthetists with prior qualifications in the field of echocardiography have successfully used this tool to aid their decision-making [22].

Of course, if focused echocardiography is to be widely adopted, work now has to begin on setting standards with regards to equipment, training and certification. The cost of setting up and maintaining such a service may be offset by reducing delays and improving outcomes. The burden of providing this service does not necessarily have to be carried by anaesthetists alone. Non-cardiology physicians are being encouraged to become more actively involved in the pre-operative period and may be interested in acquiring the skill set required [23].

The dilemma introduced by the introduction of BPT is currently only likely to widen variations between hospitals depending on the availability of a fully funded and available TTE service – those that have this service will use it, those that don’t will not want delays and have no incentive to seek it. The problem with the BPT is that it is based on ensuring a standard of process (timing and tick boxes) and not of performance (outcomes and patient satisfaction). Obviously good process contributes to good performance, but good performance requires more than just process. Although not ideal, the 30-day mortality rate remains the best indicator of how a hip fracture unit is performing and since the introduction of BPT many units have seen significant improvements in performance. Now that the funding from BPT has been used to ensure provision of increased operating capacity (to reduce delays to surgery) and ensure provision of orthogeriatric services, attention must turn to improving performance further.

The carrot approach to making TTE available is to make provision of TTE a requirement for BPT. This could be done by having as a criterion that a focused TTE must be obtained on any patient with a previously undiagnosed murmur before surgery. Even without increasing the size of the carrot, the huge sums of money from BPT currently being paid to hospitals in England should be sufficient to fund this service so that TTEs can be performed without causing delay to surgery beyond 36 hours. To give an idea of costs, if needed for research purposes our echocardiography department currently charges a sum of £75 (€96; $118) for a detailed TTE performed by an accredited echocardiographer. The sum charged by local non-NHS providers for waiting-list TTEs is approximately twice this figure. An alternative carrot for hip fracture units would be for BPT to be linked to 30-day mortality, but the varying case mix between hospitals may hinder the use of this as one of the criteria.

The stick approach would be to have a concerted effort by the NHFD to record and analyse the causes and timings of deaths in patients with hip fractures within 30 days of surgery. Although a funnel plot of the 30 day mortality rates, raw and adjusted for case mix, is provided with the annual NHFD report [24], there is a real paucity of data on why such patients die in the peri-operative period and what factors are involved in variations between hospitals.

It is our opinion that TTE for patients with previously undiagnosed heart murmurs should be included in the package of care available to all patients with hip fractures admitted to a hip fracture unit, without causing delay to surgery. Would a paediatric anaesthetist consider proceeding with urgent surgery in a child with a suspicious murmur without echocardiographic investigation? If not, why should this be acceptable for older, vulnerable, high-risk patients with hip fractures who lack the cohesive and emotive voice of advocates to argue for this on their behalf?

Competing interests

  1. Top of page
  2. Correction or optimisation of any abnormalities detected
  3. Quantification of risk for the medical teams and the patient
  4. Modification of anaesthetic, surgical and/or medical management
  5. Competing interests
  6. References

GH was a member of the recent AAGBI working party that produced the guideline Management of Proximal Femoral Fractures 2011 [12]. No external funding declared.

References

  1. Top of page
  2. Correction or optimisation of any abnormalities detected
  3. Quantification of risk for the medical teams and the patient
  4. Modification of anaesthetic, surgical and/or medical management
  5. Competing interests
  6. References