Transcript Colin Currie Updated_58

Meeting the NICE Quality Standard for Hip Fracture
ICO Conference Centre, London
10th October 2012
Progress in hip fracture care: audit and
standards in the UK
Colin Currie
Clinical Lead (Geriatric Medicine)
National Hip Fracture Database
Outline
• Hip fracture: the tracer condition for the current
epidemic of fragility fractures
• UK progress in hip fracture care: The National
Hip Fracture Database and the Blue Book
• Audit and standards working together?
– The NHFD and the NICE hip fracture quality
standards
The fragility fracture career
Morbidity
Hip fracture
Added morbidity
from fractures
Vertebral fracture
Colles' fracture
No fractures –
increasing morbidity
due to ageing alone
Age
50
60
Adapted from Kanis JA, Johnell O; 1999
70
Age
80
90
Hip fracture
“The most common serious –
and the most serious
common – injury of older
people”
The tracer condition for the
current epidemic of fragility
fractures
Hip fracture – the patient experience
• A major life-event
• Recovery of mobility often limited
• Mortality high
• Loss of home much dreaded – and fairly
common
Hip fracture – the patient experience
Hospital 16 (n= 444)
100%
90%
80%
70%
home
Residential Care
Long Term Care
other
ger rehab
Acute Ward
Orthopaedic Department
Died
60%
50%
40%
30%
20%
10%
0%
1
11
21
31
41
51
61
71
120 days post admission
81
91
101
111
Hip fracture – service implications
• 30 years ago – an unwelcome and
burdensome caseload
• Now a major surgical, medical and
rehabilitation challenge
• Resource-intensive – amid growing
service pressures
• Service response much improved!
Hip fracture care – who’s involved?
Physiotherapy
Primary Care
Nursing
A&E
Orthopaedic Surgery
Supported Discharge
Geriatric Medicine
Social
Services
Labs
Anaesthetics
Management
Portering
Radiology
Occupational
Therapy
Rehabilitation
G.P.
Carers
3250
600
629
1990 2050
Adapted from Cooper C et al,
Osteoporosis Int, 1992;2:285-9
1990 2050
1990 2050
100
Total number of
hip fractures:
1990 = 1.66 million
2050 = 6.26 million
378
400
742
668
Projected hip fractures worldwide
1990 2050
Projected to
reach 3.250
million in
Asia by 2050
Hip fracture – a suitable case for audit?
•
•
•
•
•
Common, serious, well-defined injury
Good evidence base for care – and prevention
Care is complex and costly
Care, outcomes – and costs – vary
Numbers rising as populations age
• Hip fracture care the central challenge of
current global fragility fracture epidemic
Hip fracture audit: a brief history
• 1980’s onwards: ‘Rikshoft’ (Sweden)
–
–
–
–
European bilaterals
Scottish Hip Fracture Audit (1993-2010)
Standardised Audit of Hip Fracture in Europe (SAHFE)
Growing numbers of single-centre audits
• 2007 UK National Hip Fracture Database (NHFD)
– using the synergy of audit, standards and
benchmarked feedback to improve care and
outcomes
• 2011/12 International interest – and action! (Australia,
NZ, Ireland, Canada)
National Clinical Governance for Hip Fracture Care: Scotland
The National Hip Fracture Database
• A clinically-led, web-based, continuous audit of
hip fracture care and secondary prevention in
England, Wales, and Northern Ireland
• Using the synergy of audit, standards and
feedback to improve care and outcomes
• Valued by clinicians and managers, and by the
Departments of Health
• Successive national reports show improvements
in care and secondary prevention
www.nhfd.co.uk
Development: 2004-2007
• Strategic vision and ruthless acquisition
• Dataset from Rikshoft, SHFA, etc
• IT from Myocardial Infarction National Audit Project (MINAP)
• Soft money and hard work
• Industry funding (via national organisations) 2004-2009
• Committees large and small
• To consult – and implement
• Making friends and influencing people
• Media, meetings, lobbying, etc
Blue Book and NHFD: launched together in 2007
Progress: the NHFD 2007-2012
• NHFD launched – Sept. 2007
• Recognised by NCAAG in 2009 for funding by
HQIP as a national clinical audit
• Steady growth towards national coverage
• National reports: 2009, 2010, 2011, 2012
• Growing impact on care and outcomes
• International interest – and acton!
The National Hip Fracture Database
A recurrent dilemma in clinical audit…
Simplicity vs. Complexity?
(e.g. SAHFE…)
The National Hip Fracture Database
A recurrent dilemma in clinical audit…
Simplicity vs. Complexity?
For Blue Book Standards and NHFD
dataset:
Simplicity preferred!
Six Blue Book standards – monitored by NHFD
1.
2.
3.
4.
5.
6.
All patients with hip fracture should be admitted to an acute
orthopaedic ward within 4 hours of presentation
All patients with hip fracture who are medically fit should have
surgery within 48 hours of admission, during normal working hours
All patients with hip fracture should be assessed and cared for
with a view to minimising the risk of developing a pressure ulcer
All patients presenting with a fragility fracture should be managed
on an orthopaedic ward with routine access to orthogeriatric
medical support from the time of admission
All patients presenting with fragility fracture should be assessed to
determine their need for antiresorptive therapy to prevent future
osteoporotic fractures
All patients presenting with a fragility fracture following a fall
should be offered multidisciplinary assessment and intervention to
prevent future falls
Six Blue Book standards – why comply?
• Compliance with these standards
– raises quality in hip fracture care
– and reduces its costs!
• Cost and quality not in conflict
• ‘Looking after hip fracture patients well is
cheaper than looking after them badly’
NHFD Reports: 2008-2011
12,983 records
from 64 hospitals
36,556 records from 129
hospitals
NHFD National Report 2012
NHFD coverage: September 2012
• 188/188 (100%) of eligible hospitals registered
• 186/188 (99%) submitted data in the last three
months
• 220,000+ records submitted since launch
• c. 5000 records submitted per month (c. 95+%
of all eligible hip fractures – based on c. 65,000
p.a.)
Audit and change
• Improving compliance with Blue Book
standards
• Local use of audit for service change
• Trend data: 28 hospitals, 2008 – 2011
• Implementing Best Practice Tariff
Compliance with Blue Book standards: 2009-12
Standard
2009
2010
2011 2012
1. Admission to orthopaedic ward
within 4 hours
N/A
55%
56%
52%
2. Surgery within 48 hours and during
working hours
75%
80%
87%
83%
3. Patients developing pressure
ulcers
N/A
6%
3.7%
3.7%
4. Pre-operative assessment by an
orthogeriatrician
24%
31%
37%
43%
5. Discharged on bone protection
medication
N/A
57%
66%
69%
6. Received a falls assessment prior
to discharge
44%
63%
81%
92%
NHFD: audit and change locally
Hospital-level initiatives
• NHFD offers current, credible local data on workload and
service performance
• Such data can prompt and monitor local initiatives
agreed by clinicians and managers
• Many substantial improvements: e.g. reduced time to
theatre, length of stay, mortality and service costs
Wansbeck and N. Tyneside
• Quality improvement programme: NHFD data; Kings
Fund support – addressing whole care pathway
– Pain control improved (79% of patients get nerve
block on admission)
– 95% have surgery within 36 hours
– 100% mobilise on first post-op day if medically fit
– Systematic feedback from patients and families
consistently averages >9.3/10
St Peters Hospital, Chertsey
• Two ortho-geriatricians appointed; quality initiative on hip
fracture care pathway (2010)
• In 2012, 60% of patients have surgery within 24 hours,
80% within 36 hours
• Length of stay reduced from 25 to 22 days, with
considerable efficiency savings
• 60% of patients discharged to original residence within
25 days, compared with 44% within 30 days in 2010
Chelsea and Westminster Hospital
• Meeting in May 2011 recognises hip fracture care as
sub-optimal
• Changes include dedicated trauma theatre sessions,
thrice-weekly ortho-geriatrician Ward rounds, and
weekly discharge planning rounds
• In-patient mortality reduced from 11% to 9%
• Average acute length of stay down from 24 to 19.5 days,
with estimated savings of £91,000
Trend data: 2008-2011
• 28 hospitals
– Early and sustained NHFD participation
– Good case ascertainment, data completeness
– 30,022 cases (1st April 2008 to 31stMarch
2011)
– Time to theatre, orthogeriatrician
involvement, secondary prevention, mortality
Trend data: 2008-2011
Trend data: 2008-2011
The Best Practice Tariff for hip fracture care
• A DoH initiative, based on NHFD participation
• Enhanced case-by-case payment if clinically
determined care standards met
– Surgery within 36 hours
– Joint care, joint protocol: surgeon, anaesthetist,
orthogeriatrician
– Early involvement of orthogeriatrician in care
– Multi-disciplinary rehabilitation
– Bone health, falls assessments
Audit and change: how does it work?
• NHFD offers:
–
–
–
–
–
the synergy of audit, standards and feedback
a website providing key documents and literature database
helpdesk and supportive central staff
regional meetings
national reports
• ‘Together, these measures have succeeded in creating
a critical mass of enthusiasm and expertise in hip
fracture care…’*
*NHFD 2011 Summary Report on www.nhfd.co.uk
Progress in hip fracture care?
• NHFD and the Blue Book
– the synergy of audit, feedback and standards
• National-level evidence of:
– rising care standards
• Large-series evidence of:
– lower mortality
– associated with orthogeriatric care?
Progress in hip fracture care?
• Local evidence of:
– better care and outcomes
– lower costs too
• BPT a recent and effective incentive
– with double effect?
• ‘Looking after hip fracture patients well is
cheaper than looking after them badly’
(Blue Book on the care of patients with fragility fracture)
More effort required?
• Better documentation of long-term care &
outcomes
– post-acute care
– mobility
– place of residence
• Sprint audits
– ASAP in development
– other?
• Health economics
– cost-effective care?
More progress in hip fracture care?
• Without audit, clinical standards are simply
aspirational
• As a national clinical audit of hip fracture care,
the NHFD has demonstrated the synergy of
audit and standards in improving care
• NHFD has the potential to monitor
compliance with the NICE Quality
Standards
NHFD & the NICE Quality Standards for Hip Fracture
NHFD & the NICE Quality Standards for Hip Fracture
NHFD & the NICE Quality Standards for Hip Fracture
NHFD & the NICE Quality Standards for Hip Fracture
• NHFD has the potential to monitor
compliance with (some of) the NICE
Quality Standards…
…and measure any impact on care and
outcomes?
Acknowledgements
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Prof K-G Thorngren & Rikshoft
SHFA colleagues
Dave Marsh, Professor of Orthopaedic Surgery, RNOH, Chair/Co-chair,
NHFD; Finbarr Martin, Co-chair, NHFD; Rob Wakeman, Lead Clinician,
Orthopaedic Surgery, NHFD; Maggie Partridge, Project Manager, NHFD;
NHFD Project Coordinators
NHFD Steering Group, Dataset Sub-group, & Scientific and Publications
Committee
BOA & BGS
Dept of Health and HQIP
Blue Book Authorship Group
Colleagues in NCASP/CCAD/NHS IC
Quantics Consultancy
Patients & staff in participating hospitals
www.nhfd.co.uk