The latest report from the Falls and Fragility Fracture Programme (FFFAP) National Hip Fracture Database (NHFD) shows that just over half of patients are receiving pain relieving anaesthetic (known as a ‘nerve block’) as part of their care for hip fracture.
The National Hip Fracture Database Anaesthesia Sprint Audit of Practice, published today, show that 56% of hip fracture patients receive a peri-operative nerve block for pain relief and 44% of patients do not. The audit recommends that this type of pain relieving anaesthetic should be offered to all hospital patients who suffer hip fracture.
The Anaesthetic Sprint Audit of Practice (ASAP) was commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit programme. ASAP marks a successful collaboration between several professional organisations. The NHS Hip Fracture Perioperative Network (HipPen), British Orthopaedic Association (BOA), British Geriatrics Society (BGS), Royal College of Physicians (RCP) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) have worked together to explore anaesthesia within hip fracture care using data collected by members of the HipPen.
Hip fracture is one of the most common reasons for frail, older people to require an operation under anaesthetic. The average age of a patient with a hip fracture is 83 years old. The number of people in the UK aged 85 and over is growing and the number of hip fracture cases continues to rise in line with this expanding group of people.
A nerve block is a form of anaesthetic which numbs the nerve area and is used to provide hip fracture patients with pain relief from the area of the fracture. Used in this way, nerve blocks can also help to minimise the need for, and side effects of, pain killers such as morphine.
With 56% of patients receiving nerve blocks, it indicates a growing adoption of the technique, which NICE recommended for use in 2011. The provision of this form of pain relief is varied across the UK because the preference for using them tends to come down to local standards and the individual clinician’s choice.
Dr Richard Griffiths, honorary secretary of the AAGBI said:
This audit has highlighted considerable variation in the quality of peri-operative care provided to this vulnerable and rapidly growing patient group in the NHS. The fantastic enthusiasm of anaesthetists throughout the UK in trying to address some very important clinical dilemmas has resulted in some important findings that will benefit patient safety and improve care in the future.
Professor Finbarr Martin, programme lead for FFFAP at the Royal College of Physicians said:
Hip fracture is the most common reason a frail elderly patient will need an anaesthetic and an operation and care of hip fracture requires the collaboration of several specialist teams and departments in the hospital to deliver care to these patients. It is good that over half of hospitals have adopted the use of nerve blocks as pain relief for hip fracture patients, but as this is the approach that NICE have judged most advantageous for most patients, we would expect that anaesthetists reflect on this result and guidance when making clinical decisions.
This audit was undertaken because anaesthesia is a fundamental part of hip fracture care. The aim was to investigate whether current practice accords with the recommendations for best practice in peri-operative care as outlined in NICE guidance and AAGBI guidance. The audit was designed to measure hospitals’ compliance with these standards and to highlight where variation in practice exists.
As well as recommending peri-operative nerve blocks for all patients who suffer hip fracture, the audit makes recommendations including developing evidence-based, standardised approaches to spinal anaesthesia, to reduce inconsistency of anaesthestic choices and protocols to raise awareness of Bone Cement Implantation Syndrome and specific training for its recognition, avoidance and management.
- Peri-operative nerve blocks should be offered to all patients who suffer hip fracture.
- The reduced incidence of hypotension observed with spinal anaesthesia supports the AAGBI recommendation that this approach should be considered for all cases.
- Departments of anaesthesia should develop evidence-based standardised approaches to spinal anaesthesia, to reduce inconsistency in the dose of bupivacaine, and in the administration of sedatives, oxygen and intrathecal opioids.
- Departments of anaesthesia should develop protocols to raise awareness of Bone Cement Implantation Syndrome and specific training for its recognition, avoidance and management.
- The audit was conducted between 1 May 2013 – 31 July 2013, and in the 3 months 16,904 patients were admitted with hip fracture to the 184 participating hospitals.
- Of the 16,904 patients, 97.6% underwent anaesthesia and operation.
- The NHFD is an NHS success story: more and more patients are having prompt surgery, better access to specialist care for their medical problems, and to further treatment – in the form of medication to strengthen bone, and measures to prevent falls – to reduce the risk of future fractures.
- With more than 250,000 cases now documented, the NHFD is the biggest audit of its kind in the world, and its success has led to its work being replicated in Ireland, which now has an Irish Hip Fracture Database, with similar developments in hand in Australia and New Zealand, Canada, and Hong Kong.
- The NHFD, (original founded by the BOA and the BGS) is commissioned by HQIP and managed as part of the FFFAP by the RCP.