Integrated care pathway for hip fractures – a help or a hindrance?

The cost of patients presenting with fragility fractures in the UK is nearly two billion pounds per year, which is mostly attributable to hip fracture care. With an ageing population, the burden of care will continue to rise, with 70,000 hip fractures in 2007 expected to rise to 101,000 by 2020. Both the Scottish Intercollegiate Guideline Network (SIGN) (2002) and the British Orthopaedic Association (BOA)(2007)havereleasedguidelinesforthemanagement of hip fractures. Integrated care pathways (ICP) for the management of hip fractures have in some cases been shown to decrease the length of hospital stay, a major contributortooverallcost.TheSIGNguidelineonthemanagement of hip fractures has highlighted the use of ICPs as an area for further research. Despite this, many centres acrosstheUKuseICPsforthemanagementofhipfractures. An ICP for the management of hip fractures was implemented at our district general hospital two years ago,withoutsubsequentevaluation.Anauditof40patients aged65years andolderwithhip fractures between January andFebruary2008showedthatonly63%ofadmissionshad an ICP filled in at all. Interestingly, only 48% of admissions using the ICP included a completed prefracture mobility assessment compared with 93% without. Secondly, only 16% of admissions with an ICP had a completed full drug and allergy history compared with 80% without. There was no significant difference between the two groups with the prescription of bone protection therapy, with 38% prescription and thromboprophylaxis and 25% evaluated for low molecular weight heparin. Following evaluation of these results, the pathway was edited to include spaces for drug, allergy and prefracture mobility history. A tick-box system was also introduced on the front page of the proforma including prescription of bone protection therapy and thromboprophylaxis evaluation. In the re-audit of 35 patients, there was a 97% use of the ICP. Drug and allergy history was included in 83% of admissions as well as a 94% documentation of prefracture mobility. Bone protection therapy increased to 80% and anticoagulation evaluation increased to 60%. This audit shows the importance of evaluating new ICPs to ensure that they improve patient care and, as in this case, do not have a detrimental effect. With some modifications in the ICP we were able to improve a number of aspects of hip fracture care above the results achieved without using an ICP. It was also beneficial to include a tick box on the front sheet to act as an aide memoir to the junior doctor admitting the patient. This small audit shows that an ICP for hip fractures may be beneficial and that the development of a national validated ICP may be important to prevent unnecessary local deviations from national guidelines.