Management of Hip Fractures in the Elderly

Different healthcare systems around the world monitor implementation of their hip fracture management guideline recommendations in elderly through various Key Performance Indicators (KPIs). This section contains suggested KPIs for Egyptian hip-fracture care based on the above guidelines. It is the belief of the Guideline Development Group (GDG) that inclusion of as many of the suggested KPIs as one of the Presidential Healthcare Initiatives is the best way to monitor performance of different hospitals/healthcare regions or organization and insure implementation of best practice across the country. The GDG members are ready to contribute to such initiatives upon request.

A. Registry and case capture KPIs:

Without complete case capture, outcome comparisons are unreliable. The Fragility Fracture Network (FFN) recommends an audit dataset for countries starting hip-fracture registries (https://fragilityfracturenetwork.org)

·   Case capture rate: The percentage of all patients aged 60 or older with a low-energy hip fracture who are entered into a local or national registry.

·   Minimum dataset completeness: The percentage of records that include complete information about age, sex, residence, mobility, cognitive status, ASA, fracture type, operation, surgery time, and discharge status.

·   Pre-fracture function documented: The percentage of patients with documented pre-fracture mobility/ADL and cognitive function.

B. Emergency department and preoperative KPIs:

·   Time from hospital arrival to X-ray/diagnosis: The median time from the emergency department (ED) arrival to the confirmed diagnosis.

·   Pain assessment: The percentage of patients with documented pain scores at presentation and repeatedly after administration of analgesia.

·   Analgesia within 30 minutes: The percentage of patients who receive appropriate analgesia within 30 minutes of arrival or diagnosis.

·   Preoperative medical optimization: The percentage of patients with anaemia, anticoagulation, dehydration, electrolytes, diabetes, heart failure, arrhythmia/ischemia, or chest infection assessed and addressed promptly.

C. Surgical-timing KPIs:

·   Surgery within 48 hours of presentation: The percentage of patients who are operated on within 48 hours of arrival at the operating hospital.

·   Reason for surgical delay documented: The percentage of delayed cases with documented medical or systemic reasons for the delay.

·   Planned trauma list access: The percentage of cases that are done on the planned trauma/urgent orthopaedic list, not repeatedly postponed by elective work.

·   Senior surgeon/anaesthetist involvement: The percentage of cases that are supervised or performed by a consultant or senior-trained surgeon and anaesthetist.

D. Orthogeriatric/medical co-management KPIs:

·   Orthogeriatric/physician review: Geriatrician, internist, or trained perioperative physician review within 24 hours.

·   Cognitive impairment/delirium risk screening: on admission and postoperatively.

·   Nutrition screening: within 24–48 hours.

·   Pressure-ulcer risk assessment and prevention plan documentation.

·   Pharmacological or mechanical VTE prophylaxis plan documented unless contraindicated.

·   Medication review: Prompt review of medications by a geriatrician or an internist for appropriateness and polypharmacy on admission within 48 hours from admission.

E. Operation choice and surgical-quality KPIs:

·   Operation appropriate to the fracture type: Percentage receiving evidence-based fixation/arthroplasty according to the fracture pattern and patient fitness.

·   Implant choice documentation: Percentage with documented implant type, fixation method, approach, and surgeon grade.

·   Immediate mobilization and weight-bearing plan: Percentage operation notes specifying unrestricted/full weight bearing unless contraindicated.

·   Reoperation rate: Reoperation within 30/120 days.

·   Surgical-site infection rate: Deep/superficial infection within 30/90 days.

F. Anaesthesia and perioperative KPIs:

·   ASA grade documented: Percentage with ASA grade recorded preoperatively.

·   Choice of anaesthesia spinal vs general discussed when feasible: Percentage with anaesthetic plan documented.

·   Postoperative acute pain plan documented: Percentage with documented multimodal analgesia plan.

G. Mobilisation, rehabilitation, and discharge KPIs:

·   Out of bed by day 1 after surgery: Percentage mobilised out of bed by the first postoperative day, unless contraindicated.

·   Weight-bearing status documented: Percentage with clear postoperative weight-bearing instruction.

·   Discharge rehabilitation plan documented: Percentage discharged with a written rehab and follow-up plan.

·   Return to original residence: Percentage of patients discharged back to original residence at 120-day follow-up.

H. Secondary fracture prevention KPIs:

·   Osteoporosis risk assessment: Percentage of patients assessed for osteoporosis or fracture risk before discharge or within 12 weeks.

·   Calcium/vitamin D status addressed: Percentage of patients with supplementation or documented contraindications/clinical decisions.

·   Anti-osteoporosis medication started or planned: Percentage of eligible patients discharged on therapy or with a follow-up appointment.

·   Falls risk assessment: Percentage of patients assessed for falls risk before discharge or within 12 weeks.

·   Sarcopenia/nutrition intervention: Percentage of patients with nutrition/sarcopenia risk plans if abnormal.

I. Outcome KPIs:

·   In-hospital mortality: Death before discharge.

·   Length of hospital stay: Admission to discharge from acute care.

·   30-day readmission: Any unplanned readmission.

·   Reoperation within 30/120 days: Any return to the operating room related to hip fracture surgery.

·   Pressure ulcer during admission: New pressure ulcer after admission.

·   Delirium incidence: New delirium during admission.

We can classify these KPIs into a three-level model:

Core mandatory KPIs:

·   Case capture, surgery timing, medical review, mobilization, discharge status, and mortality.

Quality-improvement KPIs:

·   Analgesia, delirium, nutrition, pressure ulcers, implant choice, and rehabilitation.

Secondary prevention KPIs:

·   Osteoporosis treatment falls assessment and prevention.