1.1 The need for a guideline

Hip fracture is a common serious injury that occurs mainly in older people. For many previously fit patients it means loss of prior full mobility; for some frailer patients the permanent loss of the ability to live at home. And for the frailest of all it may bring pain, confusion and disruption to complicate an already distressing last illness. Mortality after hip fracture is high: around 30% at one year. Despite significant improvements in both surgery and rehabilitation in recent decades, hip fracture remains, for patients and their carers, a much-feared injury.

For health service and social work professionals hip fracture is uniquely challenging. First, because it occurs in older people and is commonest in those with previous frailty and dependency, and with pre-existing medical problems. Secondly, because a simple fall, most commonly at home, marks the beginning of a complex journey of care. This takes patients through the accident and emergency (A&E) department, to an orthopaedic ward, to an operating theatre, to a ward again and then - depending on the circumstances of the patient and nature of the services available - back home either directly or via more extended in-patient rehabilitation, or to an alternative placement within the private or voluntary sector, or local authority or NHS care.

Many disciplines, specialties and agencies are therefore involved, and a patient undergoing even fairly straightforward management for hip fracture may meet in the course of one admission as many as 50 different professionals: ambulance staff, general practitioners, hospital doctors, nurses, occupational therapists, physiotherapists, social workers and many others. So hip fracture can be viewed as a tracer condition in systems of care for older patients, testing hospital and community health services and social work provision, and also - very importantly - testing how these different services are coordinated to provide acute care, rehabilitation and continuing support for a large and vulnerable group of patients. Hip fracture, as a common and costly injury with a complex journey of care and outcomes that vary demonstrably across Scotland,¹ is thus an important but challenging topic for a clinical guideline.

1.2 Incidence of hip fracture

Hip fracture is becoming commoner. Between 1982 and 1998 (the last year for which complete data is available) the number of hip fractures sustained annually in Scotland by people over 55 years rose from just over 4,000 to 5,700, with 80% occurring in women. It is estimated that the number of people alive in Scotland in 1998 who had experienced a hip fracture was around 27,000. The rise in the number of cases of hip fracture is not simply a reflection of the growing numbers of older people in Scotland. In older people the age-standardised risk is also rising: between 1982 and 1998 in those over the age of 55 it rose from 165 to 205 per 100,000 in men, and from 500 to 593 per 100,000 in women.

1.3 The cost of care

The care of hip fracture is costly. Although average length of stay - the main determinant of hospital costs - has fallen over recent decades, this has not compensated for increasing incidence and the tendency towards older and more complex cases. Costs of hip fracture vary with case-mix, and downstream costs of community support and institutional care for those who need it must be added to those of hospital care. An average figure of £5,000 for hospital care, and an average of the same again for subsequent costs, is widely accepted, with hospital costs in Scotland probably amounting to around £30 million a year, and total costs around £60 million.

1.4 Reviewing the first SIGN hip fracture guideline

In 1997 the first Scottish guideline on hip fracture, Management of Elderly People with Fractured Hip (SIGN guideline no.15)² was published. In keeping with SIGN's commitment to update its evidence-based guidelines in the light of emerging evidence, a guideline review group was convened in 1999 and completed its work in 2001. Over the period 1997 to 2001 a number of important relevant series and meta-analyses have been published and have considerably enriched the available evidence on both prevention and management. The Scottish Hip Fracture Audit (SHFA), which began in 1993 and in 1999 was documenting around 80% of cases nationwide, has accumulated a database of more than 18,000 episodes of care, with details of case-mix, surgical intervention, hospital stay and outcome at four months. This has proved a valuable resource for the guideline review group.

The SIGN guideline process itself has also developed further. In particular, the approach to assessing evidence and grading recommendations has been refined. The guideline review group, unlike its predecessor, also included a patient representative, whose views were clear and helpful, and whose mere presence served to remind all others concerned that the chief goal of a clinical guideline is to improve the quality of care and the quality of the patient's experience throughout the journey of care.

1.5 Statement of intent

This guideline is not intended to be construed or to serve as a standard of patient care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available. However, it is advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.

1.6 Review and updating

This guideline was issued in January 2002 and will be considered for further review in 2005, or sooner if new evidence becomes available. Any updates to the guideline will be available on the SIGN website: http://www.sign.ac.uk.

1.7 Audit and guidelines

The Scottish Hip Fracture Audit is based on 'Rikshoft', the Swedish multicentre hip fracture study. It began in 1993 in the Royal Infirmary of Edinburgh and Borders General Hospital and expanded, with CRAG and local funding, to a maximum of 18 participating centres, capturing around 80% of all hip fractures in Scotland, in 1999. Although funding uncertainties have affected coverage, 14 centres continue in the Audit, and around 65% of cases nationally are currently documented. It aims to document hip fracture care and outcomes; improve services by providing feedback data; facilitate comparisons between units; monitor effects of changes in surgical and rehabilitation policies; and allow national and international comparison of hip fracture care.

The Audit covers case-mix, surgical and rehabilitation care, and outcomes, with documentation on admission and discharge from acute care, at four months following admission and on readmission to orthopaedic care with a hip-related presentation. Case-mix data includes age and sex of patient, previous mobility, living circumstances and type of fracture. Care is documented in terms of time in A&E Department, time to surgery, type of anaesthetic, nature of surgical treatment, time in acute ward, destination from acute ward (home, rehabilitation ward, return to care home, etc.). Outcome data includes mobility status and living circumstances at four months, and mortality. Follow up at four months averages 98%.

A total of more than 18,000 cases has now been documented. A unitary national database of 12,000 cases has undergone preliminary analysis, and has provided detailed information to support the preparation of this guideline. National reports have benchmarked hip fracture care across Scotland. Regular local reports to participating units have prompted and monitored changes in clinical practice, and allowed evaluation of service developments. Improvements in hip fracture care in various participating centres documented by SHFA include fast-tracking through A&E departments, reduced fasting times, improved pressure area care and enhanced rehabilitation and discharge arrangements.¹

Scotland is unique in having established both a national guideline for hip fracture care and a national hip fracture audit, and the potential for synergy between the two has been recognised since the publication of SIGN guideline no.15 in 1997. An evidence-based guideline identifies good practice - what ought to happen - in hip fracture care. A robust national audit documents the realities of care - what is happening. Guidelines and audit working together allow comparisons, in detail and across the journey of care, of the care recommended with the care delivered and can hence exert continuing upward pressures on the quality of care.

In 2000 the Clinical Standards Board for Scotland (CSBS), recognising the importance of hip fracture as the most common serious injury in older patients, the complexity of the care involved, and the combined value of the SIGN guideline in setting standards and the Scottish National Hip Fracture Audit in providing data, adopted hip fracture as a tracer condition in its work on standards for older people in acute care. These standards, recently developed and still being finalised, will form the basis of a nationwide series of hospital visits to be carried out in 2002, with a view to the publication of a CSBS national report on Older People in Acute Care early in 2003.

Hip fracture care is therefore emerging as a case study in clinical governance in Scotland, with this SIGN guideline providing nationally accepted evidence-based standards; the Scottish Hip Fracture Audit documenting care; and a programme of quality assurance visits under the auspices of CSBS providing national accountability. All three initiatives seek to improve the quality of hip fracture care, but are much more likely to do so by working together. It may be some years before conclusive evidence of the effectiveness or otherwise of this combined approach emerges.