10.1 Local implementation

In general terms, implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit. Integrated Care Pathways may be a useful means by which to implement the guideline at the "bedside".

10.2 Key points for audit

Hip fracture audit should include details of case-mix, processes of care and outcome. The Scottish Hip Fracture Audit (SHFA)¹ core data sets, identical to those of the Standardised Audit of Hip Fracture in Europe (SAHFE),¹⁸³ were developed over a number of years by an international multidisciplinary group and represent a robust and practical approach to hip fracture audit that is now widely used in many countries. Forms covering core data sets, admission to acute care, discharge/transfer from acute care, four-month follow up and hip-related readmission to acute care are shown on the following pages.

In addition to the core data set, many participating units collect data on matters of local clinical and research interest, such as:

1. Time spent in A&E department
2. Medical co-mordibity
3. Abbreviated mental test score
4. Pre-fracture mobility
5. Delay to operation
6. Duration of preoperative fasting
7. Grade of surgeon and anaesthetist
8. Type of anaesthetic
9. Thrombo- and antibiotic prophylaxis
10. Pressure sore
11. Wound infection.

10.3 Synergy of audit and guidelines in hip fracture care

As noted in section 1.7, Scotland has both a national guideline for hip fracture care and national hip fracture audit on a substantial scale. This offers unique opportunities to use audit and the guideline together to document care, compare the care delivered with that recommended, and then match care more closely to recommendations by clinical and organisational initiatives undertaken and evaluated locally. This approach, applicable to the whole journey of care, has delivered measurable local improvements in specific aspects of care and the organisation of care, and continues to offer examples of evaluated initiatives that other services can learn from.

10.4 Recommendations for further research