RCEM audit calls for urgent improvement in care of patients with broken hips in Emergency Departments

21 May 2018

Emergency Departments (EDs) are missing basic standards in the care of patients with broken hips, including pain management, according to a new audit by the Royal College of Emergency Medicine. 

The 2017/18 Fractured Neck of Femur Clinical Audit shows an urgent need to improve performance across the UK in key areas of care such as assessing and treating pain, speed of x-ray, and admission to hospital within 4 hours.

The audit looked at the care of 12,642 adults presenting to 185 UK Emergency Departments with a fractured neck of femur (hip). Its key findings include: 

  • A median average of just 4% of patients in severe pain received pain relief within an hour of arrival or triage at A&E (with a target of 100% of patients).
  • Under a third of patients had their pain score assessed with 15 minutes of arrival (a median average of 29%, with a target of 100%).
Dr Adrian Boyle, Emergency Medicine Consultant and Chair of the RCEM Quality in Emergency Care Committee said: “It is disappointing that we have not made progress on this important and vulnerable group. Responding to patients with a broken hip is core business for emergency departments, and it is inexcusable that we are not able to offer better care.”

Dr Taj Hassan, President of the Royal College of Emergency Medicine said: “Patients attending the Emergency Department with a fractured neck of femur are amongst the most vulnerable. Sadly, the results suggest that the tremendous pressures of increasing demand and complexity, combined with a crowded ED, have had repercussions on clinical care delivery in this area. The key marker of flow – admission to hospital within 4hrs has slipped from a median of 86% to 41%.”

Almost all patients with a fractured neck of femur (93%) arrive by ambulance yet only 66% have documented evidence of having received analgesia before arrival. It is important to note a large drop in performance of giving analgesia to patients in the ED; RCEM believes this may be related to capacity issues. 

More positively, 87% of EDs have a written protocol for hip fracture management and 70% of patients are operated on within a day after admission. EDs are also recording pain scores better and this has consistently improved since 2003. Results show that if a pain score is recorded patients will receive analgesia sooner, especially if their pain score is high.  

Dr Jeff Keep, at the Royal College of Emergency Medicine said: “Re-evaluation of pain is important but not done well, and not done in a timely manner. This is disappointing as the graphs in this report show.  Although there is overall improvement in pain scores when they are reassessed, some patients may still be in severe pain.”

Dr Hassan added: “Finding ways to prioritise vulnerable patient access to a hospital bed in a timely fashion for such a treatable condition is utterly vital. we need to make sure we can find ways to reverse a trend that is adding to patient harm.”

RCEM makes seven key recommendations to improve care for these patients:

  1. Every ED should nominate a hip fracture lead to improve and champion standards of care in this area by working with the lead anaesthetist.
  2. Written protocols and pathways for hip fracture management should be updated to include a section on how to investigate using CT and/or MRI when the x-ray is normal but the clinical findings are still suspicious of a #NOF. Protocols should be easily accessible for all staff.
  3. Protocols and pathways should be urgently reviewed to ensure a focus on the rapid assessment and relief of pain, including utilising nurse-led prescribing.
  4. Where possible, liaise with local ambulance Trusts to encourage pain relief prior to arrival at hospital.
  5. Pain scoring should be mandatory for all patients with suspected or confirmed #NOF (Neck of Femur). EDs should undertake QIPs to find a locally accepted way of ensuring pain scores are done.
  6. Re-evaluation of pain is vital to ensure that analgesia given has been effective.
  7. Nerve blocks should be used where possible to limit the use of systemic analgesia. Patients must be monitored following blocks.

Notes to Editors
Fractured Neck of Femur Clinical Audit 2017/18 is one of three audits published by the Royal College of Emergency Medicine in May 2018.

The audits are designed to drive clinical practice forward by helping clinicians examine the work they do day-to-day and benchmark against their peers but also recognise excellence. This audit aims to monitor documented care against standards published in July 2017.

A total of 12,642 patients presenting to 185 Emergency Departments (EDs) were included in this audit. This was the seventh time this audit has been conducted. 65,000 patients a year suffer a fractured neck of femur, the majority presenting via the ED. 

This audit excluded patients ages 17 years or under, and patients who have multiple injuries or have other conditions which need immediate resuscitation.