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National Hip Fracture Database Context Page

The RCP run the Falls and Fragility Fracture Audit Programme (FFFAP) including the National Hip Fracture Database which covers all patients admitted to hospital with hip fractures collecting data on the delivery of care and clinical outcomes.

Audit Website: www.rcplondon.ac.uk/projects/falls-and-fragility-fracture-audit-programme-fffap 

Metrics:

1. Case ascertainment

  • Rationale: the proportion of all eligible patients captured by the audit in the sampling period reflects the quality of participation of this hospital in this audit. The comparison is made against Hospital Episode Statistics data.
  • Guideline/mapping: there is no national guideline related to case ascertainment and the audit does not currently specify an aspirational threshold.
  • Graph/relative performance: percentile RAG scale; hospitals have been graded according to whether their outcomes fall in the top 25%, bottom 25%, or in the middle range of trusts nationally.
  • Quality improvement prompt question: consider the metrics below in the context of case ascertainment – particularly where ascertainment is low – and should prompt questions about the quality of audit participation.

2. Crude proportion of patients having surgery on the day or day after admission

  • Rationale: in general, patient outcomes are improved when they have expeditious surgery.
  • Guideline/mapping: this metric maps exactly to NICE QS 16, statement 5. (https://www.nice.org.uk/guidance/qs16/chapter/Quality-statement-5-Timing-of-surgery). Surgery within 24 hrs of admission may not be appropriate for all patients, hence the audit specifies an aspirational target of 85%.
  • Graph/relative performance: percentile RAG scale; hospitals have been graded according to whether their outcomes fall in the top 25%, bottom 25%, or in the middle range of trusts nationally.
  • Quality improvement prompt question: for Trusts in the bottom 25%, ask questions about the timeliness of surgery.

3. Crude perioperative medical assessment rate (the proportion of patients with a hip fracture who were assessed by an orthogeriatrician within 72 hours of admission)

  • Rationale: assessment by a physician specialising in the care of the elderly, as part of good multidisciplinary care, can improve outcomes for patients with hip fracture.
  • Guideline/mapping: this metric maps approximately to NICE CG 124, section 1.8. Mapping is approximate because a) orthogeriatrician review is described as part of a formal hip fracture programme and b) a timescale for review is not directly specified; the audit itself specifies a window of 72 hours when defining this metric.
  • Graph/relative performance: percentile RAG scale as for metric 1.
  • Quality improvement prompt question: for Trusts in the bottom 25%, ask questions about the quality of and access to perioperative medical assessment for patients with hip fracture.

4. Crude proportion of patients documented as not developing a pressure ulcer

  • Rationale: development of a pressure ulcer as a result of reduced mobility is a serious complication after hip fracture. Careful assessment and preventative measures (such as regular turning) are a key part of reducing this risk. Other than potentially sub-optimal assessment and prevention, low rates could reflect poor practice with data completion for this audit (i.e. marking the pressure ulcer status as ‘unknown’ for audited patients).
  • Guideline/mapping: there is no national guideline related to development of pressure ulcer after hip fracture.
  • Graph/relative performance: percentile RAG scale as for metric 1.
  • Quality improvement prompt question: for Trusts in the bottom 25%, ask questions about the quality of perioperative nursing care, rehabilitation and quality of audit participation.

5. Crude overall hospital length of stay (LOS) (median number of days from admission with hip fracture until discharge from hospital; this may include time spent in rehabilitation or community hospital facilities)

  • Rationale: can reflect optimal perioperative care (including expeditious surgery where appropriate), post-operative rehabilitation and alignment with community healthcare services but may also be influenced by case mix (older, frailer patients with more complex care needs tend to have longer LOS).
  • Guideline/mapping: there is no national guideline related to overall hospital LOS after hip fracture.
  • Graph/relative performance: percentile RAG scale as for metric 1; caution is advised because the metric is not adjusted for case mix.
  • Quality improvement prompt question: for Trusts in the bottom 25%, ask questions about the efficiency of perioperative care, post-operative rehabilitation and community care links.

6. Risk-adjusted 30-day mortality rate (applies to all patients with hip fracture)

  • Rationale: death is the most serious outcome after hip fracture and is known to vary across regions. This metric uses case-mix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix.
  • Guideline/mapping: there is no national guideline related to mortality after hip fracture.
  • Graph/relative performance: risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 95% and 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means that the performance is different to the national average.
  • Quality improvement prompt question: ‘orange’ (caution) or ‘red’ (alarm) outlier status should prompt questions about actions which the Trust has taken to reduce their mortality rates following hip fracture.

 

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