The Victorian Audit of Surgical Mortality (VASM) hosted a webinar in April in collaboration with the Australian and New Zealand Hip Fracture Registry (ANZHFR), exploring the impact of participation in quality improvement initiatives on orthopaedic care. Dr Hasanka Ratnayake shares an orthogeriatric perspective on the management of hip fracture patients.

Tell us about yourself and your role as an orthogeriatrician.
I’m a dual-trained general physician and geriatrician, and I have been working as an orthogeriatric consultant at Alfred Health in Melbourne since 2019. I am the principal investigator at our hospital for the ANZHFR.

To deliver orthogeriatric care well, we rely on input from our nursing, allied health and pharmacy colleagues. I see our role as coordinating and collaborating with all the disciplines involved in a patient’s hip fracture journey, along with providing our own geriatrics assessment. Communicating with the patient and their loved ones and carers is also a major part of our work. Sustaining a hip fracture is often a frightening experience, and the morbidity that comes from it can be life changing. We do our best to support people through it.

A large part of my role also involves monitoring how we are meeting the Hip Fracture Clinical Care Standard by frequently auditing our ANZHFR data and disseminating that information to our teams.

Outside of work I have two young kids aged one and three, a husband who also works in medicine, and a very patient British Blue cat. So, once we clock off at work, we get to start the second, more demanding shift at home (hello three-year-old tantrums!).

New guidelines for management of fractured neck of femur (NOF) advocate for surgical fixation within 36 hours. How has this affected your practice? If surgery is delayed much past this (e.g. patient is medically unfit), then does the prospect for a positive outcome significantly diminish?

We are fortunate that at our hospital we have great access to theatre time for our hip fracture patients. The emergency department physicians, surgeons and anaesthetists work hard to expedite these cases. So, it hasn’t changed our practice per se, but it means we are more mindful than ever (especially with patients who are transferred from other hospitals) that the clock is ticking.

The literature has shown repeatedly that timely surgery for older hip fracture patients is associated with a lower risk of death, and lower rates of postoperative complications such as pneumonia, pressure injuries and delirium. Not to mention it is also kinder for our patients as it reduces fasting time and provides definitive pain relief.

There is often concern that getting patients to theatre quickly means less time to optimise medical comorbidities and risking further postoperative complications. However, this wasn’t borne out in the Hip Attack trial, which compared hip surgery at six hours versus standard care (a median of 24 hours).¹ There are few medical scenarios that warrant delaying theatre (which Dr Ben Slater and I talk about), and I think the change of standard reflects the group consensus that we need to operate as soon as possible for best outcomes.

Questions around the potential futility of surgical intervention for fractured NOFs continue to arise (e.g. death 24–36 hours post-surgery). How would you address these?
This is an important topic, but a difficult question to give a prescriptive answer to, as merit of surgical intervention must be assessed on a case-by-case basis. Needless to say, a decision to not operate on a hip fracture must be a patient-centred conversation, with shared decision-making with our surgical, anaesthetic and palliative care colleagues.

Since we know optimal pain relief comes from fixing the hip, choosing a non-operative approach also needs to be a practical and well-considered plan, with thought given as to how and where the patient will receive optimal palliative care.

One of the studies I discussed during my presentation looked at American Society of Anesthesiologists (ASA) physical status classification system grade and death rates post hip fracture surgery using data from the UK hip fracture registry.² They demonstrated that even the most frail and unwell patients (ASA 4 and 5) largely survived the first few days after surgery. They concluded that operative management would still help manage pain in these patients, despite the guarded prognosis. I tend to fall into this category of thinking, to be honest. I thought the authors of this paper put it beautifully when they said, ‘… we must not underestimate the benefit of surgery, even for dying patients, which can allow them to spend their final days in comfort and dignity’.

You touched on frailty in your presentation. What preventative measures can individuals and families engage in to mitigate this?
Frailty is a physiological decline, associated with ageing, that results in a state of vulnerability. Unsurprisingly, patients who suffer a hip fracture and are also frail have worse outcomes. The latest Hip Fracture Clinical Care Standard recommends that we screen all hip fracture patients for frailty on admission. Once we identify frailty, it is important we create individualised care plans for these patients to prevent deterioration and minimise the risk of hospital-related harms.

Preventing frailty is centred around reducing risk factors and encouraging healthy ageing. Recommendations with an evidence base include exercise (especially resistance training), medication rationalisation (as we get older and accumulate prescriptions), remaining up to date on vaccinations, maintaining adequate calorie and protein intake, stopping smoking and excess alcohol intake, and maintaining social connectivity.

You can find more information here: Orthopaedic care using Quality Improvement activities.

References
1.    Investigators HA. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet. 2020;395(10225):698-708.
2.    Johansen A, Tsang C, Boulton C, Wakeman R, Moppett I. Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database. Anaesthesia. 2017;72(8):961-6.