NHFD National Report 2012:Layout 1...† This report covers casemix, care and outcomes of 59,365...

The National Hip Fracture DatabaseNational Report 2012

F O R H E A L T H A N D S O C I A L C A R E

In partnership with:

British Orthopaedic Association

The National HipFracture DatabaseNational Report 2012

This report was prepared by the members of theImplementation Group:Colin Currie, NHFD Clinical Lead for Geriatric MedicineMaggie Partridge, NHFD Project ManagerFay Plant, NHFD Project Coordinator (North)Jonathan Roberts, Health & Social Care Information CentreRob Wakeman, NHFD Clinical Lead for Orthopaedic SurgeryAndy Williams, NHFD Project Coordinator (South)

Data analysis and chart production by:Quantics Consulting Ltd,Hudson House,8 Albany Street,Edinburgh EH1 3QBTelephone +44 (0) 131 440 2781

To speed search for individual hospital results in the e-version ofthe Report, go to ‘Edit’ at the top of the report, then ‘Find’.Type in the three-letter hospital code, and it will be highlightedin yellow wherever it appears.

Brief extracts from this publication may be reproduced providedthe source is fully acknowledged.

Enquiries and comments about this report would be welcomed.Please contact:NHFD, British Geriatrics Society, Marjory Warren House,31 St. John’s Square, London EC1M 4DN

A summary of the Report is also available online atwww.nhfd.co.uk

Copyright © The National Hip Fracture Database 2012. All rights reserved.


CONTENTS Pages

Foreword……………...............................……………………………………..……...………..4Executive summary………………..…………………………………………….................………5Introduction…………………………..…………………………………............……...……….7Participating hospitals………………………..…………………………….......………..............12Mapping NHFD to NICE Clinical Guidance 124......…………………….......………..............14Completeness of data fields submitted for the 2012 National Reports.........................…17Casemix……........…………...................…………………………...…………................….18-25Process:

A&E to orthopaedic ward in 4 hours (Blue Book Standard 1)……………...………….26Type of anaesthesia…….................................……………...…...............................….28Surgery within 36 hours of admission...................................................................29Surgery within 48 hours and during normal working hours (Blue Book Standard 2).....31Reason for delay beyond 36 hours.....................................................................32Patients treated without surgery.......…………………...………...…......................….33Operations performed by fracture type.......……...………….............................….34-40Development of pressure ulcers (Blue Book Standard 3)........................…….41Preoperative medical assessments (Blue Book Standard 4)...................................….43Bone protection medication at admission.....................…………………...............….45Bone health assessment and treatment at discharge (Blue Book Standard 5).......….46Specialist falls assessment (Blue Book Standard 6)........….................……....……….47Secondary prevention overview....................................................................……....48Length of acute and post-acute Trust stay...........……………….....…....…………….49Discharge destination from Trust………………...…………................................….51Re-operation within 30 days.......…………....................................................….52Follow up data completeness at 30 and 120 days..............................…………….53-57

Casemix adjusted outcomes:……………………….........…………………………………….58Best Practice Tariff…………....................................................…………………..60-68Facilities Audit...............................…………………………………………….……69-71Strategic Health Authority summary tables........………................…………….…72-84

Glossary (terms denoted by �)………..........……………………….......………........…………85References…………………………………………………………………….......................…87Appendix A - Structure and Governance………....…………………............…......……...88-90Appendix B - Classification Tree……………………………………….........………...…......91-93Appendix C - Facilities Audit tables.………......................…..................................…..94-99Appendix D - NHFD chart outlines………………………………..................................100-108Appendix E - Using audit to improve care - Good practice examples...................……..109-113Acknowledgements…………………………………………………………….......…..………114


Hip fracture is a common, serious injury of older people that is likely tobecome more common as the population ages. Many hip fracture patientsare already frail, and for them the injury poses the greatest risk of loss ofindependence and hence perhaps the loss of home. Care costs are high and,when both acute care and the care needed to provide for subsequentdependency are included, now exceed £2 billion a year for the UK as a whole.

The NHFD, since its launch in 2007, has done much to improve the quality ofcare for hip fracture in England, Wales, Northern Ireland, and the ChannelIslands. In particular, the much wider availability of collaborative care –provided by orthopaedic surgeons and geriatricians working together – hasbenefited older and frailer hip fracture patients most. Now they are far morelikely to have both their medical and surgical needs addressed early andeffectively. This means that more patients proceed promptly to surgery; andthat the early identification and treatment of medical problems allows earlierrehabilitation, which in turn promotes independence and hence an earlierreturn home.

Not only clinical care has improved. The NHFD, by providing managers andclinicians with credible, current local information about the services they run,can prompt and monitor significant service developments – such as dedicated7-day hip fracture lists, increased rehabilitation staffing, and fracture liaisonservices to promote effective secondary prevention – that deliver measurableimprovements in the quality and cost effectiveness of care.

This publication, the fourth National Report from the NHFD, is notable in anumber of respects. It demonstrates the widest coverage yet, documentingcasemix, care and outcomes of almost 60,000 cases from 180 hospitals; and,with more than 200,000 cases registered since 2007, establishes the NHFD asthe most extensive hip fracture audit in the world. Its impact on care is nowwidely known through international scientific meetings, and similar nationalhip fracture audits are under development in Australia, New Zealand andIreland.

In England, the NHFD has made possible the highly successfulimplementation of the Best Practice Tariff (BPT) for hip fracture care, which provides a financial incentiveto Trusts in meeting defined quality standards of care. In the two years since its inception there havebeen steady rises in the number of hospitals participating, the number of cases submitted, and thenumber of cases meeting the BPT criteria.

The recently published NICE guideline on hip fracture care has also benefited from the existence of theNHFD. This report documents current compliance with key aspects of the guideline and will thuscontribute towards the completion of the NICE baseline assessment tool.

And at a time when improving cost-effectiveness is of increasing importance for the NHS, thedemonstration in this Report of a 5% year-on-year reduction in Trust length of stay is welcome, as is theprospect of more detailed NHFD work to follow, aimed at scrutinising much more closely overall NHSlength of stay following hip fracture.

None of these achievements would be possible were it not for the NHFD’s success in having created – inthe words of its 2011 Report – ‘a truly national clinical audit, and a critical mass of enthusiasm andexpertise in hip fracture care now reflected in the findings reported here’.

The views of the Professor Willett and Professor Oliver are given in a clinical capacity and as national experts in the field. They do not in themselves impose any mandatoryrequirements on NHS organisations beyond those which already exist in the national hip fracture best practice tariff and the NICE quality standard for hip fracturemanagement, although commissioners are expected to take them into account. The National Contract for Acute Services also requires that providers participate in the NCAappropriate for the services they provide.

Foreword


Professor David OliverNational Clinical Director

for Older People

Professor Keith WillettNational Clinical Director

for Trauma Care

4


Executive summary

Copyright © The National Hip Fracture Database 2012. All rights reserved. 5

• The National Hip Fracture Database (NHFD) is a clinically led, web-based audit of hip fracture care and secondary prevention in England, Wales, Northern Ireland, and the Channel Islands. Its aim is to improve such care.

• All 188 of the eligible hospitals are now registered with NHFD. 97% of these regularly upload case records in a standard dataset format that covers casemix, care and outcomes. Hospitals receive benchmarked feedback that enables clinicians and managers to monitor and improve the care they provide.

• Around 95% of the cases occurring annually are now documented by NHFD. The total number of cases recorded since its launch in 2007 is now over 200,000, making the NHFD the largest national hip fracture audit in the world.

• Care is audited against six standards: prompt admission to orthopaedic care; surgery within 48 hoursand within normal working hours; nursing care aimed at minimising pressure ulcer incidence; routine access to orthogeriatric medical care; assessment and appropriate treatment to promote bone health; and falls assessment. Since April 2009 additional fields – most notably surgery within 36 hours – have been included to meet the needs of the Best Practice Tariff initiative.

• This report covers casemix, care and outcomes of 59,365 cases submitted between 1 April 2011 and 31st March 2012 by 180 hospitals meeting the case threshold of 100 (or a high percentage submission rate in smaller hospitals). The key charts cover compliance with the six care standards, with hospitals in rank order.

• In terms of those standards, and in comparison with the findings of the 2011 National Report:

1. 52% of patients are admitted to an orthopaedic ward within four hours(down from 56% in 2011)

2. 83% receive surgery within 48 hours (down from 87%)3. 3.7% are reported as having developed pressure ulcers (no change)4. 43% are reported as assessed preoperatively by an orthogeriatrician (up from 37%)5. 69% are discharged on bone protection medication (up from 66%)6. 92% received a falls assessment prior to discharge (up from 81%)

It is of some concern that compliance with standards 1 and 2 has fallen in the past year. (See relevant charts for further comment) However, since 2009 compliance with standards 4-6 has continued to improve year on year.

Note: in order to ensure comparability between 2011 and 2012 data, calculations for the above have been made – as for the 2010 report – with the exclusion of ‘unknown’ data.

• Case mix-adjusted reporting on two key outcomes (30-day mortality, and rate of return home by 30 days) allows fairer inter-hospital comparisons. In the case of 30-day mortality, new processes have been agreed for the identification and management of outlying hospitals. As result of this, and delays in the necessary data linkage, casemix-adjusted 30-day mortality will appear in a Supplementary Report to be published later in the year.

• Clinicians and managers have used NHFD participation to prompt, monitor and evaluate clinical and service developments to improve the quality and cost effectiveness of hip fracture care. The report includes brief summaries of such work that might encourage similar efforts elsewhere.

• In England, the NHFD has successfully supported the first two years of the Department of Health’s Best Practice Tariff (BPT) initiative, which rewards the achievement of specified standards (surgery within 36 hours; care by surgeon and geriatrician; care protocol agreed by geriatrician, surgeon and anaesthetist; pre/perioperative assessment by geriatrician; geriatrician-led multi-disciplinary rehabilitation; and secondary prevention including falls and bone health assessment).

• Over these two years there have been steady quarter-by-quarter increases in hospital participation (from 57% to 87%); in the number of cases submitted (from 9455 to 14,046); and in the number of cases achieving the enhanced tariff (from 2303 to 7654).

• Although the NHFD has steadily increased its coverage of hip fracture care since 2007, further work is required if the remaining c. 5% of the estimated total incidence is to be included. Gaps remain in the data submitted on reported cases. The total number of data fields for the 59,365 cases reported is 1,240,874, of which 1,150,404 (92.7%) were completed. ASA grade (a measure of prior fitness) and AMT score (a measure of cognitive state) are only variably documented, as is 30-day and 120 day follow-up. Again, further effort is required.

• From April 2012 the NHFD will continue its work as part of a new Falls and Fragility Fracture Audit Programme, with its funding secured for a further three years.

Copyright © The National Hip Fracture Database 2012. All rights reserved.6


IntroductionThe National Hip Fracture Database

The aim of the National Hip Fracture Database (NHFD) is to improve the care and secondary preventionof hip fracture – the commonest serious injury of older people. The NHFD was developed from 2004 asan independent, clinically-led, web-based audit, with the support of the British Orthopaedic Association(BOA) and the British Geriatrics Society (BGS) and start-up funding from industry sources.

It was launched in 2007, and in 2009 was recognised by the National Clinical Audit Advisory Group forcentral funding for 2009-2012 as a national clinical audit under the auspices of the Healthcare QualityImprovement Partnership. Its funding is again secured, from 2012 to 2015, together with its identity andfurther development, within the Falls and Fragility Fracture Audit Programme, again under the auspicesof the Healthcare Quality Improvement Partnership.

Since 2007, coverage has expanded steadily, with all 188 eligible hospitals in England, Wales, NorthernIreland and the Channel Islands now registered with NHFD, and 182 regularly contributing data.Participating units upload casemix, care and outcome details in a standard dataset format, and receiveregular feedback, with benchmarking at regional and national level. Care is measured against six qualitystandards set out in the BOA/BGS Blue Book on The care of patients with fragility fracture1, which cover:prompt admission to orthopaedic care; early surgery; the prevention of pressure ulcers�; access to acuteorthogeriatric care; assessment for bone protection therapy�; and falls assessment�.

This synergy of audit, standards and feedback supports clinicians in the improvement of the care theyprovide, and in service developments aimed at improving care and secondary prevention. The NHFDwebsite offers additional support – in the form of case studies, good practice examples, model jobdescriptions, business plans and an extensive database of the relevant medical literature.

NHFD central staff – its project manager and two project coordinators – have also organised a series ofwell-attended regional meetings. These bring together clinicians and managers to share expertise, andreport on the use of NHFD in improving the quality and cost-effectiveness of the care they provide.Together these measures have succeeded in raising awareness of hip fracture care, improving clinicalpractice and service organisation, end delivered improvements in care and outcomes documented insuccessive National Reports.

The NHFD National Report 2012

General

This publication provides details on the casemix, care and outcomes of 59,365 cases of hip fracture from180 hospitals that either submitted more than 100 cases over the year from 1st April 2011 to 31stMarch 2012 (175 hospitals); or had fewer than 100 cases, but with at least 66% of cases submitted (5hospitals). It follows three previous national reports: in 2009 (64 hospitals; 12,983 cases ); in 2010 (129hospitals; 36,556 cases); and in 2011 (176 hospitals, 53,443 cases) and therefore provides a moreextensive and more detailed – but still incomplete – picture of hip fracture care in England, Wales,Northern Ireland and the Channel Islands in 2011/2012.


In the charts comprising the bulk of this Report makes it clearer, data from participating hospitals isdisplayed comparatively, and in its first section describes casemix�: in terms of age, sex-ratio, place ofresidence, ASA grade�, cognition, walking ability, and fracture type. The next section follows the journeyof care from initial admission through to discharge, with details of time to ward and to surgery,operations performed, medical assessment, development of any pressure ulcers, secondary preventionmeasures, length of acute hospital stay and destination on discharge.

Finally, a key outcome - namely percentage of patients returning home by 30 days, is reported not interms of the raw data but by the use of a case-mix adjustment methodology that takes account of theinter-hospital variation in patients treated. (Similarly casemix-adjusted data on mortality is currently inpreparation, and will be presented in a Supplementary Report to be published later in the year).

Measuring progress

In terms of the six Blue Book standards, there are concerns that the previous year-on-year improvementin compliance with all six standards has not been sustained. Current data on admission to orthopaediccare within 4 hours and on surgery within 48 hours is disappointing. However the trend to improvementhas been maintained for preoperative assessment by an orthogeriatrician, discharge on treatment withbone protection medication, and on falls assessment prior to discharge.

52% of cases were admitted to an orthopaedic ward within four hours (down from 56% in 2011); 83%received surgery within 48 hours (down from 87%); 3.7% were reported as having developed pressureulcers (no change). 43% were reported as assessed preoperatively by an orthogeriatrician (up from 37%);69% discharged on bone protection medication (up from 66%); and 92% receiving a falls assessmentprior to discharge (up from 81%).

In order to ensure comparability with previous reports, the percentages quoted above are based on the exclusion of ‘unknown’ data.

Also of note is a small but significant reduction in the mean length of acute and post-acute stay – thelatter within the admitting Trust – from 21.2 days in 2011 to 20.2 days in 2012. With length of stay thedominant component of the overall cost of hip fracture care, this reflects the greater cost-effectivenessof improved care.

Further work is required to establish the overall NHS length of stay (as opposed to length of stay in theadmitting Trust). The NHFD has commissioned work on data linkage, to be carried out by the RoyalCollege of Surgeons Clinical Effectiveness Unit (RCS CEU) and aiming to establish variance in


1. Admission to orthopaedic ward within 4 hours N/A 55% 56% 52%

2. Surgery within 48 hours and during working hours 75% 80% 87% 83%

3. Patients developing pressure ulcers N/A 6% 3.7% 3.7%

4. Pre-operative assessment by an orthogeriatrician 24% 31% 37% 43%

5. Discharged on bone protection medication N/A 57% 66% 69%

6. Received a falls assessment prior to discharge 44% 63% 81% 92%

Standard 2009 2010 2011 2012


‘superspell’�. It is hoped that results – expected to uncover considerable variance in the cost-effectiveness of care – will be available for inclusion in the NHFD 2012 Supplementary Report, to bepublished later in the year.

Audit and Change

The aim of NHFD is to improve the care and secondary prevention of hip fracture. As will be clear fromthe above, the NHFD has had, in its early years and in relation to the Blue Book standards, some successin that aim, though recent national data on early care is disappointing.

Clearly, national progress in hip fracture care as documented in this Report simply reflects the cumulativeimpact of innumerable local initiatives by participating hospitals. The Report therefore also includes, asdid previous reports, a number of vignettes that describe how hospitals have made use of NHFD toprompt, monitor and evaluate clinical and service developments. They demonstrate how – using trustedand current data on the care they provide – clinicians and managers can work together to achieve notonly remarkable improvements in care but, in some cases, substantial efficiency savings as well, mainlythrough reduction in length of stay – by far the dominant factor in the overall costs of hip fracture care.

The Best Practice Tariff for Hip Fracture Care

The NHFD, with its detailed documentation of casemix, care and outcomes, prompted the selection ofhip fracture as a topic for the Department of Health’s Best Practice Tariff (BPT) initiative2, which offersadditional payment for cases the care of which meets agreed standards (surgery within 36 hours; care bysurgeon and geriatrician; care protocol agreed by geriatrician, surgeon and anaesthetist;pre/perioperative assessment by geriatrician; geriatrician-led multi-disciplinary rehabilitation�; secondaryprevention including falls and bone health assessment) that are monitored by the NHFD.

Between April 2010, when BPT – which applies only in England – began, and April 2012, participationhas increased steadily quarter by quarter: with ever-rising numbers of hospitals participating, of casessubmitted, and of cases meeting the tariff standards – as demonstrated in the table on page 60.

The NHFD Report and NICE CG 124

The NHFD Report has been designed to audit current practice against the standards set out in theBOA/BGS ‘Blue Book’ and the criteria set out for the Best Practice Tariff in England. In 2011 the NationalInstitute for Health and Clinical Excellence (NICE) published ‘The Management of Hip Fracture in Adults’3

along with a series of implementation tools and resources. Where the following charts provide datauseful for the completion of the NICE baseline assessment tool, this is indicated in the accompanyingtext and an identifying blue rectangle at the top of the page.

Limitations of the Report

This report demonstrates continuing expansion of the coverage of the NHFD, and its contribution to theconspicuous success of the Best Practice Tariff in hip fracture care over the last two years. However, interms of compliance with the Blue Book standards, it provides a mixed picture. There is evidence atnational level of a loss of momentum in early care (time to admission and time to surgery). Clearly, giventhe importance of prompt admission and early surgery in the overall quality of patient care, work isneeded to re-establish the previous trend to improvement. However, the reported continuing rise of


preoperative orthogeriatrician involvement, together with improvements in secondary prevention, iswelcome.

Ideally, a national clinical audit would acquire complete data on all cases occurring, but the NHFD is stillsome way from achieving this – and faces difficulties worth looking at in some detail. Progress towardscomplete coverage cannot be measured until it is possible to establish valid case ascertainment rates atboth national and hospital level: a goal that has hitherto proved elusive because at both national andhospital level valid incidence rates are not yet available. This ‘denominator problem’ is currently beingaddressed via the RCS CEU data linkage exercise mentioned above and making use of both NHFD andHES� data.

Meanwhile, ascertainment rates are therefore to some degree speculative. The 59,365 cases included inthis Report represent only around 95% of the estimated total number of cases presenting to thehospitals registered. Case ascertainment� by hospitals – also reflecting the ‘denominator problem’, withhospitals supplying their own variously sourced estimates of incidence – varies from 43.2% to 164.6%*.

At case level, as the first chart in the report (p17) shows, incomplete reporting persists, most notably inthe reporting of ASA grades and AMT� scores (both of which are casemix factors strongly predictingoutcomes); and in 30 day and 120 day follow-up, which varies by hospital with an average ofrespectively 32.3% and 24.6% completeness. To acknowledge this, and as per the 2011 National Report,the proportion of missing data in various fields is represented in the charts that follow by whiteinsertions in the horizontal bars.

As a result of the problem of missing data, the casemix-adjusted reporting of two key outcomes –particularly 30-day return home (see page 58) and 30-day mortality (to be reported in the NHFD 2012Supplementary Report) – must be regarded as indicative rather than conclusive.

In the case of return home, the data reported is frankly incomplete by reason of the currently limited 30-day follow-up data. In the case of mortality – although deaths and the timing of deaths are reliablyreported from central sources – incomplete case reporting by hospitals may under-report hospitalmortality, thus skewing the average; and hospitals submitting 100% of cases may as a result appear tobe performing less well. The consequences of this for the identification and management of outliers areobvious, and due caution should be exercised in the interpretation of relevant data. NHFD will continueto support and encourage high levels of case ascertainment to address this problem. Meanwhile, outlieridentification and management – which will be described in detail in the Supplementary Report, inwhich casemix-adjusted mortality will appear in funnel-plot format – is now being implemented.

*Case ascertainment is based on information provided for the NHFD Facilities Audit (See Appendix C)

The NHFD 2012 Supplementary Report

For a number of reasons – including staff time constraints, administrative delays arising in relation toinformation governance, and the need to deal supportively and in detail with clinical teams of possibleoutlier status in respect of mortality – it was not possible to include in this Report information on anumber of important aspects of the work of the NHFD in 2011-2012. Accordingly, a SupplementaryReport will be published later in the year. This will report include:



• Casemix adjusted 30-day mortality in funnel-plot4 form, with the exclusion of low-ascertainment hospitals in order to provide more robust average and comparative data

• The output of the RCS CEU data linkage project, which aims to address both the ‘denominator problem’ (thus enabling the provision of more robust ascertainment data), will also, it is hoped, establish NHS superspell data for hip fracture care (hence allowing more robust comparisons of both cost-effectiveness of care and rate of return home)

• Trend data from a group of hospitals with sustained NHFD involvement, high ascertainment levels, and good data completion, together with analyses to assess the impact of various care process factors on key patient outcomes

NHFD: the future

At a time of impending funding pressures for the NHS, the influence the NHFD has demonstrated overthe years in improving quality while increasing cost effectiveness should be welcomed; and the costs ofthe NHFD – both centrally and in the collection of data at hospital level – can therefore be fully justified.Care has improved measurably – with recent exceptions as noted above – and geriatrician involvementand secondary prevention both continue to improve, with the cost-effectiveness of care nationally alsoappearing to improve. The humane and economic benefits of improved secondary prevention,potentially substantial, are of course not immediate, but likely to emerge over coming years.

To sustain and strengthen the role of the NHFD in improving care, the goal of maximising datacompleteness at hospital and case level, including follow-up at 30 and 120 days, will be pursued via theNHFD’s regional meetings, and in data workshops for those directly involved in collecting and uploadingdata.

The potential of using NHFD data to improve the evidence base for hip fracture care has beenrecognised, and the NHFD Scientific and Publications Committee has supported a now published studyevaluating risks possibly associated with the use of cemented arthroplasties�5 and is currently usingtrend data from the 2011 Report to evaluate the contribution of orthogeriatrician input to care. Aproposed ascertainment study of anaesthetic practice in hip fracture care, the Anaesthetic Sprint AuditProject (ASAP), to be carried out jointly between the NHFD and the Association of Anaesthetists of GreatBritain and Ireland, is currently in preparation.

From April 2012 the NHFD has secured funding for a further three years, and will, within the new Fallsand Fragility Fracture Audit Project (FFFAP), maintain its identity and continue to develop, whilebenefiting also from links with other FFFAP work-streams currently addressing the development ofFracture Liaison Services� and the audit of injurious falls in institutional settings.



Participating hospitals (2012)

Addenbrooke's Hospital, Cambridge ADDAiredale General Hospital AIRAlexandra Hospital, Redditch REDAltnagelvin Area Hospital ALTArrowe Park Hospital, Wirral WIRBarnet Hospital BNTBarnsley Hospital BARBasildon and Thurrock University Hospital BASBassetlaw Hospital BSLBedford Hospital BEDBirmingham Heartlands Hospital EBHBradford Royal Infirmary BRDBristol Royal Infirmary BRIBronglais Hospital, Aberystwyth BRGBroomfield Hospital BFHCentral Middlesex HospitalCharing Cross Hospital CCHChase Farm Hospital CHSChelsea and Westminster Hospital WESCheltenham General Hospital CHGChesterfield Royal Hospital CHEColchester General Hospital COLConquest Hospital, Hastings CGHCountess of Chester Hospital COCCounty Hospital, Hereford HCHCraigavon Hospital, Portadown CRGCroydon University Hospital MAYCumberland Infirmary, Carlisle CMIDarent Valley Hospital, Dartford DVHDarlington Memorial Hospital DARDerriford Hospital, Plymouth PLYDiana Princess of Wales Hospital, Grimsby GGHDoncaster Royal Infirmary, DIDDorset County Hospital, Dorchester WDHEaling HospitalEast and North Herts Hospital ENHEast Surrey Hospital, Redhill ESUEastbourne Hospital DGEFairfield Hospital, Bury BRYFrenchay Hospital, Bristol FRYFrimley Park, Camberley FRMFurness General Hospital, Barrow-in-Furness FGHGeorge Eliot Hospital, Nuneaton NUNGlan Clwyd Hospital, Rhyl CLWGloucestershire Royal Hospital, Gloucester GLOGood Hope Hospital, Birmingham GHSGrantham and District Hospital GRAGwynnedd Ysbyty, Bangor GWYHarrogate District Hospital HAR

Hillingdon Hospital HILHinchingbrooke Hospital HINHomerton Hospital, London HOMHorton Hospital, Banbury HORHuddersfield Royal Infirmary HUDHull Royal Infirmary HRIIpswich Hospital IPSJames Cook University Hospital,Middlesbrough SCMJames Paget University Hospital,Great Yarmouth JPHJohn Radcliffe Hospital, Oxford RADKettering General Hospital KGHKing’s College Hospital, London KCHKing’s Mill Hospital, Sutton in Ashfield KMHKingston Hospital KTHLeeds General Infirmary LGILeicester Royal Infirmary LERLeighton Hospital, Crewe LGHLincoln County Hospital LINLuton and Dunstable Hospital LDHMacclesfield General Hospital MACMaelor Hospital, Wrexham WRXManchester Royal Infirmary MRIManor Hospital, Walsall WMHMedway Maritime Hospital MDWMilton Keynes General Hospital MKHMorriston Hospital, Swansea MORMusgrove Park Hospital, Taunton MPHNevill Hall Hospital, Abergavenny NEVNew Cross Hospital, Wolverhampton NCRNewham General Hospital, London NWGNobles Hospital, Isle of Man NOBNorfolk and Norwich University Hospital NORNorth Devon District Hospital, Barnstaple NDDNorth Hampshire Hospital, Basingstoke NHHNorth Manchester General Hospital NMGNorth Middlesex University Hospital NMHNorth Tyneside General Hospital,North Shields NTYNorthampton General Hospital NTHNorthern General Hospital, Sheffield NGSNorthwick Park Hospital. London NPHPeterborough District Hospital PETPilgrim Hospital, Boston PILPinderfields General Hospital, Wakefield PINPoole General Hospital PGHPrince Charles Hospital, Merthyr TydfilPrincess Elizabeth Hospital, Guernsey PEH

Indicates inclusion in this report (n = 180); indicates participating in NHFD but not submittingsufficient data to be included in report (n=8).



Princess of Wales Hospital, BridgendPrincess Royal Hospital, Telford TLFPrincess Royal University Hospital, Bromley BROQueen Alexandra Hospital, Portsmouth QAPQueen Elizabeth Hospital, Birmingham QEBQueen Elizabeth Hospital, Gateshead QEGQueen Elizabeth Hospital, King's Lynn QKLQueen Elizabeth Hospital, Woolwich GWHQueen Elizabeth the Queen Mother Hospital,Margate QEQQueen’s Hospital, Burton-upon-Trent BRTQueen's Hospital, Romford OLDRotherham District General Hospital ROTRoyal Albert Edward Infirmary, Wigan AEIRoyal Berkshire Hospital, Reading RBERoyal Blackburn Hospital BLARoyal Bolton Hospital BOLRoyal Derby Hospital DERRoyal Devon & Exeter Hospital, Exeter RDERoyal Free Hospital, London RFHRoyal Glamorgan Hospital, Llantrisant RGHRoyal Gwent Hospital, NewportRoyal Hampshire County Hospital,Winchester RHCRoyal Lancaster Infirmary RLIRoyal Liverpool University Hospital RLURoyal Oldham Hospital OHMRoyal Preston Hospital RPHRoyal Shrewsbury Hospital RSSRoyal Surrey County Hospital, Guildford RSURoyal Sussex County Hospital, Brighton RSCRoyal United Hospital, Bath BATRoyal Victoria Hospital, Newcastle RVNRoyal Victoria Hospital, Belfast RVBRussells Hall Hospital, Dudley RUSSalford Royal Hospital SLFSalisbury District Hospital SALSandwell General Hospital SANScarborough General Hospital SCAScunthorpe General Hospital SCUSouth Tyneside District Hospital,South Shields STDSouthampton General Hospital SGHSouthend Hospital SEHSouthport District General Hospital SOUSt George's Hospital, London GEOSt Helier Hospital, Carshalton SHCSt Helier Hospital, JerseySt Mary's Hospital, Paddington STMSt Mary's Hospital, Isle of Wight IOWSt Peter's Hospital, Chertsey SPHSt Richard's Hospital, Chichester STRSt Thomas' Hospital, London STHStafford Hospital, Stafford SDGStepping Hill Hospital, Stockport SHH

Stoke Mandeville Hospital, Aylesbury SMVSunderland Royal Hospital SUNTameside General Hospital, Manchester TGAThe Great Western Hospital, Swindon PMSThe Princess Alexandra Hospital, Harlow PAHThe Royal Cornwall Hospital, Treliske RCHThe Royal London Hospital LONTorbay District General Hospital TORTrafford General Hospital, Manchester TRATunbridge Wells Hospital TUNUlster Hospital NUHUniversity College Hospital London UCLUniversity Hospital, Nottingham UHNUniversity Hospital Aintree FAZUniversity Hospital Coventry UHCUniversity Hospital Of North Durham,Darlington DRYUniversity Hospital of North Staffordshire,Stoke-on-Trent STOUniversity Hospital of North Tees,Stockton-on-Tees NTGUniversity Hospital of Wales, Cardiff UHWUniversity Hospital, Lewisham LEWVictoria Hospital, Blackpool VICWansbeck Hospital ASHWarrington Hospital WDGWarwick Hospital WARWatford General Hospital WATWest Cumberland Hospital, WhitehavenWest Middlesex University Hospital,Isleworth WMUWest Suffolk Hospital, Bury St. Edmunds WSHWest Wales General Hospital, Carmarthen WWGWeston General Hospital,Weston-Super-Mare WGHWexham Park Hospital, Slough WEXWhipps Cross University Hospital WHCWhiston Hospital, Prescot WHIWhittington Hospital, London WHTWilliam Harvey Hospital, Ashford WHHWithybush Hospital, Haverford West WYBWorcestershire Royal Hospital, Worcester WRCWorthing & Southlands Hospital WRGWythenshawe Hospital, Manchester WYTYeovil District HospitalYork Hospital YDH

In all of the following charts hospitals areidentified by their unique three letter code.

Mapping the NHFD Report toNICE Clinical Guidance 124The NHFD report has been designed to audit current practice against the standards set out in theBOA/BGS ‘Blue book’ and, in England, the elements of the Best Practice Tariff. In 2011 the NationalInstitute for Health and Clinical Excellence published ‘The Management of Hip Fracture in Adults’ alongwith a series of implementation tools and resources. Some of the NHFD Report charts have data thatcorresponds to NICE guidance to a greater or lesser degree:

CHART 8 - AMT score

‘Healthcare professionals should deliver care that minimises the patient’s risk of delirium andmaximises their independence, by actively looking for cognitive impairment when patients firstpresent with hip fracture.’

CHART 9 - A&E to orthopaedic ward in 4 hours

‘From admission, offer patients a formal, acute orthogeriatric or orthopaedic ward-based HipFracture Programme.’

This chart is indicative of how well a hospital has organised its process for ensuring that hip fracturepatients are managed on hip fracture wards.

CHART 10 - Type of anaesthesia

‘Offer patients a choice of spinal or general anaesthesia after discussing risks and benefits.Consider intraoperative nerve blocks for all patients undergoing surgery.’

This chart demonstrates the type of anaesthetic given rather than whether or not a choice of anaestheticwas given.

CHART 11 - Surgery within 36 hours of admission

‘Perform surgery on the day of, or the day after admission.’

For the majority of patients, this recommendation is the equivalent of ‘within 36 hours’.



CHART 12 - Surgery in 48hours and during normal working hours

‘Schedule hip fracture surgery on a planned trauma list.’

Although a scheduled trauma list can take place outside of normal working hours, the small number ofhospitals that have an abnormally high rate of surgery ‘within 48hours but not within working hours’may wish to analyse their data further with a view to addressing potential risks associated with out-of-hours surgery.

CHART 13 - Reason delay beyond 36 hours.

‘Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negativeanteroposterior pelvis and lateral hip x-ray. If MRI is not available within 24 hours or iscontraindicated, consider computed tomography (CT).’

Hospitals with a high rate of delay due to ‘medically unfit – awaiting orthopaedic diagnosis orinvestigation’ may wish to analyse their data further in order to define and address remediable causes ofsuch delays.

CHART 14 - Patients treated without surgery

‘If a hip fracture complicates or precipitates a terminal illness, the multidisciplinary team shouldstill consider the role of surgery as part of a palliative care approach.’

Hospitals with a high rate of non-operation may wish to review their data to ascertain whether non-operation was appropriately associated with palliative care or late diagnosis.

CHART 16 - Surgery type for displaced intracapsular fractures

‘Perform replacement arthroplasty (hemiarthroplasty or total hip replacement) in patients with adisplaced intracapsular fracture.’

CHART 17 - Cementing of arthroplasties

‘Use cemented implants in patients undergoing surgery with arthroplasty.’

CHART 18 - Total hip replacements in displaced intracapsular fractures

‘Offer total hip replacements to patients with displaced intracapsular fractures who: were able towalk independently out of doors with no more than the use of a stick and are not cognitivelyimpaired and are medically fit for anaesthesia and the procedure.’


This chart was designed with filters that match the NICE guidance as closely as possible. An ASA of 1-3was chosen, as most elective hips fall into this range.6 However, a patient who is considered medically fitfor a hemiarthroplasty� may not be considered fit for a total hip replacement and the chart can be onlyindicative of ‘compliance’.

CHART 20 - Surgery type for intertrochanteric fractures

‘Use extramedullary implants such as a sliding screw in preference to an intramedullary nail inpatients with trochanteric fractures above and including the lesser trochanter (AO classificationtypes A1 and A2).

This chart includes all intertrochanteric fractures, but since A3 fractures form the minority of fractures inthis group (10 to 15%) the chart is a guide to ‘compliance’.

CHART 21 - Surgery type for subtrochanteric fractures

‘Use an intramedullary nail to treat patients with subtrochanteric fracture.’

Where the following charts provide data useful for the completion of the NICE baseline assessment tool,this is indicated as follows:


NICE CG 124



Complete (92.6%)

Incomplete ( 7.4%)

0% 20% 40% 60% 80% 100%

Complete (92.6%)

Incomplete ( 7.4%) Hos

pita

l

ALLVIC

RPH

BED

SDG

HIN

UHW

RGH

RLI

ALT

BAR

KCH

NTG

GEO

SEH

LDH

QEB

UCL

PLY

LGI

LGH

BAT

WIR

DAR

GWY

NDD

WWG

WDH

BRO

ESU

BRD

MAY

SOU

NUH

WHH

HOM

LER

MPH

CHS

HOR

TLF

SHH

COC

WHI

MRI

BRT

NGS

OHM

STH

IPS

CLW

RCH

AIR

EBH

CHG

KTH

STR

GGH

STD

OLD

DGE

WYT

SCU

TRA

CCH

SHC

CGH

FAZ

NMH

ADD

SAL

RSS

JPH

WAT

RVN

FRM

NOR

BOL

NWG

BRI

STM

PIL

RUS

WSH

PMS

SPH

WES

RHC

RLU

PAH

NHH

CRG

NPH

WEX

SGH

PEH

NMG

HIL

WRC

MKH

WMH

MAC

GRA

CHE

SLF

TGA

BRY

WGH

HCH

TOR

KGH

DER

HAR

WYB

RFH

FGH

RAD

RVB

SCA

LON

WHC

SCM

BNT

BRG

WDG

BFH

ENH

RSU

GWH

NTH

DRY

STO

BSL

TUN

WMU

SMV

QKL

LIN

NCR

BLA

SUN

WRG

COL

UHN

NEV

WRX

KMH

RED

CMI

MOR

DID

SAN

MDW

HRI

QEQ

RSC

PET

NOB

RDE

IOW

NTY

HUD

LEW

DVH

ASH

PIN

RBE

YDH

PGH

WHT

GHS

WAR

BAS

AEI

NUN

QAP

ROT

FRY

QEG

UHC

GLO

0% 20% 40% 60% 80% 100%

Chart 1 - Completeness of data fields on cases included in the2012 National Report

Data:Total number of fields: 1,240,874Total number of fields completed:1,150,404 (92.6%)All 180 hospitals included in chart.


60−69 (8.3%)

70−79 (22.2%)

80−89 (48.2%)

90+ (21.3%)

0% 20% 40% 60% 80% 100%

60−69 (8.3%)

70−79 (22.2%)

80−89 (48.2%)

90+ (21.3%)

Hos

pita

l (N

)

ALLDGE (377)

WHC (297)

WGH (268)

HOM (87)

TUN (224)

SCA (269)

RHC (234)

QEQ (417)

RDE (548)

RFH (196)

IPS (419)

RSU (335)

BFH (426)

HOR (169)

NPH (246)

CHS (210)

HIN (158)

CGH (279)

RBE (486)

RSC (426)

KTH (332)

SEH (407)

MPH (405)

BRO (315)

CHE (372)

SHC (412)

SMV (387)

NDD (225)

WSH (304)

NTY (329)

YDH (367)

BAT (512)

WDH (223)

HCH (268)

SLF (206)

SAL (242)

RED (244)

COC (323)

PLY (501)

JPH (348)

GEO (184)

WES (116)

ASH (330)

DAR (326)

FRM (322)

UHC (483)

OLD (549)

LIN (347)

PMS (407)

NCR (379)

DVH (342)

PIL (347)

BRG (87)

BRD (271)

LGI (651)

DID (414)

HIL (189)

RVN (425)

DRY (347)

BRY (242)

LER (813)

WWG (259)

BLA (458)

WYT (273)

RUS (468)

TGA (247)

MDW (332)

IOW (232)

SUN (377)

BRI (342)

ADD (384)

TRA (121)

SOU (270)

NUH (332)

LGH (283)

BRT (279)

HRI (513)

BAR (258)

SAN (334)

RLI (249)

NMH (122)

WMH (317)

WRX (239)

FAZ (367)

RVB (835)

STM (197)

RLU (355)

NTG (372)

UCL (112)

STH (168)

FGH (120)

WMU (178)

PEH (54)

GWY (191)

WRG (452)

WAT (379)

PGH (897)

ESU (460)

DER (503)

NUN (249)

NHH (227)

WAR (273)

RAD (531)

SGH (584)

CHG (327)

KMH (324)

QKL (350)

WHH (357)

GLO (384)

MAY (240)

TOR (438)

HAR (231)

AIR (249)

NGS (537)

MAC (236)

NTH (361)

QEB (362)

CLW (373)

GHS (370)

RCH (555)

VIC (403)

NEV (272)

PAH (308)

RSS (344)

BOL (354)

SHH (382)

ENH (462)

TLF (182)

WEX (369)

WHT (133)

WIR (430)

BNT (302)

COL (521)

SPH (387)

STR (375)

NOR (817)

PIN (526)

UHW (501)

ROT (283)

SCU (231)

GGH (265)

BSL (169)

WHI (387)

GWH (320)

CCH (103)

BED (148)

AEI (319)

QAP (688)

WRC (398)

EBH (454)

NMG (157)

FRY (417)

UHN (726)

LEW (165)

HUD (466)

RPH (400)

RGH (174)

PET (381)

QEG (293)

MKH (108)

KCH (126)

SDG (242)

STO (509)

LDH (249)

BAS (399)

WYB (131)

MOR (440)

NWG (122)

NOB (88)

OHM (229)

SCM (456)

CMI (243)

KGH (334)

GRA (97)

WDG (341)

ALT (362)

LON (123)

STD (209)

MRI (164)

CRG (130)

0% 20% 40% 60% 80% 100%

Chart 2 - Age at admission

Data:The age distribution isalmost identical to lastyear and reflects localdemography, e.g.retirement locationswith resultant olderpopulations.

Casemix



Male (26.0%)

Female (74.0%)

Unknown (0.0%)

0% 20% 40% 60% 80% 100%

Male (26.0%)

Female (74.0%)

Unknown (0.0%) Hos

pita

l (N

)

ALLMRI (164)

STM (197)

SCU (231)

CGH (279)

STH (168)

RFH (196)

SLF (206)

GWY (191)

LGH (283)

ASH (330)

RAD (531)

WEX (369)

UCL (112)

SAN (334)

TRA (121)

IPS (419)

WMU (178)

CHS (210)

NCR (379)

BED (148)

UHN (726)

QEQ (417)

NDD (225)

SEH (407)

RCH (555)

LDH (249)

PAH (308)

NOR (817)

BRT (279)

CCH (103)

RVB (835)

WMH (317)

PMS (407)

PGH (897)

TGA (247)

RED (244)

QEB (362)

BRG (87)

ENH (462)

SGH (584)

SCM (456)

ESU (460)

YDH (367)

CHE (372)

BRO (315)

LGI (651)

GWH (320)

SMV (387)

RPH (400)

PLY (501)

SHH (382)

BAS (399)

SHC (412)

FRM (322)

TUN (224)

HIL (189)

PIL (347)

TOR (438)

RLI (249)

CMI (243)

FGH (120)

COL (521)

GGH (265)

SAL (242)

STO (509)

RSU (335)

BLA (458)

RSS (344)

RSC (426)

MPH (405)

HOM (87)

GHS (370)

WIR (430)

DID (414)

AIR (249)

BNT (302)

ROT (283)

WES (116)

STR (375)

WHH (357)

WAT (379)

BRY (242)

TLF (182)

GLO (384)

KMH (324)

HOR (169)

OHM (229)

MAY (240)

WGH (268)

WDG (341)

LON (123)

NHH (227)

MKH (108)

NMG (157)

PET (381)

NUH (332)

CLW (373)

KCH (126)

SDG (242)

LIN (347)

NOB (88)

NWG (122)

WDH (223)

ALT (362)

FAZ (367)

WRX (239)

WHC (297)

DAR (326)

DER (503)

UHC (483)

RVN (425)

BRD (271)

WAR (273)

EBH (454)

GEO (184)

ADD (384)

RGH (174)

HUD (466)

BRI (342)

MDW (332)

SOU (270)

GRA (97)

BFH (426)

IOW (232)

WYB (131)

LER (813)

QAP (688)

NPH (246)

WRC (398)

WHI (387)

NTH (361)

SUN (377)

FRY (417)

LEW (165)

SCA (269)

HIN (158)

RDE (548)

STD (209)

UHW (501)

MOR (440)

RLU (355)

NTY (329)

WWG (259)

KGH (334)

NMH (122)

NEV (272)

DRY (347)

OLD (549)

RBE (486)

SPH (387)

BAT (512)

QEG (293)

BSL (169)

RHC (234)

HAR (231)

NTG (372)

JPH (348)

BAR (258)

HCH (268)

COC (323)

VIC (403)

PIN (526)

RUS (468)

HRI (513)

WRG (452)

WSH (304)

NUN (249)

CHG (327)

MAC (236)

WHT (133)

WYT (273)

QKL (350)

AEI (319)

KTH (332)

CRG (130)

DVH (342)

NGS (537)

BOL (354)

DGE (377)

PEH (54)

0% 20% 40% 60% 80% 100%

Chart 3 - Gender

This is almost identical tolast year’s chart and simplyreflects the preponderanceof osteoporosis in women.


Own home/shelteredhousing (74.7%)

Rehabilitation unit (0.8%)

Acute hospital (0.3%)

Already in hospital (3.8%)

Residential care (12.7%)

Nursing care (6.3%)

Other (0.9%)

Unknown (0.6%)

0% 20% 40% 60% 80% 100%




Already in hospital (3.8%)


Nursing care (6.3%)

Other (0.9%)

Unknown (0.6%)

Hos

pita

l (N

)

ALLVIC (403)

ASH (330)

BSL (169)

BLA (458)

SOU (270)

WAT (379)

SCA (269)

BED (148)

MAC (236)

PIN (526)

WYT (273)

ESU (460)

STD (209)

TOR (438)

HRI (513)

SAL (242)

WHI (387)

SUN (377)

NOB (88)

HAR (231)

RSC (426)

COC (323)

LGI (651)

DRY (347)

DVH (342)

UHC (483)

TUN (224)

MAY (240)

BRG (87)

SHH (382)

PLY (501)

OHM (229)

RVN (425)

WDG (341)

RCH (555)

RBE (486)

TLF (182)

QEG (293)

CHE (372)

FRY (417)

GWY (191)

WRX (239)

GEO (184)

MKH (108)

DGE (377)

NDD (225)

NMG (157)

NHH (227)

PIL (347)

WSH (304)

TGA (247)

CHG (327)

SDG (242)

IPS (419)

RLU (355)

PGH (897)

SHC (412)

WYB (131)

BRD (271)

GWH (320)

PAH (308)

CMI (243)

RLI (249)

NOR (817)

CRG (130)

RSU (335)

RFH (196)

CHS (210)

GGH (265)

LDH (249)

WAR (273)

HCH (268)

BOL (354)

NEV (272)

OLD (549)

QKL (350)

GLO (384)

LON (123)

PET (381)

PMS (407)

GHS (370)

UHN (726)

GRA (97)

ALT (362)

SMV (387)

NWG (122)

HOM (87)

STH (168)

CCH (103)

NPH (246)

WGH (268)

BRY (242)

NTH (361)

RPH (400)

NTG (372)

BNT (302)

DAR (326)

PEH (54)

NTY (329)

NGS (537)

SCM (456)

SCU (231)

FRM (322)

HUD (466)

CLW (373)

IOW (232)

DID (414)

LGH (283)

SEH (407)

LIN (347)

MPH (405)

CGH (279)

AEI (319)

AIR (249)

RED (244)

SLF (206)

STR (375)

COL (521)

RGH (174)

RHC (234)

NUN (249)

DER (503)

QEB (362)

JPH (348)

SPH (387)

NUH (332)

KGH (334)

BAR (258)

LER (813)

WRG (452)

WIR (430)

BAS (399)

KMH (324)

WES (116)

ENH (462)

LEW (165)

RVB (835)

FAZ (367)

RUS (468)

SGH (584)

QEQ (417)

WEX (369)

UHW (501)

KCH (126)

RAD (531)

RSS (344)

QAP (688)

KTH (332)

WRC (398)

HIL (189)

EBH (454)

BFH (426)

BAT (512)

STO (509)

BRT (279)

WMH (317)

BRI (342)

NCR (379)

WHC (297)

FGH (120)

TRA (121)

BRO (315)

WHH (357)

MDW (332)

SAN (334)

MOR (440)

HIN (158)

ROT (283)

WWG (259)

RDE (548)

NMH (122)

YDH (367)

WMU (178)

MRI (164)

WHT (133)

ADD (384)

STM (197)

HOR (169)

UCL (112)

WDH (223)

0% 20% 40% 60% 80% 100%

Chart 4 - Admitted from

Admissions were previouslyreported without anydistinction between thosefrom residential and nursingcare. These are nowreported separately,with two thirds of patientscoming from residential care.Otherwise, figures are similarto those of 2011.



Known (90.2%)Unknown (9.8%)

0% 50% 100%

Known (90.2%)Unknown (9.8%)

DAR (326)BRG (87)NTG (372)BOL (354)QEG (293)WRX (239)WHI (387)NCR (379)WSH (304)HOM (87)NHH (227)BAT (512)ENH (462)IPS (419)LGI (651)AEI (319)UHN (726)BRY (242)RSC (426)FGH (120)QKL (350)RLU (355)PIN (526)LDH (249)CMI (243)SHH (382)RVB (835)DRY (347)NMH (122)SCA (269)ADD (384)GGH (265)WHC (297)WAR (273)WES (116)RCH (555)BAR (258)CHG (327)COC (323)STO (509)HIL (189)HUD (466)WDG (341)PMS (407)LIN (347)GLO (384)BRI (342)WDH (223)MRI (164)HRI (513)RGH (174)CHS (210)PEH (54)WIR (430)RPH (400)QAP (688)CHE (372)MDW (332)NEV (272)RSS (344)PLY (501)GEO (184)TOR (438)DGE (377)NDD (225)BED (148)STH (168)AIR (249)ESU (460)WYB (131)BRO (315)WHT (133)PGH (897)LEW (165)SAN (334)ASH (330)PAH (308)DID (414)HAR (231)SDG (242)WRC (398)SEH (407)WHH (357)TGA (247)ALT (362)TLF (182)KTH (332)WMU (178)SPH (387)BRT (279)

BRD (271)SUN (377)NMG (157)EBH (454)

GWY (191)JPH (348)BLA (458)BAS (399)LON (123)RVN (425)NGS (537)ROT (283)FAZ (367)RLI (249)

WRG (452)HIN (158)

WWG (259)NTH (361)UCL (112)GHS (370)COL (521)MAC (236)RAD (531)NTY (329)CLW (373)LER (813)MKH (108)UHC (483)DER (503)QEB (362)SCM (456)STM (197)TRA (121)

GWH (320)CGH (279)WMH (317)NUH (332)SLF (206)SCU (231)MPH (405)BSL (169)NUN (249)RBE (486)DVH (342)

OHM (229)WYT (273)RED (244)

NWG (122)YDH (367)LGH (283)QEQ (417)RFH (196)

UHW (501)CRG (130)NPH (246)MOR (440)WAT (379)MAY (240)STR (375)BNT (302)TUN (224)BFH (426)RSU (335)

WGH (268)SGH (584)HCH (268)IOW (232)FRY (417)SHC (412)RDE (548)KCH (126)STD (209)PET (381)KGH (334)WEX (369)CCH (103)

PIL (347)FRM (322)RHC (234)OLD (549)KMH (324)NOR (817)

GRA (97)SMV (387)SOU (270)RUS (468)HOR (169)SAL (242)NOB (88)VIC (403)

ALL

ASA Grade 1 (2.4%)ASA Grade 2 (30.7%)ASA Grade 3 (55.1%)ASA Grade 4 (11.4%)ASA Grade 5 (0.4%)

0% 20% 40% 60% 80% 100%

Hos

pita

l (N

)

ASA Grade 1 (2.4%)ASA Grade 2 (30.7%)ASA Grade 3 (55.1%)ASA Grade 4 (11.4%)ASA Grade 5 (0.4%)

ALLDAR (293/326)BRG (75/87)NTG (349/372)BOL (331/354)QEG (286/293)WRX (237/239)WHI (385/387)NCR (340/379)WSH (297/304)HOM (83/87)NHH (227/227)BAT (511/512)ENH (458/462)IPS (361/419)LGI (592/651)AEI (303/319)UHN (598/726)BRY (230/242)RSC (411/426)FGH (100/120)QKL (338/350)RLU (347/355)PIN (498/526)LDH (239/249)CMI (165/243)SHH (335/382)RVB (818/835)MKH (105/108)NMH (121/122)SCA (257/269)ADD (381/384)GGH (196/265)WHC (292/297)WAR (257/273)WES (112/116)RCH (533/555)BAR (171/258)NUH (318/332)COC (312/323)STO (386/509)HIL (125/189)HUD (441/466)WDG (320/341)PMS (404/407)LIN (342/347)GLO (384/384)BRI (335/342)WDH (197/223)MRI (160/164)HRI (506/513)RGH (166/174)CHS (207/210)PEH (50/54)WIR (420/430)RPH (216/400)QAP (539/688)CHE (263/372)MDW (298/332)NEV (256/272)RSS (344/344)PLY (445/501)GEO (134/184)TOR (371/438)RSU (235/335)NDD (215/225)HCH (252/268)STH (168/168)AIR (234/249)ESU (448/460)WYB (126/131)BRO (299/315)WHT (132/133)PGH (671/897)LEW (163/165)SAN (328/334)ASH (311/330)PAH (302/308)DID (358/414)HAR (200/231)SDG (233/242)WRC (302/398)SEH (321/407)WHH (349/357)TGA (229/247)ALT (354/362)TLF (170/182)KTH (289/332)WMU (170/178)SPH (356/387)BRT (263/279)

BRD (136/271)SUN (365/377)NMG (103/157)EBH (445/454)

GWY (179/191)JPH (335/348)BLA (408/458)BAS (388/399)LON (60/123)

RVN (385/425)NGS (403/537)ROT (282/283)FAZ (361/367)RLI (160/249)

WRG (408/452)HIN (149/158)

WWG (249/259)NTH (335/361)

UCL (86/112)GHS (336/370)COL (441/521)MAC (177/236)RAD (389/531)NTY (308/329)CLW (354/373)LER (768/813)DRY (329/347)UHC (475/483)DER (471/503)QEB (237/362)SCM (445/456)STM (192/197)TRA (100/121)

GWH (258/320)CGH (258/279)WMH (251/317)CHG (318/327)SLF (188/206)SCU (156/231)MPH (405/405)BSL (161/169)NUN (242/249)RBE (471/486)DVH (329/342)

OHM (228/229)WYT (266/273)RED (243/244)

NWG (122/122)YDH (361/367)LGH (156/283)QEQ (411/417)RFH (139/196)

UHW (490/501)CRG (41/130)

NPH (238/246)MOR (395/440)WAT (360/379)MAY (224/240)STR (354/375)BNT (260/302)TUN (199/224)BFH (382/426)DGE (376/377)

WGH (214/268)BED (120/148)SGH (360/584)IOW (230/232)FRY (410/417)SHC (388/412)RDE (548/548)KCH (117/126)STD (201/209)PET (378/381)KGH (232/334)WEX (293/369)CCH (100/103)

PIL (342/347)FRM (318/322)RHC (233/234)OLD (546/549)KMH (312/324)NOR (802/817)

GRA (78/97)SMV (295/387)SOU (270/270)RUS (450/468)HOR (166/169)SAL (242/242)

NOB (72/88)VIC (235/403)

0% 20% 40% 60% 80% 100%

Chart 5 - ASA grade

There is an increase in ‘known’ ASA from 87.3% to 90.2%. ASA is an important factor is casemix adjusting; andthe range of ‘known’ (50-100%) demonstrates that some units could still greatly improve their data recording.The distribution of reported ASA grades is remarkably similar to that of 2011.


Without aids (45.8%)

One aid (24.9%)

Two aids/frame (23.7%)

Wheelchair (2.4%)

Unknown (3.2%)

0% 20% 40% 60% 80% 100%

Without aids (45.8%)

One aid (24.9%)

Two aids/frame (23.7%)

Wheelchair (2.4%)

Unknown (3.2%)

Hos

pita

l (N

)

ALLHOR (169)

BED (148)

PEH (54)

WSH (304)

SCU (231)

MPH (405)

WRC (398)

SCA (269)

CGH (279)

GHS (370)

PIL (347)

QEB (362)

BAS (399)

NDD (225)

RED (244)

WEX (369)

SCM (456)

SOU (270)

CMI (243)

NTG (372)

NTY (329)

SDG (242)

KGH (334)

RAD (531)

CHS (210)

RPH (400)

LER (813)

BRT (279)

COC (323)

MAY (240)

SGH (584)

JPH (348)

TLF (182)

SLF (206)

EBH (454)

WMH (317)

PGH (897)

WAT (379)

KMH (324)

MDW (332)

DGE (377)

COL (521)

NUN (249)

UHN (726)

NHH (227)

TUN (224)

DRY (347)

RHC (234)

HIN (158)

GWH (320)

WRG (452)

WDH (223)

MOR (440)

STO (509)

ENH (462)

RGH (174)

WMU (178)

BFH (426)

TGA (247)

HIL (189)

BRI (342)

BLA (458)

LGH (283)

HAR (231)

PLY (501)

SPH (387)

LON (123)

UHC (483)

SHC (412)

NWG (122)

FAZ (367)

SUN (377)

RVN (425)

BRD (271)

QEG (293)

BRO (315)

LGI (651)

NEV (272)

CCH (103)

NPH (246)

WDG (341)

WHT (133)

YDH (367)

STD (209)

BRY (242)

STH (168)

BNT (302)

UCL (112)

DID (414)

GEO (184)

VIC (403)

QEQ (417)

WHH (357)

NMG (157)

NOB (88)

NOR (817)

LDH (249)

BSL (169)

MKH (108)

GLO (384)

NTH (361)

NUH (332)

BAR (258)

RVB (835)

WGH (268)

SHH (382)

PAH (308)

RBE (486)

FGH (120)

SAN (334)

CRG (130)

TRA (121)

WIR (430)

WWG (259)

QKL (350)

CHE (372)

NCR (379)

RLI (249)

DVH (342)

SEH (407)

BRG (87)

IPS (419)

IOW (232)

PMS (407)

GWY (191)

RCH (555)

UHW (501)

WHC (297)

STR (375)

FRY (417)

NGS (537)

RSC (426)

WRX (239)

ESU (460)

RSS (344)

CLW (373)

RSU (335)

BOL (354)

CHG (327)

PET (381)

RDE (548)

WYB (131)

RFH (196)

GRA (97)

DAR (326)

ROT (283)

WAR (273)

SMV (387)

FRM (322)

TOR (438)

HRI (513)

RLU (355)

HCH (268)

OHM (229)

AIR (249)

ASH (330)

LIN (347)

RUS (468)

AEI (319)

GGH (265)

MAC (236)

HUD (466)

DER (503)

LEW (165)

WES (116)

ALT (362)

WHI (387)

STM (197)

ADD (384)

PIN (526)

WYT (273)

QAP (688)

KCH (126)

KTH (332)

NMH (122)

MRI (164)

BAT (512)

HOM (87)

OLD (549)

SAL (242)

0% 20% 40% 60% 80% 100%

Chart 6 - Walking ability

The distribution of walking abilities is remarkably similar to that in 2011.



Intracapsular undisplaced (10.9%)

Intracapsular displaced (46.8%)

Intertrochanteric (34.3%)

Subtrochanteric (5.4%)

Other (1.8%)

Unknown (0.8%)

0% 20% 40% 60% 80% 100%

Intracapsular undisplaced (10.9%)

Intracapsular displaced (46.8%)

Intertrochanteric (34.3%)

Subtrochanteric (5.4%)

Other (1.8%)

Unknown (0.8%)

Hos

pita

l (N

)

ALLTRA (121)

MAC (236)

NWG (122)

GEO (184)

UCL (112)

NMG (157)

NOB (88)

HOM (87)

CHS (210)

BSL (169)

STD (209)

FAZ (367)

RVN (425)

KTH (332)

BED (148)

DRY (347)

AEI (319)

NPH (246)

RED (244)

RAD (531)

BAS (399)

IOW (232)

KCH (126)

ENH (462)

WHC (297)

MAY (240)

TUN (224)

TLF (182)

WIR (430)

WSH (304)

BRY (242)

SHC (412)

SPH (387)

WMH (317)

RSS (344)

SCA (269)

NUH (332)

UHC (483)

RLI (249)

UHW (501)

YDH (367)

RGH (174)

DID (414)

MOR (440)

PIL (347)

DER (503)

BRD (271)

ROT (283)

WEX (369)

WAT (379)

NEV (272)

STR (375)

HIL (189)

GLO (384)

STH (168)

GWH (320)

LER (813)

NOR (817)

RBE (486)

HOR (169)

SCU (231)

SUN (377)

NDD (225)

ALT (362)

AIR (249)

COC (323)

HCH (268)

BAT (512)

RVB (835)

CHE (372)

LGI (651)

PLY (501)

ADD (384)

BRI (342)

MPH (405)

MKH (108)

RUS (468)

CMI (243)

WYT (273)

IPS (419)

NTY (329)

NHH (227)

RCH (555)

WRG (452)

DGE (377)

KMH (324)

PEH (54)

STO (509)

LDH (249)

FRM (322)

VIC (403)

RPH (400)

BNT (302)

LON (123)

CCH (103)

WHT (133)

NTH (361)

PAH (308)

WHH (357)

QEB (362)

GGH (265)

GWY (191)

NMH (122)

RLU (355)

TOR (438)

NCR (379)

BAR (258)

BRG (87)

STM (197)

GRA (97)

CHG (327)

SLF (206)

GHS (370)

FGH (120)

RHC (234)

EBH (454)

HUD (466)

SAL (242)

DVH (342)

SEH (407)

NUN (249)

WES (116)

BLA (458)

CRG (130)

WAR (273)

ESU (460)

QEG (293)

BFH (426)

FRY (417)

HAR (231)

BRT (279)

SAN (334)

PMS (407)

PIN (526)

PET (381)

SMV (387)

LGH (283)

QAP (688)

QEQ (417)

KGH (334)

MDW (332)

WRX (239)

RDE (548)

JPH (348)

UHN (726)

ASH (330)

WGH (268)

NGS (537)

WWG (259)

WDH (223)

NTG (372)

WRC (398)

BOL (354)

BRO (315)

LEW (165)

RFH (196)

COL (521)

CLW (373)

WHI (387)

HIN (158)

QKL (350)

RSU (335)

CGH (279)

WMU (178)

SDG (242)

SGH (584)

PGH (897)

WYB (131)

WDG (341)

DAR (326)

SCM (456)

RSC (426)

SOU (270)

LIN (347)

SHH (382)

TGA (247)

HRI (513)

MRI (164)

OLD (549)

OHM (229)

0% 20% 40% 60% 80% 100%

Chart 7 - Fracture type


Fracture type

Over the past three years the proportion of each fracture type has been remarkably constant:

However, a small number of hospitals report over 10% of fracture types as ‘unknown’. This, together withthe reporting by some hospitals of ratios of displaced to undisplaced intracapsular fractures inversely propor-tional to the preponderant and hence expected ratio of 4:1, indicates that, in some hospitals, there is a lackof clarity in clinical records and/or poor transfer of data for uploading – and hence scope for significant im-provement in audit practice locally.

Undisplaced intracapsular 12 11 11

Displaced intracapsular 45 46 47

Intertrochanteric 35 34 34

Subtrochanteric 5 5 5

Other 3 3 2

Unknown <1 <1 <1

Fracture type 2010%

2011%

2012%



0−6 (20.8%)

7−10 (44.2%)

Unknown (35.0%)

0% 20% 40% 60% 80% 100%

0−6 (20.8%)

7−10 (44.2%)

Unknown (35.0%) Hos

pita

l (N

)

ALLBFH (426)

LIN (347)

NTH (361)

RPH (400)

SOU (270)

UHW (501)

WHC (297)

HCH (268)

MAC (236)

SDG (242)

MRI (164)

KCH (126)

WEX (369)

CCH (103)

NCR (379)

SEH (407)

WDG (341)

LGH (283)

WYB (131)

UCL (112)

STR (375)

LGI (651)

HUD (466)

HOM (87)

NPH (246)

WHT (133)

NMG (157)

RLI (249)

RFH (196)

CGH (279)

KGH (334)

STH (168)

COL (521)

YDH (367)

HAR (231)

CRG (130)

QEB (362)

WWG (259)

ASH (330)

BRI (342)

BRY (242)

DER (503)

ESU (460)

NTY (329)

SAN (334)

WMU (178)

WAR (273)

RVN (425)

NEV (272)

HIN (158)

BRT (279)

DAR (326)

SAL (242)

GGH (265)

RSS (344)

BAS (399)

SMV (387)

DGE (377)

FRM (322)

VIC (403)

RLU (355)

QEQ (417)

ROT (283)

RED (244)

WES (116)

NMH (122)

GHS (370)

RSC (426)

BSL (169)

NHH (227)

RSU (335)

PMS (407)

BAT (512)

GWH (320)

KTH (332)

OLD (549)

NGS (537)

FRY (417)

WRX (239)

MAY (240)

TUN (224)

AIR (249)

ADD (384)

NWG (122)

HRI (513)

RBE (486)

OHM (229)

PAH (308)

AEI (319)

RHC (234)

BRD (271)

NDD (225)

PEH (54)

SLF (206)

TOR (438)

CLW (373)

ALT (362)

FGH (120)

WMH (317)

TGA (247)

SGH (584)

WRC (398)

WIR (430)

NTG (372)

BNT (302)

LDH (249)

LON (123)

RGH (174)

GWY (191)

WDH (223)

STM (197)

BAR (258)

HIL (189)

CHE (372)

GRA (97)

BOL (354)

SHH (382)

CMI (243)

EBH (454)

WHH (357)

TRA (121)

MOR (440)

NOR (817)

RUS (468)

CHG (327)

WGH (268)

RVB (835)

IPS (419)

GEO (184)

PGH (897)

STO (509)

LER (813)

WHI (387)

WAT (379)

SCM (456)

ENH (462)

BLA (458)

FAZ (367)

SUN (377)

TLF (182)

CHS (210)

MKH (108)

RCH (555)

HOR (169)

DRY (347)

IOW (232)

NUH (332)

RAD (531)

BRG (87)

PLY (501)

PET (381)

PIL (347)

LEW (165)

COC (323)

DVH (342)

SHC (412)

UHC (483)

PIN (526)

BRO (315)

MDW (332)

WSH (304)

QKL (350)

RDE (548)

SCA (269)

WRG (452)

BED (148)

WYT (273)

MPH (405)

JPH (348)

UHN (726)

SCU (231)

QEG (293)

SPH (387)

QAP (688)

KMH (324)

GLO (384)

DID (414)

STD (209)

NUN (249)

NOB (88)

0% 20% 40% 60% 80% 100%

Chart 8 - AMT Score

Recording the pre- and post-operative AMTS has now becomepart of the Best Practice Tariff.This shows that in the year priorto the change, AMTS wasrecorded in 65% of cases,compared with 56.9% in 2010/11,suggesting that hospitals werepreparing for the implementationof the new BPT standard.

NICE CG 124


Orth ward admissionwithin 4 hours (49.4%)

Orth ward admissionafter 4 hours (41.1%)

Not admitted toorth ward (3.8%)

Unknown (5.7%)

0% 20% 40% 60% 80% 100%

Orth ward admissionwithin 4 hours (49.4%)

Orth ward admissionafter 4 hours (41.1%)

Not admitted toorth ward (3.8%)

Unknown (5.7%)

Hos

pita

l (N

)

ALLCHS (210)

BAT (512)

WRG (452)

WES (116)

AEI (319)

ESU (460)

MAY (240)

BRI (342)

LON (123)

WHC (297)

FRY (417)

WYT (273)

WEX (369)

PAH (308)

WMH (317)

RSU (335)

RBE (486)

TUN (224)

PIN (526)

STD (209)

NWG (122)

RHC (234)

FAZ (367)

HIN (158)

QEB (362)

SEH (407)

NMH (122)

LER (813)

CGH (279)

HOR (169)

KCH (126)

BRG (87)

STM (197)

CCH (103)

OLD (549)

SDG (242)

RUS (468)

NMG (157)

NTY (329)

NUH (332)

WMU (178)

NCR (379)

CLW (373)

NUN (249)

ASH (330)

WRC (398)

NOR (817)

BRD (271)

FRM (322)

SPH (387)

SAN (334)

RED (244)

WDG (341)

BRT (279)

DID (414)

STO (509)

NHH (227)

CHG (327)

CRG (130)

RDE (548)

BAR (258)

HCH (268)

RVN (425)

SLF (206)

SGH (584)

HAR (231)

RCH (555)

PET (381)

TOR (438)

TGA (247)

WGH (268)

UCL (112)

IOW (232)

WAR (273)

SUN (377)

SAL (242)

DAR (326)

WIR (430)

PIL (347)

BOL (354)

LGH (283)

QEG (293)

UHN (726)

PEH (54)

ROT (283)

SCU (231)

PMS (407)

YDH (367)

BFH (426)

NOB (88)

SHH (382)

STR (375)

GWH (320)

EBH (454)

HOM (87)

UHW (501)

NTH (361)

KTH (332)

BAS (399)

SMV (387)

MKH (108)

LDH (249)

BRO (315)

SHC (412)

RGH (174)

GHS (370)

JPH (348)

ALT (362)

WHT (133)

GEO (184)

RFH (196)

WHI (387)

GRA (97)

VIC (403)

DGE (377)

MOR (440)

COL (521)

NPH (246)

NEV (272)

DVH (342)

PLY (501)

RSC (426)

LGI (651)

COC (323)

WHH (357)

TRA (121)

UHC (483)

RAD (531)

MDW (332)

RLU (355)

RVB (835)

CHE (372)

DRY (347)

RLI (249)

ENH (462)

GWY (191)

RPH (400)

SCA (269)

WAT (379)

BNT (302)

RSS (344)

SOU (270)

FGH (120)

WRX (239)

BSL (169)

LEW (165)

OHM (229)

PGH (897)

HIL (189)

BRY (242)

QEQ (417)

AIR (249)

MRI (164)

ADD (384)

GGH (265)

GLO (384)

HRI (513)

WWG (259)

HUD (466)

QKL (350)

WYB (131)

BED (148)

BLA (458)

TLF (182)

KGH (334)

MPH (405)

STH (168)

LIN (347)

CMI (243)

DER (503)

KMH (324)

NTG (372)

NGS (537)

NDD (225)

IPS (419)

WSH (304)

MAC (236)

QAP (688)

SCM (456)

WDH (223)

0% 20% 40% 60% 80% 100%

Chart 9 - A&E to Orthopaedic Ward in 4 hours (Blue Book Standard 1)

There is a marked improvementin data completeness for time toward: 94.3% compared with86.2% in 2010/11. However,the percentage of patientsreaching the orthopaedic wardwithin 4 hours has fallen from56% to 52%.This might be seen in the contextof a recently reported broadertrend towards A&E stays breachingthe 4 hour target.

NICE CG 124

Process



In 2009/10, with no orthogeriatrician service atSalisbury Hospital, a ‘non-collaborative approach’,and long pre-operative delays, Salisbury ranked 98thout of 100 NHS Trusts in BPT achievement. Achange programme – including increasedorthogeriatric and nurse practitioner staffing;additional theatre capacity for trauma; and activeleadership by the lead orthopaedic surgeon, the leadanaesthetist and the consultant orthogeriatrician –achieved dramatic improvements in compliance withthe six Blue Book standards. By 2012, 80% ofpatients reached orthopaedic care within fourhours; 92% had surgery within 48 hours (and 84%within 36 hours); incidence of pressure ulcerationfell from 5.4% to 1.2%; preoperative assessment bygeriatrician rose from 1.5% to 95%, and boneprotection and falls assessment from 6.2% and 3.2%respectively to 100% in both. Mortality fell from10.1% to 8.4%, and acute length of stay from 27.6days to 19.8 days between April 2011 and March2012.

BPT attainment rose from 1.5% to 84.4% – rankedfirst in South-West region, and in the top fivenationally – bringing in BPT income of £187,790.Even more impressively, cost-effectiveness of care –with savings of £391,000 (costed as 1,955 bed-daysat £200 per day) – was greatly increased.Importantly, feedback from patients, relatives andclinical staff has been positive.


GA only (23.2%)

GA + nerve block (22.6%)

GA + epidural anaesthesia (0.4%)

GA + spinal anaesthesia (6.5%)

SA only (28.6%)

SA + epidural (CSE) (0.5%)

SA + nerve block (6.8%)

None (0.0%)

Unknown (11.3%)

0% 20% 40% 60% 80% 100%

GA only (23.2%)

GA + nerve block (22.6%)

GA + epidural anaesthesia (0.4%)

GA + spinal anaesthesia (6.5%)

SA only (28.6%)

SA + epidural (CSE) (0.5%)

SA + nerve block (6.8%)

None (0.0%)

Unknown (11.3%)

Hos

pita

l (N

)

ALLALT (362)

NUH (332)

UHW (501)

NPH (246)

WWG (259)

DER (503)

HIL (189)

STD (209)

RPH (400)

WGH (268)

HCH (268)

TUN (224)

SCU (231)

HUD (466)

NUN (249)

NTG (372)

DID (414)

ENH (462)

RSC (426)

DAR (326)

BAR (258)

RUS (468)

MRI (164)

STH (168)

HAR (231)

LGI (651)

PAH (308)

BAT (512)

RHC (234)

SOU (270)

YDH (367)

CGH (279)

SLF (206)

PMS (407)

BRD (271)

LIN (347)

WYT (273)

HIN (158)

GWH (320)

BRO (315)

STR (375)

ASH (330)

HRI (513)

RSU (335)

MKH (108)

MDW (332)

LER (813)

AEI (319)

NOR (817)

WRX (239)

NMG (157)

KGH (334)

RSS (344)

BED (148)

CLW (373)

PET (381)

RLI (249)

WYB (131)

LON (123)

NTY (329)

MPH (405)

GEO (184)

DRY (347)

CHG (327)

SAL (242)

WRG (452)

SCM (456)

UHC (483)

SEH (407)

QEB (362)

BAS (399)

HOM (87)

SDG (242)

WHC (297)

GWY (191)

BRI (342)

WAT (379)

RFH (196)

RED (244)

ADD (384)

NWG (122)

WDG (341)

BNT (302)

CHS (210)

FAZ (367)

TOR (438)

FRM (322)

NOB (88)

STO (509)

FRY (417)

CRG (130)

RVB (835)

BFH (426)

TGA (247)

BLA (458)

NGS (537)

GRA (97)

BSL (169)

NHH (227)

MAC (236)

SAN (334)

ROT (283)

BRY (242)

BOL (354)

DGE (377)

TRA (121)

SHH (382)

IPS (419)

VIC (403)

DVH (342)

GLO (384)

QKL (350)

SUN (377)

KTH (332)

COC (323)

NTH (361)

QAP (688)

BRG (87)

WMH (317)

PLY (501)

MAY (240)

IOW (232)

WRC (398)

SGH (584)

PIN (526)

OHM (229)

SCA (269)

UHN (726)

FGH (120)

BRT (279)

KMH (324)

JPH (348)

RAD (531)

CHE (372)

NEV (272)

SMV (387)

QEG (293)

WHT (133)

WEX (369)

NMH (122)

LDH (249)

SHC (412)

WES (116)

HOR (169)

PIL (347)

CMI (243)

GGH (265)

GHS (370)

LEW (165)

QEQ (417)

RGH (174)

AIR (249)

WAR (273)

RCH (555)

UCL (112)

NDD (225)

EBH (454)

TLF (182)

SPH (387)

ESU (460)

WSH (304)

NCR (379)

PEH (54)

COL (521)

KCH (126)

WDH (223)

LGH (283)

MOR (440)

WIR (430)

WMU (178)

RBE (486)

CCH (103)

OLD (549)

RVN (425)

STM (197)

RLU (355)

RDE (548)

WHI (387)

WHH (357)

PGH (897)

0% 20% 40% 60% 80% 100%

Chart 10 - Type of anaesthesia

The introduction of this data fieldand the resultant chart shows thatgeneral anaesthesia (52.7%) isfavoured over spinal anaesthesia(42.4%) and that only 29.4% ofpatients are given a supplementarynerve block.

NICE CG 124



Surgery within 36hrs (67.0%)

Surgery aftermore than 36hrs (29.5%)

No operation performed (2.6%)

Unknown (0.9%)

0% 20% 40% 60% 80% 100%

Surgery within 36hrs (67.0%)

Surgery aftermore than 36hrs (29.5%)


Unknown (0.9%)

Hos

pita

l (N

)

ALLNUH (332)

RVB (835)

ALT (362)

DAR (326)

BRY (242)

WYB (131)

SCU (231)

NMG (157)

LGI (651)

BRD (271)

VIC (403)

RGH (174)

TGA (247)

PIL (347)

SDG (242)

DRY (347)

BRG (87)

CHG (327)

LON (123)

GGH (265)

NTH (361)

TOR (438)

NWG (122)

DVH (342)

WRX (239)

BED (148)

WRC (398)

LER (813)

WMH (317)

TUN (224)

WWG (259)

GHS (370)

MDW (332)

PGH (897)

ADD (384)

HIN (158)

KMH (324)

SMV (387)

GWY (191)

NEV (272)

SAN (334)

PEH (54)

CLW (373)

SUN (377)

WRG (452)

HOM (87)

BAT (512)

RCH (555)

GWH (320)

MKH (108)

NOR (817)

HUD (466)

WEX (369)

HRI (513)

STO (509)

WGH (268)

MOR (440)

BAR (258)

UCL (112)

RDE (548)

ENH (462)

AIR (249)

LEW (165)

QEB (362)

GEO (184)

MAC (236)

BLA (458)

IOW (232)

MPH (405)

HAR (231)

ROT (283)

RSU (335)

RVN (425)

NGS (537)

SCA (269)

NTG (372)

BNT (302)

FRY (417)

PMS (407)

NHH (227)

WHT (133)

DER (503)

STR (375)

NOB (88)

KTH (332)

WIR (430)

AEI (319)

SAL (242)

WSH (304)

SPH (387)

CRG (130)

RSS (344)

RPH (400)

EBH (454)

STD (209)

MRI (164)

UHW (501)

TLF (182)

NPH (246)

OHM (229)

RAD (531)

CCH (103)

FGH (120)

RLI (249)

BRO (315)

GRA (97)

OLD (549)

BRI (342)

SLF (206)

BOL (354)

PIN (526)

PLY (501)

WDG (341)

BAS (399)

RFH (196)

MAY (240)

LGH (283)

ESU (460)

WES (116)

WMU (178)

CHE (372)

SOU (270)

WYT (273)

YDH (367)

LDH (249)

LIN (347)

RSC (426)

KCH (126)

COC (323)

STM (197)

SGH (584)

KGH (334)

WHC (297)

SEH (407)

SCM (456)

HCH (268)

RLU (355)

RBE (486)

QKL (350)

JPH (348)

UHN (726)

BFH (426)

DID (414)

SHH (382)

PET (381)

NCR (379)

BSL (169)

CGH (279)

NDD (225)

HIL (189)

RED (244)

COL (521)

DGE (377)

STH (168)

IPS (419)

WHH (357)

BRT (279)

CMI (243)

TRA (121)

PAH (308)

WAT (379)

CHS (210)

NUN (249)

FAZ (367)

QEQ (417)

QAP (688)

WDH (223)

SHC (412)

WAR (273)

QEG (293)

RHC (234)

FRM (322)

HOR (169)

GLO (384)

UHC (483)

NMH (122)

RUS (468)

WHI (387)

NTY (329)

ASH (330)

0% 20% 40% 60% 80% 100%

Chart 11 - Surgery within 36 hours of admission

Reducing the time taken toget patients to theatre mayrequire a substantial effortin organisational change.The improvement from61.6% in 2010/11 to 67%in 2011/12 is likely to beas a result added stimulusof BPT.

NICE CG 124


In March 2011 Arrowe Park Hospital appointed an NHFDadministrator with the specific aims of improving data collection andsubmission rates to the NHFD, and improving compliance with BestPractice Tariff standards. Cases submitted rose from 108 in 2010 to457 in 2011. A Rapid Improvement Workshop held in July 2011resulted in new care pathway documentation that reduced duplicationand was designed to capture data reflecting clinical standards and BPTcompliance.

With real-time data, a theatre-based trauma board was able tohighlight potential delays and address them. As a result of this, andthe appointment of an additional trauma surgeon, the proportion ofpatients having surgery within 36 hours rose from 66% in 2010 to86% in 2011. The appointment of a second orthogeriatrician hasallowed the implementation of a joint protocol, and has improvedpreoperative care. Improved collaboration with A&E has resulted inthe introduction of prompt fascia iliaca analgesia and greatly improvedpain control. To review documentation and data, and to discuss issuesand review progress, a multidisciplinary team meets monthly.

At Russells Hall Hospital NHFD participation allowed the clinicalteam to focus on patient experience, minimise delay, improvecare and thus reduce morbidity and improve clinical outcomes.Between 2010 and 2012, the percentage of patients operatedon within 36 hours rose from 80.9% to 89.3%; with figures foroperation within 24 hours rising from 57.9% to 65%. Theincidence of pressure ulcers has been reduced from 7.4% to5.9%, and total Trust length of stay has fallen by 2.8 days.

The innovations behind these improvements include theintroduction of dedicated nurse hip practitioners; a dedicatedtrauma coordinator; a ‘hip suite’; patient group directivescovering pain relief and IV fluids; and monthly team meetingsto review and develop the service.



Surgery in 48 hours &working hours (82.4%)

Surgery in 48 hours butnot within working hours (0.9%)

Surgery not within 48 hours (15.9%)

Unknown (0.9%)

0% 20% 40% 60% 80% 100%

Surgery in 48 hours &working hours (82.4%)

Surgery in 48 hours butnot within working hours (0.9%)

Surgery not within 48 hours (15.9%)

Unknown (0.9%)

Hos

pita

l (n/

N)

ALLCRG (105/130)

RPH (385/400)

DAR (291/326)

STD (185/209)

WYB (124/131)

TGA (222/247)

EBH (410/454)

UHW (482/501)

BRD (248/271)

NMG (134/157)

ALT (267/362)

PEH (51/54)

CCH (97/103)

VIC (400/403)

LGI (573/651)

PIL (316/347)

RLI (239/249)

BRO (290/315)

SLF (178/206)

GGH (257/265)

KCH (123/126)

LGH (259/283)

DRY (313/347)

NTH (331/361)

PIN (471/526)

CHG (310/327)

PLY (461/501)

NOR (797/817)

SGH (543/584)

WDG (328/341)

NWG (113/122)

HOM (79/87)

CHE (356/372)

BAR (245/258)

ESU (424/460)

WYT (238/273)

WHC (280/297)

FGH (107/120)

COC (299/323)

SEH (386/407)

NCR (364/379)

NEV (254/272)

ROT (271/283)

LIN (322/347)

GWH (302/320)

SOU (240/270)

NUN (238/249)

CGH (270/279)

HIL (174/189)

SCM (413/456)

WGH (261/268)

UCL (106/112)

KGH (313/334)

PET (355/381)

SAN (321/334)

RBE (451/486)

STM (189/197)

HRI (492/513)

QKL (337/350)

BAT (489/512)

QAP (680/688)

PAH (300/308)

NDD (208/225)

QEB (344/362)

YDH (346/367)

TUN (218/224)

QEQ (403/417)

JPH (339/348)

NTG (342/372)

SHH (317/382)

WAT (360/379)

HOR (161/169)

LEW (148/165)

FAZ (334/367)

STR (357/375)

IPS (393/419)

PMS (396/407)

WHT (129/133)

CHS (201/210)

QEG (273/293)

DGE (364/377)

RHC (226/234)

TRA (105/121)

BRT (247/279)

FRY (385/417)

FRM (287/322)

SPH (373/387)

NHH (211/227)

KTH (320/332)

ASH (299/330)

NUH (242/332)

RVB (727/835)

RSS (273/344)

BRY (215/242)

BRG (75/87)

SCU (218/231)

TLF (166/182)

MRI (152/164)

NPH (242/246)

RAD (494/531)

OHM (221/229)

RGH (163/174)

WMH (294/317)

BRI (328/342)

BED (137/148)

GRA (92/97)

SDG (230/242)

OLD (518/549)

DVH (313/342)

LON (108/123)

WWG (248/259)

MAY (232/240)

WMU (172/178)

GHS (349/370)

GWY (186/191)

BOL (340/354)

WES (104/116)

MDW (315/332)

WRC (367/398)

HIN (148/158)

MOR (414/440)

LDH (227/249)

ADD (376/384)

KMH (309/324)

AIR (237/249)

WRX (213/239)

BSL (154/169)

SUN (340/377)

RED (232/244)

TOR (419/438)

BAS (365/399)

RCH (529/555)

STO (492/509)

SMV (373/387)

GEO (180/184)

PGH (854/897)

RLU (327/355)

MKH (104/108)

RFH (181/196)

UHN (714/726)

WEX (353/369)

MAC (222/236)

COL (493/521)

CLW (341/373)

HCH (248/268)

DID (391/414)

BFH (399/426)

HUD (419/466)

RVN (377/425)

WRG (427/452)

RSC (405/426)

LER (709/813)

IOW (218/232)

WHH (354/357)

CMI (226/243)

ENH (437/462)

BLA (421/458)

RDE (540/548)

SCA (260/269)

WDH (217/223)

STH (150/168)

NOB (82/88)

HAR (224/231)

GLO (365/384)

SAL (230/242)

RSU (326/335)

WSH (293/304)

NGS (483/537)

BNT (278/302)

UHC (425/483)

NMH (113/122)

WAR (257/273)

MPH (375/405)

WIR (396/430)

SHC (371/412)

AEI (292/319)

DER (485/503)

RUS (430/468)

WHI (375/387)

NTY (284/329)

0% 20% 40% 60% 80% 100%

Excludes patients already in hospital when fracture occurred, patients medically unfit after 48 hours, patients dead within 48 hours, and patients who were treated without surgery

Chart 12 - Surgery within 48 hours and during normal workinghours (Blue Book Standard 2)

This rose from 80% in 2009/10to 86% in 2010/11. The fall to82.4% in this report mayindicate that patients whohave missed the 36 hourstandard for BPT are nowbeing further delayed,taking lesser priority thanpatients still likely to meetthe 36 hour criterion.This possible unintendedconsequence of BPTimplementation raisesdifficult questions of whichclinicians and managersshould be aware.

NICE CG 124


Medically unfit − awaitingmedical review investigationor stabilisation (31.2%)

Medically unfit − awaitingorthopaedic diagnosis orinvestigation (7.3%)

Admin − awaiting inpatientor high dependency bed (0.3%)

Admin − awaiting spaceon theatre list (35.0%)

Admin − cancelled dueto list over−run (6.4%)

Admin − problem withtheatre/equipment/staff (1.9%)

Other (3.7%)

Unknown (14.2%)

0% 20% 40% 60% 80% 100%

Medically unfit − awaitingmedical review investigationor stabilisation (31.2%)

Medically unfit − awaitingorthopaedic diagnosis orinvestigation (7.3%)

Admin − awaiting inpatientor high dependency bed (0.3%)

Admin − awaiting spaceon theatre list (35.0%)

Admin − cancelled dueto list over−run (6.4%)

Admin − problem withtheatre/equipment/staff (1.9%)

Other (3.7%)

Unknown (14.2%)

Hos

pita

l (n/

N)

ALLRVB (633/835)

CRG (12/130)

NUH (270/332)

YDH (117/367)

WHH (87/357)

SCM (116/456)

BRI (137/342)

VIC (206/403)

WDH (34/223)

BFH (112/426)

RFH (67/196)

CHE (131/372)

SHC (60/412)

RSC (132/426)

MKH (29/108)

UHW (259/501)

WDG (127/341)

TOR (163/438)

SMV (117/387)

RLI (108/249)

HIN (41/158)

KGH (97/334)

FRY (77/417)

FGH (43/120)

PGH (290/897)

SDG (99/242)

WMU (63/178)

LGH (91/283)

GRA (38/97)

MDW (93/332)

DVH (119/342)

UHN (201/726)

ADD (106/384)

NDD (50/225)

JPH (99/348)

WRX (74/239)

CMI (43/243)

BRO (123/315)

NMG (63/157)

DAR (198/326)

PIL (150/347)

OHM (111/229)

LIN (105/347)

OLD (231/549)

BNT (58/302)

NEV (74/272)

GGH (99/265)

CCH (46/103)

SOU (71/270)

QAP (134/688)

RSS (174/344)

DER (79/503)

NWG (42/122)

EBH (264/454)

MRI (90/164)

SPH (39/387)

MAY (89/240)

CHS (44/210)

MPH (83/405)

WYB (72/131)

BRT (45/279)

NGS (105/537)

SLF (70/206)

STD (121/209)

PLY (192/501)

CGH (68/279)

GWY (58/191)

SHH (94/382)

COC (95/323)

SCU (125/231)

SUN (106/377)

QEQ (79/417)

RGH (77/174)

FRM (41/322)

NTG (67/372)

COL (125/521)

CLW (107/373)

WHC (90/297)

SEH (118/407)

PEH (15/54)

DID (114/414)

NPH (123/246)

BSL (40/169)

QEG (48/293)

UHC (65/483)

ROT (57/283)

BRG (30/87)

RUS (48/468)

NHH (36/227)

UCL (29/112)

ALT (246/362)

PET (99/381)

RAD (257/531)

MOR (101/440)

BAS (145/399)

TLF (84/182)

IPS (97/419)

RPH (90/400)

NTH (137/361)

WYT (86/273)

HOR (27/169)

AIR (57/249)

WES (37/116)

SAL (33/242)

CHG (134/327)

NOR (226/817)

BRY (130/242)

RCH (152/555)

RSU (64/335)

QKL (95/350)

LON (47/123)

WRG (133/452)

WAT (77/379)

RLU (98/355)

WEX (94/369)

STM (60/197)

RBE (130/486)

BRD (132/271)

BAT (143/512)

TUN (75/224)

NMH (17/122)

ESU (150/460)

GWH (92/320)

KTH (47/332)

TRA (22/121)

RHC (41/234)

WRC (137/398)

ENH (104/462)

LER (259/813)

LGI (308/651)

HAR (50/231)

SAN (101/334)

WWG (83/259)

STO (131/509)

HCH (70/268)

PAH (64/308)

HUD (116/466)

HOM (23/87)

LEW (41/165)

SCA (52/269)

LDH (70/249)

PMS (76/407)

DRY (139/347)

NOB (11/88)

HRI (136/513)

RDE (138/548)

WHT (21/133)

SGH (173/584)

DGE (93/377)

HIL (43/189)

NCR (95/379)

BED (30/148)

WAR (50/273)

WIR (57/430)

WHI (47/387)

GHS (124/370)

STR (58/375)

BOL (140/354)

WSH (36/304)

FAZ (73/367)

GEO (37/184)

IOW (52/232)

KMH (102/324)

BLA (97/458)

KCH (33/126)

MAC (52/236)

PIN (182/526)

STH (39/168)

TGA (96/247)

AEI (36/319)

WGH (70/268)

BAR (63/258)

WMH (105/317)

RVN (75/425)

GLO (60/384)

QEB (92/362)

RED (60/244)

NTY (31/329)

ASH (21/330)

NUN (49/249)

0% 20% 40% 60% 80% 100%

Includes only patients who underwent surgery after more than 36 hours.Hospitals with fewer than 10 patients delayed by 36 hours or more are not plotted

Chart 13 - Reason for delay beyond 36 hours

There has been no change in thedominance of administrativefactors over medical problemsin causing pre-operative delay.The fact that the reason fordelay is unknown in 14.2%of cases suggests that somehospitals are not as concernedabout such delays as theyshould be.

NICE CG 124



Surgery (96.5%)

No Surgery (2.6%)

Unknown (0.9%)

0% 20% 40% 60% 80% 100%

Surgery (96.5%)

No Surgery (2.6%)

Unknown (0.9%) Hos

pita

l (N

)

ALLRPH (400)

RSS (344)

CRG (130)

FGH (120)

BRY (242)

TGA (247)

HOM (87)

HIN (158)

DAR (326)

BRG (87)

PIN (526)

GEO (184)

LGH (283)

TRA (121)

LGI (651)

SCM (456)

WYB (131)

BRO (315)

EBH (454)

HUD (466)

GRA (97)

RUS (468)

LDH (249)

ESU (460)

DVH (342)

PEH (54)

BSL (169)

NOB (88)

BRD (271)

RBE (486)

RED (244)

WEX (369)

HIL (189)

WMH (317)

BLA (458)

ASH (330)

MPH (405)

CCH (103)

COC (323)

TOR (438)

BAR (258)

RSU (335)

GWY (191)

LIN (347)

QKL (350)

MAC (236)

ALT (362)

MRI (164)

QEG (293)

KCH (126)

NCR (379)

SHH (382)

SMV (387)

COL (521)

RLU (355)

DER (503)

QEQ (417)

PET (381)

SGH (584)

BRI (342)

NPH (246)

SEH (407)

NTH (361)

NGS (537)

WRG (452)

UHC (483)

NMH (122)

RLI (249)

HRI (513)

STM (197)

SAN (334)

RDE (548)

CHS (210)

UHN (726)

PGH (897)

WAT (379)

HAR (231)

GWH (320)

PMS (407)

LEW (165)

BOL (354)

FAZ (367)

GLO (384)

BNT (302)

UCL (112)

WHH (357)

QAP (688)

QEB (362)

OLD (549)

SAL (242)

VIC (403)

BED (148)

NMG (157)

MDW (332)

SOU (270)

TLF (182)

WRX (239)

BRT (279)

SLF (206)

CMI (243)

NOR (817)

SHC (412)

FRM (322)

NWG (122)

HCH (268)

RFH (196)

LER (813)

NDD (225)

WES (116)

RVN (425)

AEI (319)

NEV (272)

NUH (332)

STD (209)

WRC (398)

ENH (462)

NHH (227)

GGH (265)

SDG (242)

BFH (426)

LON (123)

NTG (372)

DRY (347)

WWG (259)

NTY (329)

SCA (269)

SUN (377)

RGH (174)

BAS (399)

MOR (440)

WDH (223)

CLW (373)

SCU (231)

PIL (347)

WYT (273)

CGH (279)

ROT (283)

AIR (249)

IPS (419)

STH (168)

HOR (169)

RCH (555)

WIR (430)

RAD (531)

UHW (501)

STO (509)

KTH (332)

KGH (334)

WDG (341)

RVB (835)

NUN (249)

PAH (308)

GHS (370)

MKH (108)

FRY (417)

RSC (426)

YDH (367)

STR (375)

SPH (387)

WHT (133)

WGH (268)

DID (414)

PLY (501)

BAT (512)

DGE (377)

WSH (304)

IOW (232)

KMH (324)

CHG (327)

JPH (348)

WAR (273)

ADD (384)

WHC (297)

TUN (224)

RHC (234)

MAY (240)

WMU (178)

OHM (229)

CHE (372)

WHI (387)

0% 20% 40% 60% 80% 100%

Chart 14 - Patients treated without surgery

Despite the concern noted in lastyear’s report regarding the twohospitals where more than 10%of patients are treated withoutsurgery, these hospitals have notyet converged with standardpractice. The range remainsfrom 0-20%.

NICE CG 124


ArthroplastyUnipolar hemi (cemented) (23.1%)

ArthroplastyUnipolar hemi (uncemented) (7.8%)

ArthroplastyBipolar hemi (cemented) (6.5%)

ArthroplastyOther (6.9%)

Internal FixationSHS (20.2%)

Internal FixationScrews (28.9%)

Other (0.5%)


Unknown (0.4%)

0% 20% 40% 60% 80% 100%







Other (0.5%)


Unknown (0.4%)

Hos

pita

l (N

)

ALL

BED (12/148)

GLO (30/384)

PMS (28/407)

LDH (44/249)

SLF (26/206)

CHG (22/327)

PAH (16/308)

DER (27/503)

RED (24/244)

RSS (60/344)

BFH (19/426)

BOL (36/354)

CLW (43/373)

IPS (25/419)

ADD (41/384)

AEI (33/319)

NUH (31/332)

FAZ (30/367)

WIR (23/430)

CRG (16/130)

ROT (30/283)

SUN (15/377)

PIL (19/347)

WAT (36/379)

TGA (13/247)

DAR (17/326)

MAY (25/240)

LON (16/123)

LER (83/813)

WMH (17/317)

QKL (27/350)

KCH (10/126)

SHH (63/382)

RBE (36/486)

QEQ (31/417)

GWY (12/191)

GHS (65/370)

BRT (41/279)

BLA (45/458)

RVB (48/835)

HUD (51/466)

STM (10/197)

MDW (29/332)

VIC (29/403)

KMH (84/324)

RGH (28/174)

COC (32/323)

RHC (16/234)

STD (11/209)

WHI (48/387)

KTH (13/332)

QAP (43/688)

WRC (48/398)

RAD (43/531)

NMG (12/157)

RUS (35/468)

ALT (44/362)

GRA (15/97)

QEG (18/293)

NUN (21/249)

PLY (35/501)

WAR (52/273)

AIR (38/249)

HAR (53/231)

UCL (34/112)

MRI (112/164)

BSL (36/169)

NOB (13/88)

FRY (22/417)

HIL (14/189)

NEV (40/272)

LEW (12/165)

WDG (70/341)

BAR (33/258)

MOR (64/440)

WGH (101/268)

DGE (40/377)

TUN (21/224)

RCH (164/555)

STH (25/168)

DVH (60/342)

SAL (73/242)

CMI (32/243)

HOR (12/169)

RPH (27/400)

MPH (28/405)

BAS (25/399)

PET (49/381)

UHC (55/483)

NTH (25/361)

NDD (23/225)

RLU (29/355)

EBH (46/454)

RFH (18/196)

FRM (94/322)

WEX (14/369)

SEH (20/407)

NHH (25/227)

PGH (55/897)

LIN (53/347)

ASH (11/330)

UHW (46/501)

RVN (20/425)

OHM (101/229)

NTY (18/329)

GGH (22/265)

CHE (34/372)

TOR (17/438)

DRY (16/347)

WDH (46/223)

WRX (24/239)

WSH (17/304)

WWG (47/259)

YDH (40/367)

SHC (23/412)

SCU (16/231)

HRI (79/513)

HIN (24/158)

SAN (50/334)

KGH (37/334)

SGH (52/584)

NOR (70/817)

BRO (15/315)

WHC (10/297)

RDE (29/548)

NGS (12/537)

NTG (42/372)

TLF (28/182)

HOM (16/87)

WYB (16/131)

SDG (24/242)

COL (61/521)

BRI (43/342)

JPH (63/348)

WYT (29/273)

ESU (24/460)

SCA (32/269)

STR (33/375)

BRY (40/242)

SMV (53/387)

LGI (163/651)

PEH (14/54)

SCM (59/456)

WRG (45/452)

ENH (143/462)

CGH (34/279)

NPH (32/246)

PIN (10/526)

STO (145/509)

FGH (16/120)

SPH (11/387)

OLD (62/549)

HCH (79/268)

SOU (73/270)

DID (92/414)

BAT (66/512)

WES (28/116)

WHH (19/357)

RSC (20/426)

QEB (59/362)

MAC (29/236)

RLI (80/249)

BRD (122/271)

GEO (19/184)

0% 20% 40% 60% 80% 100%

Hospitals excluded where less than 10 patients suffered an undisplaced intercapsular fracture

Operations performed by fracture type.

Chart 15Undisplacedintracapsularfractures

There has been no change inthe proportion of patientshaving arthroplasties (47%).









Other (0.6%)


Unknown (0.2%)

0% 20% 40% 60% 80% 100%







Other (0.6%)


Unknown (0.2%)

Hos

pita

l (N

)

ALL

TGA (151/247)

KCH (58/126)

DID (146/414)

BLA (212/458)

RSS (134/344)

DER (264/503)

HCH (83/268)

QEB (123/362)

MPH (223/405)

SHH (190/382)

HOR (88/169)

PIN (293/526)

UHN (424/726)

NEV (118/272)

OHM (104/229)

CGH (138/279)

SAN (142/334)

HRI (279/513)

BED (65/148)

LGI (233/651)

RUS (257/468)

GRA (37/97)

STO (217/509)

QEQ (211/417)

WMU (103/178)

HIN (72/158)

WWG (106/259)

NUH (157/332)

ESU (236/460)

TLF (72/182)

ALT (172/362)

BOL (175/354)

WYB (66/131)

SDG (126/242)

RCH (187/555)

NTY (189/329)

ROT (134/283)

WRX (115/239)

AIR (111/249)

WHH (158/357)

MAC (46/236)

NHH (118/227)

STD (95/209)

LER (393/813)

BAT (244/512)

STR (185/375)

RBE (251/486)

DRY (165/347)

DVH (129/342)

YDH (170/367)

UHW (240/501)

LGH (156/283)

WHI (187/387)

NUN (118/249)

SAL (60/242)

RVN (199/425)

EBH (203/454)

HAR (79/231)

GHS (135/370)

RLU (155/355)

SUN (209/377)

RED (106/244)

SGH (311/584)

QAP (356/688)

WMH (161/317)

CLW (183/373)

LIN (171/347)

NDD (111/225)

PLY (270/501)

BAS (189/399)

STH (73/168)

RFH (100/196)

PIL (181/347)

WAT (184/379)

DGE (204/377)

SPH (206/387)

CMI (120/243)

CHS (97/210)

BFH (223/426)

BRG (40/87)

KMH (131/324)

GLO (194/384)

MAY (106/240)

NMH (57/122)

QKL (186/350)

TOR (211/438)

NTH (145/361)

BRD (35/271)

LON (40/123)

UHC (219/483)

PET (171/381)

OLD (341/549)

NGS (304/537)

CRG (57/130)

NWG (45/122)

WAR (102/273)

SOU (98/270)

WDH (86/223)

RSC (249/426)

NPH (98/246)

WYT (142/273)

TRA (24/121)

FGH (49/120)

CHE (192/372)

GWH (183/320)

VIC (81/403)

MDW (164/332)

WGH (56/268)

DAR (188/326)

PEH (22/54)

HIL (96/189)

WES (37/116)

GGH (113/265)

BRI (168/342)

BSL (48/169)

WDG (144/341)

ENH (107/462)

RVB (458/835)

LEW (87/165)

WRC (189/398)

CCH (46/103)

NOB (28/88)

IPS (238/419)

HUD (205/466)

SCM (228/456)

TUN (102/224)

AEI (135/319)

SCA (120/269)

RDE (290/548)

RPH (102/400)

COL (254/521)

BRY (95/242)

BRT (119/279)

RGH (72/174)

FRM (183/322)

RLI (62/249)

WIR (214/430)

GEO (64/184)

ADD (195/384)

BRO (173/315)

SCU (121/231)

GWY (86/191)

MKH (58/108)

NMG (60/157)

WSH (152/304)

LDH (138/249)

MOR (189/440)

STM (95/197)

SLF (85/206)

SHC (207/412)

JPH (140/348)

RSU (201/335)

RHC (111/234)

SMV (171/387)

ASH (182/330)

SEH (207/407)

WHC (151/297)

NTG (179/372)

KTH (159/332)

WRG (243/452)

HOM (25/87)

WEX (200/369)

KGH (157/334)

NOR (410/817)

PMS (206/407)

QEG (148/293)

FAZ (157/367)

FRY (216/417)

PGH (505/897)

COC (162/323)

NCR (191/379)

BAR (103/258)

WHT (54/133)

RAD (241/531)

PAH (133/308)

IOW (119/232)

BNT (132/302)

CHG (154/327)

UCL (17/112)

0% 20% 40% 60% 80% 100%

Hospitals excluded where less than 10 patients suffered a displaced intercapsular fracture

Chart 16 - Displaced intracapsular fractures

There has been no changein the proportion of patientshaving arthroplasties (93%).

NICE CG 124


Cemented (73.4%)

Uncemented (26.6%)

0% 20% 40% 60% 80% 100%

Cemented (73.4%)

Uncemented (26.6%)

Hos

pita

l (n/

N)

ALLBRY (108/242)

WHT (54/133)

FRM (181/322)

NWG (47/122)

BAR (124/258)

KMH (165/324)

PIN (259/526)

GHS (149/370)

BSL (76/169)

NEV (129/272)

BRO (166/315)

STH (91/168)

HIN (76/158)

OLD (283/549)

WWG (107/259)

LON (44/123)

PAH (132/308)

WDH (87/223)

WRX (111/239)

FGH (51/120)

RLI (123/249)

CHE (170/372)

DID (194/414)

WRC (191/398)

NTG (189/372)

ENH (190/462)

CHS (95/210)

YDH (170/367)

LGH (146/283)

NMG (65/157)

BAS (182/399)

WMH (161/317)

SMV (192/387)

NOR (427/817)

WEX (197/369)

BAT (276/512)

UCL (39/112)

MDW (153/332)

CCH (43/103)

SDG (125/242)

NOB (33/88)

NHH (112/227)

CMI (116/243)

WHC (148/297)

SOU (135/270)

COC (172/323)

PGH (501/897)

NUN (122/249)

LEW (93/165)

UHN (358/726)

JPH (162/348)

RLU (149/355)

WSH (149/304)

SAL (130/242)

MOR (228/440)

BLA (181/458)

RCH (300/555)

DAR (173/326)

DVH (176/342)

ADD (186/384)

RSU (190/335)

STM (95/197)

RFH (98/196)

DRY (161/347)

STD (93/209)

PLY (278/501)

SUN (200/377)

MAC (127/236)

MPH (180/405)

GEO (93/184)

TGA (97/247)

NTY (174/329)

WYT (133/273)

IPS (216/419)

WGH (126/268)

LER (384/813)

QEG (153/293)

BRI (167/342)

SGH (315/584)

ASH (175/330)

WIR (201/430)

TUN (110/224)

BOL (160/354)

DER (211/503)

BRG (41/87)

FRY (231/417)

MKH (58/108)

PET (110/381)

SCM (242/456)

WDG (178/341)

NMH (59/122)

STO (279/509)

SPH (206/387)

RBE (242/486)

RED (102/244)

SAN (168/334)

BNT (133/302)

WHI (199/387)

NCR (196/379)

RSS (111/344)

TLF (80/182)

EBH (195/454)

WAR (112/273)

SCU (119/231)

QAP (357/688)

HRI (266/513)

WMU (92/178)

RGH (80/174)

QEQ (204/417)

SEH (204/407)

HUD (205/466)

GLO (190/384)

LIN (184/347)

HOR (73/169)

GWH (163/320)

HOM (31/87)

NTH (176/361)

KGH (164/334)

CLW (183/373)

LDH (130/249)

OHM (110/229)

WYB (68/131)

RUS (241/468)

WAT (186/379)

GGH (109/265)

CHG (155/327)

RPH (93/400)

STR (188/375)

ROT (129/283)

WHH (166/357)

GWY (85/191)

TRA (51/121)

SCA (132/269)

SHC (203/412)

BRD (143/271)

BFH (220/426)

NDD (108/225)

RHC (112/234)

COL (263/521)

MAY (111/240)

AEI (127/319)

HCH (123/268)

AIR (127/249)

BED (58/148)

PMS (200/407)

QEB (144/362)

GRA (43/97)

ESU (226/460)

FAZ (158/367)

PEH (27/54)

DGE (227/377)

RSC (226/426)

IOW (122/232)

PIL (179/347)

QKL (191/350)

SHH (180/382)

NPH (101/246)

KCH (44/126)

CGH (137/279)

UHW (236/501)

NGS (233/537)

HIL (94/189)

BRT (135/279)

WRG (259/452)

TOR (212/438)

RAD (262/531)

HAR (106/231)

UHC (123/483)

LGI (301/651)

RVN (192/425)

VIC (102/403)

NUH (144/332)

ALT (180/362)

RDE (280/548)

CRG (49/130)

KTH (158/332)

MRI (73/164)

RVB (422/835)

SLF (82/206)

WES (54/116)

0% 20% 40% 60% 80% 100%

Includes all patients who underwent arthroplasty

Chart 17 - Cementing of arthroplasties

In 2010 the rate was 63%.This rose to 68.2% in 2011and is now 73.4%.The range remains 0-99%.

NICE CG 124



Total Hip Replacement (15.6%)

Other Operation (84.4%)

Unknown Operation (0.0%)

0% 20% 40% 60% 80% 100%

Total Hip Replacement (15.6%)


Unknown Operation (0.0%)

Hos

pita

l (n/

N)

ALL

HAR (24/231)

LER (90/813)

NWG (23/122)

WYB (21/131)

NUN (47/249)

PET (83/381)

WAT (56/379)

YDH (54/367)

COL (50/521)

KMH (46/324)

OLD (174/549)

STM (19/197)

ADD (73/384)

BNT (17/302)

WMU (50/178)

BRY (32/242)

SHH (32/382)

GWH (47/320)

LEW (44/165)

BRG (13/87)

SAL (39/242)

KGH (25/334)

BRT (60/279)

WYT (71/273)

GEO (11/184)

NOR (118/817)

HRI (117/513)

MPH (76/405)

ENH (46/462)

STO (64/509)

ASH (27/330)

BRO (78/315)

CHE (17/372)

PLY (101/501)

DER (109/503)

WRG (91/452)

BAT (104/512)

LDH (16/249)

DAR (38/326)

MAY (37/240)

SCM (73/456)

IOW (57/232)

CGH (41/279)

RVN (46/425)

RGH (13/174)

SUN (45/377)

FRM (83/322)

WAR (41/273)

RSS (66/344)

FAZ (74/367)

SMV (72/387)

DGE (85/377)

RCH (63/555)

FRY (94/417)

LGH (25/283)

STD (36/209)

RBE (107/486)

GRA (15/97)

NHH (50/227)

RLU (60/355)

CHG (43/327)

WGH (13/268)

PAH (53/308)

STH (36/168)

BOL (31/354)

RSC (95/426)

PMS (73/407)

WEX (12/369)

NCR (20/379)

WDG (19/341)

GLO (77/384)

BSL (14/169)

HUD (34/466)

NPH (18/246)

QEB (20/362)

SHC (101/412)

TUN (47/224)

DID (61/414)

RSU (54/335)

IPS (77/419)

DRY (50/347)

MDW (58/332)

BED (19/148)

LGI (37/651)

KTH (70/332)

UHC (100/483)

NTY (33/329)

CHS (16/210)

RUS (79/468)

QEQ (59/417)

VIC (27/403)

NUH (26/332)

MOR (63/440)

RFH (25/196)

SCU (24/231)

WHI (46/387)

WRC (11/398)

RVB (96/835)

QAP (124/688)

OHM (47/229)

BAS (64/399)

ESU (73/460)

EBH (18/454)

HOR (26/169)

TGA (17/247)

JPH (42/348)

PIL (92/347)

QEG (57/293)

HIN (24/158)

RHC (32/234)

PGH (112/897)

UHN (154/726)

TLF (29/182)

SPH (77/387)

DVH (54/342)

GGH (39/265)

GHS (45/370)

WHH (32/357)

PIN (97/526)

NEV (57/272)

WHC (11/297)

RDE (130/548)

RED (41/244)

SCA (44/269)

WWG (30/259)

AEI (59/319)

SAN (53/334)

WES (20/116)

RAD (68/531)

WRX (40/239)

WSH (68/304)

AIR (43/249)

BRI (66/342)

NTG (16/372)

ROT (43/283)

NGS (87/537)

MKH (18/108)

BLA (33/458)

SEH (15/407)

QKL (57/350)

COC (30/323)

STR (21/375)

NMH (32/122)

0% 20% 40% 60% 80% 100%

Eligible patients : Displaced intracapsular fracture, able to walk outdoors with less than one aid, AMTS>7, ASA Grade of 3 or less and received an operationHospitals with less than 10 eligible patients excluded

Chart 18 - Total hip replacement for displaced intracapsularfractures

NICE CG124 was published inJune 2011. Analysis of the NHFDdata from 2010-11 shows a‘compliance’ rate of 10.7%.This year’s rate of 15.6%suggests a rapid adoptionof the NICE criteria for totalhip replacement. However,the age distribution suggeststhat patients who are perceivedto have lower requirements formobility are less likely to beoffered a total hip replacement.

NICE CG 124


OverallN=7563

60−64n=327

65−69n=569

70−74n=878

75−79n=1370

80−84n=1922

85−89n=1608

90−94n=750

95+n=139

Age Group

% T

otal

Hip

Rep

lace

men

t

0

20

40

60

80

100

OverallN=7563

60−64n=327

65−69n=569

70−74n=878

75−79n=1370

80−84n=1922

85−89n=1608

90−94n=750

95+n=139


Total Hip Replacement (15.6%)%

Tot

al H

ip R

epla

cem

ent

0

20

40

60

80

100

Chart 19 - Provision of total hip replacement by age of patient



NICE CG 124

Internal fixationSHS (84.3%)

Internal fixationIM nail (long) (5.9%)

Internal fixationIM nail(short) (5.1%)

Internal fixationScrews (1.0%)

Arthroplasty (1.1%)


Unknown (0.2%)

Other (0.4%)

0% 20% 40% 60% 80% 100%





Arthroplasty (1.1%)


Unknown (0.2%)

Other (0.4%)

Hos

pita

l (N

)

ALLSAN (108/334)

BRT (107/279)

HIN (52/158)

NOR (272/817)

DID (144/414)

LEW (61/165)

WES (38/116)

GRA (42/97)

SOU (64/270)

FGH (41/120)

GGH (86/265)

LDH (44/249)

NMG (60/157)

LGH (91/283)

MAC (46/236)

LIN (79/347)

CMI (80/243)

SCM (146/456)

TRA (34/121)

DAR (72/326)

ENH (130/462)

RCH (153/555)

SEH (158/407)

EBH (183/454)

DRY (148/347)

HUD (174/466)

RAD (201/531)

HIL (69/189)

WYT (95/273)

ASH (122/330)

STM (77/197)

WHH (158/357)

CGH (82/279)

MDW (111/332)

PIN (167/526)

WHT (56/133)

SCU (85/231)

WGH (86/268)

SDG (88/242)

RLI (90/249)

FRY (126/417)

NCR (163/379)

UHC (167/483)

BED (34/148)

PAH (140/308)

PMS (147/407)

BRD (74/271)

FAZ (156/367)

BRG (40/87)

TOR (161/438)

WHI (125/387)

PLY (168/501)

LER (300/813)

KMH (87/324)

SCA (88/269)

SAL (89/242)

NEV (91/272)

NTH (94/361)

MAY (99/240)

BNT (153/302)

SHC (156/412)

UHW (160/501)

CHG (115/327)

BAT (176/512)

STH (60/168)

COC (123/323)

KGH (130/334)

STR (145/375)

GLO (155/384)

TUN (79/224)

IOW (87/232)

GWH (90/320)

RED (93/244)

NTY (99/329)

WSH (109/304)

WAT (116/379)

MPH (129/405)

JPH (137/348)

RLU (149/355)

WRG (154/452)

SPH (158/387)

PGH (314/897)

BOL (118/354)

DGE (108/377)

GWY (79/191)

MKH (34/108)

OHM (17/229)

PEH (14/54)

RPH (76/400)

WDH (51/223)

RSS (134/344)

NWG (54/122)

RSC (129/426)

BSL (73/169)

TLF (65/182)

WDG (95/341)

BRY (81/242)

GEO (69/184)

TGA (52/247)

QEQ (143/417)

SLF (86/206)

LON (60/123)

CLW (136/373)

NDD (76/225)

CRG (47/130)

CCH (48/103)

ESU (178/460)

NOB (33/88)

WMH (123/317)

RVN (109/425)

LGI (186/651)

WYB (39/131)

SGH (201/584)

RGH (61/174)

ALT (127/362)

RFH (66/196)

WRX (90/239)

HCH (70/268)

NHH (73/227)

ROT (98/283)

BFH (156/426)

AEI (133/319)

PIL (137/347)

QEG (111/293)

STD (84/209)

RDE (197/548)

DER (171/503)

BAS (176/399)

MOR (148/440)

VIC (92/403)

COL (160/521)

BAR (100/258)

RUS (134/468)

SUN (138/377)

BRI (106/342)

WRC (147/398)

AIR (76/249)

HAR (79/231)

HOM (40/87)

QKL (125/350)

NUH (126/332)

RVB (298/835)

WHC (129/297)

HRI (131/513)

UCL (44/112)

WWG (90/259)

NTG (139/372)

NUN (98/249)

WAR (101/273)

BLA (156/458)

NPH (106/246)

NMH (56/122)

DVH (115/342)

WMU (59/178)

HOR (61/169)

STO (123/509)

UHN (263/726)

WIR (153/430)

SMV (157/387)

GHS (159/370)

QAP (265/688)

CHS (93/210)

NGS (189/537)

SHH (103/382)

BRO (110/315)

WEX (125/369)

KTH (136/332)

IPS (142/419)

RBE (152/486)

PET (156/381)

QEB (167/362)

ADD (124/384)

CHE (130/372)

FRM (30/322)

KCH (47/126)

MRI (39/164)

OLD (112/549)

RHC (83/234)

RSU (117/335)

YDH (132/367)

0% 20% 40% 60% 80% 100%

Chart 20 - Intertrochanteric fractures

The percentage of patientsreported as having a clinicallyunlikely cannulated screwfixation has fallen from1.9% to 1.0%. This maybe an effect of improvedcoding. The percentage ofsliding hip screws remains at 84%.






Arthroplasty (1.0%)


Unknown (0.1%)

Other (2.2%)

0% 20% 40% 60% 80% 100%





Arthroplasty (1.0%)


Unknown (0.1%)

Other (2.2%) Hos

pita

l (N

)

ALL

TLF (10/182)

GWY (11/191)

WDG (24/341)

SCA (21/269)

WEX (27/369)

DID (23/414)

NTG (12/372)

RHC (19/234)

SOU (13/270)

WRC (14/398)

BAT (22/512)

NMG (15/157)

BRY (23/242)

NGS (31/537)

SHH (17/382)

SGH (19/584)

ROT (21/283)

GHS (11/370)

ENH (34/462)

CGH (24/279)

QKL (12/350)

WIR (37/430)

QEQ (13/417)

UHW (28/501)

NEV (14/272)

STD (15/209)

WWG (15/259)

HUD (36/466)

NOR (55/817)

RVN (78/425)

KMH (20/324)

DER (41/503)

WHI (23/387)

FAZ (24/367)

RSC (24/426)

STO (24/509)

LGI (57/651)

MOR (35/440)

RUS (41/468)

AEI (13/319)

BAR (19/258)

BNT (14/302)

BRD (11/271)

CHE (15/372)

CLW (11/373)

DGE (25/377)

GEO (10/184)

HRI (20/513)

IPS (14/419)

LIN (10/347)

NDD (15/225)

NOB (10/88)

NUN (11/249)

PAH (19/308)

PMS (25/407)

QEB (12/362)

RAD (26/531)

RFH (12/196)

RLI (11/249)

RSU (13/335)

SAL (13/242)

SPH (12/387)

STR (10/375)

TGA (11/247)

WAT (40/379)

WES (11/116)

WHH (14/357)

WRG (10/452)

WSH (21/304)

BSL (12/169)

CMI (11/243)

ESU (18/460)

PIN (42/526)

BRO (16/315)

BRT (11/279)

LER (35/813)

DAR (19/326)

RSS (13/344)

SCM (20/456)

RCH (36/555)

ASH (15/330)

UCL (15/112)

HCH (23/268)

RED (16/244)

LGH (28/283)

STH (10/168)

EBH (22/454)

LDH (22/249)

RBE (47/486)

DVH (24/342)

UHN (36/726)

NWG (13/122)

TUN (13/224)

BFH (28/426)

FRY (30/417)

WMH (15/317)

NTH (16/361)

NUH (18/332)

ALT (19/362)

GWH (20/320)

SEH (20/407)

PGH (23/897)

BLA (24/458)

MPH (24/405)

SHC (24/412)

TOR (48/438)

CHG (35/327)

UHC (40/483)

ADD (24/384)

AIR (17/249)

BED (15/148)

BOL (25/354)

BRI (15/342)

CHS (13/210)

COL (39/521)

DRY (13/347)

HAR (18/231)

IOW (20/232)

KTH (24/332)

MDW (18/332)

NHH (11/227)

NTY (23/329)

OLD (33/549)

PLY (27/501)

QAP (24/688)

QEG (15/293)

RDE (32/548)

RGH (12/174)

RLU (22/355)

RVB (31/835)

SAN (16/334)

STM (13/197)

SUN (14/377)

WAR (17/273)

WDH (12/223)

WGH (13/268)

WHT (15/133)

WRX (10/239)

YDH (24/367)

0% 20% 40% 60% 80% 100%

Hospitals excluded where less than 10 patients suffered a subtrochanteric fracture

Chart 21 - Subtrochanteric fractures

The percentage of patientsreported as having clinicallyunlikely cannulated screwfixation has fallen from1.2% to 0.4%, againsuggesting an improvementin coding. The percentage ofsliding hip screws remainsconstant at 26%.

NICE CG 124



Pressure Ulcers (3.5%)

No Pressure Ulcers (90.0%)

Unknown (6.5%)

0% 20% 40% 60% 80% 100%

Pressure Ulcers (3.5%)

No Pressure Ulcers (90.0%)

Unknown (6.5%) Hos

pita

l (n/

N)

ALLLEW (140/165)

RED (227/244)

TLF (166/182)

WMU (161/178)

BAT (473/512)

YDH (344/367)

BRD (241/271)

TGA (217/247)

WHI (344/387)

HIN (149/158)

NTY (286/329)

BED (138/148)

QEQ (380/417)

BRT (250/279)

CGH (244/279)

LGI (594/651)

RBE (449/486)

TRA (105/121)

TOR (414/438)

CHG (303/327)

WRG (398/452)

STM (187/197)

ADD (366/384)

GWY (173/191)

OLD (494/549)

RVB (770/835)

SGH (530/584)

ASH (293/330)

MAC (213/236)

BNT (268/302)

RSS (327/344)

LIN (312/347)

QAP (643/688)

ENH (398/462)

KCH (110/126)

STO (490/509)

UHW (422/501)

UHN (666/726)

MOR (390/440)

IPS (389/419)

NTH (333/361)

BLA (410/458)

JPH (317/348)

PGH (848/897)

IOW (215/232)

WAR (251/273)

HUD (409/466)

DER (479/503)

BAS (366/399)

CMI (224/243)

PIN (479/526)

SDG (220/242)

RSU (311/335)

WDH (210/223)

ESU (415/460)

OHM (203/229)

RAD (499/531)

GHS (329/370)

RCH (515/555)

STR (346/375)

SLF (184/206)

BFH (394/426)

SPH (358/387)

RVN (374/425)

NOR (764/817)

WDG (317/341)

NDD (195/225)

UCL (105/112)

BOL (303/354)

CLW (318/373)

COL (473/521)

BRY (223/242)

WHT (123/133)

BRG (87/87)

PEH (48/54)

BSL (158/169)

CCH (90/103)

WYB (119/131)

QEG (260/293)

BRI (313/342)

HOM (76/87)

BRO (281/315)

WES (102/116)

NGS (487/537)

RSC (395/426)

QEB (328/362)

COC (282/323)

WGH (253/268)

PAH (283/308)

NUN (231/249)

NOB (83/88)

SOU (255/270)

WAT (342/379)

WRC (372/398)

GLO (345/384)

GWH (297/320)

PLY (471/501)

SMV (361/387)

RGH (158/174)

KMH (291/324)

SCM (425/456)

VIC (389/403)

RPH (376/400)

BAR (244/258)

SCA (241/269)

RLI (225/249)

RLU (322/355)

RDE (518/548)

KTH (308/332)

MKH (100/108)

CHS (187/210)

MPH (372/405)

UHC (437/483)

GEO (165/184)

DRY (316/347)

KGH (306/334)

DAR (298/326)

SAL (219/242)

PET (353/381)

WHC (265/297)

CRG (129/130)

WWG (241/259)

NMH (114/122)

WRX (224/239)

LON (110/123)

QKL (321/350)

PIL (310/347)

DGE (354/377)

CHE (341/372)

WYT (243/273)

WHH (319/357)

NPH (227/246)

GRA (90/97)

RFH (177/196)

SAN (301/334)

AIR (227/249)

DID (371/414)

FAZ (330/367)

AEI (278/319)

FRM (288/322)

ROT (254/283)

HAR (219/231)

NEV (241/272)

HRI (475/513)

MRI (147/164)

WMH (286/317)

SCU (220/231)

HIL (163/189)

NCR (347/379)

SEH (372/407)

NTG (337/372)

LER (741/813)

SHH (354/382)

LGH (257/283)

PMS (367/407)

STD (181/209)

WEX (337/369)

NHH (207/227)

WSH (281/304)

MDW (297/332)

HOR (149/169)

DVH (299/342)

RHC (210/234)

RUS (423/468)

STH (160/168)

ALT (341/362)

SHC (375/412)

FGH (113/120)

GGH (239/265)

TUN (207/224)

NMG (135/157)

HCH (247/268)

SUN (332/377)

FRY (380/417)

NWG (110/122)

NUH (300/332)

LDH (201/249)

WIR (389/430)

EBH (397/454)

MAY (217/240)

0% 20% 40% 60% 80% 100%

Excludes patients who died in hospital

Chart 22 - Development of pressure ulcers (Blue Book Standard 3)

The incidence of pressureulcers (3.7%) remainsunchanged from 2011;but the rate of ‘unknown’has fallen from 9.3% to6.5%, suggesting thathospitals are recognisingthe importance of thiscomplication.

NICE CG 124


In response to the challenge of BPT, the StHelier, Carshalton, trauma service establisheda 23-bed hip fracture unit with a full-timeorthogeriatrician and junior medical staff. Allpatients come under the joint care of bothorthogeriatric and orthopaedic teamsthroughout their acute stay. With the firsttwo slots on the trauma list each morningreserved for hip fracture, average time totheatre has fallen to 24 hours. In the last 12months 100% of patients have hadpreoperative, bone health and specialist fallsassessment. Over two years pressure ulcerincidence fell from 17% to 6.2%. Mortalitytoo has fallen: from 17% in Q1 2011/2012to 7.4% in Q4. BPT attainment has risenfrom 0% over Q1-Q3 2010/2011 to 92% inQ4 2011/2012.



Already under care of geriatrician/physician (6.7%)

Routine by geriatrician (42.5%)

Routine by physician (11.9%)

Routine by specialist nurse (8.0%)

Medical reviewfollowing request (2.2%)

No assessment (28.1%)

Unknown (0.6%)

0% 20% 40% 60% 80% 100%

Already under care of geriatrician/physician (6.7%)

Routine by geriatrician (42.5%)

Routine by physician (11.9%)

Routine by specialist nurse (8.0%)

Medical reviewfollowing request (2.2%)


Unknown (0.6%)

Hos

pita

l (N

)

ALLRPH (400)

LIN (347)

CGH (279)

PEH (54)

TUN (224)

CLW (373)

SDG (242)

WDG (341)

HAR (231)

SEH (407)

CMI (243)

DER (503)

HCH (268)

RLI (249)

BRG (87)

CRG (130)

WHI (387)

YDH (367)

SCM (456)

WEX (369)

MPH (405)

QEG (293)

RVN (425)

BLA (458)

RSC (426)

KCH (126)

STH (168)

JPH (348)

WMH (317)

LON (123)

GLO (384)

GGH (265)

DAR (326)

WIR (430)

NGS (537)

BRI (342)

NCR (379)

SUN (377)

MAY (240)

FAZ (367)

SCU (231)

RLU (355)

ESU (460)

SMV (387)

RAD (531)

UHW (501)

WRX (239)

RFH (196)

EBH (454)

HOR (169)

STO (509)

CHG (327)

COC (323)

LEW (165)

SPH (387)

NOB (88)

SGH (584)

RUS (468)

ENH (462)

ADD (384)

IOW (232)

LER (813)

PIL (347)

MDW (332)

SAL (242)

MAC (236)

GHS (370)

NWG (122)

CCH (103)

NMH (122)

DID (414)

TOR (438)

WHC (297)

RED (244)

KMH (324)

TGA (247)

LGI (651)

WDH (223)

QAP (688)

PGH (897)

CHE (372)

BRD (271)

CHS (210)

FRM (322)

KTH (332)

PAH (308)

PLY (501)

RHC (234)

SOU (270)

WMU (178)

NDD (225)

ALT (362)

MKH (108)

HIN (158)

NTH (361)

BRT (279)

KGH (334)

WYB (131)

TLF (182)

WRC (398)

LDH (249)

NMG (157)

NTY (329)

WGH (268)

MRI (164)

SCA (269)

NOR (817)

BED (148)

WHT (133)

SLF (206)

NTG (372)

VIC (403)

RSU (335)

AEI (319)

HIL (189)

DRY (347)

BRY (242)

BAR (258)

NUN (249)

GRA (97)

LGH (283)

UCL (112)

DVH (342)

ASH (330)

BOL (354)

GWY (191)

NEV (272)

BAT (512)

TRA (121)

RDE (548)

STR (375)

BAS (399)

QEB (362)

AIR (249)

PMS (407)

NHH (227)

RBE (486)

FRY (417)

WSH (304)

NUH (332)

QKL (350)

IPS (419)

HUD (466)

BFH (426)

SHH (382)

STD (209)

HOM (87)

COL (521)

UHC (483)

BSL (169)

GEO (184)

WHH (357)

WES (116)

WRG (452)

QEQ (417)

WWG (259)

WAR (273)

MOR (440)

RVB (835)

SAN (334)

WAT (379)

RCH (555)

FGH (120)

NPH (246)

UHN (726)

HRI (513)

PIN (526)

OHM (229)

ROT (283)

RSS (344)

BNT (302)

BRO (315)

DGE (377)

GWH (320)

OLD (549)

PET (381)

RGH (174)

SHC (412)

STM (197)

WYT (273)

0% 20% 40% 60% 80% 100%

Patients are included under the highest level of assessment which they received. Levels are plotted in the hierarchical order

Chart 23 - Preoperative medical assessments (Blue Book Standard 4)

In 2010 the reported rate ofroutine preoperative reviewby a geriatrician was 31%.This rose to 37% in 2011and is now 42%. The rangeremains 0-100%.The option ’Routine byphysician’ is intended tocapture review by aphysician at ST3 level�

or above, rather than by afoundation grade doctor�,as has been the case in aminority of units. In BPT terms,this would be misleading.


In Carmarthen a change programme initiated by orthopaedic surgeons, supported by management and led by an enthusiastic orthogeriatrician set up a 15-bed acute hip fracture unit - the first in Wales - in a former medical ward in June 2011. With a full-time orthogeriatrician supported by junior staff, a specialist trauma nurse, a fast-track A&E protocol, new procedures to ensure 7-day preoperative assessments, multidisciplinary teamwork, and routine cognitive assessment, falls assessment and osteoporosis assessment, care improved, with a 1% fall in mortality, and a reduction in average acute stay from 16 to 14 days. Improved training opportunities arose, with orthopaedic and medical juniors working well together, and effective team working resulting in improved morale.



On bone protectionmedication at admission (11.3%)

Not on bone protectionmedication at admission (87.8%)

Unknown (0.9%)

Bone protection medication at admission

0% 20% 40% 60% 80% 100%

On bone protectionmedication at admission (11.3%)

Not on bone protectionmedication at admission (87.8%)

Unknown (0.9%)

Bone protection medication at admission

Hos

pita

l (N

)

ALLLIN (347)

BRT (279)

HOR (169)

OLD (549)

HIN (158)

TRA (121)

QEQ (417)

GRA (97)

MRI (164)

MPH (405)

COL (521)

PIN (526)

BRY (242)

PLY (501)

RVB (835)

GHS (370)

SLF (206)

BED (148)

JPH (348)

EBH (454)

AEI (319)

TOR (438)

YDH (367)

BOL (354)

NWG (122)

UHC (483)

BRD (271)

SHH (382)

MAY (240)

NUN (249)

LON (123)

SCU (231)

WSH (304)

RLI (249)

PGH (897)

SMV (387)

DVH (342)

IOW (232)

UHW (501)

OHM (229)

QEB (362)

WAR (273)

STR (375)

ROT (283)

FAZ (367)

TUN (224)

NGS (537)

WRX (239)

NUH (332)

NOR (817)

RBE (486)

NHH (227)

RSC (426)

WDH (223)

BRG (87)

RCH (555)

GLO (384)

FRY (417)

RFH (196)

DER (503)

IPS (419)

ASH (330)

KGH (334)

RLU (355)

CLW (373)

STM (197)

AIR (249)

SCM (456)

ADD (384)

HOM (87)

STH (168)

HCH (268)

NEV (272)

NTY (329)

WYT (273)

TGA (247)

RGH (174)

DAR (326)

SEH (407)

ALT (362)

MAC (236)

WEX (369)

NDD (225)

CCH (103)

STO (509)

RDE (548)

COC (323)

UCL (112)

RVN (425)

NOB (88)

SOU (270)

CGH (279)

PIL (347)

FGH (120)

WHC (297)

VIC (403)

NMH (122)

GGH (265)

GEO (184)

BSL (169)

NPH (246)

WHH (357)

SDG (242)

WWG (259)

CHE (372)

BAS (399)

SPH (387)

BFH (426)

MOR (440)

NTG (372)

TLF (182)

WGH (268)

SAL (242)

PMS (407)

BLA (458)

QAP (688)

WMH (317)

WRC (398)

MKH (108)

NTH (361)

SAN (334)

WYB (131)

LDH (249)

SCA (269)

LGH (283)

RUS (468)

DGE (377)

FRM (322)

ESU (460)

WRG (452)

MDW (332)

QKL (350)

NCR (379)

ENH (462)

CMI (243)

BAR (258)

DRY (347)

BRO (315)

UHN (726)

CHG (327)

RSU (335)

RHC (234)

RPH (400)

GWY (191)

PAH (308)

BAT (512)

BRI (342)

WIR (430)

KMH (324)

WHT (133)

HAR (231)

WAT (379)

WDG (341)

KTH (332)

SGH (584)

RAD (531)

WHI (387)

LER (813)

CHS (210)

RSS (344)

RED (244)

LEW (165)

HIL (189)

SUN (377)

NMG (157)

PEH (54)

SHC (412)

GWH (320)

PET (381)

HUD (466)

CRG (130)

DID (414)

HRI (513)

LGI (651)

QEG (293)

KCH (126)

STD (209)

BNT (302)

WES (116)

WMU (178)

0% 20% 40% 60% 80% 100%

Chart 24 - Bone protection medication at admission

There has been no changein the proportion of patientsadmitted on bone protectionsince the 2011 Report.


Continued from pre−admission (11.6%)

Started on this admission (57.2%)

Awaits DXA Scan (6.6%)

Awaits bone clinicassessment (2.6%)

Assessed − no boneprotection medicationneeded/appropriate (14.2%)


Unknown (0.9%)

0% 20% 40% 60% 80% 100%

Continued from pre−admission (11.6%)

Started on this admission (57.2%)

Awaits DXA Scan (6.6%)

Awaits bone clinicassessment (2.6%)

Assessed − no boneprotection medicationneeded/appropriate (14.2%)


Unknown (0.9%)

Hos

pita

l (n/

N)

ALLSOU (255/270)

ALT (341/362)

CGH (244/279)

NOB (83/88)

HAR (219/231)

LON (110/123)

WRC (372/398)

LDH (201/249)

WMH (286/317)

RLI (225/249)

BRD (241/271)

CHE (341/372)

NEV (241/272)

HCH (247/268)

MKH (100/108)

MOR (390/440)

HIN (149/158)

CMI (224/243)

WEX (337/369)

WDG (317/341)

MDW (297/332)

NUH (300/332)

MAC (213/236)

SCA (241/269)

MPH (372/405)

BAT (473/512)

BOL (303/354)

WGH (253/268)

BRO (281/315)

BRI (313/342)

SDG (220/242)

EBH (397/454)

PEH (48/54)

NOR (764/817)

HOM (76/87)

TGA (217/247)

GEO (165/184)

JPH (317/348)

HIL (163/189)

GGH (239/265)

GHS (329/370)

WHI (344/387)

STH (160/168)

QEQ (380/417)

RSU (311/335)

CLW (318/373)

NTG (337/372)

SAN (301/334)

PLY (471/501)

QKL (321/350)

KCH (110/126)

FRM (288/322)

STO (490/509)

MRI (147/164)

BSL (158/169)

GLO (345/384)

RFH (177/196)

HRI (475/513)

LIN (312/347)

BRY (223/242)

SMV (361/387)

OLD (494/549)

WRG (398/452)

CHG (303/327)

WAT (342/379)

NHH (207/227)

NUN (231/249)

ROT (254/283)

QEG (260/293)

DID (371/414)

DER (479/503)

PGH (848/897)

AEI (278/319)

BAS (366/399)

CCH (90/103)

FGH (113/120)

GWY (173/191)

IOW (215/232)

LEW (140/165)

PET (353/381)

PIN (479/526)

RBE (449/486)

RHC (210/234)

RVN (374/425)

SHC (375/412)

STD (181/209)

SUN (332/377)

WAR (251/273)

WHC (265/297)

WYT (243/273)

GRA (90/97)

NMG (135/157)

KGH (306/334)

CRG (129/130)

NTH (333/361)

VIC (389/403)

WRX (224/239)

HUD (409/466)

RVB (770/835)

BED (138/148)

WYB (119/131)

NDD (195/225)

RGH (158/174)

LER (741/813)

BAR (244/258)

WDH (210/223)

SEH (372/407)

LGI (594/651)

TLF (166/182)

RSS (327/344)

TUN (207/224)

BFH (394/426)

MAY (217/240)

UCL (105/112)

NPH (227/246)

DRY (316/347)

SHH (354/382)

DAR (298/326)

DVH (299/342)

WIR (389/430)

OHM (203/229)

COL (473/521)

SCU (220/231)

STR (346/375)

TOR (414/438)

QEB (328/362)

WWG (241/259)

LGH (257/283)

SCM (425/456)

KMH (291/324)

SLF (184/206)

UHN (666/726)

UHW (422/501)

DGE (354/377)

RAD (499/531)

COC (282/323)

NGS (487/537)

ESU (415/460)

PMS (367/407)

RPH (376/400)

RSC (395/426)

BLA (410/458)

UHC (437/483)

AIR (227/249)

WMU (161/178)

BRG (87/87)

PAH (283/308)

IPS (389/419)

NWG (110/122)

NCR (347/379)

WHT (123/133)

SGH (530/584)

NTY (286/329)

FAZ (330/367)

FRY (380/417)

RUS (423/468)

BRT (250/279)

RCH (515/555)

WHH (319/357)

ENH (398/462)

RDE (518/548)

ADD (366/384)

ASH (293/330)

BNT (268/302)

CHS (187/210)

GWH (297/320)

HOR (149/169)

KTH (308/332)

NMH (114/122)

PIL (310/347)

QAP (643/688)

RED (227/244)

RLU (322/355)

SAL (219/242)

SPH (358/387)

STM (187/197)

TRA (105/121)

WES (102/116)

WSH (281/304)

YDH (344/367)

0% 20% 40% 60% 80% 100%

Excludes patients who died in hospitalPatients are included under the highest level of bone health assesment which they received. Levels are plotted in the hierarchical order

Chart 25 - Bone health assessment and treatment at discharge(Blue Book Standard 5)

94% of patients receivedassessment for boneprotection, with medicationwhere appropriate prescribedprior to discharge (up from 87%)This is likely to be a result of thestimulus of BPT.



Yes − performed onthis admission (81.0%)

Yes − awaits fallsclinic assessment (3.9%)

Yes − further interventionnot appropriate (4.8%)

No falls assessment (7.9%)

Unknown (2.4%)

0% 20% 40% 60% 80% 100%

Yes − performed onthis admission (81.0%)

Yes − awaits fallsclinic assessment (3.9%)

Yes − further interventionnot appropriate (4.8%)

No falls assessment (7.9%)

Unknown (2.4%)

Hos

pita

l (n/

N)

ALLALT (341/362)

HIN (149/158)

CLW (318/373)

GRA (90/97)

SDG (220/242)

PEH (48/54)

LON (110/123)

CRG (129/130)

CGH (244/279)

BRY (223/242)

LDH (201/249)

RGH (158/174)

WWG (241/259)

DGE (354/377)

BED (138/148)

WDH (210/223)

HIL (163/189)

CHE (341/372)

MKH (100/108)

SEH (372/407)

KCH (110/126)

EBH (397/454)

LER (741/813)

RLI (225/249)

WIR (389/430)

NCR (347/379)

RAD (499/531)

IOW (215/232)

SCA (241/269)

WMU (161/178)

BRT (250/279)

NPH (227/246)

DAR (298/326)

MPH (372/405)

UHN (666/726)

UHW (422/501)

NOR (764/817)

MAY (217/240)

MAC (213/236)

GEO (165/184)

JPH (317/348)

RSU (311/335)

SMV (361/387)

NOB (83/88)

RFH (177/196)

MRI (147/164)

STH (160/168)

TGA (217/247)

DER (479/503)

ESU (415/460)

QEQ (380/417)

QEB (328/362)

LGH (257/283)

SGH (530/584)

COC (282/323)

PIL (310/347)

TRA (105/121)

NWG (110/122)

WHT (123/133)

WSH (281/304)

CHG (303/327)

HRI (475/513)

FRY (380/417)

SCM (425/456)

WAR (251/273)

WHC (265/297)

RSS (327/344)

ENH (398/462)

ADD (366/384)

ASH (293/330)

BLA (410/458)

BSL (158/169)

CHS (187/210)

FAZ (330/367)

FRM (288/322)

IPS (389/419)

NHH (207/227)

NUN (231/249)

PET (353/381)

PMS (367/407)

RBE (449/486)

RDE (518/548)

RHC (210/234)

RUS (423/468)

SAL (219/242)

SPH (358/387)

STM (187/197)

UHC (437/483)

WES (102/116)

WYT (243/273)

BRG (87/87)

HUD (409/466)

TUN (207/224)

NMG (135/157)

NTH (333/361)

HAR (219/231)

PLY (471/501)

CMI (224/243)

WYB (119/131)

VIC (389/403)

BOL (303/354)

NUH (300/332)

WMH (286/317)

BAR (244/258)

NEV (241/272)

BRO (281/315)

KMH (291/324)

TOR (414/438)

TLF (166/182)

HCH (247/268)

MOR (390/440)

WGH (253/268)

UCL (105/112)

SAN (301/334)

WEX (337/369)

KGH (306/334)

QKL (321/350)

OHM (203/229)

LGI (594/651)

MDW (297/332)

BAT (473/512)

STR (346/375)

DVH (299/342)

WRX (224/239)

BRD (241/271)

COL (473/521)

WHI (344/387)

GGH (239/265)

SLF (184/206)

DRY (316/347)

HOM (76/87)

RSC (395/426)

NGS (487/537)

RVB (770/835)

NTG (337/372)

SHH (354/382)

RPH (376/400)

STO (490/509)

GHS (329/370)

AIR (227/249)

RLU (322/355)

SOU (255/270)

GLO (345/384)

WRC (372/398)

GWH (297/320)

BRI (313/342)

WHH (319/357)

WAT (342/379)

OLD (494/549)

NTY (286/329)

KTH (308/332)

GWY (173/191)

NDD (195/225)

SCU (220/231)

QEG (260/293)

LIN (312/347)

BAS (366/399)

PGH (848/897)

AEI (278/319)

BFH (394/426)

BNT (268/302)

CCH (90/103)

DID (371/414)

FGH (113/120)

HOR (149/169)

LEW (140/165)

NMH (114/122)

PAH (283/308)

PIN (479/526)

QAP (643/688)

RCH (515/555)

RED (227/244)

ROT (254/283)

RVN (374/425)

SHC (375/412)

STD (181/209)

SUN (332/377)

WDG (317/341)

WRG (398/452)

YDH (344/367)

0% 20% 40% 60% 80% 100%

Excludes patients who died in hospital

Chart 26 - Specialist falls assessment (Blue Book Standard 6)

The proportion of patientshaving falls assessment bythe time of discharge is 92%,up from 81% in 2011.This is likely to be a resultof the stimulus of BPT.


Both assessments (86.2%)

Bone protectionassessment only (4.8%)

Falls assessment only (3.3%)

No assessments (3.1%)

Unknown (2.6%)

0% 20% 40% 60% 80% 100%

Both assessments (86.2%)

Bone protectionassessment only (4.8%)

Falls assessment only (3.3%)

No assessments (3.1%)

Unknown (2.6%)

Hos

pita

l (n/

N)

ALLALT (341/362)

GRA (90/97)

SOU (255/270)

CLW (318/373)

NMG (135/157)

SDG (220/242)

HAR (219/231)

PEH (48/54)

PLY (471/501)

NOB (83/88)

WYB (119/131)

WRC (372/398)

BRY (223/242)

BOL (303/354)

WRX (224/239)

WDH (210/223)

WMH (286/317)

RVB (770/835)

BED (138/148)

DGE (354/377)

BRD (241/271)

CHE (341/372)

NDD (195/225)

KMH (291/324)

SEH (372/407)

KCH (110/126)

EBH (397/454)

UCL (105/112)

SAN (301/334)

MDW (297/332)

WDG (317/341)

WIR (389/430)

RAD (499/531)

MAY (217/240)

OHM (203/229)

IOW (215/232)

STR (346/375)

WMU (161/178)

NPH (227/246)

BAT (473/512)

SHH (354/382)

UHN (666/726)

GGH (239/265)

COL (473/521)

QEB (328/362)

STH (160/168)

HOM (76/87)

GEO (165/184)

LGH (257/283)

NTG (337/372)

NGS (487/537)

QEQ (380/417)

RSC (395/426)

COC (282/323)

RFH (177/196)

DER (479/503)

STO (490/509)

AIR (227/249)

BLA (410/458)

WHT (123/133)

LIN (312/347)

WHH (319/357)

OLD (494/549)

PAH (283/308)

IPS (389/419)

PIL (310/347)

WAT (342/379)

QEG (260/293)

WSH (281/304)

CHG (303/327)

FAZ (330/367)

NHH (207/227)

NUN (231/249)

ROT (254/283)

WHC (265/297)

DID (371/414)

PGH (848/897)

ADD (366/384)

ASH (293/330)

CCH (90/103)

FGH (113/120)

LEW (140/165)

PET (353/381)

QAP (643/688)

RED (227/244)

RVN (374/425)

SHC (375/412)

STD (181/209)

SUN (332/377)

WYT (243/273)

BRG (87/87)

HIN (149/158)

HUD (409/466)

TUN (207/224)

CRG (129/130)

NTH (333/361)

CGH (244/279)

LON (110/123)

KGH (306/334)

CMI (224/243)

VIC (389/403)

LDH (201/249)

NUH (300/332)

RGH (158/174)

RLI (225/249)

MKH (100/108)

BAR (244/258)

WWG (241/259)

NEV (241/272)

LER (741/813)

BRO (281/315)

HCH (247/268)

HIL (163/189)

TLF (166/182)

WEX (337/369)

TOR (414/438)

MOR (390/440)

LGI (594/651)

WGH (253/268)

MAC (213/236)

RSS (327/344)

NCR (347/379)

BFH (394/426)

SCA (241/269)

QKL (321/350)

DVH (299/342)

MPH (372/405)

BRT (250/279)

DAR (298/326)

DRY (316/347)

UHW (422/501)

BRI (313/342)

WHI (344/387)

TGA (217/247)

SCU (220/231)

NOR (764/817)

GHS (329/370)

SCM (425/456)

JPH (317/348)

SLF (184/206)

MRI (147/164)

RSU (311/335)

SMV (361/387)

ESU (415/460)

PMS (367/407)

RPH (376/400)

NWG (110/122)

FRM (288/322)

SGH (530/584)

UHC (437/483)

BSL (158/169)

RLU (322/355)

GLO (345/384)

HRI (475/513)

GWH (297/320)

TRA (105/121)

FRY (380/417)

WRG (398/452)

NTY (286/329)

KTH (308/332)

GWY (173/191)

RUS (423/468)

WAR (251/273)

RCH (515/555)

BAS (366/399)

ENH (398/462)

RDE (518/548)

AEI (278/319)

BNT (268/302)

CHS (187/210)

HOR (149/169)

NMH (114/122)

PIN (479/526)

RBE (449/486)

RHC (210/234)

SAL (219/242)

SPH (358/387)

STM (187/197)

WES (102/116)

YDH (344/367)

0% 20% 40% 60% 80% 100%

Excludes patients who died in hospital. 'Unknown' includes any patients with one or more unknown assessment

Chart 27 - Secondary prevention overview

97% of patients now havesecondary preventionassessments by the timeof discharge: up from 94%in 2011. This is likely to bea result of the stimulus of BPT.



MOR (343/440)RGH (143/174)UHW (390/501)RVN (379/425)CLW (327/373)GWY (162/191)EBH (427/454)WRX (216/239)FGH (108/120)MRI (148/164)STD (192/209)

WAR (248/273)NWG (109/122)NTH (334/361)KCH (80/126)

BRO (168/315)TRA (114/121)KMH (300/324)UHC (450/483)GWH (264/320)ASH (301/330)

LON (95/123)BRI (290/342)

OLD (498/549)NMG (143/157)QEB (308/362)WYT (228/273)NGS (514/537)FAZ (336/367)

CHE (346/372)MAY (204/240)NEV (192/272)ALT (316/362)

SAN (320/334)DRY (319/347)TLF (162/182)LDH (174/249)CRG (72/130)

HOR (155/169)HIN (100/158)VIC (265/403)

MAC (215/236)WIR (392/430)TUN (217/224)SUN (351/377)KGH (317/334)WHI (361/387)DID (384/414)NTY (294/329)SHH (346/382)SDG (230/242)

PEH (49/54)HUD (420/466)COC (220/323)FRY (382/417)GHS (348/370)OHM (209/229)

RLI (246/249)HIL (167/189)

RHC (214/234)RPH (372/400)SPH (364/387)NUH (312/332)RUS (426/468)UCL (110/112)WYB (120/131)WRG (429/452)FRM (295/322)NTG (354/372)SHC (398/412)ROT (265/283)QEQ (395/417)JPH (311/348)

BRG (70/87)LGI (606/651)HOM (71/87)

TOR (402/438)CGH (269/279)RSU (288/335)WES (96/116)

NDD (186/225)IOW (223/232)

WMH (293/317)RSC (402/426)DAR (307/326)CCH (99/103)

BLA (429/458)NUN (217/249)MKH (105/108)WMU (169/178)ENH (449/462)BAS (376/399)RLU (334/355)LEW (158/165)WDG (324/341)

AEI (306/319)BOL (325/354)SAL (232/242)

WGH (261/268)GEO (153/184)

WWG (148/259)QEG (277/293)ESU (435/460)

WHH (341/357)MDW (272/332)BED (115/148)QAP (664/688)WHT (119/133)HAR (157/231)DVH (309/342)HRI (484/513)

NPH (183/246)TGA (218/247)

WRC (361/398)LGH (281/283)RVB (765/835)YDH (357/367)BNT (278/302)BRT (257/279)PET (362/381)DGE (348/377)SCM (433/456)BRY (202/242)PMS (387/407)NHH (216/227)

LIN (317/347)WEX (342/369)BAR (243/258)PIL (324/347)

SOU (252/270)UHN (689/726)STH (157/168)SEH (377/407)PIN (501/526)

WAT (360/379)BRD (252/271)RED (227/244)PAH (296/308)

NOB (63/88)CHS (193/210)WSH (287/304)STM (178/197)RBE (462/486)NMH (87/122)BFH (404/426)IPS (395/419)

NOR (772/817)SCA (246/269)SMV (334/387)ADD (360/384)RSS (328/344)

WHC (275/297)SGH (549/584)GLO (358/384)NCR (366/379)KTH (319/332)QKL (333/350)AIR (230/249)

COL (497/521)CHG (307/327)SLF (178/206)STR (343/375)MPH (386/405)BSL (161/169)LER (755/813)

GRA (92/97)BAT (476/512)RFH (150/196)RAD (513/531)CMI (240/243)PLY (477/501)

RCH (534/555)GGH (254/265)RDE (533/548)HCH (260/268)WDH (215/223)SCU (227/231)STO (480/509)PGH (782/897)DER (475/503)

Mean length of acute stay(All hospitals mean = 15.8 days)

Mean length of post acute stay(All hospitals mean = 4.4 days)

0 5 10 15 20 25 30 35 40 45

0 5 10 15 20 25 30 35 40 45

MOR (343/440)RGH (143/174)UHW (390/501)RVN (379/425)CLW (327/373)GWY (162/191)EBH (427/454)WRX (216/239)FGH (108/120)MRI (148/164)STD (192/209)

WAR (248/273)NWG (109/122)NTH (334/361)KCH (80/126)

BRO (168/315)TRA (114/121)KMH (300/324)UHC (450/483)GWH (264/320)ASH (301/330)

LON (95/123)BRI (290/342)

OLD (498/549)NMG (143/157)QEB (308/362)WYT (228/273)NGS (514/537)FAZ (336/367)

CHE (346/372)MAY (204/240)NEV (192/272)ALT (316/362)

SAN (320/334)DRY (319/347)TLF (162/182)LDH (174/249)CRG (72/130)

HOR (155/169)HIN (100/158)VIC (265/403)

MAC (215/236)WIR (392/430)TUN (217/224)SUN (351/377)KGH (317/334)WHI (361/387)DID (384/414)NTY (294/329)SHH (346/382)SDG (230/242)

PEH (49/54)HUD (420/466)COC (220/323)FRY (382/417)GHS (348/370)OHM (209/229)

RLI (246/249)HIL (167/189)

RHC (214/234)RPH (372/400)SPH (364/387)NUH (312/332)RUS (426/468)UCL (110/112)WYB (120/131)WRG (429/452)FRM (295/322)NTG (354/372)SHC (398/412)ROT (265/283)QEQ (395/417)JPH (311/348)

BRG (70/87)LGI (606/651)HOM (71/87)

TOR (402/438)CGH (269/279)RSU (288/335)WES (96/116)

NDD (186/225)IOW (223/232)

WMH (293/317)RSC (402/426)DAR (307/326)CCH (99/103)

BLA (429/458)NUN (217/249)MKH (105/108)WMU (169/178)ENH (449/462)BAS (376/399)RLU (334/355)LEW (158/165)WDG (324/341)

AEI (306/319)BOL (325/354)SAL (232/242)

WGH (261/268)GEO (153/184)

WWG (148/259)QEG (277/293)ESU (435/460)

WHH (341/357)MDW (272/332)BED (115/148)QAP (664/688)WHT (119/133)HAR (157/231)DVH (309/342)HRI (484/513)

NPH (183/246)TGA (218/247)

WRC (361/398)LGH (281/283)RVB (765/835)YDH (357/367)BNT (278/302)BRT (257/279)PET (362/381)DGE (348/377)SCM (433/456)BRY (202/242)PMS (387/407)NHH (216/227)

LIN (317/347)WEX (342/369)BAR (243/258)PIL (324/347)

SOU (252/270)UHN (689/726)STH (157/168)SEH (377/407)PIN (501/526)

WAT (360/379)BRD (252/271)RED (227/244)PAH (296/308)

NOB (63/88)CHS (193/210)WSH (287/304)STM (178/197)RBE (462/486)NMH (87/122)BFH (404/426)IPS (395/419)

NOR (772/817)SCA (246/269)SMV (334/387)ADD (360/384)RSS (328/344)

WHC (275/297)SGH (549/584)GLO (358/384)NCR (366/379)KTH (319/332)QKL (333/350)AIR (230/249)

COL (497/521)CHG (307/327)SLF (178/206)STR (343/375)MPH (386/405)BSL (161/169)LER (755/813)

GRA (92/97)BAT (476/512)RFH (150/196)RAD (513/531)CMI (240/243)PLY (477/501)

RCH (534/555)GGH (254/265)RDE (533/548)HCH (260/268)WDH (215/223)SCU (227/231)STO (480/509)PGH (782/897)DER (475/503)

Mean length of acute stay(All hospitals mean = 15.8 days)

Mean length of post acute stay(All hospitals mean = 4.4 days)

Hos

pita

l (n/

N)

ALL

Length of stay (days)

Excludes patients discharged after 31/3/2012, with stays outside of range [0 days,365 days] and those with missing data for either of the phases. For CHS and WRG acute stay is measured by Trust stay. CHS has no dedicated orthopaedic ward.

WRG's orthopaedic ward closed part way through the year.

Chart 28 - Length of acute and post-acute Trust stay

The mean combined lengthof acute and post-acuteTrust stay is down from21.2days in 2011 to 20.2in this report. With suchbed days costed at £242each7, this represents asaving of c. £14.4 million.


Recognising that a traditional model of hip fracture carewas sub-optimal (“We were letting our patients down”),clinicians and managers at Pinderfields centralisedtrauma services and used NHFD data and the incentiveof BPT to transform hip fracture care. With theintroduction of a 36 bedded orthogeriatric ward – 24specifically for hip fracture patients, new staffappointments, dedicated theatre time, a hip fracturepathway, preoperative optimisation by anaesthetists andthe orthogeriatrician, a ‘future breach analysis form’ toaddress a target of 24-hour maximum pre-operativedelay, and a hip fracture steering group to monitorprogress, very substantial improvements in care andoutcomes were achieved between April 2011 andMarch 2012.

The changes depended on many factors, includingcompetency-based training, practice change, team-building sessions and additional equipment (such assensor pads to reduce in-hospital falls.) Successivequarter-by-quarter improvements were achieved in BPTcriteria compliance and in BPT achievement – with thelatter rising from 37% to 73%. Mortality fell from 11%in 2010/11 to 7% in 2011/12, and acute length of stayfrom 19 to 10 days. Feedback on patient and visitorward rounds is now ‘excellent’.






Dead (9.0%)


Nursing care (9.3%)

Other (1.9%)

Unknown (0.7%)

0% 20% 40% 60% 80% 100%




Dead (9.0%)


Nursing care (9.3%)

Other (1.9%)

Unknown (0.7%)

Hos

pita

l (n/

N)

ALLDER (477/503)

HCH (260/268)

SLF (189/206)

KTH (319/332)

STO (480/509)

BRD (256/271)

BAT (485/512)

DVH (321/342)

BAR (245/258)

CHS (193/210)

CHG (308/327)

WAT (369/379)

CMI (241/243)

BRY (203/242)

RVB (767/835)

NTY (295/329)

QEB (340/362)

BNT (279/302)

WMH (299/317)

QKL (335/350)

GGH (254/265)

UHN (689/726)

RFH (186/196)

KGH (321/334)

WDG (329/341)

WEX (352/369)

BAS (381/399)

MDW (308/332)

LIN (323/347)

TGA (227/247)

WDH (215/223)

PGH (869/897)

ROT (265/283)

SPH (365/387)

RBE (466/486)

PEH (49/54)

IOW (224/232)

JPH (321/348)

MAC (215/236)

SOU (258/270)

COL (500/521)

RHC (215/234)

NEV (192/272)

TLF (164/182)

PIL (331/347)

RLU (334/355)

LON (112/123)

DAR (307/326)

WHI (363/387)

FRM (298/322)

NTH (334/361)

WGH (266/268)

BED (115/148)

PAH (296/308)

HUD (422/466)

BLA (431/458)

NTG (354/372)

CLW (336/373)

LGI (615/651)

DID (384/414)

WES (106/116)

MKH (105/108)

WIR (400/430)

CCH (100/103)

QEG (279/293)

BRI (323/342)

NMH (114/122)

UHW (449/501)

MAY (222/240)

TOR (414/438)

ADD (365/384)

TRA (116/121)

RVN (380/425)

NUN (226/249)

NWG (111/122)

GWH (299/320)

WYB (122/131)

OHM (209/229)

KCH (109/126)

STM (180/197)

QAP (664/688)

STH (160/168)

QEQ (396/417)

RGH (143/174)

HIN (101/158)

UHC (457/483)

BFH (405/426)

PET (362/381)

HOM (76/87)

WMU (170/178)

PLY (482/501)

WHC (282/297)

UCL (111/112)

COC (291/323)

RSS (330/344)

BSL (162/169)

RAD (514/531)

MPH (391/405)

RSC (424/426)

PMS (388/407)

AEI (307/319)

ESU (435/460)

RDE (537/548)

NCR (367/379)

GLO (362/384)

RED (227/244)

STR (362/375)

SCA (248/269)

SMV (373/387)

ENH (451/462)

SCU (227/231)

SCM (434/456)

BRT (260/279)

NOR (775/817)

MRI (148/164)

LGH (283/283)

BOL (326/354)

LDH (231/249)

PIN (503/526)

YDH (357/367)

SHH (351/382)

LER (760/813)

WRC (377/398)

CHE (349/372)

SGH (553/584)

GHS (351/370)

ALT (317/362)

RSU (321/335)

SUN (366/377)

RCH (535/555)

WRG (429/452)

NGS (514/537)

NUH (317/332)

RPH (377/400)

EBH (440/454)

BRG (79/87)

SEH (384/407)

AIR (234/249)

NHH (217/227)

GEO (161/184)

RUS (431/468)

GRA (93/97)

RLI (249/249)

TUN (223/224)

BRO (218/315)

WHH (341/357)

NOB (63/88)

NPH (235/246)

DGE (350/377)

IPS (398/419)

WSH (287/304)

LEW (158/165)

CGH (275/279)

HIL (185/189)

SDG (231/242)

STD (193/209)

ASH (301/330)

WHT (121/133)

WRX (216/239)

SHC (412/412)

NMG (143/157)

FRY (383/417)

NDD (188/225)

HOR (161/169)

GWY (162/191)

DRY (319/347)

WYT (260/273)

HAR (162/231)

KMH (300/324)

HRI (491/513)

FGH (110/120)

WWG (148/259)

SAL (233/242)

WAR (249/273)

MOR (349/440)

CRG (79/130)

OLD (498/549)

FAZ (340/367)

VIC (266/403)

SAN (322/334)

0% 20% 40% 60% 80% 100%

Excludes patients discharged after 31/03/2012

Chart 29 - Discharge destination from Trust

This is largely unchanged fromlast year’s report, although it isencouraging that only 9.1% ofpatients died in hospital,compared to 9.5% reportedin 2011.


Re−operationwithin 30 days (1.0%)

No re−operationwithin 30 days (39.0%)

Unknown (60.0%)

0% 20% 40% 60% 80% 100%

Re−operationwithin 30 days (1.0%)

No re−operationwithin 30 days (39.0%)

Unknown (60.0%)

Hos

pita

l (n/

N)

ALLAIR (228/249)

BAT (478/512)

BRG (73/87)

CHE (349/372)

FAZ (336/367)

GRA (89/97)

KCH (108/126)

LER (726/813)

NPH (231/246)

QKL (327/350)

RFH (177/196)

RSU (313/335)

SHC (390/412)

TUN (221/224)

WGH (262/268)

WYB (117/131)

KGH (314/334)

RLI (245/249)

WMU (169/178)

HIL (179/189)

IPS (389/419)

PEH (47/54)

OHM (208/229)

TOR (402/438)

QEB (338/362)

UCL (110/112)

FGH (99/120)

NOB (61/88)

CRG (67/130)

RPH (377/400)

RCH (524/555)

STO (472/509)

ESU (421/460)

BFH (393/426)

MPH (379/405)

WEX (342/369)

JPH (317/348)

LGI (591/651)

VIC (266/403)

BRT (239/279)

UHN (679/726)

MAY (220/240)

QEQ (387/417)

GWY (161/191)

HOR (159/169)

RBE (451/486)

NTY (285/329)

BNT (276/302)

NMG (130/157)

STR (356/375)

NMH (112/122)

RVB (751/835)

SAN (317/334)

MKH (103/108)

NUH (304/332)

NGS (504/537)

PAH (290/308)

STD (185/209)

ROT (258/283)

LIN (315/347)

LEW (156/165)

CMI (228/243)

UHW (438/501)

MRI (144/164)

COC (282/323)

NHH (209/227)

CGH (268/279)

BAS (372/399)

CHG (304/327)

STM (177/197)

DGE (345/377)

MOR (341/440)

RSS (264/344)

RVN (364/425)

NCR (358/379)

RAD (502/531)

CLW (327/373)

BOL (322/354)

BRI (316/342)

GHS (344/370)

NTH (328/361)

QAP (659/688)

NEV (186/272)

HOM (72/87)

EBH (420/454)

QEG (272/293)

RHC (213/234)

AEI (294/319)

UHC (449/483)

WHT (121/133)

BAR (238/258)

BED (112/148)

BRO (207/315)

DAR (283/326)

GEO (158/184)

HRI (484/513)

LDH (222/249)

LGH (268/283)

PET (354/381)

RED (224/244)

RGH (138/174)

SCA (243/269)

SLF (175/206)

WDH (209/223)

WHI (363/387)

WYT (253/273)

WMH (289/317)

MAC (209/236)

STH (156/168)

TLF (152/182)

HAR (160/231)

IOW (221/232)

KMH (297/324)

DID (378/414)

SCM (416/456)

HIN (100/158)

MDW (301/332)

CCH (97/103)

NOR (760/817)

SHH (346/382)

OLD (496/549)

ENH (438/462)

RUS (412/468)

WIR (390/430)

YDH (351/367)

WHH (338/357)

ALT (309/362)

FRM (283/322)

GGH (247/265)

SAL (233/242)

NUN (221/249)

TGA (211/247)

GLO (359/384)

WDG (322/341)

BSL (156/169)

ASH (291/330)

WWG (142/259)

SGH (541/584)

PLY (475/501)

NTG (344/372)

TRA (110/121)

RDE (529/548)

KTH (312/332)

DRY (308/347)

WES (101/116)

GWH (296/320)

WHC (279/297)

WAT (366/379)

BLA (418/458)

SOU (235/270)

DVH (309/342)

SDG (225/242)

WRC (364/398)

COL (495/521)

WRG (422/452)

PIN (476/526)

CHS (190/210)

WAR (246/273)

SPH (359/387)

HUD (405/466)

PGH (857/897)

WSH (283/304)

RSC (417/426)

ADD (361/384)

SUN (356/377)

HCH (247/268)

DER (466/503)

SMV (364/387)

NDD (179/225)

PMS (383/407)

WRX (197/239)

FRY (377/417)

LON (108/123)

NWG (105/122)

SEH (376/407)

SCU (221/231)

RLU (327/355)

PIL (322/347)

BRD (247/271)

BRY (188/242)

0% 20% 40% 60% 80% 100%

Excludes patients who were not initially treated with surgery or were discharged after 31/03/2012

Chart 30 - Re-operation within 30 days

Having a second operationwithin 30 days of major hipsurgery is an extremelysignificant event, bringingincreased morbidity andmortality. The fact that solarge a proportion (60%)of the data is ‘unknown’is of great concern.Better 30-day follow upis needed.



Complete (32.3%)

Not Complete (67.7%)

0% 20% 40% 60% 80% 100%

Complete (32.3%)

Not Complete (67.7%) Hos

pita

l

ALLAIR

BFH

CCH

DAR

DRY

GRA

HRI

LER

LGH

NMG

RAD

RLI

RPH

RUS

SCA

SHH

STM

TUN

WDH

WHI

WWG

ESU

KMH

SCM

RSC

BAT

RFH

FAZ

QEB

LDH

MPH

WYT

NGS

HIL

DGE

MKH

RCH

IPS

BRO

BED

OHM

WRX

HAR

WHT

BNT

WES

RLU

ADD

STH

CHS

TOR

JPH

VIC

EBH

SUN

SDG

STR

ASH

SMV

CMI

WRC

MOR

BRI

PMS

NTY

GWH

PAH

YDH

DID

BOL

BSL

BAS

FRY

GWY

AEI

RBE

PIL

DVH

PLY

WAT

LIN

BRD

SOU

WDG

WAR

QAP

FRM

PGH

MDW

ALT

BAR

BRT

CHE

DER

GEO

HOR

KCH

LEW

MAY

NPH

RGH

ROT

RSU

SAL

SGH

SLF

STO

UHN

WGH

WMU

WYB

QKL

SEH

NOR

OLD

RED

KGH

CGH

ENH

WMH

SHC

WIR

PET

TLF

HCH

IOW

KTH

WHC

WEX

SAN

TGA

UCL

LGI

WHH

BRY

NMH

PEH

BRG

MAC

HIN

WRG

NUN

NTG

STD

GLO

TRA

HUD

FGH

RSS

NWG

SCU

GGH

COC

GHS

CRG

HOM

SPH

LON

RVN

NOB

CLW

NCR

NTH

UHW

COL

MRI

NEV

NDD

CHG

WSH

RDE

BLA

PIN

QEG

QEQ

RHC

NHH

UHC

NUH

RVB

0% 20% 40% 60% 80% 100%

Completeness of six variables collected at 30 days among patients recorded to be alive 30 days after admission

Chart 31 - Follow up data completeness at 30 days

Hospitals need to know howwell their patients recover fromthe injuries that they are treatedfor. The 30-day and 120- dayfollow up data consists of sevenfields that can be completed bymeans of a questionnaire or telephone conversation andyet less than a quarter of thesefields are completed, with halfof all hospitals making noattempt to follow up their patients.


RVH Belfast admits more than 900 hip fracture patients a year, andNHFD data is collected as part of a wider Fracture Outcomes ResearchDatabase, which now achieves 99% follow-up. Data is sourced fromclinical records and the theatre management system. Telephonereviews at 30 days, four months and one year are undertaken byaudit nurses, who contact nursing, residential and rehabilitation unitsdirectly and cross-check the remainder with hospital PAS data, GPs,patients and next of kin.

Systems queries have been created to highlight duplicates andmissing data. A monthly review of all hip fracture X-rays ensures theaccuracy of diagnosis and treatment coding. Data is then uploadedmonthly to the NHFD. Although the Best Practice Tariff does not applyin Northern Ireland, NHFD participation is valued by clinicians,managers and commissioners as providing reliable information tosupport service evaluation and change, and to influence policy.

Royal Devon and Exeter Hospital has participated in the NHFD since2008, and since then has implemented daily trauma meetings and afast-track protocol to reduce time from A&E to orthopaedic care;recruited two trauma nurse practitioners and two orthogeriatricians;and introduced monthly multidisciplinary review meetings involvingclinicians and managers. In the last four years inpatient mortality for hipfracture has fallen from 6% to 4%, and 28 day mortality from 13% to7%.

In order to determine longer-term outcomes, telephone follow-up at30, 120 and 360 days – carried out by a trauma nurse practitioner anda trauma ward administrator – has achieved over 99% completeness atall three intervals. Total time spent on telephone calls averages six hoursper week. Outcomes documented include place of residence, mobility,and compliance with bone protection medication. Patients' concerns areaddressed, and data on longer term outcomes provide a much morecomprehensive picture of outcomes following hip fracture care.



Complete (24.6%)

Not Complete (75.4%)

0% 20% 40% 60% 80% 100%

Complete (24.6%)

Not Complete (75.4%) Hos

pita

l

ALLAIR

BAT

BFH

BRT

DAR

DRY

FAZ

GRA

HIL

HRI

KCH

KTH

LER

LGH

MAY

MPH

NMG

RAD

RGH

ROT

RSC

RUS

SCA

SGH

SHH

STM

TLF

UHN

WDH

WHC

WIR

WRC

WYB

ESU

SPH

ASH

HIN

CCH

TGA

WMU

KGH

PET

RCH

HAR

BRY

WHT

RVN

BRG

UHW

ADD

LGI

PEH

NUN

OHM

SDG

TRA

NWG

RLU

HUD

PAH

NTG

FRY

SUN

SMV

CHS

CMI

LON

GLO

YDH

HOM

PMS

CHG

LIN

NCR

RBE

BAS

DID

WSH

NTH

QAP

CLW

WDG

NDD

PGH

MRI

BRD

RHC

FRM

RDE

ALT

BAR

BED

BRO

CHE

DER

ENH

GEO

HCH

HOR

IOW

KMH

LDH

LEW

MAC

MKH

NGS

NPH

RFH

RLI

RPH

RSU

SAN

SCM

SHC

SLF

STO

TUN

VIC

WGH

WHI

WMH

WWG

WYT

SEH

QKL

SAL

NTY

RED

PIN

WEX

CGH

QEB

EBH

NOR

DGE

OLD

IPS

TOR

GHS

BNT

WES

NMH

UCL

WHH

WRG

RSS

WRX

JPH

CRG

BRI

FGH

STD

GWY

STR

GGH

MOR

QEQ

BOL

DVH

COL

COC

SCU

GWH

NOB

SOU

WAT

BLA

PIL

BSL

PLY

UHC

NEV

STH

WAR

QEG

AEI

NHH

MDW

NUH

RVB

0% 20% 40% 60% 80% 100%

Completeness of six variables collected at 120 days among patients recorded to be alive 120 days after admission

Chart 32 – Follow up data completeness at 120 days

Percentage complete

Hos

pita

l

0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

WWGWGHUHNSTOSLF

SGHRUSRPHRLI

RADNMGLGHLERHRI

GRADRYDARBRTBARKMHESUSCMCCHBAT

WMUREDLDHMPHWYTNGSNORQEBTLF

HCHMKHDGERCHBROWEXSANHARWHTBNTUCLPEHBRGWHH

HINWRXEBHRLUASHSDGTRAGHSNTGRSSHUDUHWSUNCRGFGHPAHGLOSTH

MORGWYCOCPMSHOMGWHDVHCHGNCRDID

RBENTHPIL

SOUBLANEVMRIAEI

BRDWARRDERHCNHHNUHRVB

WYBWHIWDHTUNSTMSHHSCARSUROTRGHNPHMAYLEWKCHHORGEODERCHEBFHAIRSALQKLSEHRSCRFHFAZENHWMHSHCWIRKGHCGHHILPETOLDIOWKTHWHCBEDIPSTGALGIOHMBRYWESADDNMHMACTORVICNUNWRGJPHWRCNTYCHSSPHRVNNWGSTDPINBRISTRSMVCMIGGHFRYLONSCUYDHBOLCOLQEQNOBLINBASBSLCLWWATWSHPLYNDDQAPWDGUHCQEGPGHFRMMDWALT

30 day follow−up120 day follow−up

ALL

Completeness of six variables collected at 30 and 120 days after admission among patients recorded to be alive on each day.


Chart 33 – Follow-up completeness at 30 and 120 days



At Basingstoke Hospital the approach to the collectionof NHFD follow-up data developed over the first fewyears of NHFD participation. An initial plan was tocollect data from patients attending a multidisciplinaryfollow-up clinic. Telephone follow-up – largely carriedout by medical staff – was also explored, and somebenefits noted (direct contact with patient and/or carer;ability to address wider concerns) but proved difficultbecause of the limited availability of time, and problemsof scheduling the calls to the follow up intervals.Positive experience locally of postal follow-up afterelective arthroplasty suggested a switch to postalquestionnaires with pre-paid reply envelopes. Dailychecks on the NHFD website for patients reachingfollow-up points, and checks with hospital PMS toensure patients are no longer in-patients and remainalive, precede the dispatch of the postal questionnaire.Where patients raise issues, either through additionalcomments on the form or on an accompanying letter, atelephone call and/or a multidisciplinary clinic reviewmay follow. Only nine of the initial 115 patients werelost to follow-up at 120 days, and data – particularlythat relating to mobility – has been encouraging: with asubstantial decrease in patients requiring two walkingaids between the 30- and 120-day follow-ups.


Casemix adjusted outcomes:Funnel plot for return home from home at 30 days

Results: Return home from home at 30 days

For patients, a safe and early return home following hip fracture is a major priority. This analysis showsfrom the available data the rate of return home by 30 days of patients admitted from home or shelteredhousing. However, since only 74.8% of patients are admitted from home or sheltered housing, since theoverall completeness of follow-up-up data at 30 days is only 56.2%, and since hospitals submittingfewer than 60 eligible cases were excluded, only 17,374 cases are included in this plot.

Please see Appendix B for a list of excluded hospitals.

The overall rate of return home by 30 days is 44.6%. The three most important predictors of returnhome are walking ability, age, and ASA grade – which provide the basis for the casemix standardisationshown here.

Other determinants of rate of return home are clearly complex, and include: the effectiveness of earlyrehabilitation; the availability of community rehabilitation, and the provision of specialist early supporteddischarge schemes – all of which clearly vary greatly across the country. There is also evidence that readyaccess to downstream beds may result in longer overall acute hospital stay, and hence lower rate ofreturn home by 30 days. Together, these factors may account for the high degree of variance displayedhere. That variance, together with the poor completeness of 30 day follow-up data, suggests a cautiousapproach to the interpretation of this plot.

NHS superspell data, which is likely to appear in the 2012 Supplementary Report, should further clarifymatters.



St Peter’s Hospital began NHFD participation in 2009. Inorder to meet NHFD clinical standards, the trustappointed two orthogeriatricians in early 2010.Although some aspects of care improved, preoperativedelay beyond 36 hours remained common; and in thefirst quarter of BPT implementation only 49% of patientsachieved BPT standards. The Trust invested in a 4-dayEQIP (Efficiency, Quality, Improvement and Productivity)initiative on the hip fracture pathway in September2010. Analysis of NHFD data showed longest delaysoccurring during or just after the weekend. To addressthis, and all-day Saturday list was split into two half-dayweekend lists. Since November 2010, 60% of patientshave surgery within 24 hours, and 80% within 36 hours.Time to orthopaedic ward admission was also reduced:by the introduction of a priority hip fracture bleep; andby eliminating delays in obtaining air mattresses fromcentral stores by the provision of a ready-use on-wardmattress. Weekend physiotherapy and a hip fractureexercise class improved mobilisation within 24 hours ofsurgery. Length of stay dropped from 25 to 22 days –with considerable efficiency savings. Importantly,discharge to original residence has improved: to 60%within 25 days now, compared with 44% within 30 daystwo years ago.


Best Practice Tariff (BPT)The NHFD – with its extensive coverage and detailed documentation of casemix, care and outcomes –prompted the selection of hip fracture as a topic for the Department of Health’s Best Practice Tariff (BPT)initiative, which applies only in England. BPT offers additional payment for cases the care of which meetsagreed standards (surgery within 36 hours; care by surgeon and geriatrician; care protocol agreed bygeriatrician, surgeon and anaesthetist; pre/perioperative assessment by geriatrician; geriatrician-ledmulti-disciplinary rehabilitation; secondary prevention including falls and bone health assessment) thatare monitored by the NHFD.

As the table and bar-chart below show, between April 2010 and April 2012 participation has increasedsteadily quarter by quarter: with ever-rising numbers of hospitals taking part; of cases submitted; and ofcases meeting the tariff standards.

Qtr 1

Qtr 2

Qtr 3

Qtr 4

2011/12

Qtr 1

Qtr 2

Qtr 3

Qtr 4

162

165

163

167

170

166

166

168

92(57%)

105(64%)

111(68%)

118(71%)

131(77%)

133(80%)

138(82%)

147(87%)

9,455

11,839

13,136

12,680

13,070

13,221

14,116

14,046

2,303(24%)

3,328(28%)

4,502(34%)

4,671(37%)

5,210(40%)

6,170(47%)

7,193(51%)

7,654(55%)

2 – 81%

2 – 74%

1 – 83%

1 – 86%

1 – 88%

1 - 89%

2 – 88%

2 – 95%

Eligiblehospitals2010/11

Hospitalsachieving

BPT

Number ofpts

submitted

Number of ptsachieving

BPT Range

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10

20

30

40

50

60

70

80

90

10

0

% t

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heatr

e<

36

hrs

% jo

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% jo

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pro

toco

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geri

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n<

72

hrs

% M

DT

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% f

alls

assessm

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t%

bo

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he

alt

hassessm

en

t

% B

PT

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Qu

arte

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uar

ter

BPT

cri

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BPT

ach

ieve

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t: 2

010/

2011


At a ‘grand round-table’ meeting in May 2011, hip fracture careat Chelsea and Westminster was recognised as sub-optimal. Thismarked the beginning of a sustained and successful effort toimprove patient care and also to respond to the incentives offeredby the Best Practice Tariff. Resultant changes included dedicatedtheatre sessions for trauma, regular thrice-weekly orthogeriatricianrounds, weekly discharge planning meetings, and a weeklyosteoporosis ward round. An agreed assessment pro forma wasintroduced, and is now completed for 100% of patients; and theElectronic Patient Record now documents collaborative care. BPTachievement has risen from <10% to >60%, attracting additionalincome of over £127,000; and average acute length of stay hasfallen from 24 to 19.5 days, with estimated savings of £91,000.In-patient mortality has fallen from 11% to 9%, and feedbackfrom staff, patients and carers is now favourable.

Queen Alexandra Hospital, Portsmouth, has participated in the NHFDsince its launch in 2007, and has used data to highlight service issuesand improve care over the years. The 2011 NHFD National Reportshowed how QAP performed better than national and/or SHA averagesin terms of: time to admission to orthopaedic care; preoperativegeriatrician assessment; operation within 36 and 48 hours; and fallsand bone health assessment. It also performed well in terms ofdischarge to previous residence (70%, compared with a nationalaverage of 46%). Notably, in the 2011 NHFD Report, at 78% it rankedfirst in BPT achievement.This year, 99.5% of patients were assessed by an orthogeriatricianwithin 72 hours and 79.7% of patients had surgery within 36 hours.BPT achievement too has risen, to 79.7%.Resulting BPT monies to the Trust amounted to £227,000 for 2010/11,and £488,000 for 2011/12.



Eligible − meetsall 9 criteria (48.2%)

Ineligible − meets4−8 criteria (48.6%)


0% 20% 40% 60% 80% 100%

Eligible − meetsall 9 criteria (48.2%)



Hos

pita

l (N

)

ALL

SOU (270)

NTH (363)

SEH (405)

HUD (457)

HIL (189)

NDD (205)

NPH (246)

RSS (350)

NMG (143)

RPH (415)

TOR (438)

BRY (213)

SDG (245)

WRC (407)

MKH (109)

BRD (268)

SLF (197)

RLI (265)

LON (121)

HAR (176)

CMI (251)

MAY (233)

BOL (342)

GGH (265)

HOM (76)

WDH (220)

WMU (183)

LER (785)

BRI (337)

DRY (339)

LGH (293)

RAD (530)

GEO (168)

SAN (369)

ESU (456)

CCH (105)

SCA (263)

NWG (124)

DGE (357)

BAS (397)

COL (517)

SHH (365)

QEG (294)

OLD (539)

BRT (275)

STH (169)

STM (188)

SMV (394)

NCR (390)

MPH (415)

WIR (417)

JPH (340)

PGH (903)

DER (497)

WHC (300)

PET (384)

SUN (386)

ROT (284)

QEB (366)

SGH (573)

IPS (425)

BLA (453)

NGS (570)

RED (237)

RCH (561)

RBE (492)

RDE (548)

AIR (241)

LEW (165)

HRI (523)

AEI (328)

WHI (384)

WAR (263)

SHC (442)

NUN (237)

CHS (204)

RHC (215)

GLO (373)

RUS (468)

KTH (329)

SAL (242)

ASH (333)

HIN (117)

GRA (100)

KGH (343)

PLY (492)

NOB (67)

TLF (176)

KCH (114)

LIN (348)

WYT (283)

TUN (244)

CGH (288)

BRO (235)

LDH (248)

VIC (286)

KMH (312)

WDG (353)

STD (219)

DAR (327)

MRI (161)

EBH (484)

BAR (260)

PIL (348)

DVH (338)

LGI (664)

OHM (223)

SCU (239)

HCH (269)

FGH (115)

WMH (309)

RSC (455)

MAC (238)

GHS (379)

CHE (378)

WES (117)

UCL (117)

MDW (329)

WEX (376)

TGA (239)

WGH (287)

TRA (124)

BED (124)

BFH (424)

CHG (319)

RFH (192)

QKL (346)

STR (381)

WHT (129)

PIN (533)

YDH (383)

SCM (450)

GWH (321)

COC (308)

BAT (510)

UHN (722)

WRG (468)

BSL (175)

RLU (356)

DID (419)

NOR (804)

RVN (415)

IOW (234)

ADD (379)

WHH (355)

UHC (493)

STO (500)

FRM (319)

ENH (492)

RSU (340)

NTG (373)

QEQ (429)

PAH (310)

FAZ (363)

PMS (400)

NHH (226)

FRY (419)

WAT (388)

HOR (174)

BNT (295)

QAP (698)

WSH (298)

NMH (117)

NTY (312)

SPH (386)

0% 20% 40% 60% 80% 100%

Only includes hospitals in England

Chart 34 – BPT uplift eligibility (England only)


East Lancashire Hospitals NHS Trust firstparticipated in the NHFD in February 2010. Sincethen clinicians and managers have found NHFDdata invaluable in assisting the clinical team tomonitor and improve the quality of care for hipfracture patients. The introduction of anintegrated care pathway, together with closescrutiny of delays exceeding 48 hours and theappointment of an orthogeriatrician, helpedgreatly in achieving Best Practice Tariff standards inhip fracture care – which rose from 15.6% ofcases in 2010/2011 to 65.3% in 2011/2012. Inaddition, the incidence of pressure ulcers fell from5.9% in July 2010 to 2.4% now.All this was achieved by the regular sharing ofNHFD data with the team, focused efforts onproblem areas the data highlighted, and thusimproving compliance with the six Blue Bookstandards of care. A bid for funding for an EastLancashire Fracture Liaison Service has recentlysucceeded in securing re-enablement monies, withplans now to commence this service within thenext six months.

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KM

HLE

RLI

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TH

PIL

UH

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Hos

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Percentage

020406080100

Q1

Q2

Q3

Q4

CH

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HLE

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Hos

pita

l

Percentage

020406080100

AD

DB

AS

BE

DB

FH

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NH

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NO

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HP

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EH

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H

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Percentage

020406080100

Q1

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Q4

AD

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DB

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NH

HIN

IPS

JPH

LDH

NO

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HP

ET

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EH

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WS

H

Hos

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Percentage

020406080100

BN

TB

RO

CC

HC

HS

GE

OG

WH

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HO

MK

CH

KT

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WLO

NM

AYN

MH

NP

HN

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OLD

RF

HS

HC

ST

HS

TM

UC

LW

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WH

CW

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WM

U

Lo

nd

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Hos

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Percentage

020406080100

Q1

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Q3

Q4

BN

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HC

HS

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OG

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Cop

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The

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Percentage

020406080100

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AS

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AR

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Hos

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Percentage

020406080100

AE

IB

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BR

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MA

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TG

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Percentage

020406080100

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020406080100

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Percentage

020406080100

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Hos

pita

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Percentage

020406080100



Facilities AuditTo understand care of patients with hip fractures in individual hospitals, it is helpful to have data on thefacilities that are available locally. Each year the NHFD requests details of the population the hospitalserves and number of hip fracture patients treated; and also on staffing levels, details concerning thenumber of orthogeriatric ward rounds, and arrangements for secondary prevention of fractures. Detailsof how the NHFD data is collected are also requested.

This data helps to make comparisons between hospitals fairer. Case ascertainment should be based onthe number of cases reported to NHFD in relation to the number of cases admitted (the latter oftenreported in terms of numbers the previous year). However, some hospitals show wild fluctuations in theirestimated case load. This, together with its impact on estimated national figures – has created difficultiescurrently being addressed by work commissioned to link NHFD and HES data, with a view to providingmore robust denominators at both hospital and national level.

Despite current limitations, the overall catchment areas and hip fracture numbers are virtuallyunchanged from last year, although four fifths of hospitals now consider themselves to be DistrictGeneral Hospitals, compared with three quarters in 2011. The remainder have some tertiary role.

Number of hip fractures treated each year by unit

Percentile

Num

ber

of c

ases

0

100

200

300

400

500

600

700

800

900

1000

0th 20th 40th 60th 80th 100th

11.3%

4.3%

16.1%

14.5%

9.7%

36.6%

7.5%

Number of orthogeriatric wardrounds each week

0123456+

75.3%

6.5%

18.3%

On site falls clinic

Led by consultantLed by nurseNo clinic

64.5%8.1%

27.4%

On site DXA scanners

Axial scannersPeripheral scannersNo scanners


Facilities Audit Chart 1

There has been an impressive improvement in orthogeriatric provision, with the percentage of hospitalshaving no orthogeriatric ward rounds falling from 14.2% in 2011 to 11.3%, while 44.1% have five ormore ward rounds a week (compared with 31.8% in 2011).

Facilities Audit Chart 2 Facilities Audit Chart 3

There has been a marginal increase in the provision of on-site Falls Clinics and DXA scanning comparedwith 2011.



68.3%

9.7%

22%

Data collectors

NursesDoctorsAudit staff

100%

105%

110%

115%

120%

125%

130%

135%

140%

145%

2010 2011 2012

OG Consultant hrs

OG Middlegrade hrs

OG WR

WTE fragility fracture

nurse

WTE FLS nurse

Facilities Audit Chart 4

Trends in the staffing of units

One hundred and fourteen hospitals have contributed a Facilities Audit to the Report for each of the lastthree years. Taking the average figure for 2010 as the baseline there has been an improvement in theprovision of both consultant and middle-grade orthogeriatricians, with an associated substantial increasein the number of ward rounds undertaken. While fragility fracture nurse hours have increased there hasbeen no change in the provision of fracture liaison nurses.

The marked rise over three years in orthogeriatrician staffing is particularly striking. Promotingcollaborative care through the involvement of orthogeriatricians was identified from the earliest stages ofthe development of the NHFD as vital to improving hip fracture care: pre-operatively, in order tominimise unnecessary delay to surgery, post-operatively in identifying medical complications early andtreating them effectively; and in leading early multi-disciplinary rehabilitation directed at promotingpatients’ mobility and self-care. It is therefore a matter of concern that many units have not yet achievedcollaborative care through adequate orthogeriatrician staff.

Cop

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Hos

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Hospital code

Estimated number of hip fractures (Facilities Audit)

Number of cases submitted

% case ascertainment

% Data completeness of reporting fields

% Admitted to orthopaedic care within 4hrs (BB Std. 1)

% Surgery within 48hrs (BB Std 2)

% Pre-operative assessment by geriatrician (BB Std 3)

% Patients developing pressure ulcers (BB Std 4)

% Falls assessment (BB Std 5)

% Bone health medication assessment (BB Std 6)

Mean (SD) length of acute stay (days)

Mean (SD) length of post-acute stay (days)

Mean (SD) total length of stay - acute + post-acute (days)

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01.

110

0.0

97.3

NA

( N

A)

NA

( N

A)

16.9

(12.

0)St

Geo

rge'

s H

ospi

tal,

Lond

onG

EO17

618

410

4.5

88.9

32.5

87.9

6.0

1.2

100.

099

.4 7

.6 (

5.7)

12.0

(15.

1)19

.6 (1

4.3)

Que

en E

lizab

eth

Hos

pita

l, W

oolw

ich

GW

H25

832

012

4.0

91.8

6.0

84.4

3.8

0.3

99.0

96.0

26.5

(20.

7) 0

.5 (

5.5)

27.1

(21.

7)H

illin

gdon

Hos

pita

lH

IL20

018

994

.587

.363

.985

.625

.94.

193

.890

.212

.4 (

7.4)

10.1

(16.

5)22

.4 (1

7.6)

Hom

erto

n H

ospi

tal,

lond

onH

OM

9087

96.7

91.4

11.3

81.0

10.6

9.1

100.

092

.014

.8 (1

0.4)

6.9

(14.

6)21

.7 (1

7.0)

King

's C

olle

ge H

ospi

tal,

Lond

onKC

H10

112

612

4.8

88.3

39.0

81.0

45.5

1.9

91.3

74.5

27.9

(19.

6) 0

.0 (

0.0)

27.9

(19.

6)Ki

ngst

on H

ospi

tal

KTH

360

332

92.2

93.7

14.6

95.0

99.4

1.0

99.7

99.0

15.7

(12.

3) 0

.1 (

1.0)

15.7

(12.

3)U

nive

rsity

Hos

pita

l, Le

wis

ham

LE

W17

016

597

.195

.363

.090

.583

.60.

010

0.0

90.7

19.8

(15.

5) 0

.0 (

0.0)

19.8

(15.

5)Th

e Ro

yal L

ondo

n H

ospi

tal

LON

129

123

95.3

91.0

15.4

75.9

33.3

1.9

34.6

45.5

16.9

(12.

4) 9

.7 (2

6.4)

26.6

(27.

7)Cr

oydo

n U

nive

rsity

Hos

pita

lM

AY

300

240

80.0

91.1

14.7

77.5

64.6

23.1

98.6

86.4

25.0

(18.

9) 0

.3 (

2.8)

25.3

(19.

1)N

orth

Mid

dles

ex U

nive

rsity

Hos

pita

lN

MH

140

122

87.1

94.8

40.0

92.0

94.3

1.8

100.

095

.616

.5 (1

1.5)

0.3

( 2.

0)16

.8 (1

1.9)

Nor

thw

ick

Park

Hos

pita

l, Lo

ndon

NPH

490

246

50.2

83.4

37.7

67.1

93.5

3.8

95.5

94.2

18.3

(11.

5) 0

.7 (

5.2)

18.9

(12.

4)N

ewha

m G

ener

al H

ospi

tal,

Lond

onN

WG

100

122

122.

096

.128

.880

.566

.411

.010

0.0

99.1

18.9

(13.

1)10

.0 (2

0.9)

28.9

(22.

3)Q

ueen

's H

ospi

tal,

Rom

ford

OLD

600

549

91.5

94.0

43.1

74.5

5.6

1.2

99.4

93.7

8.4

( 6.

6)18

.2 (2

0.8)

26.6

(21.

6)Ro

yal F

ree

Hos

pita

l, Lo

ndon

RFH

210

196

93.3

90.2

29.2

85.6

77.6

2.3

98.3

85.9

13.9

( 9.

7) 0

.7 (

3.3)

14.6

( 9.

5)St

Hel

ier

Hos

pita

l, Ca

rsha

lton

SHC

400

412

103.

094

.523

.093

.599

.36.

710

0.0

84.8

18.6

(16.

1) 3

.1 (1

1.6)

21.7

(20.

1)St

Tho

mas

' Hos

pita

l, Lo

ndon

STH

220

168

76.4

93.2

74.1

90.0

41.1

6.2

98.1

78.1

14.1

( 9.

7) 3

.5 (1

0.2)

17.6

(13.

0)St

. Mar

y's

Hos

pita

l, Pa

ddin

gton

STM

200

197

98.5

96.3

39.8

86.8

22.3

1.1

100.

096

.316

.1 (1

2.5)

0.9

( 4.

0)16

.9 (1

2.8)

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tal

UCL

139

112

80.6

89.2

72.0

85.8

41.1

4.8

90.4

79.0

22.0

(13.

5) 0

.0 (

0.0)

22.0

(13.

5)Ch

else

a an

d W

estm

inst

er H

ospi

tal

WES

170

116

68.2

98.0

7.0

78.8

56.0

8.8

100.

078

.420

.4 (2

1.2)

0.4

( 3.

1)20

.8 (2

1.1)

Whi

pps

Cros

s U

nive

rsity

Hos

pita

lW

HC

320

297

92.8

91.0

17.6

82.9

74.4

1.5

99.6

100.

016

.0 (1

2.3)

0.1

( 0.

9)16

.1 (1

2.3)

Whi

�ng

ton

Hos

pita

l, Lo

ndon

WH

T15

013

388

.796

.228

.193

.737

.65.

710

0.0

89.4

19.2

(14.

5) 0

.0 (

0.0)

19.2

(14.

5)W

est M

iddl

esex

Uni

vers

ity H

ospi

tal

WM

U23

017

877

.492

.650

.977

.326

.40.

094

.310

0.0

17.8

(13.

0) 2

.3 (1

0.1)

20.1

(16.

4)SH

A61

6355

4490

.092

.130

.983

.752

.94.

196

.396

.817

.0 (1

4.5)

4.3

(12.

7)21

.3 (1

7.8)

ENG

LAN

D58

640

5498

593

.892

.849

.984

.249

.84

92.8

93.1

15.8

(13.

1) 3

.9 (1

1.9)

19.7

(17.

1)O

VER

ALL

6351

059

365

93.5

92.6

52.4

83.1

49.5

3.7

91.9

83.8

15.7

(13.

1)4.

5 (1

3.2)

20.2

(18.

0)

Lon

do

n

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

76

Hos

pita

l

Hospital code














Altn

agel

vin

Are

a H

ospi

tal

ALT

406

362

89.2

87.8

26.8

67.8

0.0

6.5

0.0

19.6

12.6

( 8.

7)12

.5 (2

1.8)

25.0

(23.

9)Cr

aiga

von

Hos

pita

l, Po

rtad

own

CRG

175

130

74.3

82.0

62.0

82.1

32.0

1.6

43.7

52.4

9.9

( 4.

9)13

.8 (2

1.2)

23.7

(21.

1)U

lste

r Hos

pita

lN

UH

375

332

88.5

91.2

48.8

37.3

80.4

11.8

66.4

79.9

15.4

( 8.

7) 6

.6 (1

1.7)

22.1

(14.

0)Ro

yal V

icto

ria

Hos

pita

l.Bel

fast

RVB

924

835

90.4

90.7

49.4

50.3

97.4

1.3

97.7

53.9

11.3

( 7.

3) 7

.4 (1

7.4)

18.7

(18.

6)N

ORT

HER

N IR

ELA

ND

1880

1659

88.2

89.5

45.0

52.3

67.8

4.8

66.4

63.0

12.4

( 8.

0) 8

.6 (1

7.8)

21.0

(19.

3)O

VERA

LL63

510

5936

593

.592

.652

.483

.149

.53.

791

.983

.815

.7 (1

3.1)

4.5

(13.

2)20

.2 (1

8.0)

No

rth

ern

Irel

and

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

77

Hos

pita

l

Hospital code














Wan

sbec

k H

ospi

tal

ASH

350

330

94.3

95.7

51.8

96.3

57.9

1.4

100.

088

.7 9

.4 (

6.2)

17.3

(21.

3)26

.8 (2

2.1)

Dar

lingt

on M

emor

ial H

ospi

tal

DA

R32

032

610

1.9

90.0

76.8

53.8

51.8

1.3

99.6

90.6

10.7

( 6.

9) 9

.6 (1

2.3)

20.3

(14.

2)

Uni

vers

ity H

ospi

tal O

f Nor

th D

urha

mD

RY37

034

793

.892

.152

.877

.346

.11.

398

.783

.910

.4 (

8.3)

14.1

(17.

0)24

.5 (1

9.1)

Uni

vers

ity H

ospi

tal o

f Nor

th T

ees

NTG

315

372

118.

188

.784

.889

.244

.94.

498

.288

.714

.6 (

8.8)

7.3

(14.

6)21

.9 (1

6.8)

Nor

th T

ynes

ide

Gen

eral

Hos

pita

lN

TY34

032

996

.895

.047

.596

.827

.10.

799

.378

.710

.5 (

7.5)

12.5

(23.

5)23

.0 (2

4.6)

Que

en E

lizab

eth

Hos

pita

l, G

ates

head

QEG

300

293

97.7

98.6

79.2

92.3

44.7

7.3

99.6

79.2

17.3

(10.

9) 2

.1 (1

0.6)

19.4

(14.

6)

Roya

l Vic

toria

Hos

pita

l, N

ewca

stle

RVN

450

425

94.4

95.7

66.0

87.5

47.3

4.3

100.

084

.814

.1 (1

1.9)

18.5

(26.

9)32

.6 (2

7.4)

Jam

es C

ook

Uni

vers

ity H

ospi

tal,

Mid

dles

boro

ugh

SCM

512

456

89.1

91.1

91.5

86.8

36.4

0.7

99.5

91.1

16.9

(11.

8) 1

.5 (

9.4)

18.4

(14.

8)

Sout

h Ty

nesi

de D

istr

ict H

ospi

tal

STD

208

209

100.

593

.927

.955

.77.

24.

410

0.0

90.6

16.8

(13.

2)12

.9 (2

1.6)

29.7

(22.

8)

Sund

erla

nd R

oyal

Hos

pita

l SU

N42

037

789

.893

.571

.683

.554

.99.

010

0.0

84.9

21.8

(16.

6) 1

.5 (

8.5)

23.3

(19.

1)

SHA

3585

3464

96.6

93.3

65.3

83.2

43.2

3.8

98.8

97.0

14.4

(11.

4) 9

.4 (1

8.5)

23.8

(20.

3)

ENG

LAN

D58

640

5498

593

.892

.849

.984

.249

.84

92.8

93.1

15.8

(13.

1) 3

.9 (1

1.9)

19.7

(17.

1)O

VERA

LL63

510

5936

593

.592

.652

.483

.149

.53.

791

.983

.815

.7 (1

3.1)

4.5

(13.

2)20

.2 (1

8.0)

No

rth

Eas

t

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

78

Hos

pita

l

Hospital code














Roya

l Alb

ert E

dwar

d In

firm

ary,

Wig

anA

EI35

031

991

.197

.410

.593

.845

.52.

910

0.0

97.1

18.2

(13.

5) 1

.6 (

7.3)

19.8

(15.

4)Ro

yal B

lack

burn

Hos

pita

lBL

A42

545

810

7.8

93.4

70.4

88.6

48.3

2.3

100.

092

.015

.1 (1

1.4)

5.1

(12.

2)20

.2 (1

6.8)

Roya

l Bol

ton

Hos

pita

lBO

L36

035

498

.396

.074

.978

.261

.95.

062

.794

.118

.8 (1

2.1)

0.9

( 5.

7)19

.7 (1

2.9)

Fair

field

Hos

pita

l, Bu

ryBR

Y20

024

212

1.0

89.2

65.3

57.3

50.4

5.5

60.3

97.7

12.7

( 9.

0) 5

.6 (1

2.0)

18.3

(15.

0)Cu

mbe

rlan

d In

firm

ary,

Car

lisle

CMI

275

243

88.4

94.0

74.0

88.5

20.2

3.1

43.3

76.3

13.0

(13.

5) 0

.7 (

4.1)

13.7

(14.

0)Co

unte

ss o

f Che

ster

Hos

pita

lCO

C32

032

310

0.9

92.3

41.6

83.3

34.7

12.0

98.9

96.1

18.5

(14.

4) 4

.2 (1

0.9)

22.7

(17.

8)U

nive

rsity

Hos

pita

l Ain

tree

FAZ

380

367

96.6

94.7

31.0

91.0

67.0

2.7

100.

078

.815

.1 (1

0.1)

10.2

(18.

8)25

.4 (2

0.5)

Furn

ess

Gen

eral

Hos

p., B

arro

w-in

-Fur

ness

FGH

150

120

80.0

90.4

58.0

83.2

3.3

7.5

100.

096

.525

.1 (2

0.4)

4.6

(16.

8)29

.8 (2

5.3)

Leig

hton

Hos

pita

l, Cr

ewe

LGH

250

283

113.

289

.578

.576

.824

.74.

398

.891

.817

.5 (1

1.5)

1.3

( 6.

9)18

.8 (1

4.5)

Mac

cles

field

Gen

eral

Hos

pita

lM

AC

240

236

98.3

88.6

88.3

86.0

62.6

1.4

97.2

92.0

18.1

(12.

3) 5

.3 (1

3.5)

23.5

(18.

4)M

anch

este

r Ro

yal I

nfirm

ary

MRI

175

164

93.7

92.6

73.8

65.8

25.6

3.4

98.6

80.3

11.5

( 8.

9)18

.2 (2

0.7)

29.7

(22.

6)N

orth

Man

ches

ter

Gen

eral

Hos

pita

lN

MG

249

157

63.1

86.8

49.3

70.3

11.6

8.8

22.6

31.7

21.6

(17.

5) 4

.8 (1

1.7)

26.4

(20.

2)N

oble

s H

ospi

tal,

Isle

of M

anN

OB

8088

110.

094

.893

.291

.45.

70.

098

.843

.415

.0 (

9.9)

1.9

( 7.

1)16

.9 (1

1.5)

Roya

l Old

ham

Hos

pita

lO

HM

279

229

82.1

93.1

63.4

70.2

97.4

4.0

95.4

96.5

15.6

(13.

1) 6

.8 (1

4.1)

22.5

(17.

8)Ro

yal L

anca

ster

Infir

mar

yRL

I30

024

983

.087

.652

.273

.623

.80.

989

.864

.013

.8 (

9.9)

8.5

(16.

7)22

.3 (1

8.5)

Roya

l Liv

erpo

ol U

nive

rsity

Hos

pita

lRL

U37

035

595

.998

.448

.985

.663

.10.

998

.880

.118

.6 (1

3.4)

1.3

( 6.

2)19

.9 (1

4.7)

Roya

l Pre

ston

Hos

pita

lRP

H45

740

087

.582

.055

.075

.71.

50.

810

0.0

96.2

15.0

(11.

9) 7

.1 (1

3.4)

22.1

(18.

1)St

eppi

ng H

ill H

ospi

tal,

Stoc

kpor

tSH

H37

038

210

3.2

92.2

0.0

92.2

14.4

4.4

99.7

86.8

21.8

(16.

9) 1

.2 (

8.9)

23.0

(18.

4)Ro

yal S

alfo

rd H

ospi

tal

SLF

240

206

85.8

89.0

65.5

75.3

42.4

3.9

99.4

31.8

13.9

(11.

2) 1

.7 (

7.8)

15.6

(12.

9)So

uthp

ort D

istr

ict G

ener

al H

ospi

tal

SOU

300

270

90.0

91.2

57.1

85.0

0.0

0.0

100.

00.

015

.2 (1

2.3)

2.7

( 8.

0)17

.9 (1

4.7)

Tam

esid

e G

ener

al H

osp,

Man

ches

ter

TGA

350

247

70.6

89.2

69.9

61.4

95.9

0.5

100.

090

.718

.9 (1

4.8)

0.0

( 0.

3)18

.9 (1

4.8)

Traff

ord

Gen

eral

Hos

pita

l, M

anch

este

rTR

A10

012

112

1.0

94.4

47.1

92.4

13.2

1.0

100.

010

0.0

27.3

(19.

9) 0

.4 (

2.8)

27.7

(20.

3)V

icto

ria

Hos

pita

l, Bl

ackp

ool

VIC

500

403

80.6

69.9

31.2

71.9

79.2

1.3

97.4

92.3

13.7

(11.

4) 9

.7 (1

6.1)

23.5

(20.

8)W

arri

ngto

n H

ospi

tal

WD

G38

034

189

.791

.359

.480

.210

.96.

310

0.0

86.4

19.0

(12.

4) 0

.8 (

4.6)

19.8

(13.

2)W

hist

on H

ospi

tal,

Pres

cot

WH

I40

038

796

.892

.530

.596

.028

.30.

796

.590

.716

.7 (1

3.4)

6.5

(14.

4)23

.2 (1

8.5)

Arr

owe

Park

Hos

pita

l, W

irra

lW

IR49

943

086

.289

.973

.193

.255

.814

.790

.786

.617

.1 (1

2.6)

6.3

(12.

5)23

.4 (1

7.7)

Wyt

hens

haw

e H

ospi

tal,

Man

ches

ter

WYT

300

273

91.0

94.2

20.1

82.4

9.9

2.1

100.

099

.619

.2 (1

6.4)

7.0

(15.

3)26

.2 (2

1.6)

SHA

8299

7647

92.1

90.7

50.9

82.1

38.9

4.1

91.2

89.1

17.0

(13.

4) 4

.6 (1

2.3)

21.6

(17.

6)EN

GLA

ND

5864

054

985

93.8

92.8

49.9

84.2

49.8

492

.893

.115

.8 (1

3.1)

3.9

(11.

9)19

.7 (1

7.1)

OV

ERA

LL63

510

5936

593

.592

.652

.483

.149

.53.

791

.983

.815

.7 (1

3.1)

4.5

(13.

2)20

.2 (1

8.0)

No

rth

Wes

t

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

79

Hos

pita

l Hospital code














Hor

ton

Hos

pita

l, Ba

nbur

yH

OR

160

169

105.

691

.939

.190

.181

.35.

410

0.0

83.9

19.8

(18.

3) 3

.8 (1

2.0)

23.6

(20.

8)St

.Mar

y's

Hos

pita

l, Is

le o

f Wig

htIO

W25

023

292

.895

.070

.288

.191

.82.

392

.610

.213

.4 (

9.8)

7.4

(15.

8)20

.8 (1

8.5)

Milt

on K

eyne

s G

ener

al H

ospi

tal

MKH

250

108

43.2

88.0

19.2

86.4

10.2

2.1

89.4

82.0

20.5

(14.

2) 0

.0 (

0.0)

20.5

(14.

2)Ba

sing

stok

e &

N.H

ants

Hos

pita

lN

HH

220

227

103.

299

.162

.294

.374

.44.

810

0.0

89.4

18.1

(13.

5) 0

.0 (

0.0)

18.1

(13.

5)Q

ueen

Ale

xand

ra H

osp.

, Por

tsm

outh

Q

AP

654

688

105.

298

.087

.287

.684

.71.

710

0.0

98.0

15.5

(10.

2) 3

.7 (

9.8)

19.2

(13.

3)Jo

hn R

adcl

iffe

Hos

pita

l, O

xfor

dRA

D48

053

111

0.6

90.5

61.5

67.6

72.9

3.6

92.0

86.6

13.7

( 8.

5) 0

.4 (

2.2)

14.1

( 8.

6)Ro

yal B

erks

hire

Hos

pita

l, Re

adin

gRB

E50

048

697

.296

.026

.586

.777

.20.

910

0.0

90.4

10.2

(11.

7) 6

.6 (1

1.0)

16.8

(14.

2)Ro

yal H

amps

hire

Cou

nty

Hos

pita

lRH

C27

523

485

.198

.329

.192

.097

.95.

710

0.0

51.9

15.8

(10.

4) 6

.5 (1

4.0)

22.3

(18.

1)So

utha

mpt

on G

ener

al H

ospi

tal

SGH

600

584

97.3

85.5

73.1

79.4

86.1

3.2

99.1

87.7

15.8

(10.

1) 0

.2 (

2.4)

16.0

(10.

4)St

oke

Man

devi

lle H

ospi

tal,

Ayl

esbu

rySM

V38

038

710

1.8

92.7

19.1

84.2

57.1

0.6

97.5

96.7

16.0

(14.

3) 0

.3 (

2.0)

16.4

(14.

5)W

exha

m P

ark

Hos

pita

l, Sl

ough

W

EX37

036

999

.784

.931

.486

.337

.25.

691

.684

.216

.9 (1

3.9)

1.0

( 4.

5)17

.9 (1

4.7)

SHA

4139

4015

97.0

92.6

48.3

84.0

73.9

3.0

96.0

97.1

15.2

(11.

9) 2

.6 (

8.6)

17.8

(14.

1)EN

GLA

ND

5864

054

985

93.8

92.8

49.9

84.2

49.8

492

.893

.115

.8 (1

3.1)

3.9

(11.

9)19

.7 (1

7.1)

OVE

RALL

6351

059

365

93.5

92.6

52.4

83.1

49.5

3.7

91.9

83.8

15.7

(13.

1)4.

5 (1

3.2)

20.2

(18.

0)

Sou

th C

entr

al

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

80

Hos

pita

l

Hospital code














Conq

uest

Hos

pita

l, H

as�n

gsCG

H31

827

987

.794

.537

.285

.62.

50.

846

.334

.420

.5 (1

7.6)

0.7

( 4.

1)21

.2 (1

7.9)

East

bour

ne H

ospi

tal

DG

E37

837

799

.794

.132

.392

.01.

12.

178

.483

.316

.9 (1

3.2)

1.6

( 6.

0)18

.5 (1

5.0)

Dar

ent V

alle

y H

ospi

tal,

Dar

�or

dD

VH36

334

294

.295

.638

.375

.710

.86.

194

.085

.618

.5 (1

4.1)

0.7

( 4.

1)19

.2 (1

4.7)

East

Sur

rey

Hos

pita

l, Re

dhill

ESU

485

460

94.8

90.9

12.8

82.3

66.8

6.0

100.

096

.619

.3 (1

5.6)

0.0

( 0.

3)19

.3 (1

5.6)

Frim

ley

Park

, Cam

berl

eyFR

M36

032

289

.495

.856

.693

.71.

93.

110

0.0

97.9

18.9

(14.

7) 2

.8 (1

0.9)

21.7

(18.

5)M

edw

ay M

ari�

me

Hos

pita

l M

DW

375

332

88.5

94.3

50.6

82.8

31.0

5.9

99.3

86.6

19.2

(15.

6) 0

.1 (

1.7)

19.3

(15.

6)Q

ueen

Eliz

abet

h th

e Q

ueen

Mot

her H

ospi

tal,

Mar

gate

QEQ

445

417

93.7

94.4

64.7

88.6

89.0

0.9

98.7

89.7

16.3

(12.

5) 5

.4 (1

6.3)

21.7

(21.

4)Ro

yal S

usse

x Co

unty

Hos

pita

lRS

C50

042

685

.294

.539

.787

.744

.610

.897

.790

.1 7

.2 (

6.0)

13.2

(15.

2)20

.4 (1

6.4)

Roya

l Sur

rey

Coun

ty H

ospi

tal

RSU

378

335

88.6

91.7

24.8

92.3

48.8

3.2

98.1

84.1

20.3

(18.

4) 0

.6 (

6.4)

20.9

(19.

2)St

Pet

er's

Hos

pita

l, Ch

erts

eySP

H40

038

796

.897

.955

.194

.177

.04.

310

0.0

89.4

16.9

(14.

5) 5

.3 (1

2.9)

22.1

(19.

3)St

Ric

hard

's H

ospi

tal,

Chic

hest

erST

R40

037

593

.893

.84.

791

.560

.83.

995

.094

.210

.9 (

7.6)

4.7

( 9.

8)15

.6 (1

1.6)

Tunb

ridg

e W

ells

Hos

pita

lTU

N46

022

448

.792

.541

.490

.24.

97.

83.

991

.315

.4 (1

3.4)

7.9

(13.

8)23

.3 (1

6.1)

Will

iam

Har

vey

Hos

pita

l, A

shfo

rdW

HH

485

357

73.6

91.3

43.8

88.1

69.6

2.3

99.4

93.7

18.4

(14.

1) 0

.9 (

6.7)

19.3

(15.

5)W

orth

ing

& S

outh

land

s H

ospi

tal

WRG

493

452

91.7

93.5

5.0

87.6

95.1

1.0

100.

092

.5 8

.8 (

9.8)

18.6

(22.

9)27

.4 (2

4.2)

SHA

5840

5085

87.1

93.9

33.8

88.0

47.3

4.5

88.9

93.7

16.4

(14.

3) 3

.9 (1

1.2)

20.3

(17.

2)EN

GLA

ND

5864

054

985

93.8

92.8

49.9

84.2

49.8

492

.893

.115

.8 (1

3.1)

3.9

(11.

9)19

.7 (1

7.1)

OVE

RALL

6351

059

365

93.5

92.6

52.4

83.1

49.5

3.7

91.9

83.8

15.7

(13.

1)4.

5 (1

3.2)

20.2

(18.

0)

Sou

th E

ast

Co

ast

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

81

Hos

pita

l

Hospital code














Roya

l Uni

ted

Hos

pita

l, Ba

thBA

T50

051

210

2.4

89.5

14.3

88.4

60.0

0.2

94.3

86.0

14.0

( 9.

8) 0

.7 (

5.4)

14.7

(10.

6)Br

isto

l Roy

al In

firm

ary

BRI

300

342

114.

096

.214

.672

.043

.67.

799

.779

.217

.2 (1

4.1)

9.4

(15.

2)26

.6 (2

0.5)

Chel

tenh

am G

ener

al H

ospi

tal

CHG

330

327

99.1

93.7

65.9

78.1

80.6

1.0

100.

090

.415

.7 (1

0.3)

0.0

( 0.

0)15

.7 (1

0.3)

Fren

chay

Hos

pita

l, Br

isto

lFR

Y48

041

786

.998

.421

.793

.071

.210

.610

0.0

88.2

22.6

(17.

0) 0

.1 (

2.4)

22.7

(17.

1)G

louc

este

rshi

re R

oyal

Hos

pita

lG

LO40

038

496

.099

.266

.991

.054

.40.

398

.880

.914

.8 (1

0.3)

1.1

( 5.

4)15

.9 (1

1.3)

Mus

grov

e Pa

rk H

ospi

tal,

Taun

ton

MPH

400

405

101.

291

.671

.592

.546

.02.

397

.288

.715

.1 (1

0.3)

0.5

( 5.

3)15

.6 (1

1.3)

Nor

th D

evon

Dis

tric

t Hos

pita

lN

DD

250

225

90.0

90.4

85.2

88.0

0.9

4.7

100.

080

.010

.6 (

8.5)

10.2

(18.

1)20

.8 (2

1.7)

Pool

e G

ener

al H

ospi

tal

PGH

923

897

97.2

96.1

66.8

85.2

12.4

2.2

100.

094

.811

.2 (

8.6)

0.0

( 0.

8)11

.3 (

8.6)

Der

rifo

rd H

ospi

tal,

Plym

outh

PLY

550

501

91.1

89.3

58.3

78.5

49.7

2.0

100.

096

.613

.1 (

8.0)

0.4

( 2.

8)13

.5 (

8.3)

The

Gre

at W

este

rn H

ospi

tal,

Swin

don

PMS

370

407

110.

097

.785

.691

.473

.74.

610

0.0

84.5

17.8

(14.

9) 0

.5 (

4.2)

18.3

(15.

3)Th

e Ro

yal C

ornw

all H

ospi

tal,

Trel

iske

RCH

455

555

122.

093

.572

.084

.487

.23.

710

0.0

84.8

12.7

( 8.

7) 0

.6 (

4.4)

13.3

( 9.

9)Ro

yal D

evon

& E

xete

r Hos

pita

lRD

E55

254

899

.394

.865

.288

.965

.71.

010

0.0

91.5

11.8

( 7.

1) 0

.2 (

1.6)

12.1

( 7.

3)Sa

lisbu

ry D

istr

ict H

ospi

tal

SAL

226

242

107.

195

.073

.891

.393

.81.

410

0.0

99.5

16.1

(13.

9) 3

.5 (1

1.4)

19.6

(17.

5)To

rbay

Dis

tric

t Gen

eral

Hos

pita

lTO

R46

043

895

.289

.468

.583

.883

.31.

085

.597

.8 8

.9 (

4.8)

12.5

(15.

7)21

.3 (1

6.2)

Dor

set C

ount

y H

ospi

tal,

Dor

ches

ter

WD

H30

022

374

.390

.693

.791

.50.

43.

581

.872

.411

.8 (

9.2)

0.0

( 0.

0)11

.8 (

9.2)

Wes

ton

Gen

eral

Hos

pita

lW

GH

294

268

91.2

89.3

68.4

85.8

24.6

13.1

89.3

82.6

15.3

(11.

6) 4

.4 (1

0.1)

19.6

(14.

5)SH

A67

9066

9198

.593

.755

.486

.353

.43.

596

.796

.714

.0 (1

1.0)

2.2

( 8.

3)16

.2 (1

3.4)

ENG

LAN

D58

640

5498

593

.892

.849

.984

.249

.84

92.8

93.1

15.8

(13.

1) 3

.9 (1

1.9)

19.7

(17.

1)O

VERA

LL63

510

5936

593

.592

.652

.483

.149

.53.

791

.983

.815

.7 (1

3.1)

4.5

(13.

2)20

.2 (1

8.0)

Sou

th W

est

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

82

Hos

pita

l

Hospital code














Bron

glai

s H

ospi

tal,

Abe

ryst

wyt

hBR

G85

8710

2.4

91.3

41.0

59.5

9.2

5.8

0.0

46.0

14.9

( 8.

2) 6

.6 (1

6.5)

21.5

(18.

7)G

lan

Clw

yd H

ospi

tal,

Rhyl

CLW

375

373

99.5

93.4

57.0

86.5

5.1

5.1

1.3

84.6

12.9

( 7.

9)19

.1 (2

6.5)

32.0

(28.

0)G

wyn

nedd

Ysb

yty,

Ban

gor

GW

Y15

819

112

0.9

90.1

53.2

78.8

46.8

1.3

99.4

88.4

11.8

( 8.

7)19

.1 (2

0.7)

31.0

(21.

1)M

orri

ston

Hos

pita

l, Sw

anse

aM

OR

530

440

83.0

94.0

33.3

82.3

0.2

2.1

89.1

82.9

19.7

(13.

2)21

.2 (3

4.9)

40.8

(37.

6)N

evill

Hal

l Hos

pita

l, A

berg

aven

nyN

EV29

827

291

.393

.738

.884

.557

.43.

686

.576

.813

.6 (1

2.0)

11.5

(21.

0)25

.1 (2

3.6)

Roya

l Gla

mor

gan

Hos

pita

l, Ll

antr

isan

tRG

H27

517

463

.386

.830

.269

.17.

50.

710

0.0

79.2

15.0

( 9.

1)23

.2 (3

5.8)

38.3

(35.

1)U

nive

rsity

Hos

pita

l of W

ales

, Car

diff

UH

W50

050

110

0.2

85.8

13.5

64.9

61.9

5.9

95.5

85.5

24.2

(19.

6)11

.4 (2

6.2)

35.6

(31.

1)M

aelo

r Hos

pita

l, W

rexh

amW

RX23

023

910

3.9

93.8

74.2

82.6

45.2

1.8

95.9

59.8

14.0

( 9.

3)16

.4 (2

6.4)

30.4

(27.

6)W

est W

ales

Gen

eral

Hos

pita

lW

WG

300

259

86.3

90.4

68.4

77.2

76.1

1.7

73.9

89.6

15.1

(15.

3) 4

.5 (1

8.1)

19.6

(23.

6)W

ithyb

ush

Hos

pita

l, H

aver

ford

Wes

tW

YB18

013

172

.890

.169

.258

.52.

37.

056

.380

.715

.9 (1

0.1)

6.1

(18.

1)21

.9 (2

0.5)

WA

LES

2931

2667

91.0

90.9

40.4

76.3

34.1

3.6

69.9

87.6

16.7

(13.

6)15

.2 (2

7.3)

31.9

(29.

8)O

VERA

LL63

510

5936

593

.592

.652

.483

.149

.53.

791

.983

.815

.7 (1

3.1)

4.5

(13.

2)20

.2 (1

8.0)

Wal

es

Cop

yrig

ht ©

The

Nat

iona

l Hip

Fra

ctur

e D

atab

ase

2011

. All

righ

ts r

eser

ved.

83

Hos

pita

l

Hospital code














Que

ens

Hos

pita

l, Bu

rton

-upo

n-Tr

ent

BRT

274

279

101.

892

.760

.593

.112

.30.

894

.099

.617

.2 (1

5.6)

1.5

( 8.

4)18

.6 (1

7.6)

Birm

ingh

am H

eart

land

sEB

H48

045

494

.693

.67.

162

.478

.614

.987

.867

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AMT scores Abbreviated mental test score. A rapid assessment of elderly patients to assess cognitive dysfunction.

Arthroplasty Any replacement of the upper femur including unipolar hemi-arthroplasties, bipolar hemi-arthroplasties and total hip replacements

ASA grades American Society of Anesthesiologists8 (ASA) physical status classification:-

1. A normal healthy patient

2. A patient with a mild systemic disease

3. A patient with a severe systemic disease that limits activity, but is not incapacitating

4. A patient with an incapacitating systemic disease that is a constant threat to life

5. A moribund patient not expected to survive 24 hours with or without operation

This grading does not take into account acute illness, hence a patient can be ASA 1

and ‘unfit’.

Bone protection 1. Bisphosphonatesmedication Etidronate

AlendronateRisedronateIbandronateZoledronatePamidronate

2. Denosumab

3. HRT and SERMS HRT (various)TiboloneRaloxifene

4. Parathyroid hormonePTH 1-34PTH 1-84

5. StrontiumStrontium ranelate

6. Calcium and vitamin DCalcitriol Calcium and vitamin D – variousAlpha-calcidol (or one alpha)

7. Calcitonin

GlossaryTerm Definitions


Case The number of cases submitted by the participating hospital divided by the numberascertainment of cases predicted, expressed as a percentage.

Casemix factors Demographic and functional information about patient. e.g. Age, sex, mobility, deprivation status , ASA and previous living circumstances (for mortality data only)

Cemented Polymethyl methacrylate is a plastic that may be used to hold arthroplasties in place. arthroplasties It is introduced into the reamed bone before prostheses are inserted. The ‘cement’

sets in a few minutes.

Falls Assessment A systematic assessment by a suitably trained person e.g. Geriatrician or a specialist trained nurse which must cover the following domains:- Falls history (noting previous falls), cause of index fall (including medication review), risk factors for falling and injury (including fracture) and from this information formulate and document a plan of action to prevent further falls.

Foundation A newly qualified junior doctor undertaking two years of supervised clinical practiceGrade Doctor prior to embarking on specialist training

Fracture Liaison A nurse whose primary purpose is to ensure that both inpatients and outpatients withNurse/service low impact fractures are screened for falls and osteoporosis

Hemiarthroplasty A half hip replacement that is either:/ Bipolar Unipolar – replacement of the femoral head and neckHemiarthroplasty Bipolar – replacement of the femoral head and neck, with the addition of an

acetabular cup that is not attached to the pelvis.

HES Hospital Episode Statistics9 Centrally held data used to determine a hospital’s case load.

Multidisciplinary A group of people of different professions (and including as a minimum a rehabilitation physiotherapist, occupational therapist, nurse and doctor) with job plan team responsibilities for the assessment and treatment of hip fracture patients, and who

convene (including face to face or virtual ward round) regularly (and at least weekly) to discuss patient treatment and care, and plan shared clinical care goals.

Pressure ulcer10 A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear or friction forces, or a combination of these.

ST3 level doctor A junior doctor in the third and final year of specialist training

Superspell Overall NHS length of stay: i.e. including acute care and any post-acute care/rehabilitation care prior to return home; or to admission to care home care; to other non-NHS placement; or death

Term Definitions



References1. British Orthopaedic Association. The Care of patients with fragility fracture. Br Orthop Ass 2007.

Available from: http://www.boa.ac.uk

2. Best Practice Tariff. http://www.dh.gov.uk/health/2012/02/confirmation-pbr-arrangements/

3. National Institute for Clinical Excellence www.nice.org.uk/guidance/CG124

4. Spiegelhalter, D J Funnel plots for comparing institutional performance Statistics in Medicine2005241185-1202

5. Costa, M.L. & Griffin, X.L. et al Does cementing the femoral component increase the risk ofperi-operative mortality for patients having replacement surgery for a fracture of the neck of femur? J Bone Joint Surg Br October 2011 vol. 93-B no. 10 1405-1410

6. National Joint Registry for England and Wales: 8th National Report 2011, pg 66

7. Department of Health. Internal document 2012

8. American Society of Anaesthesiologists (1963). New classification of physical status. Anaesthesiology 1963;24:111.

9. HES: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937

10. European Pressure Ulcer Advisory Panel (1999) Guidelines on treatment of pressure ulcers.EPUAP Review 1, 31–33

11. Breiman L, Friedman J, Ohlshen R, Stone S. Classification and regression trees PacificGrove: Wadsworth, 1984


Appendix AStructure and governance

NHFD Steering Group

Co-Chairs

David MarshProfessor of Clinical Orthopaedics, UCL, Royal National Orthopaedic Hospital

Finbarr MartinProfessor of Gerontology, King's College London

Guy BroomeConsultant Orthopaedic Surgeon, CumberlandInfirmary, Carlisle

James CooperPolitical Relations Officer, National OsteoporosisSociety

Colin CurrieClinical Lead for Geriatric Medicine, NHFD

James ElliottConsultant Orthopaedic Surgeon, Belfast

Colin EslerConsultant Orthopaedic Surgeon, Leicester

Karen HertzAdvanced Nurse Practitioner, University Hospital ofNorth Staffordshire NHS Trust

Antony JohansenConsultant Orthogeriatrician and Senior Lecturerin Public Health, Cardiff & Vale NHS Trust

Helen LaingContracts & Commissioning Manager, HealthcareQuality and Improvement Partnership

Paul MitchellSynthesis Medical

Chris MoranProfessor of Orthopaedic Trauma Surgery,Nottingham University Hospital

Maggie PartridgeNHFD Project Manager

Mike PearsonProfessor of Clinical Evaluation, University ofLiverpool

Margit Physant, Age UKPolicy Adviser for Health and Wellbeing

Fay PlantNHFD Coordinator (North)

Jonathan RobertsHealth & Social Care Information Centre

Opinder SahotaProfessor in Orthogeriatric Medicine & ConsultantPhysician, Queen’s Medical Centre, Nottingham

Bob SmithPatient Representative

Roz StanleyProject Manager, Health & Social Care InformationCentre

Jonathan TremlConsultant Geriatrician, Selly Oak Hospital. RCPFalls & Bone Health Audit Lead

Rob WakemanConsultant Orthopaedic Surgeon, BasildonUniversity Hospital, and Clinical Lead forOrthopaedic Surgery, NHFD

Richard GriffithsConsultant Anaesthetist, Peterborough Hospital

Keith WillettProfessor of Orthopaedic Trauma Surgery, JohnRadcliffe Infirmary, Oxford, and National ClinicalDirector for Trauma Care, Department of Health

Andy WilliamsNHFD Project Coordinator (South)



NHFD Implementation Group

Chair

Colin CurrieNHFD Clinical Lead for Geriatric Medicine

Tim BunningLead Web Developer, Health & Social Care Information Centre

Maggie PartridgeNHFD Project Manager

Fay PlantNHFD Coordinator (North)


Rob WakemanConsultant Orthopaedic SurgeonBasildon University Hospital and Clinical Lead for Orthopaedic Surgery, NHFD


NHFD Dataset Sub Group

Chair


Gary Cook,Consultant in Public Health Medicine, Stockport

James ElliottConsultant Orthopaedic Surgeon, Royal Victoria Hospital, Belfast

Antony JohansenConsultant Orthogeriatrician and Senior Lecturer in Public Health, Cardiff & Vale NHS Trust

Fay PlantNHFD Project Coordinator (North)


Rob WakemanConsultant Orthopaedic SurgeonBasildon University Hospital and Clinical Lead for Orthopaedic Surgery, NHFD


NHFD Scientific & Publications Committee

Chair


Matt Costa,Associate Clinical Professor in Orthopaedics, Warwick Medical School & University Hospitals Coventry andWarwick

James ElliottConsultant Orthopaedic Surgeon, Royal Victoria Hospital, Belfast

Karen HardingConsultant Orthogeriatrician, Frenchay Hospital

Janet LippettConsultant in Elderly Care, Royal Berkshire NHS Foundation Trust

Michael PearsonProfessor of Clinical Evaluation, University of Liverpool

Neil PendletonSenior Lecturer in Geriatric Medicine, the University of Manchester

Rob WakemanConsultant Orthopaedic Surgeon, Basildon University Hospital and NHFD Clinical Lead for Orthopaedic Surgery




Appendix BClassification tree - Rate of return home from home at 30 days

This classification tree11 shows how casemix factors can be used to predict return home of hip fracturepatients admitted from home. At each level of the tree the casemix factors are used to split cases intogroups with maximally different return home rates.

The most important predictors of return home from home at 30 days are: whether accompanied to walkoutdoors; age; and ASA grade. The tree is similar to the previous year’s tree (2011 National Report).

The important casemix factors are used to produce casemix-adjusted (standardised) estimates of eachoutcome by hospital. The raw and standardised rates are displayed in funnel plot (see p.58).


AIR 9 0.0 0.0BAR 8 0.0 0.0BAT 23 0.0 0.0BED 8 0.0 0.0BFH 11 0.0 0.0BNT 35 14.3 15.5BRG 7 14.3 15.3BRO 17 0.0 0.0BRT 19 0.0 0.0BRY 43 27.9 28.9CCH 9 0.0 0.0CGH 23 8.7 11.4CHE 10 0.0 0.0CHS 34 17.6 19.8CRG 52 53.8 49.0DAR 16 0.0 0.0DGE 17 0.0 0.0DRY 13 0.0 0.0ENH 42 9.5 11.7ESU 25 0.0 0.0FAZ 21 0.0 0.0GEO 11 0.0 0.0GRA 3 0.0 0.0HAR 15 26.7 28.7HCH 16 0.0 0.0HIL 16 6.3 7.9HIN 43 46.5 41.0HOR 14 0.0 0.0HRI 24 0.0 0.0IOW 13 15.4 17.5IPS 25 8.0 9.2KCH 9 0.0 0.0KGH 15 0.0 0.0KMH 27 0.0 0.0KTH 16 6.3 7.9LDH 25 0.0 0.0LER 35 0.0 0.0LEW 10 0.0 0.0LGH 13 0.0 0.0MAC 25 0.0 0.0MAY 9 0.0 0.0MKH 9 22.2 26.9MPH 56 44.6 49.4NGS 23 0.0 0.0NMG 19 10.5 12.7NMH 19 47.4 49.2NOB 53 49.1 49.1NOR 2 50.0 60.0NPH 13 0.0 0.0PEH 6 16.7 23.8

No. of cases eligiblefor return home

from home analysisExcludedHospitals

Percentage of eligible at30 cases returned home daysRaw Adjusted

Excluded hospitals



PET 28 3.6 4.8QEB 40 12.5 13.7QKL 21 0.0 0.0RAD 1 0.0 0.0RCH 26 3.8 5.6RED 10 10.0 16.1RFH 13 0.0 0.0RGH 9 0.0 0.0RLI 6 0.0 0.0RLU 57 78.9 70.7ROT 17 0.0 0.0RSC 18 0.0 0.0RSU 14 0.0 0.0RUS 19 0.0 0.0SAL 11 0.0 0.0SCA 12 0.0 0.0SCM 6 0.0 0.0SGH 29 0.0 0.0 SHC 32 3.1 3.9SLF 13 0.0 0.0STM 7 0.0 0.0STO 13 0.0 0.0TGA 17 5.9 7.0TLF 8 12.5 14.3TUN 4 0.0 0.0UCL 10 30.0 40.6UHN 41 0.0 0.0VIC 44 72.7 75.5WES 17 29.4 37.1WEX 31 6.5 7.7WGH 5 0.0 0.0WHC 30 6.7 7.6WHI 26 0.0 0.0WHT 17 11.8 13.6WIR 25 64.0 71.6WMH 18 0.0 0.0WMU 7 0.0 0.0WRX 49 46.9 40.3WWG 7 0.0 0.0WYB 3 0.0 0.0WYT 11 0.0 0.0

No. of cases eligiblefor return home

from home analysisExcludedHospitals

Percentage of eligible at30 cases returned home daysRaw Adjusted

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Appendix DNHFD Chart OutlinesAll charts

Data slices

Admission data slice: Patients admitted between 1st April 2011 and 31st March 2012 inclusive andaged greater than or equal to 60 years (those aged over 110 years are excluded).

Discharge data slice: Patients admitted between 1st April 2011 and 31st March 2012 inclusive,discharged from Trust during the same period and aged greater than or equal to 60 years (those agedover 110 years are excluded).All charts use the admission data set unless otherwise specified.

Hospital inclusionHospitals to be included if 100 or more records were included in the admission data slice or if thehospital had 100% case ascertainment.

Numbers of casesHospital (N) – Indicates that all cases are included and the number in brackets is the number of cases perhospital.Hospital (n/N) – Indicates that a subset has been taken. ‘n’ is the number of cases in the subset and ‘N’ isthe total number of cases in the hospital.

Chart 1 – Completeness of data fields

Description: Hospitals ranked by the percentage of complete data fields.Fields Used:For all patients: Gender, ASA Grade, Admitted From, Walking Ability Indoors, Walking AbilityOutdoors, Fracture Type, Operation Performed, Preoperative Medical Assessment, Bone TherapyMedication, Admission Time to A&E, AMTS, Ward Type, Discharge Date from Trust, Discharge from TrustDestination, Anaesthesia TypeFor admitted to Orthopaedic Ward: Admission Time to Orthopaedic Ward, Discharge Date fromWard, Discharge from Ward DestinationFor patients who did not die in hospital: Pressure Ulcers, Specialist Falls AssessmentFor patients who underwent surgery: Date of SurgeryFor patients who underwent surgery after 36 hours: Reason for 36 Hour Delay to SurgeryFor patients who underwent surgery after 48 hours: Reason for 48 Hour Delay to SurgeryFor patients who underwent surgery & were discharged before 1/04/12: 30 Day ReoperationCalculation: For each hospital, number of completed fields divided by the number of fields that shouldhave been completed.Data: All 180 hospitals included in chart.

Chart 2 – Age at admission

Description: Hospitals ranked by the percentage of patients aged over 90 years.Fields Used: AgeGroups: Patient age is grouped into four categories – 60-69, 70-79, 80-89 and 90+.Total number of patients included: 59,365All 180 hospitals included in chart.



Chart 3 – Gender

Description: Hospitals ranked by the percentage of female patients.Fields Used: GenderTotal number of patients included: 59,365All 180 hospitals included in chart.

Chart 4 – Admitted from

Description: Hospitals ranked by the percentage of patients admitted from their own home orsheltered housing.Fields Used: Admitted FromGroups: The responses ‘Residential care/Nursing Home/LTC Hospital’ (0.7% of cases) and ‘Residentialcare’ (12.0% of cases) are combined and shown on the chart as ‘Residential Care’.Total number of patients included: 59,365Data: All 180 hospitals included in chart.

Chart 5 – ASA grade

Description: Hospitals ranked by the percentage of patients with ASA grade equal to 1, 2 or 3. The lefthand side graph shows the percentage of cases with known ASA grade, the right hand side graph showsthe percentage of cases with each ASA grade (cases with unknown ASA grade excluded).Fields Used: ASA GradeTotal number of patients included in LHS chart: 59,365Total number of patients included in RHS chart: 53,542 (5823 with unknown ASA grade excluded)All 180 hospitals included in both charts.Hospital Issues: Hospitals CRG and LON have less than 50% known data.

Chart 6 – Walking ability

Description: Hospitals ranked by the percentage of patients who regularly walked indoors without aidsor with one aid prior to admission.Fields Used: Walking Ability IndoorsTotal number of patients included: 59,365All 180 hospitals included in chart.

Chart 7 – Fracture type

Description: Hospitals ranked by the percentage of patients with displaced or undisplaced intracapsularfracture.Fields Used: Fracture TypeTotal number of patients included: 59,365All 180 hospitals included in chart.Hospital Issues: Hospitals TRA and MAC have more than 40% of patients with the response ‘Other’(more than twice as much as any of the other hospitals). Hospitals RPH and VIC have more than 40% ofpatients with unknown response (more than three times as much as any of the other hospitals).

Chart 8 – AMT score

Description: Hospitals ranked by the percentage of patients with AMT score between 0 and 6.Fields Used: AMTSTotal number of patients included: 59,365All 180 hospitals included in chart.Hospital Issues: There are 10 hospitals with 0% data completion.

Chart 9 – A&E to orthopaedic ward in 4 hours (Blue Book Standard 1)

Description: Hospitals ranked by the percentage of patients admitted to orthopaedic ward (OW) within4 hours.Fields Used: Admission Time to A&E, Admission Time to Orthopaedic Ward, Ward TypeGroups: Admitted to orthopaedic ward within 4 hours, admitted to orthopaedic ward after 4 hours,not admitted to orthopaedic ward and unknown. Patients admitted to an orthopaedic ward areclassified as ‘Unknown’ if time to orthopaedic ward is missing or outside of 0-8760 hours. (1 Year)Total number of patients included: 59,365All 180 hospitals included in chart.Hospital Issues: Hospitals BAT and SHH have less than 5% known data; hospital GRA has less than50% known data. Over 80% of patients at WRG were not admitted to an orthopaedic ward, all 100% ofpatients at CHS were not admitted to an orthopaedic ward.

Chart 10 – Type of anaesthesia

Description: Hospitals ranked by the percentage of patients that received general anaesthesia eitheralone or in combination.Fields Used: Anaesthesia TypeGroups: The response ‘Other’ has been classified as ‘Unknown’ in the chart.Total number of patients included: 59,365All 180 hospitals included in chart.

Chart 11 – Surgery within 36 hours of admission

Description: Hospitals ranked by the percentage of patients who underwent surgery within 36 hours ofadmission.Fields Used: Admission Time to A&E, Admission Time to Orthopaedic Ward, Date of Surgery;Operation.Calculation: Time to surgery is calculated as the difference between admission to A&E time and surgerytime. If admission to A&E time is missing (0.1% of patients) then time to surgery is estimated as thedifference between admission to OW time and surgery time.Groups: Surgery within 36 hours, surgery after 36 hours, no operation performed and unknown.Patients who received surgery and have missing Date of Surgery or have time to surgery outside of therange 0-8760 hours are grouped as ‘unknown’.Total number of patients included: 59,365All 180 hospitals included in chart.

Chart 12 – Surgery within 48 hours and during normal working hours(Blue Book Standard 2)

Description: Hospitals ranked by the percentage of eligible patients who were treated with surgerywithin 48 hours of admission and during working hours (8am-8pm). Patients were eligible if they weremedically fit, admitted from outside of hospital and underwent surgery.Fields Used: Admission Time to A&E, Admission Time to Orthopaedic Ward, Date of Surgery, AdmittedFrom, Operation, Reason for 48 Hour Delay to Surgery.Calculation: Time to surgery is calculated as the difference between admission to A&E time and surgerytime. If admission to A&E time is missing (0.1% of patients) then time to surgery is estimated as thedifference between admission to OW time and surgery time.Groups: Surgery in 48 hours and working hours (8am-8pm), surgery in 48 hours but not withinworking hours, surgery not within 48 hours, unknown. Patients with missing surgery time and patientswith time to surgery outside of the range 0-8760 hours are grouped as ‘unknown’.Total number of patients included: 55,345 (4,020 patients were not eligible)All 180 hospitals included in chart.



Chart 13 – Reason for delay beyond 36 hours

Description: Hospitals ranked by the percentage of delayed patients who had their surgery delayed formedical reasons.Fields Used: Admission Time to A&E, Admission Time to Orthopaedic Ward, Date of Surgery, Reason for36 hour Delay to Surgery, Operation.Calculation: Time to surgery is calculated as the difference between admission to A&E time and surgerytime. If admission to A&E time is missing (0.1% of patients) then time to surgery is estimated as thedifference between admission to OW time and surgery time.Groups: Patients are included in this chart if they underwent surgery more than 36 hours (and less than8760 hours) after admission to A&E. ‘Problem with theatre/equipment’ and ‘Problem withtheatre/surgical/anaesthetic staff’ are merged into ‘Problem with theatre/equipment/staff’. ‘No delaysurgery < 36 hours’ & ‘No delay surgery < 24 hours’ are grouped as ‘unknown’.Total number of patients included: 17,524All 180 hospitals included in chart.Hospital Issues: Hospitals RVB, ALT, CRG, NUH, WHH, SCM, VIC, MKH, GRA and HCH have less than50% data completion.

Chart 14 – Patients treated without surgery

Description: Hospitals ranked by the percentage of patients who underwent surgery.Fields Used: OperationTotal number of patients included: 59,365All 180 hospitals included in chart.

Chart 15 – Undisplaced intracapsular fractures

Description: Hospitals ranked by the percentage of eligible patients who received arthroplasty. Patientswere eligible if they had an undisplaced intracapsular fracture.Fields Used: Fracture Type, OperationGroups: Operation categories accounting for less than 3% of all patients were grouped as ‘Arthroplasty– Other’ or ‘Other’ as appropriate.Total number of patients included: 6,407164 hospitals included in chart (16 hospitals with less than 10 eligible patients were excluded).

Chart 16 – Displaced intracapsular fractures

Description: Hospitals ranked by the percentage of eligible patients who received arthroplasty. Patientswere eligible if they had a displaced intracapsular fracture.Fields Used: Fracture Type, OperationGroups: Operation categories accounting for less than 3% of all patients are grouped as ‘Arthroplasty –Other’ or ‘Other’ as appropriate.Total number of patients included: 27,805179 hospitals included in chart (1 hospital with less than 10 eligible patients was excluded).

Chart 17 – Cementing of arthroplasties

Description: Hospitals ranked by the percentage of eligible patients who had a cemented arthroplasty.Patients were eligible if they underwent an arthroplasty.Fields Used: OperationTotal number of patients included: 28,502All 180 hospitals included in chart.


Chart 18 – Total hip replacements for displaced intracapsular fractures

Description: Hospitals ranked by the percentage of eligible patients who received total hip replacement(THR) surgery. Patients were eligible if they received surgery for an intracapsular displaced fracture, hadan AMTS of 8 or more, an ASA Grade of 3 or less and were able to walk outdoors with one aid or noaids.Fields Used: Operation, Fracture Type, Walking Ability Outdoors, ASA Grade, AMTS.Groups: Patients who received any total hip replacement surgery are grouped as “Total HipReplacement’. All other operations grouped as ‘Other Operation’.Total number of patients included: 7,480145 hospitals included in chart (35 hospitals with less than 10 eligible patients were excluded).

Chart 19 – Provision of total hip replacement by age of patient

Description: Percentage of eligible patients who received total hip replacement (THR) surgery by age.Eligible patients are defined as those who had intracapsular displaced fractures and received surgery(operation type not unknown), AMTS of 8 or more, ASA Grade of 3 or less and were able to walkoutdoors with one aid or less.Fields Used: Operation, Fracture Type, Walking Ability Outdoors, ASA Grade, AMTS, Age.Groups: Patients who received any total hip replacement surgery (“Arthroplasty - THR (cemented)”,“Arthroplasty - THR (uncemented - HA coated)”or “Arthroplasty – THR (uncemented - uncoated)”) aregrouped as “Total Hip Replacement’. All other operations grouped as ‘Other Operation’.Ages are grouped as 60-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90-94 and 95+.Total number of patients included: 7,563

Chart 20 – Intertrochanteric fractures

Description: Hospitals ranked by the percentage of patients with intertrochanteric fractures who receiveinternal fixation.Fields Used: Fracture Type, OperationGroups: Operation categories accounting for less than 3% of all patients are grouped as ‘Arthroplasty’or ‘Other’ as appropriate.Total number of patients included: 20,361All 180 hospitals included in chart.

Chart 21 – Subtrochanteric fractures

Description: Hospitals ranked by the percentage of patients with subtrochanteric fractures who receiveinternal fixation.Fields Used: Fracture Type, OperationGroups: Operation categories accounting for less than 3% of all patients are grouped as ‘Arthroplasty’or ‘Other’ as appropriate.Total number of patients included: 2,947139 hospitals included in chart (41 hospitals with less than 10 eligible patients were excluded).

Chart 22 – Development of pressure ulcers (Blue Book Standard 3)

Description: Hospitals ranked by the percentage of eligible patients who developed pressure ulcers.Patients are eligible if they did not die in hospital.Fields Used: Pressure Ulcers, Discharge Ward Destination, Discharge Trust Destination.Total number of patients included: 54,110All 180 hospitals included in chart.Hospital Issues: Hospitals UHW, HIN, SGH and PLY have less than 50% known data.



Chart 23 – Preoperative medical assessments (Blue Book Standard 4)

Description: Hospitals ranked by the percentage of patients who underwent any preoperative medicalassessment.Fields Used: Preoperative Medical AssessmentGroups: As multiple responses were possible for this field patients were only allocated to the highestlevel of assessment they received according to the following hierarchy:‘Already under care’ > ‘Routine by geriatrician’ > ‘Routine by physician’ > ‘Routine by specialist nurse’> ‘Medical review following request’ > ‘None’’.Total number of patients included: 59,365All 180 hospitals included in chart.Hospital Issues: Hospital VIC has less than 60% known data.

Chart 24 – Bone protection medication at admission

Description: Hospitals ranked by the percentage of patients on bone protection medication atadmission.Fields Used: Bone Therapy MedicationTotal number of patients included: 59,365All 180 hospitals included in chart.Hospital Issues: Hospital VIC has less than 60% known data.

Chart 25 – Bone health assessment and treatment at discharge(Blue Book Standard 5)

Description: Hospitals ranked by the percentage of eligible patients who were already receiving boneprotection medication, started bone protection medication, were assessed for bone protectionmedication or were awaiting DXA scan or bone clinic assessment. Patients were eligible if they did notdie in hospital.Fields Used: Bone Therapy Medication, Discharge Ward Destination, Discharge Trust DestinationGroups: As multiple responses were possible for this field patients were only allocated to the highestlevel of assessment they received according to the following hierarchy:‘Continued from pre-admission’ > ‘Started on this admission’ > ‘Awaits DXA scan’ > ‘Awaits bone clinicassessment’ > ‘Assessed – no bone protection medication needed/appropriate’ > ‘No assessment oraction taken’.Total number of patients included: 54,110All 180 hospitals included in chart.Hospital Issues: VIC has less than 60% known data. None of the patients from SOU received anyassessment.

Chart 26 – Specialist falls assessment (Blue Book Standard 6)

Description: Hospitals ranked by the percentage of eligible patients who had received or were awaitinga falls assessment. Patients were eligible if they did not die in hospital.Fields Used: Falls Assessment, Discharge Ward Destination, Discharge Trust DestinationTotal number of patients included: 54,110All 180 hospitals included in chart.Hospital Issues: Hospital SDG has less than 20% known data; Hospital PLY has less than 40% knowndata; Hospital VIC has less than 60% known data. None of the patients from HIN, BRG or ALT receivedassessments.


Chart 27 – Secondary prevention overview

Description: Hospitals ranked by the percentage of eligible patients who received both bone protectionmedication and a falls assessment. Patients were eligible if they did not die in hospital.Fields Used: Falls Assessment, Bone Therapy Medication, Discharge Ward Destination, Discharge TrustDestinationGroups: Responses to Bone Therapy Medication ‘Continued from pre-admission’/ ‘Started on thisadmission’/‘Awaits DXA scan’/‘Awaits bone clinic assessment’/‘Assessed – no bone protection medicationneeded/appropriate’ are taken as a completed bone assessment. Responses to Falls Assessment startingwith ‘Yes’ are taken as a completed falls assessment.Patients with either of the assessments unknown are grouped as ‘Unknown’.Total number of patients included: 54,110All 180 hospitals included in chart.Hospital Issues: SDG has less than 20% known data; PLY has less than 40% known data; VIC has lessthan 60% known data.

Chart 28 – Length of acute and post-acute Trust stay

Description: Hospitals ranked by total mean length of stay (mean acute stay plus mean post-acutestay). This chart uses the discharge data slice.Fields Used: Admission Time to A&E; Admission Time to Orthopaedic Ward; Discharge Time fromWard; Discharge Time from Trust.Calculation: Acute stay is calculated as time from admission to A&E to discharge from orthopaedicward. If admission to A&E is missing then acute stay is estimated as the time from admission toorthopaedic ward to discharge from orthopaedic ward. Post-acute stay is calculated as the differencebetween Discharge Time from Ward and Discharge Time from Trust.Total number of patients included: 53,651 (missing times or times outside of 0 to 365 days areexcluded).All 180 hospitals included in chartHospital Issues: CHS has no dedicated orthopaedic ward. WRG’s orthopaedic ward closed part waythrough the year. For CHS and WRG acute stay is also measured by Trust stay.BRO, CRG and WWG have less than 60% completion.

Chart 29 – Discharge destination from Trust

Description: Hospitals ranked by the percentage of patients who were discharged to their own home orsheltered housing. This chart uses the discharge data slice.Fields Used: Discharge Trust Destination, Discharge Trust DateGroups: The responses ‘Residential care/Nursing Home/LTC Hospital’ (0.1% of cases) and ‘Residentialcare’ (11.1% of cases) are combined and shown on the chart as ‘Residential Care’.Total number of patients included: 55,373All 180 hospitals included in chart.Hospital Issues: DER has less than 60% known data.



Chart 30 – Re-operation within 30 days

Description: Hospitals ranked by the percentage of eligible patients who underwent re-operation within30 days of admission. This chart uses the discharge data slice. Patients are eligible if they underwent anyoperation.Fields Used: 30 Day Reoperation, OperationGroups: Patients with any response indicating that re-operation had occurred are grouped as ‘Re-operation within 30 days’. Patients with the response ‘None’ are grouped as ‘No reoperation within 30days’. Patients with no response or the response ‘Unknown’ are grouped as ‘Unknown’.Total number of patients included: 48,215All 180 hospitals included in chart.Hospital Issues: Many hospitals with poor data completion.

Chart 31 – Follow up data completeness at 30 days (bar plot)

Description: Hospitals ranked by the percentage of complete follow-up fields for eligible patients.Patients were eligible if their status at 30 days was not dead. Data is taken from 1st December 2010 to30th November 2011 in line with the follow up data completeness chart for 120 days.Fields Used: Residential Status (30 days); Walking Ability Indoors (30 days); Walking Ability Outdoors(30 days); Accompaniment to Walk Indoors (30 days); Accompaniment to Walk Outdoors (30 days);Bone Therapy Medication (30 days);Calculation: Number of completed fields divided by the number of fields that should have beencompleted.All 180 hospitals included in chart.

Chart 32 – Follow up data completeness at 120 days (bar plot)

Description: Hospitals ranked by the percentage of completed follow-up fields for eligible patients.Patients were eligible if their status at 120 days was not dead. Data is taken from 1st December 2010 to30th November 2011 to ensure all patients had been admitted 120 days before data was extracted.Fields Used: Residential Status (120 days); Walking Ability Indoors (120 days); Walking Ability Outdoors(120 days); Accompaniment to Walk Indoors (120 days); Accompaniment to Walk Outdoors (120 days);Bone Therapy Medication (120 days);Calculation: Number of completed fields divided by the number of fields that should have beencompleted.All 180 hospitals included in chart.

Chart 33 – Follow up data completeness at 30 and 120 days (scatter plot)

Description: This chart includes the same information at charts 31 and 32. The data is displayed as asingle scatter plot rather than two bar plots. Hospitals are ranked by the average of follow up datacompleteness at 30 days and follow up data completeness at 120 days.


Chart 34 BPT uplift eligibility (England only)

Description: Hospitals ranked by the percentage of patients who meet all of the eligibility requirementsfor BPT uplift. This chart is based on the discharge data slice. Only English hospitals are included.Fields Used: NHS Number, Admission Time to A&E, Admission Time to Orthopaedic Ward, Date ofSurgery, Orthopaedic GMC number, Geriatrician GMC number, Admitted Using Jointly AgreedAssessment Protocol, Geriatrician Assessment Time, Geriatrician Grade, MDT Assessment, Bone TherapyMedication, Falls Assessment.Calculations: Time to surgery is calculated as the difference in the Admission time to surgery time. Timeto geriatrician is calculated as the difference in the Admission time to geriatrician assessment time.Admission time is taken is taken as admission time to A&E, if this is missing then it is taken as admissiontime to OW.Criteria: There are 9 criteria which must be met in order for a patient to be eligible for BPT uplift:

1) NHS number is not missing2) Time to surgery is in the range 0 to 36 hours3) Orthopaedic GMC number is not missing4) Geriatrician GMC number is not missing5) Patient is admitted using jointly agreed assessment protocol6) Time to geriatrician is between 0 and 72 hours, Geriatrician Grade is equal to ‘Consultant’, ‘ST3’ or ‘SAS’.7) MDT Assessment is equal to ‘Yes’8) Bone Therapy Medication response indicates patient received any form of assessment/action9) Falls Assessment response indicates patient received any form of assessment/action

Groups: Patients meeting all criteria are grouped as ‘Eligible’; patients meeting 4-8 of the criteria aregrouped as ‘Ineligible – meets 4-8 criteria’; patients meeting less than 4 criteria are grouped as ‘Ineligible– meets 0-3 criteria’.Total number of patients included: 54,684

Patients meeting criteria 1: 54,454 (99.6%)Patients meeting criteria 2: 37,508 (68.6%)Patients meeting criteria 3: 51,911 (94.9%)Patients meeting criteria 4: 47,492 (86.8%)Patients meeting criteria 5: 48,665 (89.0%)Patients meeting criteria 6: 39,749 (72.7%)Patients meeting criteria 7: 49,330 (90.2%)Patients meeting criteria 8: 50,565 (92.5%)Patients meeting criteria 9: 49,549 (90.6%)

165 hospitals included in chart.




Appendix EUsing audit to improve care - Good PracticeExamplesBetter data collection, better care and the Best Practice Tariff:Arrowe Park HospitalIn March 2011 Arrowe Park Hospital appointed an NHFD administrator with the specific aims ofimproving data collection and submission rates to the NHFD, and improving compliance with BestPractice Tariff standards. Cases submitted rose from 108 in 2010 to 457 in 2011. A Rapid ImprovementWorkshop held in July 2011 resulted in new care pathway documentation that reduced duplication andwas designed to capture data reflecting clinical standards and BPT compliance.

With real-time data, a theatre-based trauma board was able to highlight potential delays and addressthem. As a result of this, and the appointment of an additional trauma surgeon, the proportion ofpatients having surgery within 36 hours rose from 66% in 2010 to 86% in 2011. The appointment of asecond orthogeriatrician has allowed the implementation of a joint protocol, and has improvedpreoperative care. Improved collaboration with A&E has resulted in the introduction of prompt fasciailiaca analgesia and greatly improved pain control. To review documentation and data, and to discussissues and review progress, a multidisciplinary team meets monthly.

Better data collection and better care: Northern General Hospital, SheffieldIn 2010 only 32% of hip fracture cases were submitted to the NHFD. By 2011 this had risen to 71%, andthe figure for 2012 is expected to exceed 80%. This was achieved by close cooperation betweenclinicians, dedicated nurse time to support data collection, and clerical staff tasked with data input. Datacollected includes additional local fields covering aspects of quality and patient experience, with keyareas monitored at regular meetings. Surgeons, orthogeriatricians, anaesthetists, nursing and therapystaff work closely together to monitor outcomes, develop services and improve care.

A dedicated fragility fracture Ward opened in November 2011, and a hip fracture nurse who will workwith the teams already in place to facilitate further improvements in quality was appointed in June 2012.The use of NHFD data on time to theatre, therapy input, rates of pressure sores, length of stay, dischargedestination and mortality will continue to monitor the impact of such changes. Over the last year,average length of acute stay was reduced from 27 to 24 days.

Audit and change: Chelsea and Westminster HospitalAt a ‘grand round table’ meeting in May 2011, hip fracture care at Chelsea and Westminster wasrecognised as sub-optimal. This marked the beginning of a sustained and successful effort to improvepatient care and also to respond to the incentives offered by the Best Practice Tariff. Resultant changesincluded dedicated theatre sessions for trauma, regular thrice-weekly orthogeriatrician rounds, weeklydischarge planning meetings, and a weekly osteoporosis ward round. An agreed assessment pro formawas introduced, and is now completed for 100% of patients; and the Electronic Patient Record nowdocuments collaborative care. BPT achievement has risen from <10% to >60%, attracting additionalincome of over £127,000; and average acute length of stay has fallen from 24 to 19.5 days, withestimated savings of £91,000. In-patient mortality has fallen from 11% to 9%, and feedback from staff,patients and carers is now favourable.


Audit and change: East Lancashire Hospitals NHS TrustEast Lancashire Hospitals NHS Trust first participated in the NHFD in February 2010. Since then cliniciansand managers have found NHFD data invaluable in assisting the clinical team to monitor and improvethe quality of care for hip fracture patients. The introduction of an integrated care pathway, togetherwith close scrutiny of delays exceeding 48 hours and the appointment of an orthogeriatrician, helpedgreatly in achieving Best Practice Tariff standards in hip fracture care – which rose from 15.6% of cases in2010/2011 to 65.3% in 2011/2012. In addition, the incidence of pressure ulcers fell from 5.9% in July2010 to 2.4% now.

All this was achieved by the regular sharing of NHFD data with the team, focused efforts on problemareas the data highlighted, and thus improving compliance with the six Blue Book standards of care. Abid for funding for an East Lancashire Fracture Liaison Service has recently succeeded in securing re-enablement monies, with plans now to commence this service within the next six months.

Audit and change: Russells Hall Hospital, DudleyNHFD participation allowed the clinical team to focus on patient experience, minimise delay, improvecare and thus reduce morbidity and improve clinical outcomes. Between 2010 and 2012, the percentageof patients operated on within 36 hours rose from 80.9% to 89.3%; with figures for operation within 24hours rising from 57.9% to 65%. The incidence of pressure ulcers has been reduced from 7.4% to 5.9%,and total Trust length of stay has fallen by 2.8 days.

The innovations behind these improvements include the introduction of dedicated nurse hippractitioners; a dedicated trauma coordinator; a ‘hip suite’; patient group directives covering pain reliefand IV fluids; and monthly team meetings to review and develop the service.

Audit and change: St Mary's Hospital, Isle of WightSt Mary's Hospital, Isle of Wight, commenced NHFD participation in October 2009, with feedback datademonstrating some deficiencies in the service. Clinical and management staff then used NHFD data toprompt and monitor service improvements. With part-time orthogeriatrician support; bettercollaboration between anaesthetists, surgeons and the orthogeriatrician; and with a jointly agreedprotocol, care has improved measurably. Average time to theatre has been reduced to under 30 hours,and orthogeriatrician, bone protection and falls assessments all exceed 90%. BPT attainment rose from22% to 75% over Q1 to Q4 2010/2011. Acute length of stay has fallen by 2.4 days. The case has nowbeen made for a full-time consultant orthogeriatrician post, as hip fracture care continues to benefitfrom clinical commitment and managerial support.

Audit, Best Practice Tariff and improved care: St Peter’s Hospital, ChertseySt Peter’s Hospital began NHFD participation in 2009. In order to meet NHFD clinical standards, the trustappointed two orthogeriatricians in early 2010. Although some aspects of care improved, preoperativedelay beyond 36 hours remained common; and in the first quarter of BPT implementation only 49% ofpatients achieved BPT standards. The Trust invested in a 4-day EQIP (Efficiency, Quality, Improvement andProductivity) initiative on the hip fracture pathway in September 2010. Analysis of NHFD data showedlongest delays occurring during or just after the weekend. To address this, and all-day Saturday list wassplit into two half-day weekend lists. Since November 2010, 60% of patients have surgery within 24hours, and 80% within 36 hours.

Time to orthopaedic ward admission was also reduced: by the introduction of a priority hip fracturebleep; and by eliminating delays in obtaining air mattresses from central stores by the provision of aready-use on-ward mattress. Weekend physiotherapy and a hip fracture exercise class improvedmobilisation within 24 hours of surgery. Length of stay dropped from 25 to 22 days – with considerableefficiency savings. Importantly, discharge to original residence has improved: to 60% within 25 daysnow, compared with 44% within 30 days two years ago.


Improving care and achieving Best Practice Tariff: Queen Alexandra Hospital,PortsmouthQueen Alexandra Hospital, Portsmouth, has participated in the NHFD since its launch in 2007, and hasused data to highlight service issues and improve care over the years. The 2011 NHFD National Reportshowed how QAP performed better than national and/or SHA averages in terms of: time to admission toorthopaedic care; preoperative geriatrician assessment; operation within 36 and 48 hours; and falls andbone health assessment. It also performed well in terms of discharge to previous residence (70%,compared with a national average of 46%). Notably, in the 2011 NHFD Report, at 78% it ranked first inBPT achievement.

This year, 99.5% of patients were assessed by an orthogeriatrician within 72 hours and 79.7% ofpatients had surgery within 36 hours. BPT achievement too has risen, to 79.7%.Resulting BPT monies to the Trust amounted to £227,000 for 2010/11, and £488,000 for 2011/12.

Developing and implementing an orthogeriatric model of care: PinderfieldsHospital, YorkshireRecognising that a traditional model of hip fracture care was sub-optimal (“We were letting our patientsdown”), clinicians and managers at Pinderfields centralised trauma services and used NHFD data and theincentive of BPT to transform hip fracture care. With the introduction of a 36 bedded orthogeriatricward – 24 specifically for hip fracture patients, new staff appointments, dedicated theatre time, a hipfracture pathway, preoperative optimisation by anaesthetists and the orthogeriatrician, a ‘future breachanalysis form’ to address a target of 24-hour maximum pre-operative delay, and a hip fracture steeringgroup to monitor progress, very substantial improvements in care and outcomes were achieved betweenApril 2011 and March 2012.

The changes depended on many factors, including competency-based training, practice change, team-building sessions and additional equipment (such as sensor pads to reduce in-hospital falls.) Successivequarter-by-quarter improvements were achieved in BPT criteria compliance and in BPT achievement –with the latter rising from 37% to 73%. Mortality fell from 11% in 2010/11 to 7% in 2011/12, and acutelength of stay from 19 to 10 days. Feedback on patient and visitor ward rounds is now ‘excellent’.

An acute hip fracture ward to improve care: Carmarthen Hospital, Wales In Carmarthen a change programme initiated by orthopaedic surgeons, supported by management andled by an enthusiastic orthogeriatrician set up a 15-bed acute hip fracture unit - the first in Wales - in aformer medical ward in June 2011. With a full-time orthogeriatrician supported by junior staff, a specialisttrauma nurse, a fast-track A&E protocol, new procedures to ensure 7-day preoperative assessments, multidisciplinary teamwork, and routine cognitive assessment, falls assessment and osteoporosis assessment, care improved, with a 1% fall in mortality, and a reduction in average acute stay from 16 to14 days. Improved training opportunities arose, with orthopaedic and medical juniors working well together, and effective team working resulting in improved morale.

Better and more cost-effective hip fracture care: Salisbury HospitalIn 2009/10, with no orthogeriatrician service, a ‘non-collaborative approach’, and long pre-operativedelays, Salisbury ranked 98th out of 100 NHS Trusts in BPT achievement. A change programme –including increased orthogeriatric and nurse practitioner staffing; additional theatre capacity for trauma;and active leadership by the lead orthopaedic surgeon, the lead anaesthetist and the consultantorthogeriatrician – achieved dramatic improvements in compliance with the six Blue Book standards. By2012, 80% of all patients reached orthopaedic care within four hours; 92% had surgery within 48 hours(and 84% within 36 hours); incidence of pressure ulceration fell from 5.4% to 1.2%; preoperative


assessment by geriatrician rose from 1.5% to 95%, and bone protection and falls assessment from 6.2%and 3.2% respectively to 100% in both. Mortality fell from 10.1% to 8.4%, and acute length of stayfrom 27.6 days to 19.8 days between April 2011 and March 2012.BPT attainment rose from 1.5% to 84.4% – ranked first in South-West region, and in the top fivenationally – bringing in BPT income of £187,790. Even more impressively, cost-effectiveness of care –with savings of £391,000 (costed as 1,955 bed-days at £200 per day) – was greatly increased.Importantly, feedback from patients, relatives and clinical staff has been positive.

Hip fracture service redesign, improved care and BPT attainment: St HelierHospital, CarshaltonIn response to the challenge of BPT, the St Helier trauma service established a 23-bed hip fracture unitwith a full-time orthogeriatrician and junior medical staff. All patients are under the joint care of bothorthogeriatric and orthopaedic teams throughout their acute stay. With the first two slots on the traumalist each morning reserved for hip fracture, average time to theatre has fallen to 24 hours. In the last 12months 100% of patients have had preoperative, bone health and specialist falls assessment. Over twoyears pressure ulcer incidence fell from 17% to 6.2%. Mortality too has fallen: from 17% in Q12011/2012 to 7.4% in Q4. BPT attainment has risen from 0% over Q1-Q3 2010/2011 to 92% in Q42011/2012.

Hip fracture service redesign, improved care and BPT attainment: NorthumbriaHealthcare NHS Foundation TrustIn 2009, clinicians and managers from the trauma units in two hospitals (Wansbeck and North Tyneside)embarked upon HIP QIP, a quality improvement programme specifically to improve hip fracture care fromthe time of admission to discharge home, and including secondary prevention. Pain control hasimproved, with 79% of patients now having highly effective nerve block analgesia on admission. 95% ofpatients have surgery within 36 hours, and 95% of patients who are medically fit are mobilised on theday following surgery. With the help of specially appointed nutrition assistants, 81% of patients nowreceive additional feeding daily. Following requests from patients and carers, an information booklet onhip fracture is now provided. Feedback on care from patients and families is high: with monthly averagescores consistently above 9.3 out of 10.

Best practice in data collection and follow-up: Royal Victoria Hospital, BelfastRVH Belfast admits more than 900 hip fracture patients a year, and NHFD data is collected as part of awider Fracture Outcomes Research Database, which now achieves 99% follow-up. Data is sourced fromclinical records and the theatre management system. Telephone reviews at 30 days, four months andone year are undertaken by audit nurses, who contact nursing, residential and rehabilitation unitsdirectly and cross-check the remainder with hospital PAS data, GPs, patients and next of kin.

Systems queries have been created to highlight duplicates and missing data. A monthly review of all hipfracture X-rays ensures the accuracy of diagnosis and treatment coding. Data is then uploaded monthlyto the NHFD. Although the Best Practice Tariff does not apply in Northern Ireland, NHFD participation isvalued by clinicians, managers and commissioners as providing reliable information to support serviceevaluation and change, and to influence policy.

Basingstoke Hospital: piloting follow-up by postAt Basingstoke Hospital the approach to the collection of NHFD follow-up data developed over the firstfew years of NHFD participation. An initial plan was to collect data from patients attending amultidisciplinary follow-up clinic. Telephone follow-up – largely carried out by medical staff – was alsoexplored, and some benefits noted (direct contact with patient and/or carer; ability to address widerconcerns) but proved difficult because of the limited availability of time, and problems of scheduling thecalls to the follow up intervals.



Positive experience locally of postal follow-up after elective arthroplasty suggested a switch to postalquestionnaires with pre-paid reply envelopes. Daily checks on the NHFD website for patients reachingfollow-up points, and checks with hospital PMS, to ensure patients are no longer in-patients and remainalive, precede the dispatch of the postal questionnaire. Where patients raise issues, either throughadditional comments on the form or on an accompanying letter, a telephone call and/or amultidisciplinary clinic review may follow. Only nine of the initial 115 patients were lost to follow-up at120 days, and data – particularly that relating to mobility – has been encouraging: with a substantialdecrease in patients requiring two walking aids between the 30- and 120-day follow-ups.

Improving follow-up to monitor outcomes: Royal Devon and Exeter HospitalRoyal Devon and Exeter Hospital has participated in the NHFD since 2008, and since then hasimplemented daily trauma meetings and a fast-track protocol to reduce time from A&E to orthopaediccare; recruited two trauma nurse practitioners and two orthogeriatricians; and introduced monthlymultidisciplinary review meetings involving clinicians and managers. In the last four years inpatientmortality for hip fracture has fallen from 6% to 4%, and 28 day mortality from 13% to 7%.

In order to determine longer-term outcomes, telephone follow-up at 30, 120 and 360 days – carried outby a trauma nurse practitioner and a trauma ward administrator – has achieved over 99% completenessat all three intervals. Total time spent on telephone calls averages six hours per week. Outcomesdocumented include place of residence, mobility, and compliance with bone protection medication.Patients' concerns are addressed, and data on longer term outcomes provide a much morecomprehensive picture of outcomes following hip fracture care.



Acknowledgements:

NHFD participants: clinical and audit staff in all contributing hospitals

British Geriatrics Society


Department of Health

Dr. Richard Keen, Metabolic Bone Unit, Royal National Orthopaedic Hospital

Healthcare Quality Improvement Partnership

National Clinical Audit Advisory Group

NHS Information Centre

Quantics Consulting Ltd


The National HipFracture DatabaseNational Report 2012

F O R H E A LT H A N D S O C I A L C A R E

In partnership with:

Need to know more?Contact:NHFD Headquarters:British Geriatrics SocietyMarjory Warren House31 St. John’s SquareLondon EC1M 4DN

Tel: 020 7251 8868

Project ManagerEmail: [email protected]: 020 7251 8868

Project Coordinator (South) - Andy WilliamsEmail: [email protected]: 07818 065915

Project Coordinator (North) - Fay PlantEmail: [email protected]: 07792 213369


NHFD National Report 2012:Layout 1...† This report covers casemix, care and outcomes of 59,365...

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Transcript of NHFD National Report 2012:Layout 1...† This report covers casemix, care and outcomes of 59,365...