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$: · Web viewOsteoporosis is the most common bone disease in humans affecting both women and men (10); the clinical manifestation of this disease is fragility fracture. An illustration$
A systematic approach to hip fracture care and preventionA toolkit for securing resources

1. Hip fracture careNational Hip Fracture Database participation by fracture units

This document aims to provide lead clinicians in fracture units with the necessary materials to efficiently assemble a business case to support the employment of personnel who can enter data on the unit’s hip fracture patients into the National Hip Fracture Database. It is distributed electronically so that the various modules can be modified to fit the local situation.

The sequence of argument suggested is the following:

• Hip fracture presents a massive burden of cost both to the patient and the NHS. The incidence is rising rapidly

• Good practice can both improve quality and reduce costs

• Participation in the NHFD is an effective mechanism for establishing best practice, will improve quality and will be at least self-funding because of:

- Reduced length of stay- More accurate coding- Reduced impact of hip fractures on elective work and achievement of 18 week

targets

• In (add in your Trust’s) fracture unit, the best model for NHFD data collection is to make it one of the duties of a (add role)

2. Hip fracture preventionFracture Liaison Services to deliver secondary fracture prevention

Half of hip fracture patients have suffered a prior fragility fracture that could and should have served as a trigger for secondary fracture prevention. Fracture Liaison Services provide a proven mechanism to ensure that patients presenting with fragility fractures receive secondary preventative care to reduce their risk of subsequent hip fracture. FLS have been implemented within 30% of NHS Trusts across the UK to deliver NICE TA87 and SIGN71.

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FLS has been endorsed by the Department of Health and the Royal College of Physicians as an example of best practice to deliver secondary fracture prevention. The rationale to inform a business case is provided for NHS Trusts that are yet to implement an FLS.

The following documents are in word format to allow you to insert identifiers and figures relevant to your own organisation.

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1. Hip fracture careThe National Hip Fracture Database:Rationale for (add in your Trust) participation

The burden of hip fracture on patients and (your Trust)

Hip fracture is the most common cause of acute orthopaedic admission for older people. During 2006/7, in excess of 70,000 hip fractures occurred in the UK which translates to 300-400 presentations per year to an acute hospital serving a population of 300,000. Hip fracture incidence has been projected to increase by 50% by 2020 because of the ageing population. (1)

Hip fracture is associated with substantial morbidity and mortality. Up to 20% of patients admitted from home will be moved into residential or nursing care homes as a result of the hip fracture. (2)

Elderly patients are profoundly fearful of suffering a hip fracture; a published survey of elderly women found that 80% would prefer to die rather than move into a nursing home as a result of suffering a “bad hip fracture”. (3) Mortality is 5-10% after one month and about 30% after one year. (4)

Hip fracture exerts an enormous burden upon NHS budgets. The current hospital costs of treating hip fractures have been estimated at £12,000 per case (5); three-quarters of this expenditure is attributable to the acute stay. Accordingly, the average District General Hospital spends £3.6 - £4.8 million per year on the acute management of hip fractures. Hip fracture care represents one of the more expensive tariffs for acute care at a median cost of £5,523 (HRG version 3.5, H82 to H99) in comparison to the average hospital tariff of around £1,250. (6) However, clearly a major disparity exists between the standard costs incurred by hospitals caring for hip fracture patients relative to the reimbursement received from Primary Care Trusts through the Payment by Results system. For a large English trauma unit that serves a population of 685,000, admission of 750 patients with hip fractures annually has been estimated to result in an annual PbR deficit of £3 million per year for the NHS Trust. (7)

Burden of hip fracture on (your Trust)

The burden placed upon orthopaedic and geriatric service provision by (your Trust) can be put into context by collation of the following data:

- Annual number of patients admitted with hip fracture- Length of Stay (average, range and total number of bed days for hip fracture patients)- Acute care costs (average, range and total incurred by [your Trust] for 2006/7)- Total PbR reimbursement from local Primary Care Trusts for acute hip fracture care

The National Hip Fracture Database: Reducing costs through improving quality

Hip fracture has a substantial impact on elderly patients’ quality of life and local NHS budgets. Accordingly, all NHS Trusts that provide services for patients with hip fracture should consider participation in NHFD. The aim of NHFD participation is to improve the quality of hip fracture care, and at the same time improve its efficiency. The NHFD has been modelled upon the highly successful MINAP database (Myocardial Infarction National Audit Project) which has contributed to significant improvements nationally in the management of patients with acute coronary syndromes. (8) Participation in NHFD, including advice and data analyses, is free; but data collection is a local responsibility. Arrangements for data collection will depend on case volume and local service structures; and effective participation will depend heavily on the degree of commitment and support offered by key stakeholders.

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The National Hip Fracture Database: Underpinning effective ortho-geriatric care

The multi-factorial nature of the problems facing hip fracture patients, and the healthcare professionals responsible for their care, necessitates a multi-disciplinary approach. Most UK hospitals have implemented one of a range of systems to ensure geriatrician involvement in the medical management of hip fracture patients. Indeed, the National Service Framework for Older People advocates that “at least one general ward in an acute hospital should be developed as a centre of excellence for ortho-geriatric practice.” The NHFD provides hospitals with a mechanism to underpin a cycle of continuous audit and quality improvement of hip fracture care and as such provides a central component of good ortho-geriatric service provision aligned with national policy.

To ensure that all stakeholders in the locality are fully engaged in the process of NHFD participation at (your Trust); a multi-disciplinary stakeholder group should be established from the outset. This group will likely include:

- NHFD Lead Clinician (most likely to be an Orthopaedic Surgeon or Ortho-geriatrician)- Consultant Orthopaedic Surgeon- Consultant Geriatrician or Ortho-geriatrician- Consultant Anaesthetist- Lead Clinician in Osteoporosis for (your Trust)- Relevant specialist nurses, physiotherapists and other AHPs- Personnel responsible for NHFD data entry (when identified/appointed)- Representative from hospital IT Department- Representative from hospital Finance or Coding Department re: PbR coding issues- Representative from local Primary Care Trusts

The National Hip Fracture Database: Spend to save

Participation in the National Hip Fracture Database will be self-funding and is likely to result in a significant reduction in the cost of hip fracture care to (your Trust).

Hospital stay accounts for 80% of the current £12,000 average cost incurred by NHS hospitals for each hip fracture admission. (5) Long-term hip fracture audit in Nottingham has demonstrated that a 1 day pre-operative delay leads to a 2.5 day increased length of stay post-op. The Scottish Hip Fracture Audit has been associated with reductions in length of stay. NHFD participation will provide (your Trust) with a new capability to:

1. Scrutinise length of stay: NHFD participation enables NHS Trusts to focus on the process of care for hip fracture patients and so identify which steps in the pathway could be improved and lead to consequent reductions in acute care costs. For example, in an average District General Hospital (300 hip fracture patients per year treated):

- An early result of effective NHFD participation - quantifying, addressing, and reducing preoperative delay - might shorten acute LoS by 1 day, and total LoS by more

- Assuming an acute orthopaedic bed costs £200 per day and data collection £70 per patient the efficiency gain over a year could amount to around £40,000 for the orthopaedic unit alone

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2. Focus on accurate PbR coding: The 2007/8 tariff for fractured neck of femur is in the range £4,518 to £7,936. The importance of accurate coding practice has been highlighted by a recent audit of a UK hospital suggesting that a £318,300 - £424,400 annual loss of income could be directly attributed to inaccurate PbR coding for hip fracture for an average DGH. (6)

3. Deliver the 18 week patient pathway: An October 2007 publication from the 18 weeks Orthopaedic Co-ordinating Group has highlighted the potential for service transformation of hip fracture care to support local delivery of the 18 week target for elective work. (9)

Models for National Hip Fracture Database data collection

The optimal model for participation in NHFD by (your Trust) will be determined by local case volume and service structures. As an illustration of how colleagues throughout the NHS have addressed the issue of local data collection, examples of how NHFD data collection has been incorporated into a range of NHS job descriptions are included as Appendices. These appendices are provided to the (your Trust) stakeholder group to illustrate potential local solutions:

- Appendix 1: Elderly Trauma Nurse Co-ordinator - example Job Description- Appendix 2: Trauma Audit Coordinator - example Job Description- Appendix 3: Trauma Co-ordinator - example Job Description

Regarding post 1 and 3 above - if an organisation is considering one of these posts, an amalgamation of the job descriptions may best suit the service and that this would be appropriate. A trauma co-ordinator’s role is a good management strategy for total patient care in all trauma; but there should be an emphasis on providing excellent hip fracture (and trauma) care to older people..The business plan for NHFD participation by (your Trust) will likely consider the following:

- Aims and objectives of NHFD participation- Burden of hip fracture care on Anywhere NHS Trust

• Annual number of patients admitted with hip fracture• Length of Stay (average, range and total number of bed days)• Acute care costs (average, range and total incurred in 2006/7)• Total PbR reimbursement from local PCTs for acute hip fracture care

- Critical appraisal of actual/perceived strengths/weaknesses of current care- Review of performance indicators versus national averages e.g. 30 day mortality- Identification of opportunities for audit-based clinical/service change- Start-up costs for establishing NHFD data collection at (your Trust)- Plan for using NHFD outputs to benchmark and improve care

• Stakeholder group constitution, remit and membership• Proposed reporting arrangements

- Accountability and clinical governance issues- Draft job description of individual responsible for NHFD data entry

How to register with NHFD

The lead clinician sends an email to their Project Manager/Coordinator at [email protected] (London) [email protected] Midlands and The North or [email protected] The South, Northern Ireland and Wales (from an NHS email address) to request access to the database. The minimum information required to register each person must include the following:

- Name and job title- Full address of hospital(s)

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mailto:[email protected]



- Email address - Contact telephone number

After registration, a username will be emailed directly to the lead clinician with a request to contact the NCASP helpdesk for issue of a personal password. Then, go to www.nhfd.co.uk, click on the NHFD ‘Log In’ where you will be asked to enter your username and password.

NHFD Facilities audit

This allows the NHFD to understand your hospital's facilities. This needs to be completed at time of registration and annually. The components of the facilities audit are provided in Appendix 6. The data needs to be completed 'on-line’ by entering website > Database Records > Records [on left of page] > Facilities Audit > save as ‘complete’. This will enable the data analysts to gain a clear picture of the nature of your unit and see how differences in structure are related to differences in function, so please be as accurate as possible.

The NHFD audit tool is provided in Appendix 7.

A generic version of a patient information leaflet describing NHFD is provided in Appendix 8.

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http://www.nhfd.co.uk/

2. Hip fracture preventionFracture Liaison Services:Rationale for implementation at (add in your Trust)

The case for secondary fracture prevention

Osteoporosis is the most common bone disease in humans affecting both women and men (10); the clinical manifestation of this disease is fragility fracture. An illustration of the consequences of unchecked osteoporosis amongst elderly patients is provided in figure 1. As with other chronic diseases such as hypertension or hyperlipidaemia, osteoporosis sufferers experience an asymptomatic disease phase prior to the occurrence of end-organ damage. Fragility fractures usually result from a fall in older patients that have compromised bone strength. Hip fracture is all too often the final destination of a thirty year journey fuelled by decreasing bone strength and increasing falls risk.

Figure 1. Fracture and quality of life over the life span

Adapted from J Endo Investigation 1999 Kanis JA & Johnell O

Half of hip fracture patients have suffered a prior fragility fracture that could and should have served as a trigger for secondary fracture prevention. (11-14) In January 2005, NICE published Technology Appraisal 87 (15) which mandated osteoporosis assessment for all post-menopausal female fragility fracture patients. Targeting all older patients who present with fragility fractures at any skeletal site for anti-fracture therapy provides a means to intervene in up to a half of all future hip fracture cases. A comprehensive meta-analysis of the principle agents licensed for the treatment of osteoporosis suggests that a 50% reduction in fracture incidence can be achieved during three years of pharmacotherapy. (16)

The current management gap in the UK

Many UK studies have established that routine provision of secondary fracture prevention is occurring for a maximum of 30% of fragility fracture patients in the absence of a systematic approach to healthcare delivery. (17-27) In August 2007, the first UK national evaluation of standards of care for osteoporosis and falls in primary care was commissioned. (28) This study established that NICE TA87 was not implemented for the majority of fragility fracture patients. A subsequent national audit commissioned by the Healthcare Commission into standards of care for patients presenting to hospital with a new fragility fracture found similar shortcomings. (29) Given that 50% of all future hip fracture patients are likely to have suffered a prior fragility fracture, a lack of implementation of NICE

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Morbidity

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age

Morbidity

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age

Morbidity attributable to ageing alone

secondary prevention guidance will result in a continued escalation of the burden of hip fracture on patients, orthopaedic trauma units and NHS budgets.

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Fracture Liaison ServicesA systematic approach to secondary fracture prevention

Osteoporosis care of the fragility fracture patient has been characterised as a Bermuda Triangle comprised of osteoporosis experts, orthopaedic surgeons and primary care physicians into which the fracture patient disappears. (30) Sub-optimal care has been attributed in part to a lack of clarity regarding which speciality should take responsibility for the medical management of patients with fragility fractures. (31) Fracture Liaison Services (FLS) have been demonstrated within the UK NHS and healthcare systems in other countries to provide a reliable mechanism to close this ubiquitous management gap.

The FLS model was originally developed within the Glasgow University Teaching Hospitals and has been described in detail in 2 peer-reviewed publications. (32, 33) In summary, the FLS relies upon a dedicated nurse specialist working within the orthopaedic environment under the guidance of an expert in metabolic bone disease. Usually the “Lead Clinician in Osteoporosis” will be a geriatrician, orthopaedic surgeon, rheumatologist or endocrinologist. The specialist nurse is responsible for establishing systems of care in the particular hospital to ensure that every fracture patient over 50 years (excluding high trauma and road traffic accidents) receives a “one-stop-shop” osteoporosis assessment, with DEXA where appropriate, by the nurse working to protocols devised by clinicians. The FLS will integrate with local falls services and other agencies as described in the 2007 edition of the BOA-BGS Blue Book on the care of patients with fragility fracture. (1)

The Fracture Liaison Service model has been recognised by the Department of Health (34) and the BOA-BGS (1) as an example of best practice to implement NICE TA87. The 2006 National audit of the organisation of services for falls and bone health for older people found that only 27% of hospitals in England had established an FLS.

Establishing a Fracture Liaison Service in (add in your Trust)

Establishing a Fracture Liaison Service at (your Trust) will implement a systematic approach to secondary fracture prevention with potential to intervene in half of all future hip fracture cases

The 2007 BOA-BGS Blue Book on care of patients with fragility fracture (1) states “…the most practical option available to the NHS to attenuate the rising incidence of hip fractures is to ensure that every patient presenting today with any fragility fracture receives effective secondary preventative care”. The Blue Book advocates establishment of an FLS in every UK hospital as the means to achieve this objective.

In the event that your hospital is yet to establish a Fracture Liaison Service resources follow to support you and your colleagues to construct an FLS business case. For hospitals in England, financial support for the FLS is likely to come from a commissioning arrangement with local PCTs.

To ensure that all stakeholders in the locality are fully engaged in the establishment of FLS participation at (your Trust), a multi-disciplinary stakeholder group should be established from the outset. This group will likely include:

- Osteoporosis Lead Clinician (geriatrician, orthopaedist, rheumatologist or endocrinologist)- Consultant Orthopaedic Surgeon- Consultant Geriatrician or Ortho-geriatrician- NHFD Lead Clinician for (your Trust)- Relevant specialist nurses, physiotherapists and other AHPs- Personnel responsible for development/installation of FLS database- Representatives from hospital and primary care medicines management- Representative from local PCT and/or PBC groups

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- Representative from local general practice- Representative from local Public Health

Service design for FLS in (your Trust)

The optimal model for establishing an FLS in (your Trust) will be determined by local case volume and service structures. Illustrations of how colleagues have staffed their services are provided as appendices to the stakeholder group at (your Trust) to illustrate potential local solutions:

- Appendix 4: Fracture Liaison Specialist Nurse – example Job Description- Appendix 5: A&E Falls and Comprehensive Geriatric Assessment Practitioner - JD

Consideration of a published cost-effectiveness analysis of an FLS established overseas (35) may be useful to Lead-Clinicians at project out-set. The business plan will probably consider the following:

- Aims and objectives of the Fracture Liaison Service- Burden of fragility fracture care on Anywhere NHS Trust

• Annual number of patients admitted with hip fracture and other fragility fractures• Length of Stay (average, range and total number of bed days)• Acute care costs (average, range and total incurred in 2006/7)• Total PbR reimbursement from local PCTs for acute fracture care

- Critical appraisal of actual/perceived strengths/weaknesses of current care- Plan for communication between secondary and primary care- Plan for set-up of an FLS database to enable reporting to GPs and audit- Identification of opportunities for audit-based clinical/service change- Start-up costs for establishing the Fracture Liaison Service- Accountability and clinical governance issues- Draft job description of clinicians and allied healthcare professionals involved in FLS

Several UK-based Fracture Liaison Service teams have published work on the set-up, audit and outcomes of their services:

- Glasgow (32, 33, 36, 37)

- Ipswich (38)

- Peterborough (39)

- Belfast (40)

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References

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Appendix 1

Example Job Description: Elderly Trauma Nurse Co-ordinator

Post: Elderly Trauma Nurse Co-ordinatorLocation: Surgical DirectorateReports to: Managerially: To be completed locally

Professionally: To be completed locallyGrade: Band 7

Job summary

1. To assist in developing a culture that understands and meets the specialist and complex needs of hip fracture patients, whilst ensuring that performance targets such as decreased length of stay are met.

2. Physically assess all hip Fracture patients, ensuring effective patient management plans are created and carried out in a timely manner.

3. To identify and meet the training needs of all staff caring for hip fracture patients.4. To work as part of the multi-disciplinary team, acting as a liaison between Orthopaedic

Consultants and ward staff/A & E/Rehabilitation and Community Staff.5. To manage own case load.6. To provide a quality service to patients suffering from hip fracture and ensure all patient’s data

are included in the National Hip Fracture Database(NHFD)

Core responsibilities

1. To attend daily trauma meetings and trauma ward rounds involving the orthopaedic consultants and team.

2. To monitor and advise in the care of all patients with hip fracture, ensuring appropriate treatment and nursing care is provided from 'decision to admit', by regularly monitoring A & E and identifying hip fracture patients who are not admitted into direct access bed.

3. To ensure that theatre space is used effectively and prevents unnecessary pre-op fasting of patients with fractured neck of femur.

4. Audit the progress of all hip fracture patients and complete NHFD audit tool with attention to detail and accuracy and produce reports as requested and present at Directorate Audit meetings.

5. Ensure effective liaison within the multi-disciplinary team.6. To request appropriate investigations for all fractured neck of femur patients to ensure patients

are in their optimum physical condition prior to theatre. 7. To ensure continuity of care, specialist advice, training and liaison within the clinical area

(including Consultants and GP’s), in order to provide a high standard of patient care.8. To be a contact for discharged hip fracture patients if advice regarding their injury is required. 9. To ensure that all patients and their relatives are fully informed, psychologically prepared for

theatre and educated about their injuries, the intended management and discharge plans.10. To run a nurse-led clinic for fractured neck of femur patients requiring post-op monitoring. 11. Apply current research findings to clinical care and actively disseminate these findings.12. To regularly provide structured teaching sessions to A & E, ITU and ward staff on the role of the

Hip Fracture Nurse Specialist and the needs of hip fracture patients.13. To ensure maximum effectiveness of the service within the resources available.

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14. A willingness to undertake research projects with an aim to publish results.15. To ensure compliance with all Trust policies and those procedures relevant to the area of work.16. At all times maintain high levels of confidentiality and information security complying with the

relevant legislation such as the Data Protection Act and the Computer Misuse Act.17. Where any processing of information takes place (paper records or electronically) ensure that

the data is of good quality, accurate and relevant for purpose.

This job description should be regarded only as a guide to the duties required and is not intended to be definitive.

Person specification – Elderly Trauma Nurse Co-ordinator

Requirements Essential Desirable

Education and Qualifications

RGN Level 1- UKCC RegisteredENB 998 or City & Guilds 998 or equivalentHealth Assessment Skills – level 4, or willingness to work towards

Evidence of management experience ENB 219/ONC/A&E course

Job related Experience

At least 2 years at Band 6At least 2 years experience working within Older person, trauma specialty or A/E areas

Evidence of extended role activity. IV cannulation, ECG trained, ALERT Course.Experience in caring for acutely ill older people.

Skills / Attributes

Ability to manage own workload and prioritiseExcellent interpersonal and negotiation skills Communication skills of tact and diplomacy.Ability to communicate with all clinical groups of staff to achieve patient care of a high standard.Presentation skills Proven good line-management skillsAdept at working in multi-disciplinary teams

Audit awareness / use of spreadsheetsBudgetary awarenessComputer literacyPrevious project work

Personal qualities

Ability to work flexiblyAbility to meet the demands/hours.Good team playerEnthusiastic and motivated

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Appendix 2Example Job Description: Trauma Audit Co-ordinator

Job title: Trauma Audit CoordinatorLocation: Surgical DirectorateResponsible to: Managerially: To be completed locally

Professionally: To be completed locally Grade: A & C Grade 5, Hours per week to be specified

JOB SUMMARY:To coordinate data collection across the Trust and to facilitate trauma audit as part of the development of high quality clinical practice. To support the development of an initiative which aims to improve the quality of trauma services and the sharing of good practice.

CORE RESPONSIBILITIES: Injuries in the Elderly Patient Audit

1. To support and promote trauma audit at the Trust, liaising closely with clinical staff and clinical audit and information staff to ensure that good quality data is available

2. To collect and coordinate accurate, reliable and timely data. To maintain the audit database3. To liaise with other cooperating centres and research unit staff working with the elderly4. To organise regular trauma audit reports and events for the Trust and to support educational

events5. To develop effective networks and channels of communication across multi-professional

groups to facilitate trauma audit6. To assist clinicians and hospital staff in the interpretation of information and in identifying

areas requiring further audit, change or research7. To make presentations to educational meetings, seminars and symposia as required8. To participate in individual performance appraisal arrangements9. Any other allied duties as requested by the line-manager10. To cross cover core data collection/identification for the parallel audit in injuries in the Critically

Injured Patients during periods of leave


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Person specification - Trauma Audit Co-coordinatorSpecification Essential Desirable

Education /Training

Trained in the use of PCs with Windows operating systems, Word, Excel, email and AccessExperience of clinical terminology in trauma careExperience of SPSS or other statistical applicationRetrieval and refiling training for ORH notes

Research qualification or experience

OccupationalExtraction of data from hospital notesAbility to interact with clinical staff to clarify dataAbility to manipulate databases to produce summary statistics Ability to statistically analyse dataKnowledge of data protection and security

Ability to create and enhance databases

Special skills / aptitudes

Presentation skills Ability to work with multidisciplinary teams to effect practice change based on auditContribution to the development of improved methods for data collection and handling in Critical Care

Personal Qualities

Great attention to detail and thoroughness in data retrieval and entry. Ability to work in partnership with other data team members and their auditsWillingness to attend specific audit training courses/sessions at other hospitals e.g. initially and for regular updates

CircumstancesWorking collaboratively with partner Critical Care Audit staff to maintain core data collection for all audit projects during periods of leave.Flexibility in working hours to ensure live data capture in this emergency field, over either 4 or 5 days per week

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Appendix 3

Example Job Description – Trauma Co-ordinatorJob title: Trauma Co-ordinatorLocation: Surgical DirectorateResponsible to: Managerially: To be completed locally

Professionally: To be completed locally

Grade: Band 7Job Summary

1. To comprehensively assess trauma patients, assist and co-ordinate trauma activity with the Directorate, liaising with various healthcare professionals to ensure that each patient’s hospital episode is managed in the most effective and efficient way, in line with the Trust strategies on nursing, midwifery and patient centred care.

2. To improve the scheduling of surgery for trauma patients, reduce cancelled operations and reduce pre-operative starvation. To assist in the data collection pertaining to these issues by means of quantative/qualitative audit, on-going monitoring and general feedback.

3. Maintaining close liaison with patients, relatives/carers, medical teams ward nursing teams, anaesthetic and operating department staff.

CORE RESPONSIBILITES

1. Patient management

Physically assess all trauma patients, ensuring effective patient management plans are created and carried out in a timely manner.

Undertake autonomous lead role in the appropriate prioritisation of the trauma list, taking into account the clinical needs of the patients.

Participation in the consultant led trauma ward round and lead a cohesive and streamline service formulating a specific management plan for each trauma patient.

Assessing the patient and liaison with any necessary parties to facilitate operative management, including physical examinations, history taking and documentation as necessary.

To ensure that patients admitted onto the Trauma Unit/Wards are appropriately assessed and to ensure that all pertinent tests, specialist investigations and clerking are completed and available. Liaising and ensure these have been undertaken buy all disciplines involved in patient care.

To discuss individual patients with appropriate consultants and/or their medical team to ensure that theatre lists reflect patients’ priorities, matching complexity of the patient’s surgery against the availability of surgeons and anaesthetists.

Communication and documentation with patients, surgeons, anaesthetists, ward nursing teams, operating department teams, junior medical staff and all professionals allied to medicine.

To ensure that all procedures within the unit are carried out according to established standards within the Trust.

Liaising with relevant disciplines to ensure a holistic approach to patient care.

2. Communication

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To report the unit’s activity to the medical teams to enable the co-ordination of junior doctors input for trauma management.

To develop collaborative partnerships and effective working relationships with clinical staff and in particular Clinical Area Leads both within the Division and the Trust to influence the management, planning and development of the service.

To liaise with theatre staff to ensure that theatre availability and equipment meets the demands of patients requiring trauma surgery and that all orthopaedic operating sessions are fully utilised.

To communicate with the Nurse Manager for Orthopaedics, the Bed Management team, A & E staff and the Orthopaedic Outpatients to ensure that optimum bed usage is provided at all times.

To participate in clinical audit (including the National Hip fracture Database- NHFD) and research. Ensure that there is a local strategy is in place to support collection of NHFD data and web input on ALL hip fracture patients. To collect agreed data on trauma activity to enable theatre utilisation remains effective and efficient.

After the consultant led trauma round, close liaison must then take place with the Operating Department, giving them as much information about their patients and their surgical management to facilitate the smooth running of the day’s list.

Re-planning and trouble shooting throughout the day. To monitor activity within the unit and identify and minimise potential problems through pro-active working practices.

To facilitate cross Divisional communication networks and develop strategies to ensure that each patient’s hospital episode is managed individually and in the most effective and efficient way.

Complete a formal handover taking place at the end of the day with the Consultant on call and other disciplines. This meeting informs and updates the Consultant on call team and prioritise the workload for the following day.


Person specification – Trauma Co-ordinator



RGN Level 1- UKCC RegisteredENB 998 or City & Guilds 998 or equivalentENB 219/ONC/A&E course preferredHealth Assessment Skills – level 4, or willingness to work towards

Evidence of management experience


At least 2 years at Band 6At least 2 years experience working within Trauma or A/E areas

Evidence of extended role activity. IV cannulation, ECG trained, ALERT Course.

Skills / Attributes


Audit awareness / use of spreadsheetsBudgetary awarenessComputer literacyPrevious project work

Personal qualities


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Appendix 4:Example Job Description: Fracture Liaison Specialist Nurse

Job title: Fracture Liaison Specialist NurseLocation: Surgical DirectorateResponsible to: Managerially: To be completed locally

Professionally: To be completed locally

Grade: Dependant on specifics of post

JOB SUMMARY1. To co-ordinate and be responsible for the development of the Fracture Liaison Service for

location.2. To be aware of the Osteoporosis Guidelines for location involved in the Osteoporosis initiative.3. To develop links and communication between the orthopaedic services and metabolic bone unit.4. To develop appropriate referrals and pathways of care for patients admitted with fragility

fractures that may have osteoporosis.5. To be autonomous and be prepared to make decisions where appropriate, manage own time

and workload and work individually as well as contributing to the team when necessary.6. To assist in the establishment of a multidisciplinary unit for the diagnosis and management of

bone disorders principally osteoporosis.7. To act as a link person enhancing co-ordination and communication between the various

members of the orthopaedic and medical teams, to the metabolic bone team as well as other areas that refer patients to the unit.

8. To help establish educational and health promotion programs for patients attending the unit and those seen at other sites.

9. To perform audit of the unit the developing service and associated bone densitometry screening programs.

10.To be aware of time constraints and financial implications of developing the service projects.11.To be responsible for accurate data entry and of data associated with research and be proficient

in appropriate computer packages.12.To identify any areas of opportunity within the unit for development of research, and assist in

their evolution. To be involved in the submission of ethics proposals, grant applications and the setting up of research and audit.

CORE RESPONSIBILITIES

1. To ensure an efficient and effective service is given to patients who may have osteoporosis who are admitted with fragility fracture.

2. To liaise with all members of the team to ensure smooth running of the referral service and unit.3. To develop and maintain accurate data collection and storage using computer skills.4. To be skilled in patient assessment techniques such as taking histories and clinical skills

including venepuncture for patients needing investigations.5. To be a source of knowledge and provide educational support concerning osteoporosis and

identification of research areas.

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6. To be involved in the development of proposals, ethical requirements and implementation of research within the unit.

7. To maintain and update own knowledge and clinical skills of bone disorders to enable education and advice to be given to patients and their families.

8. To maintain and develop own personal and professional development according to UKCC guidelines.

9. To liaise with all members of the team to ensure smooth running of the unit.


Person specification – Fracture Liaison Specialist Nurse



RGN Level 1- UKCC RegisteredENB 998 or City & Guilds 998 or equivalentENB 219/ONC/A&E course preferredHealth Assessment Skills – level 4, or willingness to work towards

Evidence of management experience / counselling advantageous


At least 2 years at Band 6At least 2 years experience working within Trauma or A/E areas

Skills / Attributes


Audit and research awareness / use of spreadsheetsComputer literacyPrevious project work

Personal qualities


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Appendix 5:Example Job Description: A+E Falls and Comprehensive Geriatric Assessment Practitioner

Job title: A+E Falls and Comprehensive Geriatric Assessment Practitioner Location: Surgical DirectorateResponsible to: Managerially: To be completed locally

Professionally: To be completed locallyGrade: Band 7

Job SummaryThe A&E Falls and Comprehensive Geriatric Assessment (CGA) Practitioner post has been developed to improve the comprehensive assessment of older people (aged 65+) presenting to A+E. The A+E Falls & CGA Practitioner will specifically focus on patients presenting with a fall. The post holder will assess fallers and appropriately refer to other services with streamlining of referrals to the Falls Clinic and community services. They will also apply CGA methods in assessing older people in A&E and the Clinical Decision Unit (CDU). An important aspect of the post will be to embed this assessment approach into routine practice by nurses and junior medical staff working in A&E and the CDU.

The post holder would ensure that older people who have presented in A+E with a fall or other geriatric syndrome (confusion, reduced mobility, incontinence, frailty) are assessed and referred to appropriate teams/agencies for further assessment and treatment. The nurse will be responsible for assessing fallers when they present at ED using a structured proforma and identifying the appropriate referrals. The nurse will also be responsible for triaging out of hours attendees and ensuring appropriate follow up care.

Core responsibilities1. To work closely with A+E staff to ensure that older people presenting with falls and other issues

have access to an appropriate level of assessment and intervention and/or with appropriate onward referral.

2. To ensure that people who have fallen are assessed using an identified proforma with a view to identifying risk factors for both falls and osteoporosis

3. Demonstrate good CGA assessment skills using a structured approach to a holistic assessment of the older person incorporating environmental issues. This will include embedding a brief structured CGA proforma into routine A&E practice.

4. Support carers and patients during their attendance in ED and providing explicit details of and follow-up care.

5. Ensure patients and carers are involved in decision making process and give valid consent to all treatment of referrals.

6. Using ED consultation information and telephone follow-up to assess the need of the patient in a proactive manner to ensure appropriate follow up care.

7. To actively identify, assess and intervene in people at risk of osteoporosis and fractures.8. Key role at primary/secondary health care interface. Facilitating the safe discharge of people

who fall and ensuring follow-up with appropriate members of the multidisciplinary team. Close working and integration with SLIPS project to streamline ED into Falls ICP.

9. Link with existing improvement programmes in the specialist area: SLIPS project, OPAL, TACT, Day Hospital and Intermediate care centres.

10. Work closely with POPS (proactive management of older people requiring surgery) in relation to patients with hip fractures.

11. To engage in clinical audit activity and maintain the falls database.12. Implement and evaluate innovations in clinical practice13. Practice and further develop advanced clinical skills

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14. Lead nursing input in A+E decision-making15. Participate in quality assessment of the project on an ongoing basis with quarterly reports on the

impact of service and quality of care16. Participate in the formalisation of assessment forms, standards of care and policies for patients

who have presented with a fall.17. Optimise appropriate post-operative discharge from hospital by working with the other clinical

members of the team and other agencies such supportive discharge and other intermediate care provision, and linking with voluntary organisations and groups.

18. Review, maintain and develop agreed standards of documentation and electronic record keeping.

Teaching and Staff Development

1. To meet patients information needs. Advice will be given with respect to diet, exercise, vision, and footcare through the patient assessment and consultation with patients.

2. To provide A+E staff with information on falls management through regular teaching and education support fro all staff within ED. Medicine and Primary Care.

3. Together with ED staff to identify training, educational sessions and discussions and provide recommendations to meet these with training needs and secure plans to address needs.

4. To identify, provide and develop required literature for patients about falls and ensure that all fallers are given this information on discharge.

5. To communicate all developments, Day Hospital steering group.6. Develop and maintain effective lines of communication with relevant hospital Clinicians, Nursing

Staff and across the Primary/Secondary Care interface.7. To collect and record patient data as required and to take appropriate actions as indicated.8. Provide support and advice to all staff involved in the care of patients who have fallen.9. To keep abreast of professional and managerial developments10. To organise and participate in regular meetings with the Clinical Nurse Manager and Day

Hospital Manager.11. To attend the Day Hospital Operational Meetings and keep informed of other elderly care activity

e.g. falls clinic, POPS etc.

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Person specification - A+E Falls and Comprehensive Geriatric Assessment PractitionerRequirements Essential Desirable


RGN Level 1- UKCC RegisteredENB 998 or City & Guilds 998 or equivalentDegree or willingness to work towards

Evidence of management experience / counselling


At least 18 months at Band 6At least 5 years post registration experience, preferably within a hospital setting and with elderly patientsManagement of change both personally and as a facilitatorSound Knowledge of current issues in the profession and practice of nursingUnderstanding of health and social care policy especially the NSF of Older People

Skills / Attributes

Ability to manage own workload and prioritiseExcellent interpersonal and negotiation skills Ability to communicate with all clinical groups of staff to achieve patient care of a high standard.Presentation skills Proven good line-management skillsAdept at working in multi-disciplinary teamsAble to work under pressure and achieve deadlinesProficient in the use of IT applications including word and Excel

Audit and research awareness / use of spreadsheetsComputer literacyPrevious project work

Personal qualities

Interest in promoting improved care for the older personAbility to work flexibly and meet the hours/demands of the postGood team playerEnthusiastic, innovative and self motivatedDiplomatic, flexible and politically sensitiveCommitment to personal development and professional effectiveness

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Appendix 6, NHFD Facilities AuditHeadings Your Information Comments/Options

Hospital

Trauma catchment population (DGH workload)

Number of hip fracture cases each year

Trauma service description DGH/Tertiary/both

Acute admission Hip# ward / any ortho bed /Older person ward / any ward

Best description of hip fracture serviceAll pts > acute ortho then transferred to Medicine for Older People Ward / community Hospital bed at Day 5 post op

Hours of designated trauma list /per week

Number of WTE orthopaedic consultants

Number of WTE orthopaedic middle grades

Number of hours per week worked by orthogeriatric consultants in orthopaedic department

Number of hours per week orthogeriatric middle grades work in orthopaedic department

Number of OG ward rounds a week

Number of clinical nurse practitioner WTE specialising in fragility fracture patients

Number of WTE fracture liaison nurses

Falls clinic None / Consultant led / nurse led

Dexa on site Axial / peripheral / none (If you have axial & peripheral just put axial)

Dexa Since E.g. since 2001

Who predominantly collects and enters data? nurses, doctors or audit staff

Do you use local audit software, if so what is it called Access/Excel/ Teleform / other (please state)

Rehabilitated In admission ward / GORU

Characteristics of hospital

Free text – comment on unique aspects of your hospital - e.g. pts transferred > other hospital post op

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Appendix 7, National Hip Fracture Database – Audit Tool 5.0Patient Information

First Name Surname NHS / CHI Number

Date of Birth M Gender M Patient’s Post Code

__ __ /__ __ /__ __ __ __ Male Female

Patient ID / Hospital number K

AdmissionFirst Presenting Hospital Admitted from

Own home/sheltered housing Residential Care / Nursing Home / Long Term Care hospital Rehabilitation Unit Already in hospital OtherNote: Holiday residence/respite care = Own home/sheltered housing

Admission via A & E Date & time of admission to A & E Yes No __ __ / __ __ / __ __ __ __ __ __:__ __hrs

Note: Use presentation to trauma team if not admitted via A&EDate & time left A & E Type of ward admitted to

__ __ / __ __ / __ __ __ __ __ __:__ __hrs

Hip fracture unit Orthopaedic ward Hip fracture unit – Medicine for older people Never admitted to orthopaedic ward Other

Date & time of admission to orthopaedic ward M Consultant Code

__ __ / __ __ / __ __ __ __ __ __:__ __hrsNote: This is for your hospital use only.

Orthopaedic GMC number B M Geriatrician GMC number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Admitted using jointly agreed assessment protocol B Yes No Unknown

AssessmentWalking ability indoors pre-admission M Walking ability outdoors pre-admission Regularly walked without aids Regularly walked with one aid Regularly walked with two aids or frame wheelchair or bedbound Unknown

Regularly walked without aids Regularly walked with one aid Regularly walked with two aids or frame Electric buggy wheelchair or bedbound Unknown

Accompanied to walk indoors pre-admission M Accompanied to walk outdoors pre admission No Yes wheelchair or bedbound Unknown

No Yes wheelchair or bedbound Unknown

Abbreviated Mental Test Score (AMTS) on admission Pathological

__ __ / 10Yes No Unknown Note: Yes only if primary or secondary malignancy present at the fracture site

Side of fracture K Type of fracture Left Right

Intracapsular – displaced Intracapsular – undisplaced Intertrochanteric Subtrochanteric OtherNote: Basal/basicervical #s are to be classed as Intertrochanteric

Pre-op medical assessment M Already under care of geriatrician/physician Routine by geriatrician Routine by physician routine by specialist nurse Medical review following request None

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TreatmentASA grade 1 2 3 4 5 unknown

Date & time of primary surgery B Operation Performed

__ __ / __ __ / __ __ __ __ __ __:__ __hrs

Internal fixation – SHS Internal fixation – Screws Internal fixation - IM nail (long) Internal fixation - IM nail (short) Arthroplasty - Unipolar hemi (uncemented- uncoated) Arthroplasty - Unipolar hemi (uncemented- HA coated) Arthroplasty - Unipolar hemi (cemented) Arthroplasty - Bipolar hemi (uncemented - uncoated) Arthroplasty - Bipolar hemi (uncemented – HA coated) Arthroplasty - Bipolar hemi (cemented) Arthroplasty - THR (uncemented - uncoated) Arthroplasty - THR (uncemented – HA coated) Arthroplasty - THR (cemented) Other No operation performed

Reason if delay > 36hours M Reason if delay > 48hours

No delay- surgery < 36hrs Medically unfit –awaiting orthopaedic diagnosis/investigation Medically unfit – awaiting medical review/investigation or stabilisation Administrative/logistic- awaiting inpatient or high dependency bed Administrative/logistic – awaiting space on theatre list Administrative/logistic – problem with theatre /equipment Administrative/logistic - problem with theatre/surgical/anaesthetic staff cover Administrative/logistic - Cancelled due to theatre over-run Other Unknown

Note: Delay is calculated from time of admission in A&E

No delay- surgery < 48hrs Medically unfit –awaiting orthopaedic diagnosis/investigation Medically unfit – awaiting medical review/investigation or stabilisation Administrative/logistic- awaiting inpatient or high dependency bed Administrative/logistic – awaiting space on theatre list Administrative/logistic – problem with theatre /equipment Administrative/logistic - problem with theatre/surgical/anaesthetic staff cover Administrative/logistic - Cancelled due to theatre over-run Other Unknown

Note: Delay is calculated from time of admission in A&EPressure ulcers M Re-operation within 30 days Yes No Unknown

Note: Grade 2 + above during acute admission

Reduction of dislocated prosthesis Washout or debridement Implant removal Revision of internal fixation Conversion to Hemiarthroplasty Conversion to THR Girdlestone/excision arthroplasty Surgery for periprosthetic fracture None Unknown

Note: Most significant procedure onlyDate & Time assessed by Geriatrician B M Geriatrician grade

__ __ / __ __ / __ __ __ __ __ __:__ __hrs Consultant SAS ST3+ Unknown

Specialist falls assessment B M Bone protection medication No Yes - performed on this admission Yes - awaits falls clinic assessment Yes - further intervention not appropriate

Started on this admission Continued from pre-admission Awaits DXA scan Awaits bone clinic assessment Assessed – no bone protection medication needed/appropriate No assessment or action taken

Multidisciplinary rehabilitation team assessment B M Yes No Unknown

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DischargeDate & time of discharge from acute Orthopaedic ward M Discharge destination from acute Orthopaedic ward M

__ __ / __ __ / __ __ __ __ __ __:__ __hrs

Own home/sheltered housing Residential care/nursing home/LTC hospital Rehabilitation unit Acute hospital Dead Other

Date & time of final discharge from Trust M Discharge destination from Trust M

__ __ / __ __ / __ __ __ __ __ __:__ __hrs

Own home/sheltered housing Residential care/nursing home/LTC hospital Rehabilitation unit Acute hospital Dead Other Unknown

Discharge date/time of final discharge from NHS care Discharge destination from NHS care

__ __ / __ __ / __ __ __ __ __ __:__ __hrs

Own home/sheltered housing Residential care/nursing home/LTC hospital Rehabilitation unit Acute hospital Dead Other Unknown

Follow Up30 days

Date.............................

120 days

Date...................................

1 year

Date...............................

Residentialstatus

Own home/sheltered housing Residential care / nursing home / LTC hospital Rehabilitation unit Acute hospital Dead Other Unknown

Own home/sheltered housing Residential care / nursing home /LTC hospital Rehabilitation unit Acute hospital Dead Other Unknown

Own home/sheltered housing Residential care / nursing home / LTC hospital Rehabilitation unit Acute hospital Dead Other Unknown

WalkingAbility

indoors

Regularly walked without aids Regularly walked with one aid Regularly walked with two aids or frame wheelchair or bedbound Unknown



Walkingability

outdoors

Regularly walked without aids Regularly walked with one aid Regularly walked with two aids or frame Electric buggy wheelchair/bedbound Unknown



Accompanied to walk indoors

Yes NoUnknown

Yes NoUnknown

Yes NoUnknown

Accompanied to walk

outdoors

Yes NoUnknown

Yes NoUnknown

Yes NoUnknown

Bone protection medication

Yes NoUnknown

Yes NoUnknown

Yes NoUnknown

K= key fields. If missing or invalid data entered, the record will be rejected.

M = mandatory fields. If missing or invalid data entered, the record will remain in draft form.We would strongly encourage you to collect data in all other fields (but if missing, the record will still be considered complete)

B = Required for Best Practice Tariff. If missing or invalid data entered BPT will not be available

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Appendix 8

Why a National Hip Fracture Database?~ why information about your care is important.

Hip fracture is a common injury, and caring for patients with hip fracture is an important part of the work of the NHS.

This hospital takes part in the National Hip Fracture Database (NHFD), which has been set up to improve the care of patients who have broken a hip.Information gathered about care in hospital and about recovery afterwards enables us to measure the quality of that care and helps us to improve the services we provide.

Reports based on NHFD data are made to our clinical staff to assist them in improving care here. NHFD national reports show how different hospitals compare, thus helping to improve standards of care nationally.

So, information about your care and progress is important, and will be collected during your hospital stay. And, because your progress after you leave hospital matters to us, you may be contacted later about how you are getting on.

All information collected is confidential, and no information is ever made public about you or about any other patient. All NHFD information is stored, transferred and analysed securely – both in this hospital and within the national database – in keeping with the provisions of the Data Protection Act (1998). Participation is, of course, voluntary; and you are free, if you so wish, not to take part - tell your doctor if you do not wish to participate. However, the more people take part, the more helpful NHFD will be in improving care.

NHFD is supported by the National Clinical Audit Support Programme, a division of the Information Centre for Health and Social Care.

More details are available at www.nhfd.co.uk

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http://www.nhfd.co.uk/

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