Best Practice

The NHFD collects data on a series of standards (based on national guidelines) and hospitals which meet them are recognised as delivering best practice. NICE recommend that patients are treated as part of a hip fracture programme – that they are managed in partnership between orthopaedic surgeons, geriatricians and other health professionals. In 2010 the Department of Health introduced a Best Practice Tariff which rewards hospitals in England which provide the key elements of a hip fracture programme for each patient.

• Percentage cases having surgery in 36 hours: NICE guidelines recommend that surgery should take place on the day of admission to hospital or the following day. This is because it is uncomfortable, undignified and distressing to be confined to bed with a hip fracture and patients are unable to get up out of bed until they have had the operation. This recommended time for surgery may not be possible for some patients – for instance if they have medical problems which need other treatment first to make them well enough for surgery.

• Percentage cases having orthogeriatric assessment in 72 hours: The chart shows the proportion of patients who are assessed by an orthogeriatrician in their first 72 hours in hospital. A geriatrician is a doctor who specialises in treating the complex problems of frail and older patients and the NHFD has encouraged hospitals to appoint ‘orthogeriatricians’ – specialists in the care of such people when they are admitted with hip fractures and other orthopaedic problems. These doctors help to make sure that patients are as fit as possible before their operation, support them following surgery and lead the rehabilitation team.

• Percentage cases having bone health assessment: The chart shows the proportion of patients who have received an assessment of their bone health during their hospital admission. Most people who suffer a hip fracture will have osteoporosis, which means their bones have become weaker. This is a normal consequence of ageing and NICE guidelines recommend that all older patients with a hip fracture should be considered for bone strengthening treatment. If patients are younger they may need a bone density scan (DXA) to help decide if they need this treatment. Various treatments are available, in the form of tablets, drips or injections. Doctors should also consider whether a patient needs calcium and vitamin D supplements as well. These need to be continued over a number of years to protect against future fractures. Without treatment, one in five people will suffer another hip fracture in future years.

• Percentage cases having preoperative cognitive assessment: The chart shows the proportion of patients who are assessed with an Abbreviated Mental Test Score (AMTS) before their operation. Memory problems are common in older people. Some patients or their families and friends may have noticed memory problems before they suffered a hip fracture, and some may already have a diagnosis of dementia. Being admitted to hospital and having surgery for a hip fracture can be bewildering for such people, and many will become more confused or see a change in their behaviour as a result. Such changes can be very upsetting for patients and their families, so all patients should receive a simple ‘memory test’ type of assessment when they are admitted to help plan their care.

• Percentage cases having falls assessment: The chart shows the proportion of patients who have received an assessment of falls risk during their hospital admission. Falls are common in older people, and one in three people over 65 will fall each year. Hip fractures usually follow a fall and prevention of further falls is part of rehabilitation and discharge planning. But rehabilitation requires a balance so that sensible measures to avoid falls do not prevent people from returning to mobility and independence. NICE recommend that patients are assessed to reduce their risk of future falls while they are still in hospital. This should be part of the multidisciplinary rehabilitation process and should include assessment by an orthogeriatrician, review of medication, physiotherapy work on strength and balance, and an assessment of the home environment.

• Percentage cases meeting all best practice tariff (BPT) criteria: The blue area of the chart shows the proportion of patients who meet all of the best practice criteria and are eligible for the tariff payment each month. This tariff is paid by commissioners to the hospital treating the patient in addition to the baseline rate for the cost of treating them. The national average for this achievement is shown as a blue dotted line.

For more information on hip fracture, please see the NHFD patient report ‘My Hip Fracture Care: 12 questions to ask’. This is a guide to hip fracture injury and treatment for patients, their families and carers and is available on the NHFD homepage: www.nhfd.co.uk

Technical Summary

Introduction
The 'Best Practice' run-chart contains % data on key indicators required to meet 'Best Practice Tariff' and seeks to show which criteria are being met and what percentage of patients meet BPT criteria.

Data Selection
All records from April 2012 to Date (To the end of month before the previous month) where a patient has been discharged

Time-base
The charts use 'Trust Discharge Date' as the main monthly time-base. Patients are counted based on the year and month of trust discharge.

Update Frequency
Chart data is recalculated every hour, but new records for the current or previous month will not be included.

Excluded Data
1. Errors (Missing data/Erroneous data)
2. Duplicates
3. Patients < 60 years old
4. Record Conflicts

NOTES:
Best practice is based on a number of criteria, but the BP chart only displays some of these criteria:

Best practice Indicators displayed on the chart:	Indicators not displayed on the chart, but count towards the overall attainment BP score:
BPT V4 (from April 2020)	BPT V2 (April 2010 - Mar 2017)	BPT V3 (April 2017 to date)
Time To Surgery Geriatrician Assessment undertaken Bone Protection Medication Cognitive Assessment (Pre-op AMTS) Specialist Falls Assessment Nutrition Assessment * Delirium Assessment * Physiotherapist Assessment *	Patient NHS Number obtained Orthogeriatrician GMC obtained Geriatrician GMC obtained Joint Protocol Assessment applied Post-Op AMTS2 Geriatrician Grade Rehabilitation Assessment completed	Patient NHS Number obtained Geriatrician Grade

* These BPT elements were added to BPT V3 (from April 2017)
For BPT V4 (from April 2020) the delirium assessment includes an assessment timing element - only assessments taking place within 7 days of surgery count for BPT.