Hip Fracture

Care for People With Fragility Fractures

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Emergency Department Management
Patients with suspected hip fracture are diagnosed within 1 hour of arriving at hospital. Preparation for surgery is initiated, and patients are admitted and transferred to a bed in an inpatient ward within 8 hours of arriving at hospital.

Quality Statement 2: Surgery Within 48 Hours
Patients with hip fracture receive surgery as soon as possible, within 48 hours of their first arrival at any hospital (including any time spent in anonsurgical hospital).

Quality Statement 3: Multimodal Analgesia
Patients with suspected hip fracture have their pain assessed within 30 minutes of arriving at hospital and managed using a multimodal approach, including consideration of non-opioid systemic analgesics and peripheral nerve blocks.

Quality Statement 4: Surgery for Stable Intertrochanteric Fractures
Patients diagnosed with a stable intertrochanteric fracture are treated surgically with sliding hip screws.

Quality Statement 5: Surgery for Subtrochanteric or Unstable Intertrochanteric Fractures
Patients diagnosed with a subtrochanteric fracture or unstable intertrochanteric fracture are treated surgically with intramedullary nails.

Quality Statement 6: Surgery for Displaced Intracapsular Fractures
Patients diagnosed with a displaced intracapsular hip fracture are treated surgically with arthroplasty.

Quality Statement 7: Postoperative Blood Transfusions
Patients with hip fracture do not receive blood transfusions if they are asymptomatic and have a postoperative hemoglobin level equal to or higher than 80 g/L.

Quality Statement 8: Weight-Bearing as Tolerated
Patients with hip fracture are mobilized to weight-bearing as tolerated within 24 hours following surgery.

Quality Statement 9: Daily Mobilization
After surgery, patients with hip fracture are mobilized on a daily basis to increase their functional tolerance.

Quality Statement 10: Screening for and Managing Delirium
Patients with hip fracture are screened for delirium using a validated tool as part of their initial assessment and then at least once every 12 hours while in hospital, after transitions between settings, and after any change in medical status. Patients receive interventions to prevent delirium and to promote recovery if delirium is present.

Quality Statement 11: Postoperative Management
Patients with hip fracture receive postoperative care from an interdisciplinary team in accordance with principles of geriatric care.

Quality Statement 12: Patient, Family, and Caregiver Information
Patients with hip fracture and/or their family and caregivers are given information on patient care that is tailored to meet the patient’s needs and delivered at appropriate times in the care continuum.

Quality Statement 13: Rehabilitation
Patients with hip fracture participate in an interdisciplinary rehabilitation program (in an inpatient setting, a community setting, or a combination of both) with the goal of returning to their pre-fracture functional status.

Quality Statement 14: Osteoporosis Management
While in hospital, patients with hip fracture undergo an osteoporosis assessment from a clinician with osteoporosis expertise and, when appropriate, are offered pharmacologic therapy for osteoporosis.

Quality Statement 15: Follow-Up Care
Patients with hip fracture are discharged from inpatient care with a scheduled follow-up appointment with a primary care provider within 2 weeks of returning home and a scheduled follow-up appointment with the orthopaedic service within 12 weeks of their surgery.

Resources Quality Statements Advisory Committee About

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Multimodal Analgesia

Patients with suspected hip fracture have their pain assessed within 30 minutes of arriving at hospital and managed using a multimodal approach, including consideration of non-opioid systemic analgesics and peripheral nerve blocks.

Background

For patients who have experienced a hip fracture, pain is one of the main physiological and psychological stresses. A patient’s pre–hip fracture pain medications should be reviewed (as applicable) to assess the need for continuation or substitution while in hospital.

Opioids are effective at relieving acute pain; however, they are associated with side effects including confusion, vomiting, constipation, sedation, and respiratory depression. It is important to consider the use of multimodal analgesia to reduce dose-dependent opioid-related side effects. Nonnarcotic systemic analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (if not contraindicated), and peripheral nerve blocks, such as a fascia iliaca or femoral nerve block, can improve pain control, reduce postoperative delirium, and reduce overall opioid requirements. Peripheral nerve blockade should be performed by medical practitioners with appropriate training, with consideration of the benefits and risks of the procedure, and with an explanation of the procedure to the patient.

Choice of Anaesthesia

Patients undergoing hip fracture surgery receive either neuraxial or general anaesthesia. As current evidence suggests that the two modalities are equivalent for most outcomes, the choice of anaesthesia should be made based on patient characteristics and, where possible, in consultation with the patient and family or caregivers. Neuraxial anaesthesia may be contraindicated for patients on anticoagulation medication; surgery should not be delayed if general anaesthesia is an acceptable option.

What This Quality Statement Means

For Patients

Your pain should be assessed and treated promptly upon arriving at the emergency department. Various pain relief treatments should be considered, including non-opioid treatments.

For Clinicians

If you suspect that a person has a hip fracture, ensure that their pain is immediately assessed and managed. If the patient needs opioids, consider augmentation with non-opioid systemic analgesics and/or a peripheral nerve block to reduce the opioid dosage needed to manage the patient’s pain.

For Health Services

Ensure that systems, processes, and resources are in place to assist clinicians with the rapid assessment of pain in the emergency department. Ensure that appropriate training and resources are available for clinicians such that all can become competent at inserting and initiating peripheral nerve blocks.

Quality Indicators

Process Indicators

Percentage of patients with suspected hip fracture whose pain is assessed within 30 minutes of arrival at hospital

Denominator: total number of patients presenting to hospital with suspected hip fracture
Numerator: number of people in the denominator whose pain is assessed within 30 minutes of arrival at hospital
Data source: local data collection

Percentage of hip fracture patients with an order for opioids who do not also receive non-opioid systemic analgesia or a nerve block

Denominator: total number of adults admitted to hospital with a primary diagnosis of fragility hip fracture with an order for opioids
Numerator: number of people in the denominator who do not receive non-opioid systemic analgesia or a nerve block
Data source: local data collection

Evidence to Improve Care