Many people with a hip fracture wait longer for surgery despite some hospitals making a dramatic improvement in time to surgery in the past few years.
On September 11, the Australian Commission on Safety and Quality in Health launched the updated national clinical care standard for hip fracture at the binational Hip Fest 2023 conference, hosted by the Australian and New Zealand Hip Fracture Registry (ANZHFR).
The updated standard reduces the recommended maximum time to surgery - along with other improvements for better care - and will drive meaningful change as hospitals establish protocols to meet these targets.
Every year in Australia, 19,000 people fracture their hip, usually after a fall. Most hip fractures happen to people over 65 years and are often a life changing event.
Australia's ageing population makes taking action on hip fracture more important than ever.
Hip fracture significantly increases an older person's risk of death, with one in four people dying within 12 months after a hip fracture injury. Of those who survive, many lose their ability to live independently or return to their former lifestyle.
The updated Hip Fracture Clinical Care Standard (2023) for hospitals has reduced the maximum time to surgery from 48 hours to 36 hours in line with international guidelines. For the first time, this explicitly includes patients who need to be transferred to a hospital that can perform the surgery.
The Commission's Acting Chief Medical Officer, emergency physician Associate Professor Carolyn Hullick, said there was an urgent need for health services to offer better care for people with a hip fracture, using the framework in the updated standard.
"Anyone who has seen someone live through a hip fracture knows it's much more than a broken bone. People with a hip fracture tend to be older, frail and more vulnerable, so it is critical the fracture is repaired quickly to reduce pain and get them on the road to recovery back to independence," she said.
"The data is sobering, as an Australian with a hip fracture is almost four times more likely to die within a year than someone of the same age who isn't injured. This has an immense personal toll on individuals and families, in addition to the burden on our health system of around $600 million each year."
Much has improved since the Hip Fracture Clinical Care Standard was introduced in 2016, according to ANZHFR annual reports. The ANZHFR contains around 90,000 records, with 91 per cent of hospitals performing hip fracture surgery in Australia participating to help improve their hip fracture care.
While some hospitals have substantially reduced their time to surgery, there is still marked variation. In 2022, the average time to surgery ranged from 16 to 92 hours,ii with the longest waiting times for people being transferred for surgery. 78 per cent of patients had surgery within 48 hours.
A lever for change
Geriatrician Professor Jacqueline Close, Co-Chair of the ANZHFR and Co-Chair of the expert advisory group for the standard, knows first-hand the value of high-quality care for hip fractures and believes the updated standard will be a lever for change.
"The Hip Fracture Clinical Care Standard sets expectations for how every patient should be cared for, while allowing for treatment to be tailored to the individual," she said.
"The adage 'don't let the sun set twice before hip fracture repair' has merit for several reasons. Firstly, no-one wants to see their mum or dad fasting and in pain waiting for surgery; and shorter time to surgery is associated with fewer complications, better recovery and survival.
"It is also more cost efficient to manage these patients well. Every day surgery is delayed, two days are added to the length of stay. The sooner you operate, the quicker patients can get walking and go home."
Professor Close said the registry data shows Australia can do better in several key areas of hip fracture care. "The evidence tells us the sooner you are supported to get out of bed, the better your functional recovery. Last year, fewer than half (45 per cent) of patients walked on the first day after hip fracture surgery.
"Also, only one third (32 per cent) of patients leave hospital on bone protection medication for osteoporosis to prevent another fracture. We absolutely can and should do better," she said.
Professor Hullick said: "Older people can have complex needs, and research shows the best results come when specialists from both orthopaedic surgery and geriatric medicine work together on a patient's care - known as an orthogeriatric model of care.
"This means that as well as repairing the bone, we are managing the person's other medical conditions, their cognitive function, their mobility and reducing the risk of more falls and fractures. This has been a focus since the standard was first introduced, with many hospitals now having orthogeriatric teams.
"The standard has already been a catalyst for change. By updating it and addressing the gaps, care will continue to improve. It will be fantastic to see a solid boost to patient outcomes as hospitals embed these latest changes."
Conquering distance in WA
Geriatrician Dr Hannah Seymour, based at Fiona Stanley Hospital Perth, knows better than most that time can be the enemy when treating people who break their hip - especially when facing geographical barriers.
From her experience of working closely with older patients who have had a hip fracture, Dr Seymour understands that prompt surgery reduces pain, hastens recovery and reduces time spent in hospital.
Yet as hip fracture surgery can only be performed at larger hospitals with suitable facilities, some people in regional and remote areas must be transferred large distances.
In 2022, 14 per cent of hip fracture patients were transferred from another hospital for their surgery.
Across Australia, there is stark variation in the average time to surgery for hip fracture - from 16 to 92 hours for all patients last year.
This is set to improve with the updated Hip Fracture Clinical Care Standard (2023), released by the Australian Commission on Safety and Quality in Health Care on September 11.
For Dr Seymour, this change in the standard will be a key driver to improve time to surgery for all patients.
"Nationally, we haven't reduced our average time to surgery and are failing patients. It is disappointing and needs to change because frail, older people are lying in hospitals in pain for longer than they need to be.
"We know that it is possible to reduce the time to surgery if you have the right systems in place," she said.
"We've shown in WA that it often takes just as long for a patient being transferred for surgery from a hospital 45 minutes away by car, as it does for someone flown in from hundreds of kilometres away. It doesn't matter where you transfer from, all patients are waiting, even if they are just down the road."
Dr Seymour has long advocated for older people who needed to be transferred to a larger hospital for surgery after they fractured their hip.
WA Health has streamlined the interhospital transfer of patients. There are now clear arrangements, so hospitals in smaller WA towns know where they need to transfer the patient.
WA Country Health Service's partnership with the Royal Flying Doctor Service (RFDS) and St John Ambulance has set a target for patient transfer within 24 hours to a metropolitan hospital.
For Esperance grandmother Jill Bower, 85, it was a relief to know she was in good hands when she arrived by ambulance at Esperance Hospital after fracturing her hip. The ED team swung into action to transfer Jill from the coastal town to Fiona Stanley Hospital with the RFDS.
Jill, who slipped while having a quiet night at home watching a Fremantle Dockers footy match in late July, said she couldn't fault the care she received from healthcare workers throughout her journey.
"The staff caring for me were all truly wonderful. At Esperance they gave me the nerve block in my groin for pain before they moved me, which was great.
"Early the next morning they put me on the RFDS flight, and I arrived in Perth by midday. I went straight to Fiona Stanley Hospital because they'd been alerted - so I got a bed straight away, I didn't have to wait," Jill explained.
The whole process meant that Jill had surgery less than 48 hours after presenting to Esperance Hospital. The next day, she began her recovery under the care of Dr Seymour.
"They got me up the day after surgery on a tall frame and I felt good. Later they changed me onto a four-wheel walker and had me walking up the hallways once a day, using the side rails to keep me moving."
Jill completed her recovery in two smaller hospitals where she was able to build up her strength before heading home to Esperance on a regional flight.
"If a patient like Jill falls and breaks their hip in Esperance - it's a small place so they can't operate at the local hospital. But they know how to deliver a nerve block and which hospital to call. The patient is put on our surgery list when they call, so are in the queue based on the time of fracture." Dr Seymour said.
"With established communication channels in place, much of the time we can operate in that 36-hour window because we have a system with transfer protocols and straight-to-ward arrangements. We have a partnership with the RFDS who know that Fiona Stanley Hospital wants to operate promptly."
The WA Country Health Service team worked hard with their emergency departments to ensure staff were well trained to deliver a nerve block prior to moving patients, ensuring effective pain relief.
Dr Seymour said it was encouraging that 90 per cent of hip fracture patients nationally now receive nerve blocks before surgery, but sometimes only in the operating theatre. She supports the increased emphasis in the revised standard on patients receiving nerve blocks before transfer to decrease pain during transportation.
For Jill Bower, who is recovering well, she feels like the winner in a system that's working well.
"Everybody has been absolutely wonderful to me, and I felt very well cared for, even when they moved me."
After seven weeks, Jill felt in good shape and was pleased to go home in late August. As she reflects upon her experience, Jill offers a word of warning to others: "If you break your hip, definitely have a nerve block, and get up walking the day your surgery - but not too fast," she said.
Therese Murray
Wordsmith. Senior journalist. Editor. I have a proven track record in helping people and communities solve their problems. My career is all about telling stories.
Wordsmith. Senior journalist. Editor. I have a proven track record in helping people and communities solve their problems. My career is all about telling stories.
