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There should be a dedicated trained assistant, i.e. an operating department practitioner (ODP) or equivalent, who holds a valid registration with the appropriate regulatory body, immediately available in every location in which anaesthesia care is being delivered, whether this is by an anaesthetist or a AAs.^3,5

Patients presenting with a neurological deficit should have immediate referral to a specialist unit and be discussed with the neurosurgical or spinal surgeon.

In suspected spinal injury, hard spinal boards should only be used as a prehospital extrication device and not be used for transport.³⁸ A scoop stretcher or full length vacuum mattress should be used for transfer.

Acute nerve or spinal cord compression requires immediate referral to a neurosurgeon or specialist spinal surgeon within four hours of injury.⁴⁰

A fully equipped high dependency unit (HDU) of Level 2 standards should be available on site for high risk patients undergoing major orthopaedic surgery, including revision joint replacement and surgery involving instrumentation of the spine. If the hospital does not have a Level 3 facility, protocols should be in place to determine when and how to transfer to a hospital...

Critical care outreach services should be considered to provide a vital link between trauma and orthopaedic wards and intensive care unit (ICU) facilities. Clinical deterioration can be identified using early-warning scores and mitigated by proactively reviewing patients at risk.

Patient positioning for elective and trauma orthopaedic surgery involves a variety of specialist equipment, tables and attachments. These should be suitable to manage patients across a wide weight range, with theatre personnel aware of the upper weight limits.^{48, 49}

The majority of hip fracture patients are >65 years of age and often have multiple comorbidities, some of which may be undiagnosed. Decisions on their treatment should ideally be made using a multidisciplinary team that involves senior anaesthetists, perioperative physicians, orthopaedic surgeons and orthogeriatricians, all with a specific interest in this patient population.⁵⁰

Facilities to provide total hip replacement to hip fracture patients with limited comorbidities should be available seven days a week.⁵¹

Unoperated hip fractures in the elderly have a higher mortality rate. Evidence shows ASA4 patients have a higher survival rate when managed surgically.⁵² Hip fracture surgery should be considered for patients even in the presence of significant comorbidities. Provision for safe anaesthesia and recovery of these patients, including handover to ward teams, should be available to facilitate this.