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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.

A fall of <2m is the commonest mechanism of injury in older patients. Prehospital triage to aid early identification of severe injuries in older patients should be available to allow quick transfer from TU to a MTC for specialist investigation and intervention.⁵³

Staff assigned to the role of anaesthetic assistant should not have any other duties that would prevent them from providing dedicated assistance to the anaesthetist during anaesthesia.⁵

Comprehensive geriatric assessment and frailty screening tools may  facilitate more informed early decision making in older trauma patients.⁵⁴ Protocols for end of life care should be in place for management of elderly patients with frailty that may prove unsurvivable days or weeks after the initial trauma by a multidisciplinary team.⁵⁵

All anaesthetists providing anaesthesia for trauma and orthopaedics should have appropriate knowledge, skills, attitudes and behaviour in accordance with the RCoA training standards.

Anaesthetists with responsibility for the intraoperative care of trauma patients should ensure that their skills and knowledge of current recommendations are up to date, particularly in the management of major haemorrhage.