There should be a local protocol in place for emergency access to an operating theatre or intervention suite, to provide rapid intervention in life threatening or limb-threatening conditions.27
All acute hospitals should have a defined major incident plan. The plan should be built around the regional network of MTCs, TUs and local emergency hospitals (LEHs).19
For patients who have sustained hip fractures, femoral or fascia iliaca nerve blocks should be provided in the emergency department (ED) and at the time of surgery (provided that six hours has passed between blocks).45
Hospitals providing surgical treatment for hip fractures should have a formal pathway including prompt provision of analgesia (including nerve blocks) and hydration, preoperative assessment of high-risk patients by the anaesthetic team. In addition, orthogeriatrician input should be prioritised on orthopaedic trauma lists.46,47,48,49
Risk assessment should be performed in all patients with hip fracture. The Nottingham Hip Fracture score and National Hip Fracture Database Tool could be used to assess risk.50 Frailty scores, the four ‘A’s test score for delirium and the Nottingham Hip Fracture Risk Score for Kidney Injury are useful organ-specific assessment tools.
Anaesthetists should facilitate surgery within 36 hours of a hip fracture.51 Surgery should be delayed only if the benefits of additional medical treatment outweigh the risks of delaying surgery. The risks of delay associated with pain and immobility contribute to poor outcomes to a far greater extent than correction of an abnormality to a particular numerical value.45
Dedicated trauma operating lists should be scheduled daily, including weekends to meet local demands, and to ensure 36-hour targets for hip fracture are met. Extra provision during the day and in the evenings may be necessary to meet local demands and limit overnight operating.52
Unoperated hip fractures in older patients have a high mortality rate. Evidence shows that ASA4 patients assessed as American Society of Anaesthesiologists class 4 have a higher survival rate when managed surgically.53 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...
Perioperative anaesthetic care for a patient who is older with a hip fracture should be standardised with the overarching goals of management being patient remobilisation, re-enablement and rehabilitation.
Anaesthesia (and surgery) for hip fractures should be undertaken by an appropriately experienced anaesthetist (and surgeon).
