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Organisations should have a service improvement team that coordinates national and local projects, and encourages a multidisciplinary approach to trauma and orthopaedic services. Data should be collected to provide high quality information to drive change and support service development. Good data, quality improvement tools and organisational support can create feedback strategies which drive improvement.²⁷

Informed consent may not be possible for many patients undergoing hip fracture and major trauma surgery because of delirium, dementia, altered conscious level, severe pain or the effects of sedative drugs. Patients should not be asked to sign a consent form if they do not have capacity to do so. Standard operating procedures must be compliant with the Mental Capacity...

All decisions concerning the consent process and treatment plans, including decisions about whether or not to operate, should be documented clearly, noting the risks, benefits and alternatives that were explained to the patient.^86,89

Patients should have easy access to reliable sources of information (web based and written) for joint replacement surgery. Options for anaesthesia and analgesia, and potential benefits and risks of each option should be discussed with patients to support shared decision making.^46,113

Patient information leaflets on hip fractures should be available for patients, relatives and carers.^114,115 The clinicians should collaborate with the patients in selecting the most suitable treatment option based on best available evidence and informed patient preferences.^{63,116,117,118,119}

Enhanced recovery programmes for patients undergoing primary arthroplasty surgery should provide comprehensive details of the patient journey including MDT led hip and knee school and expectations in terms of postoperative physiotherapy and early mobilisation where necessary. Information provided should be comprehensive and should include details of regional anaesthesia

When it is considered appropriate for a do not to attempt cardiopulmonary resuscitation in the event of a cardiopulmonary arrest (DNACPR) order, this should be discussed with capacitous patients, including those who have expressed their own wish not to be resuscitated.¹²⁰ In patients not without capacity to consent, every attempt should be made to discuss this with next of...

Major surgery performed in satellite sites should routinely use formal risk assessment tools both before and after the procedure to ensure patients receive the appropriate level of postoperative care. The level of intraoperative and postoperative monitoring should match patients risk. A lower threshold for continuous invasive arterial blood pressure monitoring should be considered in high risk patients.^71,72

Patients with >1% mortality risk should only be considered for surgical hubs if enhanced care facilities and access to critical care and/ or perioperative medicine services are available on site. ^{NOTEREF _Ref153263212 \h  \* MERGEFORMAT 71
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