September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Treatment toDate: Initial Presentation: & Designation: Completed byNameDate&Time: Function: Residence: How didthefalloccur? Urgent 7steppathwayresuscitationplanningrequired Urgent 7steppathwayresuscitationplanningrequired Advance CareDirectivescopyinmedicalrecord Does thepatientrequireaSubstituteDecisionMaker? Person toContact: Does thepatientdemonstrateanylifethreateningsymptomsthat requirereviewand/ortreatmentbefore  RACF  Home Lyell McEwin HOSPITAL HIP FRACTURE:TOBEUSEDFORALLSUSPECTEDPROXIMALFEMORALFRACTURES Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip practice. Yes, addressasperlocalEmergency Assessment HOSPITAL Modbury Modbury FastingSince: addressing thesuspectedhipfracture?(Checkbox) PRE-FRACTURE INFORMATION EMERGENCY SCREENING PATIENT IDENTIFICATION SITUATIONAL ANALYSIS PRESENTATION D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable Baseline dietandfluids: Mobility:  Stick4WW/Frame  Independent(Noaid) YES /NO YES /NO YES /NO YES /NO Emergency Assessment No, continuewithSuspectedHipFracture Identified asATSI:YES/NO Substitute DecisionMakerDetails: MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Lyell McEwin HOSPITAL Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip Assessment HOSPITAL Modbury Modbury Past MedicalHistory D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable MR589.1 PAGE 2 OF 16 September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Date &Time Observations: Neurovascular Temp Medication Allergies: eg.medication/latex Lyell McEwin HOSPITAL Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip HR Assessment CAPILLARY REFILL: RR C: AREA ASSESSED: HOSPITAL Modbury Modbury Dose andFrequency BP EMERGENCY ASSESSMENT SaO W: D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable 2 Fi0 Medication Details includingreaction: 2 M: BSL PULSE PRESENT: PAIN SCORE Dose andFrequency S: MR589.1

GCS

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK and systemsreview Identify otherassociatedinjuries Date &Time U Pa S P N L H F D C B A - (stage1,2,3,4) - UlcerSite - Paralysis - Swelling - Pain - Numbness - Laceration - Haemorrhage - Fracture - Dislocations - Contusions - Burns - Abrasion Patient handed overto: MOSignature: Working Diagnoses/Problems: Lyell McEwin HOSPITAL

Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip Assessment BRIEF CLINICALEXAMINATIONCOMMENTS HOSPITAL Modbury Modbury BRIEF CLINICALEXAMINATIONCOMMENTS R L D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable R L R MR589.1 PAGE 4 OF 16 September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time MO Signature: CHEST LONG FEMURVIEWSAP Imaging Other Urinalysis / /interpretation ECG Comment Nerve Block Fascia Iliaca Paracetamol New AnalgesiaAdministered: Analgesia Review: Initial ManagementPlan: Pathology Other /comment: IDC InsertionYES/NO Opioids Lyell McEwin HOSPITAL Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip Complete MR720NALHNEmergencyDepartmentInterim ManagementPlan Assessment AP PELVIS Time: FBE Time: Time: HOSPITAL Modbury Modbury DIAGNOSTICS (writeandsignresults) OTHER INJURIESANDTREATMENTS Comments: Time: Comments: Comments: Name (blockprint): G&H MANAGEMENT PLAN D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable OTHER: LONG FEMURVIEWSLATERAL LATERAL OBLIQUEHIP ANALGESIA Comment: COAG Time: MBA20 MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Lyell McEwin HOSPITAL Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip PROGRESS NOTES(includingproceduralnote).Timeandsigneachentryplease. Assessment HOSPITAL Modbury Modbury MANAGEMENT PLAN D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable MR589.1 PAGE 6 OF 16 September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Date &Time Date &Time Date &Time Patient handed overto: MOSignature: ED ConsultantNote:Name: Time: Time patienttransferred: Transfer Bookedwith: Up TransferRequired Contacted: Orthopaedic Diagnosing Doctor: Diagnosis includingimagingresult: Ward: Patient providedwithappropriatepressureareacaremattress: YES/NO Lyell McEwin HOSPITAL Fracture Medical Emergency Department Please CircleRelevantHospital Suspected Hip ADDITIONAL COMMENTSorPROGRESSNOTES(Timeandsigneachentryplease): TRANSFER TOWARD-Complete UP-TRANSFER –Complete Assessment HOSPITAL YES /NO Modbury Modbury

Orthogeriatrics CONFIRMED HIPFRACTUREDIAGNOSIS Allocated HipFractureCentre: MR012RequestforNon-ElectiveAdmission D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable Other/Comment: MR012RequestforNon-ElectiveAdmission Imaging filmsincludedintransfer:YES/NO Time ofTransfer: Time: MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK MO Name: Designation (blockprint): Completed by:Name(blockprint): WarfarinINR: Dualantiplatelet: Antiplatelet: Holdanti-hypertensivesexceptbeta-blocker Groupandholdordered Fluidbalancereviewedandintravenoustherapyprescribed VitaminD+Calcium/Thyroidfunctiontest/LFTsOrdered Hb: Na: ECG: Consult Orthogeriatricanandcardiology Contact oncallGeriatriciantodiscussmanagementof medically unstablepatient. Liaisewithmedical • • •

If repeatINR>1.5,giveIVVitaminK3mgand in 6hours Give IVVitaminK5mg,checkINR@6hr Hold warfarin sub-specialty registrarformedicalreviewmedically unstable patient.InterimPlan: Lyell McEwin HOSPITAL Please CircleRelevantHospital Medical Pre-Op To becompletedbyOrthopaedic/OrthogeriatricRMO Hip Fracture or afterhoursadmittingsurgicalmedicalstaff Checklist BLOOD /FLUIDELECTROLYTESCHECKED: HOSPITAL PRE-OPERATIVE INVESTIGATIONS: Modbury Modbury Platelets: K: CXR: REVIEW OFMEDICATIONS: Signature: Dabigatran: Indication dose): Indication Date: Holddirectoralanticoagulant Apixaban /rivaroxabandruglevel(includedoseandtimeoflast

Indication: D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable Indication: Urinalysischecked Creatinine: Urea: X-Rays Indwellingcatheter Time: Designation:

Thrombinclottingtime MR589.1 PAGE 8 OF 16

September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK MO Name: Past MedicalHistory: Profile: Designation (blockprint): Completed by:Name(blockprint): Physical Examination RR:  Consentobtainedwithpatient/  LiaisewithOrthogeriatrics  LiaisewithAnaesthetics Plan: Assessment:  Patientaddedto interpreter ifnecessary substitute decisionmaker.Request following: Advise theatresofthe emergency theatrelist.

Lyell McEwin HOSPITAL Please CircleRelevantHospital Neck ofFemur Orthopaedic Admission BP: Temp: • • •  Discuss7-steppathway • company reprequired If companyequipmentrequired –IfYes,LoanorConsignment,Companynameandif ORMIS ClinicalPriorityCode OR ExpectedOperationDate(if>24/24) Location (Hip/LeftorRight ProximalorDistal) Name andURN with patientandfamily HOSPITAL Modbury Modbury  Non-operablemanagement:consideranddiscussendof lifepathway Signature: with orthogeriatrics

• Surgeon D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable HR: BGL: Presenting Complaint: Delay surgery/ProceedtotheatreNotfor Outcome (circle): Date: • Procedure Designation: SaO Pain: Time: 2 : MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Lyell McEwin HOSPITAL Please CircleRelevantHospital PROGRESS NOTES(includingproceduralnote).Timeandsigneachentryplease. Orthopaedics Admission Medical HOSPITAL Modbury Modbury MANAGEMENT PLAN D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable MR589.1 PAGE 10 OF16 September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Allergies: Eg.:Medication/Latex Route ofadministration(writedrugnamesinfull) Medication: GenericName/Form/Strength/ Past Medical/SurgicalHistory Presenting ComplaintandHistoryoffalls: Designation (blockprint):Date:Time: Completed by:Name(blockprint): Lyell McEwin HOSPITAL Please CircleRelevantHospital Orthogeriatric Admission Medical HOSPITAL Modbury Modbury D.O.B. Sex: First Name: Surname: UR No.:

Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable Types ofreaction Dose Frequency        Falls Riskfactors: impairment/dementia Cognition: delirium/cognitive Postural dizziness Hearing impairment Urinary/faecal incontinence Visual impairment Polypharmacy: regular≥5meds Previous falls/# Indication MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK inattentive) Untestable (cannotstartbecause unwell,drowsy, Starts butscores<7months/refuses tostart Achieves 7monthsormorecorrectly Months oftheyearbackwards: is themonthbeforeDecember?”permitted. To assistinitialunderstandingonepromptof“what year inbackwardsorder,startingatDecember.” Ask thepatient:“Pleasetellmemonthsof [3] ATTENTION Clearly abnormal then normal Mild sleepinessfor<10secondsafterwaking, assessment) Normal (fullyalert,butnotagitatedthroughout [1] ALERTNESS raises concernsofdelirium 4AT: Screeningforpatient≥65yearsold,knownhistoryofdementiaorcognitiveimpairmentassessment Physical Examination Baseline dietandfluids: Mobility: Independent(noaid),stick,4WW/frame,other: Social history: Living situation(e.g.alone,withfamilyetc):  HomeRACFcareservice(circle)(shower/cleaningmedicationsbladderbowelcare) Residence: Smoking: Lyell McEwin HOSPITAL Please CircleRelevantHospital Neck ofFemur Orthogeriatric Admission BP: Medical HOSPITAL Modbury Modbury HR: Score Score 2 1 0 4 0 0 SaO 2 D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable : Pressure Area: Alcohol: weeks andstillevidentinlast24hrs Paranoia, hallucinations)arisingoverthelast2 alertness, cognition,othermentalfunction(eg. Evidence ofsignificantchangeorfluctuationin: COURSE [4] ACUTECHANGEORFLUCTUATING (nameofhospital),currentyear [2] AMT4: Age, dateofbirth,place cognitive assessment. 4AT score:IF≥4,requires further Yes No 2 ormoremistakes/untestable 1 mistake No mistakes Temp: RR: BGL: MR589.1 PAGE 12 OF16 Pain: ______Total Score Score 4 0 2 1 0 September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK NALHN PPG on refer topreoperative diabetesguidelinesSSI01210 Is patientonoral hypoglycaemic/insulin?Ifyes, please Endocrine Medication review delirium Document historyofMCI/neurodegenerativehistory/ Cognition: Renal Respiratory Cardiovascular Analgesia #NOF secondarytofall Active Issues Impression andPlan(Recordobservationsplanasneeded.Completepre-operativewardchecklistifnotdonealready.) Investigations: Refertopre-operativewardchecklistforresults Lyell McEwin HOSPITAL Please CircleRelevantHospital Neck ofFemur Orthogeriatric Admission Medical HOSPITAL Modbury Modbury

D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable exclude reversiblecausesofdelirium If 4AT≥4:requirefurthermedicalassessmentand Interventions topreventandtreatdelirium: 4AT, SMMSE,Clockface Fluids Monitor forsignsofHAP Sit patientupastolerated Plan • • • • • • • • • management protocol Nursing: alertnursingstaffregardingdelirium Promote sleepandavoiddisturbance Pain assessmentandmanagement Avoid hypoxia constipation Correction ofdehydration,malnutritionand Medication review Ensure patienthassensoryaids Regular orientation info sheet For patients:giveninformantformanddelirium MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK to surgerywithin24hours? Is patientmedicallystabletoproceed Plan: (includingadditionalinvestigationsrequested) Fall Skin integrity:pressurearea Nutrition Management ofanticoagulation VTE prophylaxisYESNO GIT andGenitourinary(includingconstipation) Active Issues MO Name: Designation: Delay surgery/Proceedtotheatre/ Notforsurgery Outcome afterdiscussion: Time: Name:  DiscussedwithdutyAnaesthetist Lyell McEwin HOSPITAL Neck ofFemur Orthogeriatric Please CircleRelevantHospital Admission Medical

HOSPITAL Modbury Modbury YES/ NO

D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable Name:  DiscussedwithOrthogeriatrician Osteoporosis Dynamic pressurerelievingmattress hours priortoscheduledsurgeryifnotcontraindicated) Minimise fasting(NOFsupplementtobegivenup2 Speech Pathologyindicated New swallowingconcernsduringadmission–referralto and/or fluids–referraltoSpeechPathologyindicated Pre-morbid dysphagiarequiringmodifiedconsistencydiet indicated e-MUST score=2+,orderHEPdietandreferraltoDietetics e-MUST score=0or1,orderHEPdiet Wt: Ht:BMI:e-MUSTscore: If not,documentreasonswhy: mobilisation (within24hours) IDC removalwhensittinguprightandcommenced Regular aperients Plan  Hipfractureregistry:patient informationstatement Time: Name:  DiscussedwithOrthopaedicregistrar/RMO If NO,outlineissues given andexplainedtopatient/ family MR589.1 PAGE 14 OF16 September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Date &Time Lyell McEwin HOSPITAL Please CircleRelevantHospital Orthogeriatric PROGRESS NOTES(includingproceduralnote).Timeandsigneachentryplease. Admission Medical HOSPITAL Modbury Modbury MANAGEMENT PLAN D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable MR589.1

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MR589.1 SUSPECTED HIP FRACTURE HIP SUSPECTED September 2018 NALHN 19041629 NORTHERN ADELAIDELOCALHEALTH NETWORK Lyell McEwin Nursing andAlliedHealthcontinuewith HOSPITAL Please CircleRelevantHospital HOSPITAL Modbury Modbury D.O.B. Sex: First Name: Surname: UR No.: Do nothandwritethesedetails, except whenadhesivebarcodelabelsareunavailable MR589.2 MR589.1

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