ANNUAL REPORT 2O2O ENHANCING OUTCOMES FOR OLDER PEOPLE
The ANZHFR would like to thank the clinical and administrative staff of the 77 hospitals (58 Australian and 19 New Zealand) and the 117 hospitals contributing to the Patient Level Report and the Facility Level Report, respectively. The ANZHFR acknowledges that without the support, dedication and energy of staff at Australian and New Zealand hospitals, this report would not be possible.
The ANZHFR has received funding from the Australian Government Department of Health, New Zealand Accident Compensation Corporation, Amgen, NSW Health Agency for Clinical Innovation, SA Health, WA Health and Queensland Health, and receives in-kind support from Neuroscience Research Australia, UNSW Sydney and the New Zealand Orthopaedic Association.
ABBREVIATIONS
ACEM Australasian College of Emergency Medicine HDU High Dependency Unit AFRM Australasian Faculty of Rehabilitation Medicine HFCCCS Hip Fracture Care Clinical Care Standard AIHW Australian Institute of Health and Welfare ICU Intensive Care Unit ANZ Australia and New Zealand MRI Magnetic Resonance Imaging ANZBMS Australian and New Zealand Bone NDI National Death Index and Mineral Society NHFD National Hip Fracture Database ANZCA Australian and New Zealand College of Anaesthetists NHMRC National Health and Medical Research Council ANZHFR Australian and New Zealand Hip Fracture Registry NZ New Zealand ANZONA Australian New Zealand Orthopaedic NZOA New Zealand Orthopaedic Association Nurses Association OA Osteoporosis Australia ANZSGM Australian and New Zealand Society for Geriatric Medicine ONZ Osteoporosis New Zealand AOA Australian Orthopaedic Association OT Operating Theatre APA Australian Physiotherapy Association RACP Royal Australasian College of Physicians ASA American Society of Anaesthesiologists RACS Royal Australasian College of Surgeons AUS Australia VTE Venous Thromboembolism CT Computed Tomography NOTE: Rehabilitation – when used in the Figures, rehabilitation ED Emergency Department refers to inpatient rehabilitation at a public or private hospital. FLS Fracture Liaison Service It does not include rehabilitation provided in the community or GP General Practitioner private residence. CONTENTS
2 ABBREVIATIONS
4 CO-CHAIRS’ FOREWORD
6 EXECUTIVE SUMMARY
8 2019 SNAPSHOT
10 INTRODUCTION Hip Fracture Types and Surgery ANZHFR Participation ANZHFR Development 2019/2020
14 HIP FRACTURE CARE CLINICAL CARE STANDARD Quality Statement 1: Care at presentation Quality Statement 2: Pain management Quality Statement 3: Orthogeriatric model of care Quality Statement 4: Timing of surgery Quality Statement 5: Mobilisation and weight-bearing Quality Statement 6: Minimising risk of another fracture Quality Statement 7: Transition from hospital care
16 PARTICIPATION 2020 Patient Level Audit Facility Level Audit
18 DATA QUALITY, CAVEATS AND LIMITATIONS Caveats Completeness Correctness Capture/Ascertainment
20 PATIENT LEVEL AUDIT 22 Section 1: Demographic information 29 Section 2: Care at presentation
For enquiries or comments, please contact the ANZHFR, Neuroscience 38 Section 3: Surgery and operative care Research Australia, 139 Barker Street, Randwick NSW Australia 2031. 54 Section 4: Postoperative care Additional copies of this report may be accessed at www.anzhfr.org or can be requested from the ANZHFR. Extracts from this report may 70 Section 5: 120 day follow-up be reproduced provided the source of the extract is acknowledged. Report prepared on behalf of the ANZHFR Steering Group by: 78 FACILITY LEVEL AUDIT Ms Elizabeth Armstrong, AHFR Manager; Mr Stewart Fleming, Webmaster; Professor Jacqueline Close, ANZHFR Co-Chair Geriatric 80 Results 1: General information Medicine; Professor Ian Harris AM, ANZHFR Co-Chair Orthopaedics. 81 Results 2: Service model of care The ANZHFR would like to thank Barbara Toson, Biostatistician Flinders University SA, for the risk-adjusted mortality analysis. 82 Results 3: Protocols and elements of care Report Design: patterntwo creative studio patterntwo.com.au 84 Results 4: Beyond the acute hospital stay Suggested citation: Australian and New Zealand Hip Fracture Registry Annual Report of Hip Fracture Care 2020. Australian and New Zealand 86 APPENDICES Hip Fracture Registry, August 2020; Sydney. ISBN: 978-0-7334-3937-7 | EAN: 9780733439377 Appendix 1: ANZHFR Steering Group
ANZHFR / ANNUAL REPORT 2020 3 CO-CHAIRS’ FOREWORD
Welcome to the 2020 Annual Report which includes the fifth patient level report and the eighth facility level report. This year, 77 hospitals have contributed patient level data and 117 hospitals have provided facility level data to the report. We are enormously grateful to all of the teams working in our hospitals across Australia and New Zealand who give of their time to enter data to the Registry.
As always, we report against the Australian The year 2020 is proving a year to be remembered, Commissions’ Hip Fracture Care Clinical Care with the outbreak of the Covid-19 pandemic. It won’t be Standard and this year we can see improvements in until next year that we have data to objectively evaluate a number of these indicators, including assessment the impact the pandemic has had on hip fracture care and management of pain, use of nerve blocks and in Australia and New Zealand. Anecdotal tales from assessment and management of cognition. The number sites across the two countries paint differing pictures of procedures where a consultant surgeon is present – sudden drop in numbers of patients presenting with continues to increase. Median and mean time to surgery a hip fracture as restrictions were imposed, a rebound has decreased this year and whilst we have a number of and possible overshoot in numbers as restrictions were consistently high performing hospitals, it is pleasing to initially lifted, delays in surgery due to requirements to see substantial improvements this year in hospitals that test for Covid-19 in some sites, whilst others reporting a have previously found themselves at the bottom of the reduced time to surgery due to the reduction in elective table. A particular mention to the Wollongong Hospital surgery. And of course at the time of writing this piece, team whose quality improvement activities have taken the pandemic is far from over. them well and truly off the bottom spot for 2020. Our annual Hip Fests have been a casualty of the Areas requiring more work include access to theatres pandemic given the restrictions on travel and need for and delays relating to anticoagulation and medical social distancing. However we have developed our own stability. There is substantial variability across hospitals in YouTube channel and are now hosting a series of videos what is causing delay and it is likely that timely medical on topics ranging from management of anticoagulation assessment and protocols for managing anticoagulants to when not to operate. We are also keen to showcase could reduce some of this observed delay. success stories and recent additions to the collection include conversations with Nepean and Wollongong Debutant variables reported this year include hospitals, both of which have seen improvements in their assessment of nutrition and mortality data. The Registry time to surgery. data has been linked to the National Death Index allowing us to provide case mix adjusted 30 day and We have always been cognizant of the need to keep 1 year mortality for hip fracture patients entered in to data collection to a minimum and that remains our intent. the Registry over the past 3 years. This will be a regular However, over the years, a number of sites have requested feature in future reports providing an additional measure the ability to collect additional items for their own quality of outcome for hip fracture care and one that we can improvement activities. This year we have introduced track over time. new custom fields which will enable sites to collect additional data fields of their own choosing. We would strongly encourage teams who are undertaking quality improvement projects to use this new feature. There are no limits to how many customizable fields can be added and they can be switched on and off by the site.
4 ANNUAL REPORT 2020 / ANZHFR Whilst the focus of the Registry is using data to drive the Registry. Thanks also to Stewart Fleming, our IT guru quality improvement, and ultimately improve outcomes with his bright red boots, who has also been with us for older hip fracture patients, it is important to from the outset and who continues to help us maintain remember that good quality care is underpinned by high the Registry and also develop new functionality for our quality research. The number of applications to use Hip users. And not forgetting our colleagues across the Fracture Registry data for research is increasing and Tasman – Roger Harris, Sarah Hurring and Nicola Ward we hope to see a number of publications from these – a sincere thanks for the work you do in running the research activities in the not too distant future. New Zealand Hip Fracture Registry.
And finally, a sincere thanks to the people who run the Registries in Australia and New Zealand. Elizabeth Armstrong has been with us on this journey from the Professor Professor outset and has been a key figure in the success of the Jacqueline Close Ian Harris AM Registry. She is well known to all of the Australian sites Geriatrician Orthopaedic Surgeon having helped numerous people navigate the ethics approval processes required to enter data, as well as Co-Chair Co-Chair Australian and New Zealand Australian and New Zealand supporting sites in the day to day operational aspects of Hip Fracture Registry Hip Fracture Registry
ANZHFR / ANNUAL REPORT 2020 5 Patients with hip fractures often have complex problems requiring a multidisciplinary team approach, so it makes sense that registry activities also have a team approach.
Recently, both St. George and Sutherland Hospitals were struggling to make ends meet with their data. ‘We discovered that our commitments to the Registry were being handled by a single individual from a single team. Our patients are never managed like that, so it wasn’t surprising to discover that this approach failed’ said Ms. Renee Tate, Nursing Unit Manager at St. George Hospital.
Since then, a local Hip Fracture Committee was set up at St. George Hospital, with representatives from the Nursing, Anaesthetic, Geriatric, and Orthopaedic teams. ‘The committee was made up of a champion from each of the teams who has a special interest in improving care for these most vulnerable of patients’ said Dr. Sam Adie, Orthopaedic Surgeon at St. George Hospital. Both St. George and Sutherland now have at least 98% data completeness and this allows the data to inform hip fracture care.
‘We are using the power of the data to feedback to the broader stakeholders involved in hip fracture care, and have already noticed lots of improvements’ said Dr. Ilana Delroy-Buelles, an Anaesthetist at St. George Hospital, ‘but there is still a lot of work to be done’.
6 EXECUTIVE SUMMARY
The Australian and New Zealand Hip Fracture Registry › Hospital acquired pressure injuries (ANZHFR) is a clinician driven audit of hip fracture care in › Active treatment for bone health at discharge Australia and New Zealand. It is one of several global hip fracture audits developed with the purpose of improving This year, for the first time, the ANZHFR has undertaken the health care provided to older people admitted to linkage of its Australian record data with the Australian hospital with a broken hip and their health outcomes. Institute of Health and Welfare’s (AIHW) National Death Index (NDI) to accurately understand patient survival The ANZHFR and its minimum data set was developed after hip fracture. This allows a more comprehensive and to allow hospitals to audit the care provided against the accurate reporting of this important outcome. key markers of high quality and safe care described in the Australian and New Zealand Guideline for In New Zealand, date of death is available in hospital Hip Fracture Care in Adults, and the bi-national information systems within a few days. This provides Hip Fracture Care Clinical Care Standard. This is the reasonable confidence that the New Zealand data 5th report combining patient level and facility level on survival after hip fracture, collected in this way, is data. It reports on 13,504 cases admitted between correct. Linking with the National Mortality Collection 1 January 2019 and 31 December 2019 at 77 hospitals, within the NZ Ministry of Health would ensure accuracy spread across two countries. of the survival data and this is being investigated for future reporting. Since the first combined report in 2016, more than 50,000 records from 85 hospitals have contributed to As in previous years, throughout this report, case the Registry. These 85 hospitals represent almost three- studies highlight use of the ANZHFR data where quarters of Australian and New Zealand public hospitals clinicians have undertaken quality improvement providing definitive management to older people activities in areas highlighted by ANZHFR data as sustaining this life-changing injury. Despite new hospitals opportunities for improvement. The ANZHFR does not being added each year, several aspects of care show change hip fracture care simply by storing the data improvement over the years of patient level reporting: submitted. To improve care for older people, clinicians and administrative staff are required to use the data to › Preoperative cognitive assessment monitor, implement and assess change. Summaries › Assessment of pain in the emergency department of these initiatives and innovations may encourage › The use of nerve blocks for pain management others to undertake similar activities in their health services. Alternatively, these summaries facilitate peer › The participation of a consultant surgeon in the to peer communication between sites that identify operation similar challenges to the improvement of hip fracture › The assessment of delirium care. In this way, the ANZHFR provides an important Conversely, there are still areas that show little change mechanism to improve the management of this over the five years of patient level reporting and significant injury. additional efforts are required to better understand the reasons for this. These areas include:
› Preoperative medical assessment › Reasons for delay to surgery › Weight bearing after surgery › First day mobilisation
ANZHFR / ANNUAL REPORT 2020 7 2O19 SNAPSHOT CALENDAR YEAR ANZ PATIENT LEVEL REPORT
60% of patients had a of patients had preoperative assessment a documented 57% of cognition assessment of pain within 30 minutes of arrival at the ED 76% 77 of patients had a nerve block 13,504 ANZ to manage pain RECORDS HOSPITALS before surgery
of patients had surgery 27% within 90% of patients 81% 48 hours of patients were on active were given the treatment for of patients are opportunity to osteoporosis allowed to full mobilise on the at discharge weight bear day of or day from hospital 95% after surgery after surgery ANZ FACILITY LEVEL DATA 46% 26% of hospitals had of hospitals planned operating routinely provide lists for hip fracture patients individualised written information on the prevention 117 of future falls ANZ HOSPITALS 84% and fractures of hospitals use a pain protocol for hip fracture 28% patients at presentation to ED of hospitals utilise an orthopaedic/geriatric medicine shared care service model
8 ANNUAL REPORT 2020 / ANZHFR KEY RECOMMENDATIONS Utilising the data from the 2020 annual report, it is possible to identify several areas that may benefit from future initiatives for improving hip fracture care. These areas include:
› Acute hospital care may be reviewed with a ‘whole of pathway’ approach to ensure prehospital and post-discharge services are integrated to achieve the aims of the Hip Fracture Care Clinical Care Standard › Investigation of the reasons for persistently low rates of prescribing treatments for osteoporosis › Follow up after hospital discharge is encouraged as outcome after discharge from hospital care is an important consideration in this cohort and it may provide information that is useful for improving aspects of acute care › Regular use by sites of aggregated ANZHFR data to facilitate hospital-wide review and monitoring of care, which will also encourage a culture of continuous quality improvement › Ensuring data collected is of high quality and therefore useful for informing quality improvement initiatives › Where no local document exists, hospitals are encouraged to utilise the ANZHFR Hip Fracture Care Guide (English 90% language and translated versions) to facilitate communication between patients, families and clinical staff of patients were given the opportunity to mobilise on the day of or day after surgery
ANZHFR / ANNUAL REPORT 2020 9 INTRODUCTION
10 ANNUAL REPORT 2020 / ANZHFR The Australian and New Zealand Hip Fracture Registry Commission New Zealand. The ANZHFR Steering (ANZHFR) is managed by the Falls, Balance and Injury Group then developed the Hip Fracture Registry and Research Centre at Neuroscience Research Australia, its minimum dataset, intentionally aligned with the a medical research institute affiliated with the UNSW Hip Fracture Care Clinical Care Standard and Clinical Sydney Faculty of Medicine. In New Zealand, the Practice Guideline. Registry is supported by the New Zealand Orthopaedic This year is the 5th year of the ANZHFR Annual Report and Association. From the beginning, the ANZHFR has been it includes the 5th patient level report and the 8th facility guided by a multidisciplinary advisory group consisting of level report. These annual reports provide a rich source representatives of key clinical stakeholder and consumer of documentation of the collaboration between clinicians organisations. Since inception, this advisory group has and health departments, between professional groups and been chaired by both a Geriatrician and an Orthopaedic consumer organisations, as well as the multidisciplinary Surgeon, reflecting the ideal, shared approach to high teams providing health care to older people who have quality hip fracture care in the 21st century. sustained this common and serious injury. The development of the ANZHFR commenced in The ANZHFR is pleased to present this 2020 Annual 2011/2012 as a clinician-driven initiative with the aim Report of hip fracture care using data from 77 hospitals of improving hip fracture care for older people. At the for patients admitted in 2019. Once again, this report beginning, the ANZHFR Steering Group developed provides data reporting the two countries individually the ANZ Guideline for Hip Fracture Care in Adults against the seven quality statements of the Hip (2014), a guideline adapted for the Australian and New Fracture Care Clinical Care Standard. The ANZHFR Zealand context from the National Institute for Health acknowledges the commitment of all those in New and Care Excellence (NICE) clinical guideline 124: the Zealand and Australia providing high quality health care Management of Hip Fracture in Adults (2011). This at this challenging time. The ANZHFR extends its sincere was followed by the development of the bi-national thanks to local hip fracture teams for their continued Hip Fracture Care Clinical Care Standard, an initiative dedication to collecting and submitting data, and using of the Australian Commission for Safety and Quality in the data to improve hip fracture care. Health Care, in partnership with the Quality and Safety
ANZHFR / ANNUAL REPORT 2020 11 HIP FRACTURE TYPES AND SURGERY a sliding hip screw and an intra-medullary nail (Figure 30 on page 49). The ANZHFR does not distinguish The term ‘hip fracture’ is used to describe different types between simple and comminuted or unstable fracture of fracture of the proximal (upper) femur. A hip fracture types and this may influence the choice of implant. is an injury to the proximal femur and is more common For subtrochanteric fractures, intramedullary fixation is in older people. The injury is often a result of a slip, trip recommended (Figure 31 on page 50). or fall combined with decreasing bone strength due to osteopenia or osteoporosis. In many cases, it is a The ANZ Guideline for Hip Fracture Care recommends life-changing injury. Classification of the type of hip fracture the use of cemented stems for hip arthroplasty. Figures is important, as it will determine the most appropriate 32 and 33 show the rates of cement use reported by management of the fracture. The majority of people who sites for both hemiarthroplasty and total hip arthroplasty. sustain a hip fracture will undergo surgical intervention. Image 1: Zones of hip fracture The goals of surgery are primarily to relieve pain and give people the chance to walk again. In a very small number of people, surgery may be judged unlikely to provide benefit for a person and they will be treated without surgery (Figure 18, page 38). The types of hip fracture are classified by the location, or zone, of the fracture. See Image 1 for the terms used to identify the zones of hip fracture.
There are different types of fracture with subtrochanteric fractures making up 5% to 10% of all hip fractures and the remainder (90-95%) being fairly evenly divided between intertrochanteric and intracapsular (subcapital) Intracapsular fracture fractures. See Figure 27 (page 46) for the types of Intertrochanteric fracture 5cm fracture reported. Different fracture types are generally Subtrochanteric fracture treated by different surgical techniques. Fractures occurring in the intracapsular area (femoral neck) usually undergo an arthroplasty (replacement). Hemiarthroplasty involves removing the head of the femur (ball of the hip joint) that has broken away from the shaft of the bone ANZHFR PARTICIPATION and replacing it with an artificial (metal) ball that is held in place by a connected stem that sits inside the upper Participation in the ANZHFR has increased each end of the femur (thigh bone). A total hip arthroplasty year and continues to grow. Some jurisdictions involves the same procedure, but also involves replacing have complete registration of public hospitals, whilst the socket of the hip joint with a metal and plastic challenges remain for gaining approvals in others. In cup. Fractures that occur in the extracapsular region New Zealand, all hip fracture care is provided in the (trochanteric) generally undergo internal fixation with an public sector. In Australia, the majority of hip fracture intramedullary nail or a sliding hip screw and plate. care is provided in the public hospital sector with a small proportion (approximately 15%) provided by private Figures 28 and 29 (pages 47 and 48) show the proportions sector hospitals. Full participation of public sector of intracapsular fractures (femoral neck or subcapital hospitals and increased participation of private sector fractures) treated with various techniques, reported hospitals (in Australia) are future aims of the ANZHFR. separately for undisplaced and displaced fractures. Undisplaced fractures (Figure 28) may be treated by The governance requirements for individual hospitals to inserting screws across the fracture rather than replacing participate are approval by a Human Research Ethics the broken part of the bone (arthroplasty). Although the Committee (HREC) in the relevant jurisdiction and then proportion of displaced femoral neck fractures treated with site specific governance approval at the level of the total hip arthroplasty is increasing, hemiarthroplasty remains relevant health district. Whilst the ANZHFR provides the most common treatment for this fracture type. administrative assistance to individual hospitals to gain the necessary approvals, limited resourcing and Intertrochanteric fractures are usually treated by internally duplication of processes can lead to delays between securing the fractures using metallic devices, rather than sites identifying resources for data collection and replacing the broken part (arthroplasty). There is variation submission, and the requisite approvals to contribute in the use of the two most common types of implant: data to the ANZHFR.
12 ANNUAL REPORT 2020 / ANZHFR Since 2016, the proportion of hospitals eligible to be At the time of this report, 100% of New Zealand reported in the annual report has increased from 21% hospitals and 76% of Australian hospitals have approval of ANZ hospitals to 66% in 2020. Not all approved to contribute data. Image 2 shows public hospital hospitals are contributing data to the ANZHFR and participation by Australian state and territory and New efforts continue to support those sites approved but Zealand. In addition to the public hospitals, two private not contributing to identify sustainable processes hospitals contributed data to the ANZHFR in 2019; one for participation. in Western Australia and one in Queensland.
Image 2: Public sector hospital participation New Zealand and Australian at June 2020
NT WA 2 Identified 6 Identified 0 Approved 4 Approved (plus one private)
QLD 17 Identified 16 Approved (plus one private)
NSW 37 Identified 30 Approved SA 5 Identified 5 Approved ACT 1 Identified 0 Approved VIC 23 Identified 12 Approved TAS NZ 3 Identified 22 Identified 3 Approved 22 Approved
ANZHFR DEVELOPMENT 2019/2020
The ANZHFR Dashboard has been well received initiatives to be undertaken by local clinicians familiar with by Registry users and is utilised for its reporting of the needs of their setting and community. Utilising the aggregated data specific to many of the Hip Fracture same functionality, the ANZHFR has developed the ability Care Clinical Care Standard quality statements and to run ‘sprint audits’. These are defined, additional fields, indicators. The ANZHFR is receptive to requests collected for a specific time period to collect additional from users for additional features and depending on information about specific aspects of care. These are availability of resources the Registry is willing to develop planned to commence in 2021. those features that have broad support. As a result of The very successful Hip Fests have continued in 2020 repeated requests for an assessment of health-related although in a very different form. The preferred face quality of life, at the beginning of 2020, the ANZHFR to face format of these events has been affected by made available the EuroQol EQ-5D-5L1 as optional fields COVID-19 and instead moved online. The ANZHFR for collection at 120 days. has utilised the online space to create a series of This year, the ANZHFR has developed the additional lectures on specific aspects of clinical care or change feature of customisable fields. That is, individual hospitals initiatives. These can be viewed via the ANZHFR website are able to create site specific fields for local collection @ www.anzhfr.org that can be used for local quality improvement initiatives.
These fields will not be used or reported by the ANZHFR, 1 The EuroQol Group (1990). EuroQol-a new facility for the measurement of but will provide a mechanism for context specific health-related quality of life. Health Policy 16(3):199-208.
ANZHFR / ANNUAL REPORT 2020 13 HIP FRACTURE CARE CLINICAL CARE STANDARD
The Hip Fracture Care Clinical Care Standard was QUALITY STATEMENT 2: released in 2016 by the Australian Commission on Safety and Quality in Health Care, in collaboration with PAIN MANAGEMENT the Health Quality and Safety Commission New Zealand. The Care Standard plays a role in ensuring the delivery of appropriate hip fracture care by describing the A patient with a hip fracture is assessed for pain at components of care that ought to be provided to older the time of presentation and regularly throughout their people admitted with a hip fracture. hospital stay, and receives pain management including the use of multimodal analgesia, if clinically appropriate. The Hip Fracture Care Clinical Care Standard contains seven quality statements and 16 indicators. The quality › 84% of hospitals had a pathway for pain statements and indicators enable the calculation of a management in hip fracture patients: 48% across quantitative measure of care processes, structures, the whole acute patient journey and 36% in the or outcomes. They are used by clinicians or health emergency department only providers to identify areas of high quality care, or areas › 58% and 61% of patients in New Zealand that may require review or redevelopment. and Australia, respectively, had a documented assessment of pain within 30 minutes of presentation to the emergency department QUALITY STATEMENT 1: › 58% and 71% of patients in New Zealand and Australia, respectively, received analgesia in transit or within 30 CARE AT PRESENTATION minutes of presentation to the emergency department › 67% and 79% of patients in New Zealand and Australia, respectively, received a nerve block before surgery A patient presenting to hospital with a suspected hip fracture receives care guided by timely assessment and management of medical conditions, including diagnostic imaging, pain assessment and cognitive assessment. QUALITY STATEMENT 3: ORTHOGERIATRIC MODEL OF CARE › 90% of hospitals reported having a hip fracture pathway: 60% across the whole acute patient journey and 30% in the emergency department only › 54% of hospitals reported the presence of a A patient with a hip fracture is offered treatment based on protocol for Computed Tomography (CT) / Magnetic an orthogeriatric model of care as defined in the Australian Resonance Imaging (MRI) if plain imaging of a and New Zealand Guideline for Hip Fracture Care. suspected hip fracture is inconclusive › 75% of hospitals had an orthogeriatric service for › 59% of patients in New Zealand and 60% of patients older hip fracture patients: 28% utilising a shared-care in Australia were documented as having no cognitive arrangement with orthopaedics; 31% utilising a daily issues prior to admission week-day geriatric medicine liaison service; and 16% › 42% and 63% of patients in New Zealand an alternative orthogeriatric service model. and Australia, respectively, had a documented › 32% and 61% of patients in New Zealand and assessment of cognition using a validated tool prior Australia, respectively, were assessed by a to surgery geriatrician prior to surgery
14 ANNUAL REPORT 2020 / ANZHFR QUALITY STATEMENT 4: QUALITY STATEMENT 6: TIMING OF SURGERY MINIMISING RISK OF ANOTHER FRACTURE
A patient presenting to hospital with a hip fracture, Before a patient with a hip fracture leaves hospital, they or sustaining a hip fracture while in hospital, receives are offered a falls and bone health assessment, and a surgery within 48 hours, if no clinical contraindication management plan based on this assessment, to reduce exists and the patient prefers surgery. the risk of another fracture.
› 84% and 80% of patients in New Zealand and › 76% and 72% of patients in New Zealand and Australia, respectively, were operated on within 48 Australia, respectively, had undergone a fall-risk hours of presentation to hospital assessment during their inpatient stay › 35 hours in New Zealand and 36 hours in Australia › 31% and 25% of patients in New Zealand and was the average time to surgery for patients Australia, respectively, were receiving bone presenting directly to the operating hospital protection medication at discharge from hospital › 40 hours in New Zealand and 47 hours in Australia was › Of those followed up at 120 days after presentation the average time to surgery for patients transferred to to hospital, 45% and 38% of patients in New the operating hospital from another hospital Zealand and Australia, respectively, were receiving bone protection medication to reduce the risk of another fracture
QUALITY STATEMENT 5: MOBILISATION AND WEIGHT-BEARING QUALITY STATEMENT 7: TRANSITION FROM HOSPITAL CARE
A patient with a hip fracture is offered mobilisation without restrictions on weight bearing the day after Before a patient leaves hospital, the patient and their carer surgery and at least once a day thereafter, depending on are involved in the development of an individualised care the patient’s clinical condition and agreed goals of care. plan that describes the patient’s ongoing care and goals › 94% and 95% of patients in New Zealand of care after they leave hospital. The plan is developed and Australia, respectively, had unrestricted collaboratively with the patient’s general practitioner. weight-bearing immediately after hip fracture surgery The plan identifies any changes in medicines, any new medicines, and equipment and contact details for › 85% and 91% of patients in New Zealand and rehabilitation services they may require. It also describes Australia, respectively, were offered the opportunity mobilisation activities, wound care and function post- to mobilise on the first day after surgery injury. The plan is provided to the patient before discharge › 4% of hip fracture patients in both countries were and to their general practitioner and other ongoing clinical reported as experiencing a new stage II or higher providers within 48 hours of discharge. pressure injury of the skin during their hospital stay › 81% of patients in New Zealand and 51% of patients › 23% and 26% of hospitals in New Zealand and in Australia were followed up at 120 days after Australia, respectively, reported providing written, presentation to hospital: of those followed up, 51% individualised information on discharge that describes and 35% of patients in New Zealand and Australia, ongoing care, goals of care and recommendations for respectively, were reported as having returned prevention of future falls and fractures to their preadmission mobility at 120 days after › Of those who lived at home prior to injury and presentation to hospital were followed up at 120 days after presentation to hospital, 80% and 62% of patients in New Zealand and Australia, respectively, have returned to their own home at 120 days
ANZHFR / ANNUAL REPORT 2020 15 PARTICIPATION 2O2O
PATIENT LEVEL AUDIT
NEW ZEALAND HOSPITALS
REPORT ID N REPORT ID N Auckland City Hospital ACH 283 Rotorua Hospital ROT - Christchurch Hospital CHC 484 Southland Hospital INV 88 Dunedin Hospital DUN 209 Tauranga Hospital TGA 209 Gisborne Hospital GIS 39 Timaru Hospital TIU 70 Hawkes Bay Hospital HKB 138 Waikato Hospital WKO 316 Hutt Valley Hospital HUT 113 Wairau Hospital (Blenheim) BHE 38 Middlemore Hospital MMH 261 Wellington Hospital WLG 119 Nelson Hospital NSN 107 Whakatane Hospital WHK 33 North Shore Hospital NSH 414 Whanganui Hospital WAG 57 Palmerston North Hospital PMR 161 Whangarei Hospital WRE 140
AUSTRALIAN HOSPITALS
REPORT ID N REPORT ID N Albany Hospital ABA 43 Nepean Hospital NEP 209 Armidale Hospital ARM 57 Orange Health Service Hospital OHS 173 Austin Hospital ### 42 Port Macquarie Base Hospital PMB 57 Bankstown / Lidcombe Hospital BKL 155 Prince Charles Hospital PCH 342 Blacktown Hospital ### 153 Prince of Wales hospital POW 188 Box Hill Hospital BOX 266 Princess Alexandra Hospital PAH 184 Cairns Hospital CNS 181 QEII Hospital QII 136 Campbelltown Hospital CAM 99 Queen Elizabeth Hospital QEH 127 Coffs Harbour Base Hospital CFS 96 Redcliffe Hospital RED 165 Concord Hospital CRG 138 Robina Hospital ROB 285 Dandenong Hospital DDH 359 Rockhampton Hospital ROK 91 Fiona Stanley Hospital FSH 528 Royal Hobart Hospital ### 35 Flinders Medical Centre FMC 181 Royal North Shore Hospital RNS 198 Footscray Hospital FOO 399 Royal Perth Hospital RPH 381 Frankston Hospital FRA 76 Royal Prince Alfred Hospital RPA 108 Geelong Hospital GUH 156 Ryde Hospital RYD 67 Gold Coast University Hospital GCH 13 Sir Charles Gairdner Hospital SCG 286 Gosford Hospital GOS 319 St George Hospital STG 249 Hornsby Ku-ring-gai Hospital HKH 37 St Vincent's Hospital Darlinghurst SVD 159 Ipswich Hospital IPS 118 St Vincent's Hospital Melbourne ### 43 John Hunter Hospital JHH 421 Sunshine Coast University Hospital SCU 223 Joondalup Hospital JHC 166 Tamworth Hospital TAM 99 Launceston Hospital LGH 105 The Alfred TAH 119 Liverpool Hospital LIV 291 The Northern Hospital TNH 219 Logan Hospital LOG 89 The Sutherland Hospital TSH 161 Lyell McEwin Hospital LMH 296 Toowoomba Hospital TWB 160 Maroondah Hospital MAR 228 Townsville Hospital TSV 159 Mater Hospital MSB 128 Westmead Hospital WMD 237 Nambour Hospital NBR - Wollongong Hospital TWH 225
16 ANNUAL REPORT 2020 / ANZHFR For this 2020 report, 77 hospitals contributed at least 10 records in 2019 and they have been included in the patient level report. Seventy-three hospitals have chosen to be identified. For the facility level report, 117 hospitals completed the audit for 2019.
The total number of hospitals eligible for both patient and facility audits may vary each year as public health system services are reconfigured, or private hospitals increase their participation in the ANZHFR.
FACILITY LEVEL AUDIT New Zealand Hospitals
Auckland City Hospital Rotorua Hospital Taranaki Base Hospital Whanganui Hospital Christchurch Hospital Middlemore Hospital Tauranga Hospital Wellington Regional Hospital Dunedin Hospital Nelson Hospital Timaru Hospital Whakatane Hospital Gisborne Hospital North Shore Hospital Waikato Hospital Whangarei Base Hospital Hawkes Bay Hospital Palmerston North Hospital Wairarapa Hospital Hutt Valley Hospital Southland Hospital Wairau Hospital
Australian Hospitals
NEW SOUTH WALES The Sutherland Hospital QUEENSLAND SOUTH AUSTRALIA The Tweed Hospital Armidale Hospital Bundaberg Hospital Albany Hospital The Wollongong Hospital Bankstown-Lidcombe Cairns Base Hospital Bunbury Hospital Wagga Wagga Base Hospital Hospital Gold Coast University Fiona Stanley Hospital Westmead Hospital Bathurst Base Hospital Hospital Geraldton Hospital Bega District Hospital Hervey Bay Hospital VICTORIA Joondalup Health Campus Blacktown Hospital Ipswich Hospital Royal Perth Hospital Bowral and District Hospital Albury Wodonga Health Logan Hospital Sir Charles Gairdner Hospital Campbelltown Hospital Ballarat Health Service Mackay Base Hospital Canterbury Hospital Bendigo Hospital Mater South Brisbane WESTERN AUSTRALIA Box Hill Hospital Coffs Harbour Base Hospital Princess Alexandra Hospital Flinders Medical Centre Dandenong Hospital Concord Hospital QEII Jubilee Hospital Lyell McEwin Health Service Frankston Hospital Dubbo Base Hospital Redcliffe Hospital Mount Gambier Geelong Hospital Gosford Hospital Robina Hospital Royal Adelaide Hospital Goulburn Valley Health Goulburn Base Hospital Rockhampton Base Hospital The Queen Elizabeth Hospital Grafton Hospital (Shepparton) Sunshine Coast University Latrobe Regional Hospital Hornsby Ku-ring-gai Hospital Hospital TASMANIA John Hunter Hospital Maroondah Hospital The Prince Charles Hospital Launceston General Hospital Lismore Base Hospital Mildura Base Hospital Toowoomba Hospital North West Regional Hospital Liverpool Hospital Northeast Health Wangaratta Townsville Hospital (Burnie) Maitland Hospital Royal Melbourne Hospital Royal Hobart Hospital Manning Base Hospital Sandringham Hospital Nepean Hospital South West Healthcare (Warrnambool) NORTHERN TERRITORY Northern Beaches Hospital St Vincent’s Hospital Alice Springs Hospital Orange Health Service Melbourne Royal Darwin Hospital Port Macquarie Base Hospital The Alfred Prince of Wales Hospital The Austin Hospital AUSTRALIAN CAPITAL Royal North Shore Hospital The Northern Hospital TERRITORY Royal Prince Alfred Hospital West Gippsland Healthcare Ryde Hospital Group (Warragul) Canberra Hospital Shoalhaven and District Western District Health Hospital Service Hamilton St George Hospital Western Health (Footscray) St Vincent’s Hospital Wimmera Health Care Group Darlinghurst (Horsham) Tamworth Base Hospital
ANZHFR / ANNUAL REPORT 2020 17 DATA QUALITY, CAVEATS AND LIMITATIONS
The patient level report includes data from 77 hospitals. In 2019, 13,504 records were contributed for the calendar year 1 January 2019 to 31 December 2019: 10,225 records from 58 Australian hospitals and 3,279 records from 19 New Zealand hospitals. The level of completeness from all 77 hospitals was 98% (Figure 1, page 19). The facility level report includes aggregated data from 117 hospitals invited to participate.
CAVEATS The ANZHFR piloted a methodology for participating sites to audit the quality of their data entered into › The figures in this report include data from Australia the ANZHFR2. Data completeness was very high, and New Zealand for all records with an Emergency and agreement between the Registry data set and a Department Arrival, In Hospital Fracture, or Transfer replicated data collection was 82%. The information date, from midnight 1st January 2019 to midnight on generated by this study resulted in the ANZHFR 31st December 2019. adding further explanatory text to the online database, › Figures in the patient level report only include data collection form and data dictionary, as well as records where data is available. introducing an additional mobilisation variable in › Hospitals must have contributed at least 10 patient January 2020 to better collect this important variable. records during the relevant calendar year to be The methodology piloted by Tan et al (2019) has included in the patient level report. subsequently been replicated in New Zealand and › All figures adhere strictly to a minimum 10 records identified additional opportunities to improve the quality required rule other than Follow-ups where at least of data held by the ANZHFR. 10 records and a follow up rate of more than 80% is required for inclusion in the figure. CAPTURE/ASCERTAINMENT › Where the figure has featured in previous years, average bars from the previous reports are included Capture/Ascertainment refers to the proportion of eligible for comparison. patients that are captured by the Registry. High levels of capture allow the findings of the ANZHFR to be generalised › New Zealand has elected to identify all hospitals to the whole population. If the capture rate is low, selection with a hospital specific code. In Australia, a hospital specific code is used where local principle investigators bias may be introduced whereby patients included or and their hospital executive have elected to opt-in excluded are systematically different from each other. to identified reporting. Four Australian hospitals In New Zealand, the number of hip fracture cases have elected not to opt-in and have been randomly in the registry can be compared with the discharge assigned a number that has been used consistently coding from the National Minimum Data Set (NMDS). throughout this report. The number has been provided The numbers are extracted in March for the previous to the listed principle investigator for each hospital. calendar year during which the data collection took › The mortality analysis has been adjusted for age, place. There is minimal change in the numbers after this sex, premorbid level of function (mobility), fracture date and this provides a good comparator with which to type, residence type and ASA. judge ascertainment. In the 2017 report, ascertainment was 20%, in 2018 60%, in 2019 70% and in 2020, has CORRECTNESS reached 86%. This improvement reflects both increasing hospitals collecting data as well as more resilient data Correctness refers to the accuracy of the data entered collection systems. into each individual data field. The ANZHFR utilises data validation rules and inbuilt date/time sequence In Australia, ascertainment is difficult to source due to checks to reduce the possibility of incorrect data being jurisdictional differences in the collection and reporting entered. Warning pop-ups alert users if the data falls of data, although similar trends are likely to be seen in outside any of the limits specified and this assists users the Australian context. The ANZHFR is investigating to identify potentially wrong temporal data. This helps resource efficient ways to be able to report this with data accuracy. Date and time variables that use information for Australia in future reports. these warnings include ED arrival and discharge, time to surgery and length of stay.
2 Tan AC, Armstrong E, Close J, et al Data quality audit of a clinical quality registry: a generic framework and case study of the Australian and New Zealand Hip Fracture Registry. BMJ Open Quality 2019;8:e000490. doi: 10.1136/bmjoq-2018-000490
18 ANNUAL REPORT 2020 / ANZHFR COMPLETENESS Completeness refers to the number of variables completed per record over the number of variables eligible to be completed for that patient. The Registry utilises automated and manual data completeness checks for each record. When logged into the Registry users can view the percentage of variables complete per record. Figure 1 shows the average completeness of all data for each patient record in 2019, shown as an average for each site, and for each country. There is no clear threshold for ‘satisfactory’ completeness and 100% completeness is not always possible as some data may not be available for some patients or from some sites.
FIGUREFigure 1 DATA1 – Data COMPLETENESS completeness
NZ Avg 2015
NZ Avg 2016
NZ Avg 2017
NZ Avg 2018
NZ Avg 2019
WHK TGA NSN BHE TIU HKB MMH WKO GIS NSH WLG WAG INV WRE CHC HUT PMR DUN ACH
Aus Avg 2015
Aus Avg 2016
Aus Avg 2017
Aus Avg 2018
Aus Avg 2019
RYD HKH H04 DDH RNS PAH LIV JHC TAH RED QEH LGH MDH CAM TWH H02 PCH ABA BOX PMB TAM TSH H01 IPS GOS CNS GUH QII STG JHH WMD ROB FOO POW LOG ARM NEP BKL TWB TSV SCU CFS MSB SVD OHS CRG ROK FRA H03 GCH SCG RPA FSH RPH TNH LMH FMC 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANZHFR / ANNUAL REPORT 2020 19 ANZHFR | ANNUAL REPORT 2020 Version 1.6 26 | Page
20 ANNUAL REPORT 2020 / ANZHFR PATIENT LEVEL AUDIT PATIENT
ANZHFR / ANNUAL REPORT 2020 21 22 PATIENT LEVEL AUDIT respectively. fracture patientsin2018, Zealand andAustralianhip and 67%oftheNew Females comprised69% FIGURE 2 INFORMATION DEMOGRAPHIC SECTION 1: ANNUAL REPORT2020 /ANZHFR SEX Females comprised 69% and 67 and 69% comprised Females ANZHFR Figure 2–Sex INFORMATION DEMOGRAPHIC 1: SECTION Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD POW WAG WKO MMH WHK WRE WLG MDH TWH CAM GUH GCH PMR TWB ARM CRG GOS DDH OHS MSB PMB DUN CHC FMC QEH ROK SCG ROB FOO LMH RPH CNS PCH SCU NSH RNS RED RYD HKH ACH NSN TAM BOX LOG PAH LGH SVD TNH RPA HUT HKB BHE NEP STG TGA CFS TAH ABA TSH FRA FSH JHC JHH TSV BKL H01 H03 H04 H02 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
10% 20% % of the New Zealand and Australi and NewZealand the of % 30%
40% Male 50%
Female an hip fracture patients in 2018, respectively. 60% 70% 80% 90% 28 | | Page 100%
fracture hasincreased. presenting withahip people aged<80years and theproportion of Australia andNewZealand fracture patientsinboth make up25%ofhip People aged>90years by 10-yearagebands. of hipfracture patients 3 showsthedistribution age is84years.Figure and inwomenthemedian age ofmenis83years, countries, themedian and Australia.Inboth years inbothNewZealand fracture patientsis82 The averageageofhip FIGURE 3 After working in health for many years I can see many improvements but not After workinginhealthformanyyearsIcanseeimprovementsbutnot everything has changed. I find it helpful in stressful times to be positive, so, can everything haschanged.Ifindithelpfulinstressfultimestobepositive,so,can MICHAEL /AGE68AUSTRALIA something be done to address the negative connotations expressed by health something bedonetoaddressthenegativeconnotationsexpressedbyhealth workers assoontheyseeyouareover60yearsold?.” AGE AT ADMISSION and New Zealand and t and New Zealand and 10 by patients age of men is 83 years, The average age of hip fracture patients is 82 years in Figure 3–Age at admission ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WKO POW WAG WHK WRE MDH WLG TWH GCH GUH CAM PMR CRG ARM GOS TWB DUN CHC DDH QEH ROK SCG PMB OHS MSB ROB FMC FOO NSN HKH LMH RED SCU PCH RPH CNS ACH NSH RYD RNS BOX LOG TAM HUT BHE HKB SVD LGH TNH NEP PAH TGA RPA STG CFS TSH FSH TAH FRA ABA JHH JHC TSV BKL H01 H02 H03 H04 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% - year age bands.People aged 90 years and older make up25% of hip 10%
he and in women in and proportion proportion 20% 50-59 of people aged <80 years presenting with a hip fracture
themedian age84 fractureis years. hip Figureof 3shows thedistribution 30%
60-69 40% both New Zealand and Australia. In both countries, the median 50% 70-79
60% ANZHFR /ANNUAL REPORT2020 80-89 70% 90+ fracture patients in 80% has increased. 90% 29
both Australia | | Page 100%
23 PATIENT LEVEL AUDIT 24 PATIENT LEVEL AUDIT known tobevariable. of Indigenousstatusis accuracy inreporting reported forAustraliaand Equivalent dataare not of European origin. patients report being New Zealandhipfracture data. Themajorityof New Zealandreported made up4.4%ofthe Maori andPacificPeoples FIGURE 4 ANNUAL REPORT2020 /ANZHFR NEW ZEALANDETHNICITY variable. be knownto is status Indigenous patients report beingofEuropean origin. Equivalent data were not collected in Australia Maori Figure 4–New Zealand ANZHFR NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WAG WKO MMH WHK WRE WLG PMR CHC DUN NSN NSH ACH HUT HKB TGA BHE and Pacific Peoples madePeoples Pacific and GIS INV TIU | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% 10% ethnicity 20% up Not elsewhere included African American/ Latin Eastern/ Middle Peoples Pacific European 4.4 30% %
of the New Zealand reported data. The majority of New Zealand hip fracture fracture hip NewZealand of majority The data. reported NewZealand the of
40% 50%
60% OtherEthnicity Asian Maori 70% 80%
and a and ccuracy in reporting of of reporting in ccuracy 90% 30 | | Page 100%
aged care facilities. the numberofresidential local populationincluding reflects themake-upof seen betweenhospitals literature. Thevariation national andinternational and consistentwith a findingthatisexpected up 28%ofthoseadmitted, aged care facilitiesmake People from residential Australian patients. patients and72%of 73% ofNewZealand a hipfracture liveathome: admitted tohospitalwith The majorityofpeople FIGURE 5 and I am very impressed I am getting a call to see how I am doing. Please let the and Iamveryimpressedgettingacalltoseehowdoing.Pleaseletthe I am 73 years old and fit and lean. Everything has been fabulous since my surgery I am73yearsoldandfitlean.Everythinghasbeenfabuloussincemysurgery MARGARET /AGE73AUSTRALIA staff knowhowfantastictheywere:thewardstaff,Physio,hydrotherapyetc.” USUAL PLACE OFRESIDENCE between hospitals betweenhospitals population, Australian patients. This indicates The majority of people admitted to hospital with Figure 5–Usualplace of residence ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG POW WKO WHK WRE MDH TWH WLG GUH CRG ARM GCH PMR CAM GOS TWB DDH DUN CHC OHS FMC MSB PMB ROB QEH SCG ROK FOO HKH LMH RED RYD PCH SCU RNS RPH CNS NSN NSH ACH BOX LOG TAM TNH LGH RPA NEP SVD BHE HUT HKB PAH STG TGA FRA TSH FSH CFS TAH ABA JHC JHH TSV BKL H04 H01 H03 H02 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
a finding that is expected and consistent with national and national with consistent expectedand is that finding a reflects 10% Private Residence
the make the 20% over representation of of representation over - up of the local populationincluding the numberof residential aged care facilities.
30%
Residential agedcare facility
40%
a hip fracture live at home: 73 people from residentialaged care facilities 50%
60%
international literature. Theliterature. international ANZHFR /ANNUAL REPORT2020 70% Other % of New Zealand patients and 72% of of 72% and patients NewZealand of % 80% Not known Not 90% riation seen variation in the hip fra thehip in 31 | | Page 100%
cture
25
PATIENT LEVEL AUDIT 26 PATIENT LEVEL AUDIT patients inAustralia. New Zealandand3%of for 5%ofpatientsin admission isnotknown Cognitive statuspriorto or knowndementia. had impaired cognition hospitalised inAustralia and 37%ofpatients of patientsinNewZealand admission. However, 36% cognitive issuespriorto Australia hadnoreported and 60%ofpatientsin patients inNewZealand Fifty ninepercent of FIGURE 6 ANNUAL REPORT2020 /ANZHFR PREADMISSION COGNITIVE STATUS 3% of Australia patients in and New Zealand in patients of 5% for known not is admission to prior status Cognitive dementia. known or cognition impaired had Australia in hospitalised patients of 37% and New Zealand in patients However,of 36% admission. prior issues cognitive reported no had Australia in patients of 60% and NewZealand in patients of percent nine Fifty ANZHFR Figure 6–Preadmission cognitive Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 dementia atpresentation impaired cognition orknown 37% ofhipfracturepatientshad WMD MMH WAG WKO POW WHK WRE WLG MDH TWH GUH CAM CRG GCH PMR TWB ARM GOS DDH CHC DUN SCG PMB ROB MSB OHS FMC QEH ROK FOO NSN RED CNS PCH RPH SCU ACH NSH LOG TAM RYD RNS LMH BOX HKH BHE RPA TNH PAH SVD NEP LGH HUT HKB TGA STG ABA TAH FSH CFS TSH FRA JHC JHH TSV BKL H02 H01 H04 H03 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% 10% .
Normalcognition 20% status 30%
40% Impaired cognition or known dementia known or cognition Impaired 50%
60% 70% Not known Not 80% 90% 32 | | Page 100%
to to PATIENT LEVEL AUDIT PATIENT
PULLOUT 37% OF HIP FRACTURE PATIENTS HAD IMPAIRED COGNITION OR KNOWN DEMENTIA AT PRESENTATION FIGURE 7 PREADMISSION WALKING ABILITY Figure 7 – Preadmission walking ability
In New Zealand and NZ Avg 2015 NZ Avg 2016
Australia, 45% and NZ Avg 2017 46% of hip fracture NZ Avg 2018 patients, respectively, NZ Avg 2019 WAG NSN walked without any TGA ACH WLG assistive device prior to BHE NSH GIS hospitalisation. This is HUT CHC TIU important information as MMH WKO WRE it provides baseline data DUN PMR HKB to inform discussions with WHK INV patients and families about Aus Avg 2015 a person’s post-injury Aus Avg 2016 Aus Avg 2017 goals of treatment. There Aus Avg 2018 is variation seen between Aus Avg 2019 ABA SVD hospitals, which is likely to TAH NEP reflect the make-up of the FRA CFS TAM local population. JHC RPH STG CAM RNS IPS GOS TWH CNS SCG LOG TWB RPA FOO WMD ROB TSV CRG LIV PAH ROK JHH GCH TSH POW RED FSH QEH DDH SCU PMB FMC QII H01 TNH LGH ARM H02 RYD H04 OHS BOX BKL MDH HKH MSB H03 LMH GUH PCH 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Usually walks without walking aids Usually walks with either a stick or crutch Usually walks with two aids or a frame Usually uses a wheelchair or bedbound Not known
ANZHFR | ANNUAL REPORT 2020 Version 1.6 33 | Page
ANZHFR / ANNUAL REPORT 2020 27 28 PATIENT LEVEL AUDIT used as a general measure of physicalhealth or comorbidity. Increasing ASA Grade associated is with mortality and The Figure 8–ASA known ANZHFR quality forthis variable. Figure 8provides datathatcanbeused byhospitalswithlowrates ofcollectiontoinforminitiatives toimprove data 50% ofrecords andthismay reflect difficultyinsourcing theinformationin medical record, oritmaybemissing. or higher, indicatingsignificantcomorbidities andanaestheticrisk.Forsomehospitals, ASA isunknownformore than to survivesurgery. TheASAgradesprovided inFigure 9showthatmosthipfracture patientshave anASAgradeof3 with severe systemicdiseasethatisaconstantthreat tolife.ASAGrade5indicates thatthepatientisnotexpected activity, andGrade3issevere systemicdiseasethatlimitsactivitybutisnotincapacitating. Grade4indicatesapatient anaesthetic risk.Grade1isahealthyindividualwithno systemicdisease,Grade2ismilddiseasenotlimiting and morbidityriskinpatients.Forpatientsateachhospital forwhomtheASAisknown,Figure 9showsthegradingof often usedasageneralmeasure ofphysicalhealthorcomorbidity. Increasing ASAGradeisassociatedwithmortality The AmericanSocietyofAnaesthesiologists(ASA)developed theASAgradingasameasure ofanaestheticrisk.Itis FIGURE 8 ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 American Soci WMD MMH WAG WKO POW WRE WHK MDH WLG TWH ARM CAM CRG TWB PMR GCH GUH GOS DUN CHC MSB DDH ROB PMB SCG OHS ROK QEH FMC FOO RYD NSH PCH LOG TAM NSN ACH LMH HKH RED RNS SCU RPH CNS BOX PAH BHE TGA HUT HKB SVD RPA NEP LGH TNH STG ABA CFS FRA FSH TAH TSH TSV JHH JHC BKL H02 H04 H03 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
used as a general measure of physicalhealth or comorbidity. Increasing ASA Grade associated is with mortality and The Figure 8–ASA known ANZHFR Known Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 ASA KNOWN NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 ety of Anaesthesiologists (ASA) developed the developed (ASA) Anaesthesiologists of ety American Soci WMD MMH POW WAG WKO WRE WHK MDH TWH WLG GCH GUH CRG ARM CAM PMR GOS TWB DDH DUN CHC OHS ROK QEH ROB SCG FMC PMB MSB FOO HKH RED LMH RNS SCU RPH CNS PCH RYD NSN ACH NSH LOG BOX TAM RPA NEP LGH TNH SVD PAH BHE HUT HKB STG TGA TAH TSH CFS FRA FSH ABA JHC JHH TSV BKL H01 H02 H04 H03 GIS INV 50% TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
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WMD MMH POW WAG WKO WRE WHK MDH WLG TWH GCH GUH CRG ARM CAM PMR GOS TWB DDH DUN CHC OHS ROK QEH ROB SCG FMC PMB MSB FOO NSH HKH RED LMH RNS SCU RPH CNS PCH RYD NSN ACH BOX LOG TAM RPA NEP LGH TNH SVD PAH BHE HUT HKB STG TGA CFS FRA FSH TAH TSH ABA JHC JHH TSV BKL H03 H01 H02 H04 ASA Grade 1 Grade ASA
GIS INV 100% IPS TIU LIV QII 0%
10% Figure 9–ASA grade Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 FIGURE 9 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015
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is often is transferred patients. on timetosurgeryfor there maybeanimpact transition isincluded, and thetimespentin the transferringhospital When theperiodspentin delineation ofthehospital. delivery, andtherole geography, service reflects differences in fracture. Thisvariation management oftheirhip transferred fordefinitive respectively, are of hipfracture patients, Australia, 7%and14% In NewZealandand patients transferred. in theproportion of variation betweensites There isconsiderable of theirhipfracture. definitive management operating hospitalfor transferred toan proportion ofpatients Figure 10showsthe FIGURE 1O PRESENTATION CARE AT SECTION 2: TRANSFERRED FROMANOTHER HOSPITAL Australia, 7 fracture. There fracture. Figure 10 shows the proportion of patients transferred in transferred patients of proportion the shows 10 Figure Figure 10–Transferredfromanother hospital ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WHK WRE TWH WLG MDH GUH ARM GCH PMR CRG GOS TWB CAM DDH CHC DUN OHS FMC PMB ROK ROB SCG QEH MSB FOO PCH SCU RPH CNS ACH NSN NSH LMH RNS LOG HKH RED RYD TAM BOX NEP PAH BHE HUT HKB TNH LGH RPA SVD TGA STG CFS FSH ABA FRA TAH TSH JHH TSV JHC BKL H01 H03 H04 H02 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% Thisvariation reflects differences in geography, service delivery, and the role % and 14% and %
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29 hen PATIENT LEVEL AUDIT 30 PATIENT LEVEL AUDIT respectively. is 4.5hoursand6.4hours, New ZealandandAustralia, ED in2019,forpatients median lengthofstayinthe hospitals remains. The variation betweenindividual trended upinAustralia,but in NewZealandand (ED) hastrended down the EmergencyDepartment Stay (LOS)forpatientsin 2015, averageLengthof Since thefirst report in FIGURE 11 ANNUAL REPORT2020 /ANZHFR AVERAGE LENGTH OFSTAY (LOS)INTHEEMERGENCYDEPARTMENT (ED) length of stay in the ED the in stay of length Australia in up trended and NewZealand in down 2015, reportSincein the first a ANZHFR Figure 1–Average length of Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WRE WHK MDH WLG TWH PMR CRG GUH ARM GCH CAM GOS TWB DUN CHC DDH FMC PMB ROB ROK OHS QEH SCG MSB FOO NSH ACH NSN LMH CNS RED RNS HKH RPH RYD PCH SCU TAM LOG BOX HKB BHE HUT RPA SVD TNH PAH TGA NEP LGH STG TSH FRA ABA FSH TAH CFS JHC JHH TSV BKL H02 H03 H04 H01 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0 0
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, but variation betweenvariation but remains., hospitals The median individual 6 6 Hours Hours
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.
and Australia. New Zealand 91%, respectively, in in 2019was94%and or orthopaedicward a specifichipfracture of patientsadmittedto hospital. Theproportion size andtherole ofthe to factorssuchasthe varies betweensitesdue for hipfracture patients The typeofward used FIGURE 12 WARD TYPE respectively hospital. The type of ward used for hip fracture patients variesbetween sites due to factors such as the size and the role of the Figure 12–Ward ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WRE WHK MDH WLG TWH GUH CAM CRG TWB PMR GOS GCH ARM DDH SCG QEH ROB OHS CHC DUN FOO ROK FMC PMB MSB PCH SCU NSN RNS CNS ACH NSH LOG HKH RYD LMH RPH RED TAM BOX TNH HUT BHE PAH HKB TGA RPA LGH SVD NEP STG FSH FRA TAH ABA TSH CFS JHC TSV JHH BKL H02 H03 H04 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | The 0% Hip fracture unit / Orthopaedic ward / preferred ward preferred / ward Orthopaedic / unit fracture Hip , in New in , Australia. Zealandand proportionof patients admitted to a specific hip frac 10% type 20% 30%
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was 94% and 91%, and 94%was 40 | | Page 100%
31 PATIENT LEVEL AUDIT 32 PATIENT LEVEL AUDIT understand thisdifference. investigation tobetter may beanarea forfurther the twocountriesand area ofdifference between assessment. Thisisan a preoperative medical respectively, didnothave and 19%ofpatients, and Australia,55% nurses. InNewZealand practitioners orspecialist physicians, general undertaken bygeneral assessment maybe preoperative medical medicine servicesand access togeriatric hospitals donothave prior tosurgery. Some are seenbyaGeriatrician Australia, 61%ofpatients prior tosurgery. In are seenbyaGeriatrician patients inNewZealand Thirty-two percent of FIGURE 13 ANNUAL REPORT2020 /ANZHFR PREOPERATIVE MEDICALASSESSMENT are seen by a seenby are Thirty undertake preoperative medical assessment by general physicians, general pra ANZHFR medicalFigure 13–Preoperative assessment Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 - two two WMD POW WAG WKO MMH WRE WHK MDH TWH WLG CAM GUH GCH TWB CRG GOS PMR ARM QEH DDH DUN MSB ROK OHS FOO PMB ROB SCG FMC CHC RNS RPH RYD HKH CNS RED LOG SCU LMH PCH NSN ACH NSH TAM BOX PAH RPA TNH LGH SVD NEP BHE HKB HUT STG TGA TAH TSH FRA CFS FSH ABA JHH JHC TSV BKL H01 H04 H03 H02 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% s in New Zealand are seen by a by seen are percentZealand New of patient in s G eriatrician prior to surgery.to prior eriatrician Specialist Nurse Specialist Team Geriatric / Geriatrician 10% 20% 30% Some hospitals do not have access to geriatric medicine services and may and services medicine geriatric to access have not do hospitals Some
40% No assessment conducted assessment No Team Physician / Physician 50%
G eriatrician pri eriatrician 60% or to surgery. In Australia, 61 ctitioners or specialist nurses. In New In nurses. specialist or ctitioners 70% Not known Not GP 80% 90% 41 | | % of patients patients of % Page 100%
Preoperatively, 24% of patients have cognitive impairment when assessed with a validated tool PATIENT LEVEL AUDIT PATIENT
FIGURE 14 PREOPERATIVE COGNITIVE ASSESSMENT Figure 14 – Preoperative cognitive assessment
The Hip Fracture Care NZ Avg 2018 Clinical Care Standard NZ Avg 2019 MMH recommends the use WAG NSH BHE of a validated tool to WLG NSN assess and document PMR GIS TIU cognition prior to surgical CHC WKO intervention. In New HKB WRE HUT Zealand, 42% of patients TGA ACH had their cognition INV DUN assessed using a validated WHK tool prior to surgery, Aus Avg 2018 Aus Avg 2019 and 16% are recorded PAH GCH as having cognitive ROB LGH impairment. In Australia, TSV SCU LMH 63% of patients had CAM SCG their cognition assessed IPS STG QII and 26% are recorded BOX MDH as having cognitive SVD H02 impairment. Prior POW H03 RED to last year’s report, H04 QEH this information was RNS RPH TAH presented simply as TSH JHC whether cognition was GOS TWB HKH assessed. Since the first TWH MSB report in 2016, there CFS FSH LOG have been year on year RPA FMC improvements in the CRG FOO preoperative assessment PCH H01 ROK of cognition in patients. BKL FRA This information prior ABA CNS OHS to surgery is important JHH WMD for the identification and ARM TAM GUH prevention of avoidable LIV RYD complications such NEP PMB TNH as delirium. DDH 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Assessed and normal Assessed and abnormal or impaired Not assessed Not known
The Hip Fracture Care Clinical Care Standard recommends the use of a validated tool to assess and document cognition prior to surgical intervention. In New Zealand, 42% of patients had their cognition assessed using a validated tool prior to surgery, and 16% are recorded as having a cognitive impairment. In Australia, 63% of patients had their cognition assessed and 26% are recorded as having a cognitive impairment. Prior to last year’s report, this information was
ANZHFR | ANNUAL REPORT 2020 Version 1.6 ANZHFR / ANNUAL REPORT43 | Page 2020 33
34 PATIENT LEVEL AUDIT of presentation. of painwithin30minutes a documentedassessment patients, respectively, have and Australianhipfracture 61% oftheNewZealand ED. Onaverage,58%and 30 minutesofarrivalinthe pain documentedwithin of patientswhohavetheir hospitals intheproportion variation seenbetween There isconsiderable quality hipfracture care. measurable indicatorof to thefirsthospitalasa 30 minutesofpresentation assessment ofpainwithin includes thedocumented Clinical Care Standard the HipFracture Care Quality Statement2of FIGURE 15 ANNUAL REPORT2020 /ANZHFR PAIN ASSESSMENT INTHEED 30 within documentedpain the assessment of includes Standard Care Clinical Care Fracture Hip the Statementof 2 Quality considerable variation seen between hospitals in the proportion of patients who havewho patients of proportion the in seenbetween hospitals variation considerable ANZHFR Figure 15–Painassessment in the emergency d Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 minutes ofpresentation as tothe hospital a first measurable fracture indicator ofquality hip care. WMD MMH WAG POW WKO WHK WRE MDH WLG TWH CAM PMR GOS CRG GUH GCH ARM TWB MSB ROB PMB QEH DDH DUN CHC SCG FOO OHS ROK FMC NSN NSH CNS PCH RYD RPH RED RNS SCU LMH HKH ACH LOG BOX TAM HUT BHE HKB SVD TNH LGH TGA NEP PAH RPA STG TAH CFS ABA TSH FRA FSH JHH TSV JHC BKL H03 H02 H04 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% 10% 20% Not known Not Pain assessment notdocumented or not done Documented assessment ofpain greaterthan 30 minutes of ED presentation Documented assessment ofpain within 30minutes of ED presentation 30%
40% epartment (ED) 50%
60% 70% their pain their 80%
documented within 30 documentedwithin 90% 45 There is is There | | Page 100%
to theED. within 30minutesofarrival transit (byparamedics)or received analgesiaeitherin patients, respectively, and Australianhipfracture 71% oftheNewZealand Fifty eightpercent and FIGURE 16 PAIN MANAGEMENT INTHEED
either in transit (byparamedics) 30withintransit the or at eitherminutes in arrival of eightFifty percent and 71 Figure 16–Painmanagement in the emergency d epartmentD) (E ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 NZ Avg 2017 NZ Avg 2019 NZ Avg 2018 WMD WKO WAG MMH POW WHK WRE MDH WLG TWH GUH CRG CAM GOS PMR ARM TWB GCH DDH CHC DUN FMC PMB ROB MSB QEH FOO ROK SCG OHS SCU PCH CNS RYD ACH NSH LOG NSN BOX RNS RED TAM LMH HKH RPH LGH TNH HUT SVD TGA HKB BHE RPA NEP PAH STG TSH TAH CFS FSH FRA ABA JHC JHH TSV BKL H03 H01 H02 H04 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% Not known Not Analgesiagiven more than 30 minutes after ED presentation paramedics by provided Analgesia 10% % of the New Zealand and Australian hip fracture patients, respectively, received analgesia analgesia received respectively, patients, fracture hip Australian and NewZealand the of % 20% 30%
40% 50%
Analgesia not required not Analgesia presentation ED of minutes 30 within given Analgesia 60%
ED. ANZHFR /ANNUAL REPORT2020
70% 80% 90% 47 | | Page 100%
35 PATIENT LEVEL AUDIT 36 PATIENT LEVEL AUDIT intervention. block before surgical patients received anerve and inAustralia,79%of before surgicalintervention nerve blockadministered 67% ofpatientshada 2019. InNewZealand, years hascontinuedin blocks seeninprevious increased useofnerve likely tobeintheED.The most hospitalsthisis prior tosurgery, butfor block wasadministered not record where thenerve fracture. TheRegistrydoes assess andmanagethe in order toinvestigate, moved anumberoftimes fracture patientmaybe in theEDwhenanewhip care settingandparticularly manage painintheacute Nerve blocksare usedto FIGURE 17 ANNUAL REPORT2020 /ANZHFR USE OFNERVE BLOCKS to surgery had anerve blockprior In 2O19,76% ofpatients increased use of nerve blocks seen in previous years has continued in 2019. 2019. in continued has years previous in seen blocks nerve of use increased record where the nerve b patient may be moved a number of timesorder in to investigate, assess and managethe fracture. The Registry does not Nerve blocks are used to manage pain in the acute the in pain manage to used are blocks Nerve ANZHFR Figure 17–Useof Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD POW WAG MMH WKO WHK WRE MDH TWH WLG GUH TWB GOS CAM CRG ARM GCH PMR QEH OHS SCG ROB MSB PMB FMC DDH DUN CHC FOO ROK HKH RED CNS RPH RNS PCH SCU LMH LOG RYD BOX TAM ACH NSH NSN RPA TNH PAH LGH SVD NEP BHE HKB HUT STG TGA ABA FSH TSH CFS TAH FRA JHC JHH TSV BKL H03 H01 H02 H04 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% Not known Not Nerve block administered inOT OT in and OT before Both 10% n erve b lock waslockadministered is surgery, to this most prior for but hospitals locks 20%
30%
40% care setting and particularly in in settingparticularly and 50%
Neither Nerve block administered before arriving in OT 60% In New Zealand, New Zealand, In 70% the the ED whena new hip fracture 80% 6
7 likely to be in the ED. ED. the in be to likely % of patients had a nerve a had patients of % 90% 48 | | Page 100%
The technique; the importance of high quality data submitted technique; theimportanceofhighqualitydatasubmitted awareness and empowers staff to consider options for awareness andempowersstafftoconsideroptionsfor analgesia. Reviewing the data for pain management at analgesia. Reviewingthedataforpainmanagementat Hip Fracture Committee; ongoing education to include Hip FractureCommittee;ongoingeducationtoinclude to the ANZHFR to inform review of clinical care by the to theANZHFRinformreviewofclinicalcareby further consultation with all stakeholders to ensure a further consultationwithall stakeholderstoensurea The documentation of pain assessment scores raises The documentationofpainassessmentscoresraises our monthly LBVC Hip Fracture committee facilitated our monthlyLBVCHipFracturecommitteefacilitated a falls injury balance workshop, and a junior medical a fallsinjurybalanceworkshop,andjuniormedical This project incorporated nurse education sessions, This projectincorporatednurseeducationsessions, for JMOs and Nurses on analgesia options and pain for JMOsandNursesonanalgesiaoptionspain an annual workshop for Registrars; and education an annualworkshopforRegistrars;andeducation were identified: collaboration between the ED and were identified:collaborationbetweentheEDand Anaesthetics; standardisation of the nerve block Anaesthetics; standardisationofthenerveblock analgesia prior to surgery, in-line with the well analgesia priortosurgery,in-linewiththewell officers teaching session. The following needs officers teachingsession.Thefollowingneeds improvement project to ensure hip fracture improvement projecttoensurehipfracture patients were reliably receiving regional patients werereliablyreceivingregional Care Hip Fracture Committee led an Care HipFractureCommitteeledan ANZHFR /ANNUAL REPORT2020 documented recommendation. documented recommendation. Informed by baseline data, the Informed bybaselinedata,the Nepean Leading Better Value Nepean LeadingBetterValue GERIATRICIAN /NSW coordinated approach. coordinated approach. assessment methods. assessment methods. 37 PATIENT LEVEL AUDIT 38 PATIENT LEVEL AUDIT their families. expressed bypatientsand specific goalsofcare should alsoconsiderthe non-surgical management Decisions onsurgicalor who are abletomobilise. stable undisplacedfractures mortality orthosewith high riskofperioperative such asforpatientsat in somecircumstances, may beareasonable option Non-operative treatment in thepopulationstreated. clinical managementand may reflect differences in between hospitals,which 18 showssomevariation data presented inFigure or alleviatingpain.The optimising functionand/ surgically withaviewto a hipfracture willbetreated that nearlyallpatientswith Australia, itisanticipated In NewZealandand FIGURE 18 OPERATIVE CARE SURGERY AND SECTION 3: ANNUAL REPORT2020 /ANZHFR TREATED WITHSURGERY hospitals, which m view to optimising function and/or alleviating pain. In In ANZHFR Figure 18–Treated with SurgerySECTION3: and operative care Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 New Zealand and Australia, i Australia, and NewZealand WMD WKO MMH WAG POW WHK WRE MDH WLG TWH PMR CRG GCH TWB GUH ARM CAM GOS DUN CHC PMB SCG MSB QEH FMC OHS DDH FOO ROB ROK ACH NSH NSN SCU RPH LMH PCH RYD RED RNS BOX LOG TAM CNS HKH LGH SVD HUT HKB BHE NEP TNH TGA STG RPA PAH TSH ABA CFS TAH FSH FRA JHH TSV JHC BKL H01 H04 H03 H02 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% ay reflect differences in clinical management and in the populations treated. Non treated. populations the managementin and clinical in differences reflect ay 10% surgery 20% t is anticipated that nearly all patients with a hip fracture will betreated fracture will a hip withsurgically a withpatients nearlythat all anticipated is t 30%
40%
The data presented in Figure 18 Yes
50%
No 60% 70%
shows 80% somebetween variation 90% - 50 operative operative | | Page 100%
scheduled operatinglists. hip fracture surgeryon recommends performing for HipFracture Care The ANZGuideline these results are pending. consultant surgeonand with thepresence ofa characteristics associated surgical andhospital explored thepatient, The ANZHFRhasfurther difference are unclear. for thisintercountry reporting, butthereasons over thefiveyearsof have remained consistent countries, anddifferences supervision between also different levelsof availability. There are staff seniorityandtheatre differences instaff levels, which islikelytoreflect institutional variation, supervision showshigh The levelofconsultant FIGURE 19 CONSULTANT SURGEONPRESENTANDSCRUBBEDDURINGSURGERY The Figure 19–Consultant ANZHFR The ANZHFR has further investigated the patient,surgical and hospital characteristics associated with the presence of a consist remainedhave theatreseniorityand staff availability Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 level of cons of level WMD MMH WAG POW WKO WHK WRE MDH WLG TWH ARM GUH CAM PMR GCH CRG TWB GOS DUN CHC DDH QEH OHS MSB ROB FMC PMB SCG FOO ROK RYD NSH NSN ACH SCU RNS RED PCH RPH LMH CNS HKH BOX LOG TAM HUT HKB BHE NEP PAH RPA LGH SVD STG TNH TGA ABA TSH CFS FRA FSH TAH JHC JHH TSV BKL H01 H03 H02 H04 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% ultant supervision supervision ultant 10% entover thefive years reporting of and scrubbed presentandscrubbed surgeon 20% shows . There are also different levels of supervision betweencountries 30% high institutional
Yes 40% No ,
50% during surgery but thereasons for this intercountrydifference variation,
Not known Not 60% ANZHFR /ANNUAL REPORT2020 which is which
70% likely to reflectto 80%
differences in staff levels, 90% 52 ,
and differences differences and | | Page are unclear. 100%
39
PATIENT LEVEL AUDIT 40 PATIENT LEVEL AUDIT to surgery. alter theaveragetime outliers cansignificantly of patientsandafew note thatsmallnumbers hours). Itisimportantto time tosurgeryis35 hours in2019(average time tosurgeryis26 In NewZealand,median to surgeryis36hours). Australia (averagetime surgery is30hoursin presentation and time betweeninitial This year, themedian surgical anaesthesia. and commencementof the operatinghospital time ofpresentation to between thedateand theatre isthedifference Calculation oftimeto to thetreating hospital. patient initiallypresenting reflecting ofa thejourney the operatinghospital, patients transferred to Figure 20excludes because earlysurgeryhasbeendemonstratedtoreduce morbidity, hastenrecovery andreduce lengthofstay. The HipFracture Care ClinicalCare Standard statesthatsurgeryshouldbeperformedwithin48hoursofpresentation FIGURE 2O ANNUAL REPORT2020 /ANZHFR AVERAGE TIMETOSURGERY EXCLUDING TRANSFERREDPATIENTS F because early surgery has been demonstrated to reduce morbidity, hasten recovery and reduce length of stay. The Hip Fracture CareClinical Care ANZHFR Figure 20–Average t to the treating hospital. Calculation of timeof theatretheto difference is Calculation thebetweentreatingto hospital. thetimedate and presentationof to igure 20 igure Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WRE WHK MDH TWH WLG CRG CAM GCH PMR GOS GUH TWB ARM DDH DUN CHC FOO MSB PMB FMC OHS ROB ROK SCG QEH HKH SCU RED NSH NSN ACH LOG CNS LMH RPH RNS PCH RYD TAM BOX RPA BHE HUT STG PAH LGH SVD NEP TNH TGA HKB CFS FRA ABA FSH TSH TAH JHH JHC TSV BKL H02 H01 H03 H04 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | excludestransferredthepatients into 0 0 10 10 to surgery excludingsurgery ime to transferred patients 20 20 Standard states that surgery should be performed within 48 hours of presentation presentation of hours 48 within performed be should surgery that states Standard Average Time to Surgery to Time Average
30 30 operat ing hospita ing Hours Hours 40 40
MedianTime to Surgery l, reflecting the journey of a patient initially presenting reflecting l, theinitially patientjourney a of
50 50 60 60 70 70 54 | | Page 80 80
(see Figure 20). hours, respectively patients of35and36 for non-transferred average timetosurgery This compares with and 47hoursinAustralia. 40 hoursinNewZealand transferred patientsis time tosurgeryfor patients). Theaverage hours fornon-transferred (compared with30 and 40hoursinAustralia non-transferred patients) with 26hoursfor New Zealand(compared patients is34hoursin surgery fortransferred The mediantimeto from otherhospitals. the operatinghospital are transferred into longer forpatientswho time tosurgeryis Figure 21showsthe 30 hospitals(24AustralianandsixNewZealandhospitals)withtenrecords ormore. transfer ofhipfracture patients,orthatdonotdeliverpatientsdirectly tooperatinghospitals.Thisisonlyreported for and showsthetreatment delaysthatresult from healthsystemsthatdonothaveexpeditedpathwaysforthe Reporting timetosurgeryfortransferred patientsalonetakesintoaccountthetimespentattransferringhospital FIGURE 21 AVERAGE TIMETOSURGERY –TRANSFERREDPATIENTS ONLY average time to surgery for non timesurgerto non- hospitals. The mediantime to surgeryfor transferred patientsis 34 Figure21 shows thetime surgeryto longerpatients who for is are transferred theoperating frominto hospital o 30 ( hospitals transfer of hip fracturepatients hip transferof hospital and shows thetreatment delays thatresult from health systemsthat do not have expedited pathways for the Reporting time to surgery for transferred patients alone Average timetosurgeryFigure – transferre 21–Average ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 transferred(compared Australia 40 and patients)in 30hours withnon for hours WKO WRE TWH ARM GUH GOS TWB DDH SCG FMC PMB ROK OHS ROB DUN CHC PCH SCU CNS RPH TAM NSH PAH NEP FSH ABA JHH TSV INV LIV | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0 0 24 Australian hospitalsandNew six Zealand hospitals y for transferred 40 patients is hours New in Zealand and 47 10 10 , - 20 20
transferredof patients or that do not deliver patients directly to directly patients deliver not do that or Average Time to Surgery to Time Average 30 30
d p 40 40 atients only 35 and 36 hours, respectively
takes into account thetakestimeaccount transferringinto the spentfirst at Hours Hours
MedianTime to Surgery 50 50 )
hours with with ANZHFR /ANNUAL REPORT2020 ten in New Zealand (compared with 26 hours for for hours 26 with (compared Zealand New in operating
hours in Australia 60 60 records or more.
hospitals. hospitals. -
transferredTheave patients). (see Figure 20) 70 70 . This compares with
Thisis only reported for 80 80 . 56
| | Page 90 90 ther
rage 41 PATIENT LEVEL AUDIT 42 PATIENT LEVEL AUDIT ANZHFR within48hours Figure 2-Surgery attributed totheatre accesshas decreased inthis report. causes forsurgical delay. Accesstotheatres isstilltheprimary reason fordelayhoweverthe proportion ofdelays for hospitalsandhealthservices wishingtoimprove the proportion ofpatientstreated within 48hoursasithighlights respectively, were operatedwithin48hoursofpresentation tothefirsthospital.Figure 23provides usefulinformation 22 showsthatofthosepatients whowere treated operatively, 84%and80%ofpatients inNewZealandandAustralia, Figures 22and23includebothtransferred patientsand admitteddirectly tothe operating hospitals.Figure SURGERY WITHIN48HOURS FIGURE 22 ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD WAG WKO MMH POW WRE WHK WLG MDH TWH PMR GOS GCH GUH CAM CRG ARM TWB DUN CHC SCG ROB DDH FOO MSB ROK OHS FMC PMB QEH ACH NSN NSH RNS LMH RYD SCU LOG RPH PCH BOX TAM CNS RED HKH HKB TGA LGH HUT BHE SVD PAH RPA NEP STG TNH ABA FSH TAH TSH CFS FRA TSV JHC JHH BKL H03 H04 H01 H02 GIS INV TIU IPS LIV QII <= 48 hours 48 <= 0% | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT |
50% within48hours Figure 2-Surgery ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 >48 hours WMD POW WAG WKO MMH WRE WHK WLG MDH TWH GOS ARM TWB PMR CAM CRG GUH GCH PMB MSB ROK QEH OHS ROB SCG FOO FMC DUN CHC DDH LOG BOX TAM SCU PCH CNS RED HKH RPH LMH RYD RNS ACH NSN NSH PAH RPA NEP STG SVD HKB TGA BHE LGH TNH HUT ABA CFS FRA TSH TAH FSH TSV JHH JHC BKL H01 H02 H04 H03 GIS INV IPS TIU LIV QII <= 48 hours 48 <= 100% 0% | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015
50% &Figure 23-Reason for WMD POW WAG WKO MMH WRE WHK WLG MDH TWH >48 hours GOS ARM TWB PMR CAM GCH CRG GUH FOO PMB MSB ROK QEH OHS ROB SCG FMC DUN CHC DDH LOG BOX TAM SCU PCH CNS RED HKH RPH LMH RYD RNS ACH NSN NSH PAH RPA NEP STG SVD HKB TGA BHE LGH TNH HUT ABA CFS FRA TSH TAH FSH TSV JHH JHC BKL H01 H02 H04 H03 GIS INV IPS TIU LIV QII 0%
100% Notknown fracture hip of diagnosis delayed to due Delay Delay due to patient deemed medically unfit Delaytodue theatre availability REASON FORDELAY LONGERTHAN48HRS FIGURE 23 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 20% NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015
&Figure 23-Reason for WMD WAG WKO MMH POW WRE WHK WLG MDH TWH PMR GOS GCH CAM GUH CRG ARM TWB DUN CHC SCG FOO DDH MSB ROK ROB PMB QEH FMC OHS ACH NSN NSH RNS LOG SCU LMH RYD PCH TAM CNS RED BOX RPH HKH HKB TGA LGH HUT BHE SVD PAH RPA NEP STG TNH ABA TAH FSH TSH CFS FRA TSV JHH JHC BKL H03 H04 H01 H02 GIS INV TIU IPS LIV QII
0%
d Notknown fracture hip of diagnosis delayed to due Delay Delay due to patient deemed medically unfit Delaytodue theatre availability elay 40%
longer than48hrs longer 20%
Other type of delay of type Other anticoagulation with issues to due Delay Delaydue to surgeonavailability 60% d elay 40%
longer than48hrs longer 80% Other type of delay of type Other anticoagulation with issues to due Delay Delaydue to surgeonavailability 60% 57 | | Page 100%
80% 57 | | Page 100%
GERIATRICIAN /NSW It takesawholeofhospital approach tofixabrokenhip. pathway (eHIP),outlinedin this videohttps://youtu.be/bcFJlznq34A Health andMedicalResearch Institute,weareworkingonanewearlymultidisciplinary notificationandresponsecare collegiate workingwillallow ustodeliverchange.ThanksfundingfromtheNSW ACIgrantround,andtheIllawarra compliance withallcomponentsoftheHipFractureCare ClinicalCareStandard.Ourestablishedinterdepartmental The continualauditcyclewillallowustostriveforfurther improvement.Thereisstillmoretodoincreaseour orthogeriatric team.Ourtimestotheatrehaveimproved significantly.Weareveryproudofallourhardwork. was agreedtoestablishasecondfulltimeorthopaedic traumaserviceinthatlocaleaccompaniedbyadeveloping In addition,werecognised25%ofourpatientsannually weretransferringfromanotherhospitalintheLHDsoit 10 listsperweekinsteadofseven. patients. Threeadditionallistswerefunded,thenstaffed, andbyApril2019wewereuprunning.Wenowhave theatre timewasrequiredtomeettheneedsofourhip fracturegroupbutalsoalltherestofourorthopaedictrauma We tookourdatatoexecutivesponsorandchieftheresponsewasunequivocal.Moretrauma annual cyclesofpatientdatacollectionwecouldseeimprovedoutcomesinmanycategoriesbutnottheatre times. clinic. Weintroducedmanystrategiestoimproveinterhospitaltransferandreduceourdelaystheatre.Over two We focussedonstreamliningperioperativeassessmentandday1mobilisation.developedarefractureprevention revolutionised whatwedeliver. Early participationintheRegistryanddevelopmentofanenthusiasticteamworkingpartyhasliterally aware wewerenotroutinelymeetingourminimumstandardsforhipfracturecare. At ourhospital,evenbeforetheANZHFR,wewereactivelyauditingandacutely the deliveryofimprovementsforsystemandpatientoutcomes. and theexecutiveteamsofclinicaldivisionstoworktogetherensure worked hardtocreateaforumfortheDirectorofClinicalOperations Standards fortheManagementofHipFractures.TheCommittee Committee providedleadershiptoimplementtheMinimum done thingsrequiresdata.TheWollongongHospitalSteering hip. Secondlytochangethewaywehavehistorically whole hospitaltolookafterolderpeoplewithabroken I haveunderstoodtwothings.Firstly,ittakesa practising inorthogeriatricmedicine For aslongIhavebeen ANZHFR /ANNUAL REPORT2020 43 PATIENT LEVEL AUDIT 44 PATIENT LEVEL AUDIT 16% 7% 10% 9% 19% 12% 10% 5% availability ofoperating theatres orbeingdeemedmedically unfit. Australia, 51% and55%ofpatientsrespectively are delayedtosurgery duetooneoftwomodifiable reasons: the Figures 24and25provide acomparisonbetween countriesforthereasons forsurgicaldelay. In NewZealandand FIGURE 25 FIGURE 24 ANNUAL REPORT2020 /ANZHFR anticoagulation Delay duetoissueswith diagnosis ofhipfracture Delay duetodelayed anticoagulation Delay duetoissueswith diagnosis ofhipfracture Delay duetodelayed Other typeofdelay Not known Other typeofdelay Not known REASON FORDELAY >48HRSFORAUSTRALIA REASON FORDELAY >48HRSFORNEWZEALAND medical stabilityandanticoagulation. three modifiablefactors-theatreaccess, 7O% ofpatientsaredelayed tosurgery for deemed medicallyunfit deemed medicallyunfit Delay duetosurgeon Delay duetosurgeon Delay duetopatient Delay duetopatient theatre availability theatre availability Delay dueto Delay dueto availability availability
27% 31% 24% 24% 3% 3% or thedepartment. of theanaesthetist personal preference is likelytoreflect the between hospitalsand variation isnoted 75% Australia.Marked in NewZealandand anaesthesia: 71% with orwithoutregional general anaesthetic hip fracture havea intervention fora undergoing operative The majorityofpeople FIGURE 26 TYPE OFANAESTHESIA regional The majority of people undergoing operative intervention forhip a fracture have a general anaesthetic with or without to reflectto thepers Figure 26–Type of ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD POW MMH WAG WKO WRE WHK MDH TWH WLG GUH ARM CRG GOS TWB GCH CAM PMR DDH ROK SCG PMB FOO MSB QEH OHS FMC CHC DUN ROB CNS HKH RYD RED RNS SCU PCH LOG BOX RPH LMH NSN NSH ACH TAM SVD PAH LGH TNH NEP RPA STG BHE HKB HUT TGA FSH FRA ABA CFS TSH TAH JHH JHC TSV BKL H01 H03 H02 H04 GIS INV IPS TIU LIV QII anaesthesia: 71% in New Zealand and 75% and New Zealand in 71% anaesthesia: | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% General anaesthetic onal preference of the anaesthetist or the department.the or anaesthetist the of preference onal 10% anaesthesia 20% General and spinal/regional anaesthesia 30%
40% Australia. Marked variation is noted between hospitals and is likely 50%
Spinal / regional anaesthesia 60% ANZHFR /ANNUAL REPORT2020
70% 80% Other 90% 60 Not known Not | | Page 100%
45 PATIENT LEVEL AUDIT 46 PATIENT LEVEL AUDIT Figure 27–Fracturetype or thewithissuesclassification variat wide with 33 to 27 Figures in reported been not have surgery of type any for cases (10) ten than fewer with hospitals NOTE: Figures 27,28,29,30,31,32,AND33Fracture type and o ANZHFR FIGURE 27 with theclassificationorcodingoftypefracture. wide variationfrom expectedaveragesmayreflect lownumbersofcases.Alternatively, variationmayhighlightissues Hospitals withfewerthanten(10)casesforanytypeofsurgeryhavenotbeenreported inFigures 27to33.Siteswith Figures 27,28,29,30,31,32,and33Fracturetypeoperationsbyoffracture ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH POW WAG WKO WHK WRE MDH WLG TWH GUH ARM CAM GOS CRG PMR GCH TWB DDH CHC SCG DUN MSB OHS PMB FMC ROK ROB QEH FOO RNS RPH NSH PCH SCU LMH RED CNS NSN ACH RYD BOX HKH TAM LOG LGH BHE PAH NEP SVD HUT HKB TGA RPA TNH STG FSH TSH TAH CFS FRA ABA JHH JHC TSV BKL H01 H04 H02 H03 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% FRACTURE TYPE ion from ion expected 10% Per / intertrochanteric (incl basal / basicervical) / basal (incl intertrochanteric / Per Intracapsular - undisplaced/ impacted 20%
coding of the type of fracture.
average 30% s
m
ay reflect low numbers of cases. cases. numbersof low reflect ay 40% 50%
perations by type of fracture 60% Subtrochanteric Intracapsular - displaced 70% Alternatively, variation may highlight 80%
90% 61 | | Page 100%
.
Sites
Procedure Figure 28–Procedure ANZHFR FEMORAL NECKFRACTURES FIGURE 28 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD WKO WAG MMH POW WRE WHK MDH TWH WLG PMR GCH CRG GUH ARM CAM TWB GOS CHC DDH DUN ROK PMB MSB ROB OHS QEH SCG FMC FOO CNS RNS PCH RPH RED NSN ACH RYD HKH SCU LMH NSH BOX LOG TAM LGH PAH TNH BHE HKB HUT SVD RPA NEP STG TGA TSH TAH FSH CFS FRA ABA JHH JHC TSV BKL H04 H02 H03 H01 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% PROCEDURE TYPEFORINTRACAPSULAR UNDISPLACED/IMPACTED 10% Intramedullary nail Intramedullary Hemiarthroplasty type for type 20% intracapsular undisplaced/impacted femoralneck fractures 30% Other Total hip replacement
40% 50%
Not known Not Cannulated screws 60% 70% Sliding hip screw hip Sliding 80% ANZHFR /ANNUAL REPORT2020 90% 62 | | Page 100%
47 PATIENT LEVEL AUDIT 48 PATIENT LEVEL AUDIT
ANZHFR Figure 29–Procedure NECK FRACTURES FIGURE 29 ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WHK WRE MDH WLG TWH PMR ARM CRG GCH GUH CAM TWB GOS CHC DUN DDH MSB PMB SCG QEH ROB ROK OHS FMC FOO ACH NSN NSH CNS PCH RED LMH HKH RPH RYD SCU RNS TAM BOX LOG HUT BHE TGA HKB LGH PAH TNH SVD RPA NEP STG TSH CFS FSH FRA TAH ABA JHC JHH TSV BKL H01 H03 H04 H02 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% PROCEDURE TYPEFORINTRACAPSULAR DISPLACED FEMORAL 10% Intramedullary nail Intramedullary Hemiarthroplasty type for type 20% intracapsular 30% Other Total hip replacement
displaced femoralneck fractures 40% 50%
Not known Not Cannulated screws 60% 70% Sliding hip screw hip Sliding 80%
90% 63 | | Page 100%
Figure 30–Procedure ANZHFR FIGURE 3O (INCL BASAL/BASICERVICAL) Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD MMH WAG WKO POW WRE WHK MDH WLG TWH GUH PMR GCH ARM CRG TWB CAM GOS DDH MSB ROB OHS CHC DUN FMC FOO SCG ROK PMB QEH RPH RED CNS NSN NSH PCH HKH RNS SCU BOX LOG ACH LMH RYD TAM TNH LGH SVD PAH HUT HKB BHE NEP RPA TGA STG FSH ABA FRA TAH CFS TSH JHC TSV JHH BKL H03 H04 H02 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% PROCEDURE TYPEFORINTERTROCHANTERICFRACTURE 10% Total hip replacement screw hip Sliding type for type 20% intertrochanteric 30% Other nail Intramedullary
40% fracture 50%
(incl (incl Not known Not Cannulated screws b 60% asal / b asal / asicervical) 70% ANZHFR /ANNUAL REPORT2020 Hemiarthroplasty
80% 90% 64 | | Page 100%
49
PATIENT LEVEL AUDIT 50 PATIENT LEVEL AUDIT
Figure 31–Procedure ANZHFR FIGURE 31 ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 NZ 2019 avg WMD MMH WKO POW WAG WRE WHK TWH MDH WLG GUH CRG CAM TWB ARM GOS PMR ROK QEH PMB MSB DDH SCG ROB OHS FMC FOO DUN CHC RYD RNS RED TAM LOG LMH PCH CNS SCU BOX RPH NSN ACH NSH RPA TNH NEP SVD LGH STG PAH HUT HKB BHE TGA TSH TAH CFS ABA FRA FSH JHC TSV JHH BKL H04 H03 H02 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% PROCEDURE TYPEFORSUBTROCHANTERICFRACTURES 10% Total hip replacement nail Intramedullary type for type 20% subtrochanteric 30% Other screw hip Sliding
40% fractures 50%
Not known Not Hemiarthroplasty 60% 70% Cannulated screws 80% 90% 65 | | Page 100%
ANZHFR Figure 32–Hemiarthroplasty:use of cement FIGURE 32 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH POW WKO WAG WHK WRE MDH TWH WLG ARM CRG CAM GUH PMR GCH TWB GOS DUN CHC ROB FMC MSB SCG DDH PMB ROK OHS QEH FOO LMH RNS CNS RPH PCH SCU ACH NSH TAM RYD HKH RED NSN LOG BOX PAH NEP RPA TNH SVD STG LGH BHE HUT HKB TGA CFS FRA FSH ABA TSH TAH JHH TSV JHC BKL H02 H04 H01 H03 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% HEMIARTHROPLASTY: USEOFCEMENT 10% 20% 30%
Cemented 40% 50%
Uncemented 60% 70% ANZHFR /ANNUAL REPORT2020 80% 90% 66 | | Page 100% 51
PATIENT LEVEL AUDIT 52 PATIENT LEVEL AUDIT
Figure 3–Totalhip replacement: cemented stem ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 FIGURE 33 ANNUAL REPORT2020 /ANZHFR NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WKO WAG POW WRE WHK WLG MDH TWH PMR GUH GCH CAM ARM CRG GOS TWB CHC DUN QEH PMB DDH FMC MSB SCG OHS FOO ROB ROK NSH HKH NSN ACH PCH RYD RED SCU LMH RNS RPH TAM CNS BOX LOG HUT TNH BHE HKB TGA LGH RPA SVD PAH NEP STG TAH FRA CFS FSH TSH ABA TSV JHC JHH BKL H04 H03 H02 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% TOTAL HIPREPLACEMENT: CEMENTEDSTEM 10% 20% 30%
Cemented 40%
50%
Uncemented 60% 70% 80% 90% 67 | | Page 100%
NURSE /QLD continually monitorourperformance. patients isvitaltothecontinuing effortstoimprovecare.TheANZHFRhipfracture dataallowsourhospitalto Having amultidisciplinaryteam workingcollaborativelytoimproveoutcomesforthis vulnerablecohortof able toconsistentlyfilltheallocated space. surgery atthebeginningoforthopaedicconsultant’s operatinglistprovedunsuccessfulduetonotbeing orthopaedics toadvocateforprioritisationofpatientswith hipfractures.Atrialofschedulingfracture emergency theatrelists.Adailyhuddleforoperatingtheatres withallsurgicaldisciplinespresentallows theatre andadditionofdailytraumalists,whichenables hipfracturesurgerytobeperformedoutsideofthe as soonappropriateandtherehasbeenimprovedaccess totheoperatingtheatrebyadditionofanew Anaesthetics havealsodevelopedanticoagulationguidelines toensurepatientsareablegetsurgery and optimizethemforsurgeryassoonpossible. during workinghours,toallowtheteamreviewpatients (oftenintheemergencydepartment) promptly andearlynotificationtotheorthogeriatricservice onpresentationtothehospital service. TheseincludeaNoFchecklistforruralfacilitiestoensurepatientsaretransferred This improvementhasbeenduetoseveralinitiativesimplementedwithinthehealth hospital hassignificantlyimprovedfrom58%in2018to80%2019. Executive Management.Havingsurgerywithin48hoursoffirstpresentationtoa Orthopaedics, Anaesthetics,OperatingTheatres,AlliedHealth,Geriatricsand group atToowoombaHospital.Thisincludesstakeholdersfrom of thekeyperformanceindicatorsforFracturedNoFworking Timetosurgeryforfracturedneckoffemur(NoF)patientsisone ANZHFR /ANNUAL REPORT2020 53 PATIENT LEVEL AUDIT 54 PATIENT LEVEL AUDIT weight bearingaftersurgery. respectively, are allowedfull New ZealandandAustralia, and 95%ofpatientsin Figure 34showsthat94% restrictions whenmobilising. to adhere toweight-bearing fracture surgeryare unable patients recovering from hip and there isevidencethat impacts surgicalfixation, full weight-bearingadversely is littleevidencetosuggest the surgicalfixation.There surgery forfearofdisturbing to fullyweightbearafter patients were notpermitted of function.Previously, many rehabilitation andrestoration after surgerypermitsearly unrestricted weightbearing Allowing immediate FIGURE 34 CARE POSTOPERATIVE SECTION 4: ANNUAL REPORT2020 /ANZHFR WEIGHT BEARINGSTATUS AFTERSURGERY Previously,many werepatients permittednot weight fully to bearafter surgery dis fearof for Allowing immediate unrestricted weight bearing aftersurgery permits early rehabilitationand restoration of function. ANZHFR Figure 34–Weightbearingstatusaftersurgery PostoperativeSECTION4: Care Aus Avg 2019 Aus Avg 2016 Aus Avg 2015 Aus avg 2018 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 Aus Avg 217 WMD MMH POW WKO WAG WRE WHK MDH TWH WLG ARM CAM CRG PMR GUH GCH TWB GOS ROK OHS QEH PMB FOO DDH DUN CHC MSB ROB FMC SCG HKH RPH RYD RNS NSN BOX RED LMH CNS ACH NSH TAM LOG SCU PCH SVD NEP STG RPA TNH LGH HUT HKB PAH BHE TGA TSH CFS FRA ABA TAH FSH JHC JHH TSV BKL H04 H02 H01 H03 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% 10%
Unrestricted weightbearing 20% 30%
40%
Restricted / non weight bearing 50%
60% 70% Not known Not 80% turbing theturbing surgical 90% 68 | | Page 100%
first timein2021. and itwillbereported forthe record ifthepatientwalked variable wasincludedto surgery. In2020,anew to mobilisethedayafter are giventheopportunity of patients,respectively, Australia, 85%and91% In NewZealandand be suitableformobilisation. and somepatientsmaynot opportunity wasprovided, mobilise; onlywhetherthe on whetherapatientdid Figure 35doesnotreport functional outcomes. associated withpoorer during hospitalisationis after surgery. Lowmobility bed, orwalk,onthefirstday to standupandsitoutof patients withtheopportunity mobilisation byproviding that encourageearly into serviceconfigurations Figure 35provides insight FIGURE 35 OPPORTUNITY FORFIRSTDAY MOBILISATION mobilise prior toinjury mobilise prior provided was opportunity the outcomes. functional poorer with associated opportunity to opportunity Figure 35 provides insight into service configurations service into insight provides 35 Figure Figure 35–Opportunity forfirstday mobilisation ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD POW MMH WKO WAG WRE WHK MDH TWH WLG CRG ARM CAM GCH TWB GUH PMR GOS SCG ROK QEH DDH OHS FMC MSB ROB DUN CHC FOO PMB RPH RED CNS HKH RYD LMH PCH RNS TAM SCU LOG BOX ACH NSH NSN TNH RPA NEP SVD LGH PAH STG HUT HKB BHE TGA FRA FSH ABA CFS TSH TAH JHH JHC TSV BKL H02 H03 H04 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% stand up and sit out of bed, or walk or bed, of out sit and up stand Opportunitygiven day 1 postsurgery 10% In New Zealand and Australia, 85% and 91% of patients, respectively, are given the opportunity opportunity the given are respectively, patients, 91%of 85%and Australia, and New Zealand . In 20% , and someand , patientsmay those as not such who mobilisation, bedid for not suitable 30%
Figure 35 does not rep not does 35 Figure
40% ,
on the first day after surgery. Low mobility during hospitalisation is
that encouragethat byearlyproviding thewithpatientsmobilisation Opportunitynot given day 1 post surgery 50%
ort on whether a patient did mobilise; only whether only mobilise; did patient whethera on ort 60% ANZHFR /ANNUAL REPORT2020 70% 80% Not known Not 90% 70 | | Page 100%
55 PATIENT LEVEL AUDIT PATIENT LEVEL AUDIT PATIENT
This year for the first time, Ryde and Hornsby Ku-ring-gai Hospitals (HKH), together with the Level 1 trauma centre at Royal North Shore Hospital, entered data into the ANZHFR. They form part of the Northern Sydney Local Health District (NSLHD) in New South Wales, and between the three facilities they see over 350 patients a year with hip fracture.
The teams at each hospital have used their participation in the ANZHFR to work with the NSW Agency for Clinical Innovation (NSW ACI) to bring some innovative hip fracture ideas to life. The introduction of early alert systems in Ryde Emergency, the development of a hip fracture pathway, and discussions with ICT about automating 120-day follow-ups were priorities for the team. Anna Butcher, Service Development Manager, Musculoskeletal, Integumentary and Trauma and Neurosciences Networks NSLHD: ‘I want to see continued exemplar patient care for everyone, including vulnerable elderly hip fracture patients and that will call for out-of-the-box multidisciplinary team thinking’.
Mary, who recently had a fall at her Hornsby home that resulted in her breaking her right hip, spoke about the care she received. “I was really worried that I might have to wait. It was reassuring for me and my family, that I received really prompt care and had my hip fixed the very next morning. My pain was well controlled and I was even up walking the next day after surgery.” Mary’s daughter, Sharon had praise for the staff: ‘Mum was in so much pain in the beginning, and the nurses, doctors and allied health staff worked to prioritise her care.’.
Our results, measured in hard data and patient stories, show how years of behind-the-scenes team work has led to successes in hip fracture care in Northern Sydney. Strong clinical-led steering groups with regular executive briefings using peer comparable data to present unambiguous evidence, is essential. Raising awareness of issues at all levels of our health service has given NSLHD clarity and transparency. Data has given us the opportunity to identify areas for improvement, and focus targeted solutions. It’s during these regular team meetings that Registry data is used to clarify concerns and identify areas to focus on. Our teams use the live Registry dashboard to isolate and target areas for improvement at individual hospitals - an approach that has allowed us to concentrate on site-specific solutions.
The next stage will be for all NSLHD hospitals to take ANZHFR data and use it to leverage further system-wide improvements, even in a health system that may find itself under enormous pressure. COVID-19 may pressure our hospitals, but the core business of caring for patients with a hip fracture will need to remain agile, targeted and responsive to continue to maintain safe quality care.
CLINICAL NURSE CONSULTANT / NSW
56 ANNUAL REPORT 2020 / ANZHFR outcome There good is evidence to support surgeons and physicianssharing the provision of hip fracture care to
ANZHFR byFigure 36–Assessed geriatricmedicine proportionas smallersites and non- theirac proportion assmallersites andnon-metropolitan sitesare lesslikelytohaveaccessageriatricmedicineservice. their acutehospitalstaycompared to91%inAustralia.Asmore hospitalsjointheRegistry, adrop maybeseeninthis outcome ofacutehipfracture care. InNewZealand,83%ofhipfracture patientssawageriatricianatsomestagein There isgoodevidenceto supportsurgeonsandphysicianssharingtheprovision ofhipfracture care toimprove the FIGURE 36 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD WAG WKO MMH POW WHK WRE MDH WLG TWH ARM GCH GUH PMR CAM CRG GOS TWB QEH SCG DUN CHC DDH FMC MSB ROK OHS ROB PMB FOO LMH PCH RPH SCU LOG NSN NSH ACH HKH CNS RNS RED RYD TAM BOX PAH HKB BHE TNH RPA TGA HUT LGH NEP SVD STG TAH ABA TSH CFS FSH FRA JHC TSV JHH BKL H01 H03 H02 H04 GIS % in Australia. As more hospitals join the Registry utethe hospitaljoin stay compared hospitals moreAs Australia. to 91in % INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT |
of acute of 0% ASSESSED BY GERIATRIC MEDICINE hip fracture 10% Yes 20% care .
In New Zealand, 83% of hip fracture patients saw a saw patients fracture hip 83%of New Zealand, In metropolitan sites are No 30%
No geriatricmedicine service available 40% 50% likely to ha to less likely
60% ve access to a geriatric medic geriatric a to access ve 70% ANZHFR /ANNUAL REPORT2020 Not known Not geriatrician at some stage in 80% , a drop a 90% may be seen this in 72 ine serviceine improve improve | | Page 100% the the
.
57 PATIENT LEVEL AUDIT 58 PATIENT LEVEL AUDIT having sustainedapressure injuryoftheskinduringacutehospitalstay. functional recovery andanincreased lengthofstay. InNewZealandandAustralia,4%ofpatientsare documentedas of pain,qualitylife,costscare, andmortality. Asacomplicationofhipfracture, itisassociatedwithdelayed A pressure injuryoftheskinisapotentiallypreventable complicationofhipfracture care andcanaffect aperson’s level Figure 37showstheproportion ofpatientsthatacquire anewpressure injuryoftheskinduringacutehospitalstay. FIGURE 37 ANNUAL REPORT2020 /ANZHFR of pain, quality of life, costs of care, and mortality A pressure injury of the skin is a potentially preventable stay. hospital acute the during skin the of injury pressure new a acquire that patients of proportion the shows 37 Figure ANZHFR Figure 37–Hospital acquired Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WHK WRE WLG MDH TWH PMR GCH CRG ARM CAM GUH TWB GOS CHC DUN DDH FMC SCG MSB PMB OHS ROK QEH ROB FOO NSH RED SCU ACH NSN RPH CNS PCH LOG RNS LMH RYD HKH TAM BOX TGA BHE HUT HKB LGH NEP TNH SVD RPA PAH STG TAH FSH TSH CFS ABA FRA JHC JHH TSV BKL H02 H01 H04 H03 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% HOSPITAL ACQUIRED PRESSURE INJURIESOFTHESKIN 10% 20% p ressure injuries ofthe skin 30%
No 40% . Ascomplication a
complication of hip fracture care fracture hip of complication Yes 50%
Not known Not 60%
of a hip fracture, 70%
it 80% is associated with delayedwithassociated is
and can affect a person’s level level person’s a affect can 90% 73 | | Page 100%
recognised thataspecialist fallsassessmentisnotalwayspossibleintheacutehospitalisedperiod. during theirinpatientstay. InAustralia,72%ofpatientsunderwentafallriskassessmentduringtheirin-patientstay. Itis of aplantoprevent furtherfalls.InNewZealand,76%ofpatientsare reported tohaveundergoneafallsassessment trained healthprofessional andcoverfallhistory, riskfactorsforfalls,includingamedicationreview, andformulation hip fracture patientsbeassessedfortheirindividualriskoffalls.Thisassessmentshouldconductedbyasuitably documented andputinplacetomanageidentifiedrisks.TheANZGuidelineforHipFracture Care recommends that Standard requires thateachhipfracture patientisassessedforfuture fallandfracture risk,andthataplanis A minimaltraumafracture isastrong predictor ofriskasecondfracture. TheHipFracture Care ClinicalCare FIGURE 38 assessed for their individual risk of falls. This assessment should be conducted by a suitably trained health professional professional health trained suitably a by conductedbe assessmentshould This falls. of risk individual their assessedfor manageto place in TheANZ risks. identified GuidelineFractureHip Ca for requires that each hip fracture patient is assessed for future fall and fracture risk, and that a that and risk, fracture and fall future for assessed is patient fracture hip each that requires A minimal trauma fracture is a strong predictor of risk of a secon ANZHFR Figure 38–Specialist fallsassessment Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD POW MMH WAG WKO WHK WRE TWH MDH WLG CRG GCH ARM CAM GOS TWB GUH PMR DDH SCG FMC ROB MSB QEH OHS ROK PMB FOO CHC DUN RPH PCH HKH RYD RNS RED CNS LMH SCU BOX TAM LOG NSN ACH NSH PAH TNH SVD RPA NEP LGH HUT STG HKB TGA BHE FSH ABA TSH CFS FRA TAH JHC JHH TSV BKL H03 H01 H02 H04 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | SPECIALIST FALLS ASSESSMENT 0% 10% Not relevant Yes- Further intervention not appropriate admission during Performed - Yes 20% 30%
40% 50%
d fracture. The Hip Fracture Care Clinical CareStandard 60% Not known Not No assessment clinic falls Awaits - Yes re recommends that hip fracture patients be patients fracture recommends re hip that 70% ANZHFR /ANNUAL REPORT2020 80% plan is documented is plan 90% 75 | | Page 100%
and put and
59 PATIENT LEVEL AUDIT 60 PATIENT LEVEL AUDIT under reported inFigure 39. the acutehospitalstay. Inbothcountries,alargeproportion ofpatientsare notassessedsuggestingdeliriummaybe Australia, 66%ofpatientshadanassessmentfordeliriumand24%were identifiedasexperiencing deliriumduring had anassessmentfordeliriumand24%were identifiedasexperiencingdeliriumduringtheacutehospitalstay. In was includedintheANZHFRdataset2018andthisissecondyearofreporting. InNewZealand, 55%ofpatients condition more commoninpeoplewithacognitiveimpairmentandmaybepoorlyrecognised. Assessmentofdelirium Delirium isanacutechangeinmentalstatuscommonamongolderpatientshospitalisedwithahipfracture. Itisa FIGURE 39 ANNUAL REPORT2020 /ANZHFR n assessmentan had NewZealand, In reporting. of year second the is this and 2018 in dataset ANZHFR the in included was condition more common people in with a cognitive impairment and may be poorly recognised. Delirium an is acute change mental in status common among older patients with hospitalised fracture. a hip Figure ofdelirium 39–Assessment ANZHFR Aus Avg 2019 Aus Avg 2018 NZ Avg 2019 NZ Avg 2018 WMD WKO WAG MMH POW WRE WHK WLG MDH TWH PMR CAM TWB ARM GUH CRG GCH GOS CHC DUN FMC QEH DDH ROB SCG MSB ROK OHS PMB FOO ACH NSN NSH LMH LOG SCU RNS PCH BOX RPH RED RYD HKH CNS TAM HUT BHE HKB PAH TGA RPA STG TNH NEP LGH SVD TAH TSH ABA CFS FSH FRA TSV JHC JHH BKL H01 H04 H02 H03 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% ASSESSMENT OFDELIRIUM
10% for deliri Assessed and not identified not and Assessed % were identified as experiencing delirium during the acute hospital hospital acute the during delirium experiencing as identified were24% umand 20%
30%
40% Assessed and identified and Assessed 50%
60% Not assessed Not 70% 80% Not known Not Assessment of delirium delirium Assessment of 90% 77
% of patients patients of 55% | | Page stay. In stay. 100% It is a It is
NURSE UNITMANAGER /SA to staff,isdoneatdaily4AT huddlediscussions. been commenced.Regular use oftheauditdata,andfeedback developed, andaseniornurse deliriumscreeningprojecthas delirium boardsusinginfographics postershavebeen Steering Committee.Delirium championshavebeenidentified, on cognitiveimpairment,andconvenedaimpairment network-wide approachanddevelopedaneducationin-service The SurgicalDivisionofSouthernAdelaideLHNhavetaken a nurses withat-riskpatients. accessibility), andtheintroductionofatooltoengagefamily and local neckoffemurpatientinformationpackage(toimprove of clinicaldocumentation,theinclusion4ATin impairment workshop.Thebundlealsoincludedarestructure inform preventionstrategies,aswellaface-to-face cognitive factors, andthesignificanceofusingascreeninginstrumentto module, anin-servicefocusedonrecognisingdeliriumrisk bundle includedanonlinecognitiveimpairmenteducation An interventionbundlewasdevelopedandimplemented.The informed thenextsteptotailorinterventionslocalcontext. assessment, preventionandmanagementofdelirium.Thiswork their perceptionsofthebarriersandenablerstorecognition, Initially, wesoughtbaselinedatafromfocusgroups.Cliniciansdiscussed was initiatedtoimprovethisareaofpatientcare. Flinders MedicalCentresawanopportunityforimprovement,soaproject Delirium isabarriertopatientrecovery,wellbeinganddischarge. identify anyissuesandrectifytheminrealtime. these excellentresultscontinue,weconstantlyreviewourdatato with deliriumtoimproveoutcomesforourpatients.Toensure comorbidities arekeytoreducingdeliriumandmanagingthose Early interventionsandcomprehensivemanagementofmedical identify patientswhorequireclosernursingcareandsupervision. more. Earlyidentificationofpatientsatriskdeliriumhelpsus assessment iscarriedoutwithpatientswhohaveascoreof1or ease ofadministrationtheassessmenttools.Further,cognitive the 4ATinourintegratedelectronicmedicalrecordstofacilitate This hasbeenachievedwitheducationanddedicatedtoolslike assessment screen,improvinggreatlyin2020to96%. In 2019,only65%ofourpatientsreceivedadeliriumandcognitive patients, resultingina31percentincreasepatientscreening. first fewdaysofadmissionforallfracturedneckfemurelderly orthopaedic wardtoincreasethecognitivescreeningwithin The GeriatricsteamhasworkedwiththeNursingstaffonour adversely affectspatientoutcomesandlengthofstayinhospital. management ofpatientswithdelirium,recognisingthatdelirium team hasworkedtoimprovethedetection,assessmentand During 2019-2020,TownsvilleUniversityHospital’sOrthogeriatrics ANZHFR /ANNUAL REPORT2020 61 DELIRIUMPATIENT LEVEL AUDIT 62 PATIENT LEVEL AUDIT countries, alargeproportion ofpatientsnotassessedsuggestsmalnutritionmaybeunderreported inFigure 40. Australia, 65%ofpatientshadanassessmentformalnutritionand21%were identifiedasbeingmalnourished. Inboth New Zealand,44%ofpatientshadanassessmentformalnutritionand13%were identifiedasbeing malnourished.In malnutrition, clinicalassessmentofaperson’s nutritionalstatusisencouragedduringacutehospitaladmission.In and mortalityadecrease inreturn topre-fracture functioning.Whilstthere isnogoldstandard forassessing already malnourished.Malnutrition inolderpeoplewithafractured hipisassociatedwithincreased morbidity Hip fracture patientsare athighriskofmalnutritionduringhospitaladmission,ortheymay beadmittedtohospital CLINICAL MALNUTRITIONASSESSMENT FIGURE 4O ANNUAL REPORT2020 /ANZHFR malnutrition, c mortality and a decrease return in topre morbidit increased with associated is hip fractured a with people older in Malnutrition malnourished. already theyor admission, may hospital during be admittedmalnutrition hospital of riskto highfractureare Hippatientsat Figure 40–Clinica ANZHFR Aus Avg 2019 NZ Avg 2019 WMD WKO WAG MMH POW WHK WRE MDH WLG TWH PMR CAM TWB GCH ARM CRG GUH GOS DDH OHS SCG DUN CHC PMB MSB FMC FOO ROK ROB QEH SCU CNS RNS ACH NSN RPH HKH RED PCH RYD LOG LMH NSH TAM BOX RPA HUT BHE SVD PAH NEP TNH LGH HKB STG TGA ABA FRA CFS TSH FSH TAH JHC JHH TSV BKL H02 H01 H04 H03 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% linical assessment of a person’s nutritional status is en is assessmentstatus person’snutritional a linical of 10% alnutrition l malnutrition Not malnourished Not 20% assessment 30% - fracture functioning. Whilst functioning. fracture
40% Malnourished 50%
60% couraged during acute hospital admission. I admission. hospital acute during couraged
Not done there is no gold standard for assessingfor standard goldthere no is 70% Not known Not 80% 90% 79 | | Page 100% y and n Newn
Figure 42–Dischargeto Figure 41–Average lengthof stay in acute ward ANZHFR because ofthe movementofpatientsbetween hospitals,includingto theprivatesector, thisisnotcurrently available. community that candeliverhome-based rehabilitation. Mediantotallengthof stayisthepreferred measure but A multitudeoffactorscontribute toacutelengthofstayincludingaccesssubacute facilitiesorservicesinthe to rehabilitation. to rehabilitation. InAustralia,themedianlengthofstay intheacuteward is7.6daysand49%are transferred both NewZealandandAustralia. ThemedianLOSinNewZealandis6.4daysand 57%ofpatientsare transferred Variation isseeninmeanandmedianlengthofstay(LOS)theacuteward itissimilarto theprevious yearin ACUTE WARD FIGURE 41 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 Figure 42–Dischargeto Figure 41–Average lengthof stay in acute ward ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD POW MMH WAG WKO WHK WRE MDH TWH WLG GUH CAM GCH CRG ARM GOS TWB PMR MSB DDH OHS ROB FMC PMB QEH ROK SCG DUN CHC FOO HKH RNS SCU LMH RED RPH RYD PCH CNS BOX TAM LOG NSH NSN ACH LGH RPA SVD TNH PAH NEP HKB HUT STG TGA BHE TAH CFS TSH ABA FRA FSH JHH TSV JHC BKL H04 H03 H02 H01 GIS INV IPS TIU LIV QII WMD MMH POW WAG WKO | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | WHK WRE MDH TWH WLG GUH GCH CRG CAM ARM PMR GOS TWB DDH DUN CHC FMC QEH ROK OHS ROB SCG MSB PMB FOO NSH NSN ACH RYD PCH CNS RED HKH RNS SCU LMH RPH BOX TAM LOG TNH LGH HUT RPA SVD NEP PAH HKB BHE STG TGA CFS TSH TAH FRA FSH ABA JHH JHC TSV BKL H02 H01 H04 H03 GIS INV TIU IPS LIV QII 0 | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0 AVERAGE LENGTH OFSTAY IN Average LOS Average 5 Average LOS Average 5 rehabilitation rehabilitation Days Days 10 Median LOS Median 10 Median LOS Median
15 15
20
20
Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015
NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 DISCHARGE TOREHABILITATION FIGURE 42 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 Discharged to Rehabilitation WMD MMH WAG WKO POW WHK WRE MDH WLG TWH PMR CAM GCH CRG ARM GUH GOS TWB DUN CHC DDH SCG FMC QEH ROK OHS ROB MSB PMB FOO SCU LMH RPH NSH NSN ACH RYD PCH CNS RED HKH RNS LOG TAM BOX HUT TNH LGH PAH HKB BHE RPA SVD NEP TGA STG TAH FRA FSH CFS TSH ABA JHH JHC TSV BKL H02 H01 H04 H03 GIS INV TIU IPS LIV QII Discharged to Rehabilitation WMD POW MMH WAG WKO WHK WRE MDH TWH WLG CAM GCH CRG ARM GUH GOS TWB PMR DDH MSB PMB QEH ROK FMC OHS ROB DUN SCG FOO CHC RED HKH RNS RYD PCH CNS LMH RPH SCU LOG BOX TAM NSH NSN ACH RPA SVD LGH NEP TNH PAH HUT STG HKB TGA BHE CFS TSH TAH ABA FRA FSH JHH JHC TSV BKL H04 H02 H01 H03 GIS INV 0% IPS TIU LIV QII 0% 20%
20% 40% 40% ANZHFR /ANNUAL REPORT2020 60% 60% Other Discharge Other 81 Other Discharge Other 80% 81 80% | | Page | | 100% Page 100%
63 PATIENT LEVEL AUDIT 64 PATIENT LEVEL AUDIT
Figure 43–Discharge ANZHFR DISCHARGE DESTINATION FROMACUTE WARD FIGURE 43 ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH WAG WKO POW WHK WRE MDH TWH WLG CAM PMR GUH GCH CRG ARM TWB GOS DDH CHC DUN FMC QEH MSB OHS PMB ROB SCG ROK FOO LMH SCU RYD RED ACH NSH NSN RNS RPH CNS PCH HKH BOX LOG TAM PAH BHE HKB HUT RPA SVD TNH LGH NEP STG TGA FRA TAH CFS FSH ABA TSH JHH JHC TSV BKL H04 H01 H02 H03 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
10% Deceased Other /specialty /ward hospital Other Rehabilitation unit -public Private residence (including unit in retirement village) d estination fromacute ward 20%
30%
40% 50%
60% Not known Not facility care residential in care term Short Rehabilitation unit -private Residential agedcare facility 70% 80% 90% 83 | | Page 100%
area to explore why the variation exists and moreimportantly and exists variation thewhy explore to area Australia, slightly lower than 16% the previousyear. Wide variation in practice is evident. More work is needed in this fracture New in Overall,37% peopleof from agedresidential careafter areacute their hip transferredtheircare for rehabilitation for ANZHFR Figure 4–Residentsof aged care facilities discharged to r area toexplore whythevariation existsandmore importantly, theimpact ithasontheindividuallonger term. Australia, slightly lowerthan16%theprevious year. variationin practiceisevident.More workis needed inthis Wide fracture inNewZealand. Thisisconsistentwiththeprevious year. Thiscontrastswith14%ofhipfracture patients in Overall, 37%ofpeoplefrom residential aged care are transferred forrehabilitation aftertheiracutecare fortheirhip (PUBLIC ORPRIVATE) FIGURE 44 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 WMD WKO MMH POW WAG WHK WRE MDH WLG TWH GCH ARM GUH CRG PMR CAM GOS TWB DUN CHC PMB SCG DDH ROK FMC OHS ROB QEH MSB FOO LMH SCU PCH RPH NSN NSH ACH RED HKH RYD RNS CNS LOG TAM BOX PAH LGH STG TNH SVD NEP RPA BHE HUT HKB TGA FSH ABA CFS TAH TSH FRA JHH TSV JHC BKL H04 H03 H02 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
RESIDENTS OFAGED CAREFACILITIES DISCHARGEDTOREHABILITATION Zealand. This is consistentwiththe is previous This withZealand.year.14% contrasts This hi of 10% 20% 30%
40% To Rehab 50%
, the impact it has on the individual longer thetheon term.individual , has impact it ehabilitation (p Not to Rehab to Not 60% 70% ublic or private) ANZHFR /ANNUAL REPORT2020 80% p fracture patients in 90% 84 | | Page 100%
65 PATIENT LEVEL AUDIT 66 PATIENT LEVEL AUDIT In New Zealand, 71 New Zealand, In preadmission impaired cognition Figure 45–Transferred ANZHFR hip fracture, were transferred for rehabilitation after their ac longer term. work isneededinthisarea toexplore whythevariationexistsandmore importantly, theimpactithasonindividual with pre-existing variationinpracticeisevident.More cognitive impairment inprivateresidences inAustralia.Wide hip fracture, were transferred forrehabilitation aftertheiracutecare. Thiscontrastswith61%ofhipfracture patients In NewZealand,71%ofpeoplewithapre-existing cognitiveimpairment,wholivedinaprivateresidence before their FROM PRIVATE RESIDENCEWITHPREADMISSION IMPAIRED COGNITION FIGURE 45 ANNUAL REPORT2020 /ANZHFR Aus Avg 2019 Aus Avg 2018 NZ Avg 2019 NZ Avg 2018 WMD MMH POW WKO WAG WRE WHK WLG MDH TWH GCH GUH PMR CRG CAM ARM TWB GOS DDH DUN CHC PMB QEH OHS MSB ROK FMC ROB SCG FOO ACH RYD HKH SCU RED LMH RNS PCH CNS NSN NSH LOG TAM BOX RPH HUT LGH TNH PAH SVD BHE HKB NEP STG TGA RPA FRA CFS ABA TSH TAH FSH JHC JHH TSV BKL H04 H03 H02 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% TRANSFERRED TOREHABILITATION (PUBLICORPRIVATE) FORPATIENTS 10% % of people with a pre- a with people of % to rehabilitation (public or private) for for private) or (public rehabilitation to 20% 30% existingcognitive impairment, privateresidencea who in livedbefore their To Rehabilitation
40% 50%
ute care. This contrasts with 61 Not to Rehabilitation patients fromp 60% 70% rivate 80% residence with % of hip fracture patients patients fracture hip of % 90% 85 | | Page 100%
fracture trauma minimal a prior totheir fracture The majority of people admitted withhip a fracture were not on any form of
ANZHFR Figure 46-Bone protection medication on admission fracture prevention inbothcountries,andacare gapthathasbeenresilient tochangeoverthefiveyearsof reporting. (bisphosphonates, denosumaborteriparatide).Theseproportions suggestasignificantandongoingcare gapinsecondary not takinganymedicationtoprotect theirbonesandonly9%were recorded astakingactivetreatment forosteoporosis taking activetreatment forosteoporosis aboveandbeyondcalciumand/orvitaminD.InAustralia,62%ofpeoplewere In NewZealand,61%ofpeoplewere nottakinganymedicationtoprotect theirbonesandonly9%were recorded as minimal traumafracture, and fracture prevention servicesare effective inreducing subsequentfractures. prior totheirfracture. Thisis despiteevidencedemonstratingthatupto50%ofthesepeoplewillhavealready sustaineda The majorityofpeopleadmittedwithahipfracture were notonanyformofpharmacologicaltreatment forbonehealth BONE PROTECTION MEDICATION ONADMISSION FIGURE 46 Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD MMH POW WAG WKO WRE WHK WLG MDH TWH ARM GUH CAM GCH CRG PMR GOS TWB DDH DUN CHC PMB MSB OHS SCG ROK ROB QEH FMC FOO ACH NSH SCU RPH PCH HKH RYD BOX CNS RNS RED NSN LOG LMH TAM BHE SVD NEP RPA LGH HKB HUT TGA TNH STG PAH TAH TSH ABA CFS FSH FRA JHH JHC TSV BKL H02 H04 H03 H01 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0%
10% No bone protection medication Yes- Bisphosphonates, denosumab or teriparatide . Thisis despite evidence demonstrating that up to50% of these people will have already sustained , and fractureand , prevention services are effective reducing in subse 20% 30%
40% 50%
60% Not known Not Yes- Calciumand / or vitamin D only pharmacological treatment for bone health 70% 80% quent fractures ANZHFR /ANNUAL REPORT2020 90% 87 | | Page .
100%
67 PATIENT LEVEL AUDIT 68 PATIENT LEVEL AUDIT towards preventing anotherfracture. the datacontinuestohighlightsubstantialvariationandasignificantcare gapandmissedopportunity tocontribute compares withto9%ofpatients onadmission.Whilstnotalwayspossibletoinitiatetreatment intheacutesetting, Australia, 25%ofpatientslefthospitalonbisphosphonateordenosumabteriparatide.Forbothcountries,this In NewZealand,31%ofhipfracture patientslefthospitalonbisphosphonateordenosumabteriparatideandin available andsothedatareported here mayunderestimate thenumberofpeople treated forosteoporosis. acute settingbutinformationontreatments initiatedaftertransfertoanotherfacility, suchasasubacutehospital,are not including initiationoftreatment forosteoporosis inhospitalwhere appropriate. TheRegistryisabletocapture thisinthe The HipFracture Care ClinicalCare Standard requires anassessmentandmanagementplanforfuture fracture prevention, FIGURE 47 BONEPROTECTION MEDICATION ONDISCHARGE ANNUAL REPORT2020 /ANZHFR capture this in the acute settacutethe in this capture prevention, including initiation of treatment for osteoporosis in hospital where appropriate. The Registry is able to The Hip Fracture CareClinical Care Standard requires an assessment andmanagement plan for future fracture ANZHFR Figure 47–Bone protection medication on discharge Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WMD POW MMH WKO WAG WHK WRE MDH WLG TWH CRG PMR GUH GCH ARM CAM TWB GOS ROB QEH DUN CHC FMC DDH ROK PMB MSB OHS SCG FOO LMH RNS PCH CNS RED NSN LOG ACH NSH SCU HKH RYD RPH BOX TAM PAH STG HUT LGH HKB BHE TNH TGA NEP RPA SVD ABA FSH FRA TSH CFS TAH JHH JHC TSV BKL H04 H03 H02 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% No bone protection medication Yes- Bisphosphonates, denosumab or teriparatide 10% ing but information on treatmentsinformationon a but ing as such after anothertransfer facility, to initiated 20% 30%
40% 50%
60% Not known Not Yes- Calciumand / or vitamin D only 70% 80% 90% 89 | | Page 100%
their bonesfrom afracture taking anymedication toprotect More than6O%ofpatientsarenot CLINICAL NURSESPECIALIST/NEWZEALAND appropriate bonemedication”. Vitamin Dasaninpatientorisdischargedwiththe patient eithercommencesonbisphosphonatesor her physicianbackground.Sheensuresthatthe hip patientswithhergeriatricianhatbutalsoutilizes ANZHFR statistics.Shenotonlyreviewsthefractured 2018, shehasmadeasignificantcontributiontoour Geriatrician hasbeenemployedsinceNovember has hadaresidentgeriatrician.Inthetimeour It hasbeenover10yearssinceHauoraTairawhiti ANZHFR /ANNUAL REPORT2020 ANZHFR /ANNUAL REPORT2020 69 69 PATIENT LEVEL AUDIT 70 PATIENT LEVEL AUDIT least 10records. patients andhaveat than 80%ofeligible have followedupmore only reported ifthey to 59,hospitalsare days. Forfigures 49 51% haddatafor120 120 days.InAustralia, records haddatafor New Zealand,81%of prioritisation. In in resources and local differences the variationreflects via telephone,and the treating hospital completed bystaff at hospital. Followupis follow upforeach the rateof120day Figure 48shows FIGURE 48 12O DAY FOLLOW-UP SECTION 5: ANNUAL REPORT2020 /ANZHFR 12O DAY FOLLOW UP
ANZHFR up Figure 48–120dayfollow Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD MMH WKO WAG POW WHK WRE MDH TWH WLG CRG PMR ARM GOS GUH GCH CAM TWB DDH CHC QEH FMC PMB OHS DUN ROK SCG MSB ROB FOO HKH RED RPH RYD SCU RNS NSN NSH BOX CNS PCH ACH LOG LMH TAM LGH SVD HUT STG RPA BHE HKB TGA TNH PAH NEP TAH TSH CFS FRA FSH ABA JHC JHH TSV BKL H02 H03 H01 H04 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% 10% 20%
30% 120 day follow up
40% 50%
No 120 day follow up 60% 70% 80% 90% 92 | | Page 100%
FIGURE 49 REOPERATION WITHIN12ODAYS Thank you so much for calling to see how my husband is doing. I am very impressed. impressed. very am I doing. is husband my how see to calling for much so you Thank PATRICIA /AGE75 His surgerywentwellbuthemayhavetriedtoohardandhastakenacoupleof steps backwardssincegettinghome.Butoverall,heisdoingwell.”
Figure 49–Reoperation ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 NZ Avg 2016 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 WMD MMH POW WKO WAG WRE WHK MDH WLG GCH CRG TWB CAM GUH ARM PMR TWB GOS DDH QEH PMB OHS DUN CHC MSB SCG ROK ROB FMC FOO HKH SCU RYD RPH RNS RED NSN BOX CNS LMH PCH ACH NSH TAM LOG LGH SVD BHE HUT STG PAH NEP RPA TNH HKB TGA TAH CFS TSH FRA ABA FSH JHH JHC TSV BKL H03 H02 H01 H04 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% 10% / NEWZEALAND within 120days 20% No Reoperation 120 30%
40% Reoperation 120 50%
60% Not known Not 70% 80% ANZHFR /ANNUAL REPORT2020 90% 93 | | Page 100%
71 PATIENT LEVEL AUDIT 72 PATIENT LEVEL AUDIT New ZealandMinistryofHealthtoensure accuracyofthesurvivaldata. data onsurvivalislikelytobecorrect, theintentioninfuture istolinkwiththeNationalMortalityCollectionwithin In NewZealand,dateofdeathisavailableinhospitalinformationsystemswithinafewdays.Whilethismeansthatthe will informkeystakeholdersandthebroader healthsystemontheimpactofinitiativestoimprove hipfracture care. outcome hasbeenanobjectiveoftheRegistrysinceitsstart,andusethisindependentaccuratedataset also reported usinglinked data from theNationalDeathIndex(figures 54to57).UtilisingNDIdataforthisimportant up toreport survivalat120 daysafteradmissiontohospitalwithhipfracture. InAustraliaforthefirsttime,survivalis This year, Figure 50includesrecords forwhichthisoutcomeisunknownasthefigure usesdataobtainedduringfollow FIGURE 5O ANNUAL REPORT2020 /ANZHFR up to report survival after hip fracture. In Australia, this yearfor the firsttime, This year, Figure 50includes records for which this outcome is unknownas the figure Survival at 120 days 120 Figure 50–Survivalat ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 WMD MMH POW WKO WAG WRE WHK MDH WLG TWH GUH CRG TWB PMR GOS ARM GCH CAM DDH CHC DUN FMC ROB ROK QEH PMB OHS SCG MSB FOO LMH PCH HKH CNS TAM NSN ACH NSH SCU RYD RPH RNS RED LOG BOX TNH LGH NEP PAH HUT HKB BHE SVD RPA TGA STG ABA FRA CFS FSH TSH TAH JHC JHH TSV BKL H03 H02 H04 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% SURVIVAL AT 12ODAYS 10% 20% Survived at 120 days 30%
40% Not survived at 120 days 120 at survived Not 50%
60%
70% survival is reported survivalis linkedusing data Unknown uses data obtained during follow follow during obtained data uses 80% 90% 94 | | Page 100%
in NewZealandandAustralia,respectively, reported receiving boneprotection medication. reduce theriskofanother fracture. Whenreporting onlythosewhohavebeenfollowedupat120days,45%and42% risk ofanotherfracture. Followupratesare lowinAustraliaand38%were receiving boneprotection medicationto New Zealand,followupisover80%and45%ofpatientsreported receiving boneprotection medicationtoreduce the admission tohospitalforahipfracture andforthefirsttimeincludes records forwhichthisoutcomeisunknown.In Figure 51showsthemajority ofpatientsare notprovided withmedicationtoprevent future fractures at120daysafter FIGURE 51 admission to hospital for for hospital to admission Figure 51 shows the majority of patients are not provided with med with provided not are patients of majority the shows 51 Figure ANZHFR Figure 51–Bone Protection Medication at 120days risk of another fracture another of risk and 80% over is up follow NewZealand, Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 NZ Avg 2017 NZ Avg 2019 NZ Avg 2018 WMD WAG POW WKO MMH WHK WRE MDH WLG TWH CRG GUH PMR GOS ARM GCH TWB CAM DDH DUN FMC ROB ROK QEH PMB OHS MSB SCG FOO CHC HKH CNS LMH PCH ACH NSN SCU RYD RPH RNS RED LOG BOX TAM NSH LGH NEP TNH PAH HKB BHE HUT SVD RPA STG TGA FRA CFS FSH ABA TSH TAH JHC JHH TSV BKL H03 H02 H01 H04 GIS INV IPS TIU LIV QII BONE PROTECTION MEDICATION AT 12ODAYS | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% No bone protection medication Yes- Bisphosphonates, denosumab or teriparatide 10% . Follow up rates are38 lowand Austral in ia a hip fracture 20% 30%
and for the first time includes records for which this outcome is unknown outcomeis this which for records includes time first the for and % of patients reported patients of 45%
40%
50% receiving bone prot % ication to preventto ication future 60% were receiving bone protection medication to medication protection bone receiving were Not known Not only D vitamin and/or Calcium - Yes 70% ANZHFR /ANNUAL REPORT2020 ection medicationreduceection to the 80%
fractures 90% 96 at 120 days after | | Page 100%
. In
73 PATIENT LEVEL AUDIT 74 PATIENT LEVEL AUDIT of patientsinAustraliareturned totheir ownhomeat120daysaftertheirhipfracture surgery. home at120daysafteradmission.Whenonlyusingrecords withfollowup,80%ofpatientsinNewZealandand62% who livedathomepriortohipfracture, 59%and35%inNewZealandAustralia,respectively, returnedtotheirown fracture. Thisyear, Figure 52includesrecords forwhichthisoutcomeisunknown.Forallrecords in2019,ofthose Being abletoreturn homeafterahipfracture isoneofthemostimportantoutcomesforapatientfollowinghip to privateresidence orisnotknown. Figure 52captures allpatientswhocamefrom privateresidence andwere returned toprivateresidence, didnotreturn FIGURE 52 ANNUAL REPORT2020 /ANZHFR or either null or not known. known. not or null either or This chart capturesall patients who came from Private Residence and where returned to private residence, not returned Figure 52–Return ANZHFR reported respectively, Australia, and NewZealand fracture another of risk thereduce Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 WMD MMH WKO WAG POW WHK WRE WLG MDH TWH CAM GUH GCH PMR CRG TWB GOS ARM CHC DUN DDH ROB FMC FOO ROK QEH PMB OHS MSB SCG LMH NSN NSH ACH HKH CNS PCH TAM SCU RYD RPH RNS RED LOG BOX HUT NEP PAH TNH TGA HKB BHE LGH SVD RPA STG FSH ABA FRA CFS TSH TAH JHC JHH TSV BKL H04 H03 H02 H01 GIS INV TIU IPS LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% RETURNED TOPRIVATE RESIDENCEAT 12ODAYS Return to private residence 120 residence private to Return 10% to private residence at 120 days 120 at residence private ed to
20% .
When reporting only those who have been followed up at 120 days, 45% an 45% days, 120 at up followed beenhave who those only When reporting 30%
40% Non return to private residence 120 receiving bone protection medication
50%
60% 70% Nullor not known at 120 days 80% .
90% 97 | | Page 100% d 42% in 42%in d
at 120days.Lowratesoffollowupsuggestcautionwiththeinterpretation ofFigure 53forAustralia. to preadmission walkingability at120days.InAustralia,19%ofpatientshavereturned topreadmission walkingability year, Figure 53includesrecords forwhichthisoutcomeisunknown.InNewZealand,49%ofpatientsreported areturn From apatientperspective, therecovery offunctionincludingmobilityisacriticaloutcome followingahipfracture. This FIGURE 53 ow rates of follow up suggest caution with the interpretation of Figure 53 Figure of interpretation the with caution suggest up at 120follow days.of rates Low to to 53 Figure year, out critical a is mobility including function of recovery the perspective, patient a From Figure 53–Return ANZHFR Aus Avg 2019 Aus Avg 2018 Aus Avg 2017 Aus Avg 2016 NZ Avg 2019 NZ Avg 2018 NZ Avg 2017 NZ Avg 2016 preadmission walking abili WMD POW MMH WKO WAG WRE WHK MDH TWH WLG ARM CAM GCH GUH CRG GOS TWB PMR DDH FMC SCG MSB ROK PMB QEH OHS ROB DUN CHC FOO RPH PCH RNS CNS HKH RYD RED SCU LMH BOX LOG TAM ACH NSH NSN SVD RPA NEP PAH LGH TNH STG BHE HKB HUT TGA TAH TSH CFS FRA ABA FSH JHH TSV JHC BKL H02 H04 H03 H01 GIS INV IPS TIU LIV QII | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 0% RETURNED TOPRE-FRACTURE MOBILITYAT 12ODAYS Nullor not known at 120 days Return to preadmission walking ability at 120 days includes records for which this outcome is unknown is outcome this which for records includes 10% to pre-fracture mobility at120days ed to 20% ty at 120tyat Australia, In days. 30%
40% % of patients have returned to preadmissi to returned have patients of 19% 50%
Not returnedto preadmission walkingability at 120 days .
60% In New Zealand In 70% % of patients reported a return a reported patients of 49 % , ANZHFR /ANNUAL REPORT2020 come following a hip fracture. hip a comefollowing
for Australia. 80% 90% 99
on walking ability ability walking on | | Page 100%
This This 75 PATIENT LEVEL AUDIT 76 PATIENT LEVEL AUDIT FIGURE 55 FIGURE 54 number ofpatients,datapointsshould‘funnel’toanarrower distributionontherightsideoffunnel plot. dot represents ahospital,andthex-axisrepresents hospitalvolume.Becauseofthehigherprecision from thegreater beyond hospitalcare, butremains animportantoutcomeforpatients.Dataare presented infunnelplots,where each mortality isacommonbenchmarkforhipfracture care. 365daymortalityismore likelytobeinfluencedbyfactors and dataispresented fortwofollow-upperiodsandinways.Theare 30and365days.30-day Mortality hasbeenadjustedforage,sex,premorbid leveloffunction(mobility),fracture type,residence typeandASA available atthetimeofprinting. reported totheRegistry, from eachsite,from thestartof2016toend2018asthiswasonlyinformation mortality foreachhospitalpatientstreated intheprevious year. Inthisreport, pooleddataisusedforallpatients National DeathIndex(NDI).Infuture, theANZHFRwillundergoregularly linkagewiththeNDIandwillreport the30-day For thefirsttime,AnnualReportincludesmortalitydataderivedfrom linking registry datawiththeAustralian ANNUAL REPORT2020 /ANZHFR ANNUAL REPORT2020 /ANZHFR Figure 56 Funnel plot of adjusted mortality rate at 365 days 365 at rate mortality adjusted of plot Funnel 56 Figure 1.6 Version ANNUAL2020 REPORT ANZHFR| a of plot Caterpillar 55 Figure adjusted of plot 54 Funnel Figure H22 H08 H21 H12 H30 H48 H47 H14 H20 H26 H27 H41 H07 H35 H01 H33 H29 H24 H18 H43 H32 H10 H28 H46 H09 H45 H31 H03 H06 H36 H23 H44 H39 H13 H37 H11 H49 H40 H25 H34 H02 H38 H04 H16 H17 H42 H05 H19 H15 0% FUNNELPLOT OFADJUSTEDMORTALITY RATE AT 3ODAYS CATERPILLAR PLOT OFADJUSTEDMORTALITY AT 3ODAYS Figure 56 Funnel plot of adjusted mortality rate at 365 days 365 at rate mortality adjusted of plot Funnel 56 Figure Funnel plot of adjusted adjusted of plot 54 Funnel Figure 1.6 Version 2020 ANNUALREPORT ANZHFR| a of plot Caterpillar 55 Figure H33 H29 H24 H18 H43 H32 H10 H28 H46 H09 H45 H31 H03 H06 H36 H23 H44 H39 H13 H37 H11 H49 H40 H25 H34 H02 H38 H04 H16 H17 H42 H05 H19 H15 H22 H08 H21 H12 H30 H48 H47 H14 H20 H26 H27 H41 H07 H35 H01 5% 0% djustedmortality at 30 mortality rate at 30 days Figure 56 Funnel plot of adjusted mortality rate at 365 days 365 at rate mortality adjusted of plot Funnel 56 Figure Funnel plot of adjusted adjusted of plot 54 Funnel Figure a of plot Caterpillar 55 Figure ANZHFR | ANNUAL REPORT 2020 Version 1.6 Version ANNUAL2020 REPORT ANZHFR| H22 H08 H21 H12 H30 H48 H47 H14 H20 H26 H27 H41 H07 H35 H01 H33 H29 H24 H18 H43 H32 H10 H28 H46 H09 H45 H31 H03 H06 H36 H23 H44 H39 H13 H37 H11 H49 H40 H25 H34 H02 H38 H04 H16 H17 H42 H05 H19 H15 0% 5% djustedmortality at30
mortality rate at 30 days
10%
days 5%
djustedmortality at30
10% mortality rate at 30 days
days
10% 15%
15% days
15% 20% Hospital 20% 103 | | 20%
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FIGURE 57 FIGURE 56 comfortable withtheformatandfindings,weplantonamehospitalsinfuture reports. As thisisthefirsttimethatmortalityhasbeen reported intheseways,hospitalshavenotbeennamed.Ifare https://www.hqsc.govt.nz/our-programmes/mrc/pomrc/publications-and-resources/publication/3372/ New Zealandreport examiningperioperativemortalityafterhipfracture. Itcanbeaccessedusingthefollowinglink: Review Committee,anindependentcommitteethatadvisestheHealthQuality&SafetyCommission,released a Whilst linkeddataisnotavailableforNewZealandinthisreport, in2018,theNewZealandPerioperativeMortality smaller volumeare likelytohavelonger‘legs’. according tothemortality rate andthe‘legs’ofcaterpillarrepresent the95%confidenceinterval.Hospitalswith graphs are ‘caterpillar’plots(namedbecauseoftheirresemblance toacaterpillar)where eachhospitalisranked Confidence limitssetat2and3standard deviationsare includedsothatoutlierhospitalscanbeseen.Theother 1.6 Version ANNUAL2020 REPORT ANZHFR| a of plot Caterpillar 57 Figure H22 H47 H21 H14 H16 H28 H31 H07 H01 H48 H20 H30 H09 H29 H23 H43 H26 H18 H41 H13 H25 H08 H24 H27 H35 H32 H10 H33 H06 H44 H37 H11 H02 H49 H45 H39 H34 H36 H12 H15 H42 H03 H46 H38 H19 H40 H17 H04 H05 5% CATERPILLAR PLOT OFADJUSTEDMORTALITY AT 365DAYS FUNNEL PLOT OFADJUSTEDMORTALITY RATE AT 365DAYS 10% 1.6 Version 2020 ANNUALREPORT ANZHFR| a of plot Caterpillar 57 Figure H22 H47 H21 H14 H16 H28 H31 H07 H01 H48 H20 H30 H09 H29 H23 H43 H26 H18 H41 H13 H25 H08 H24 H27 H35 H32 H10 H33 H06 H44 H37 H11 H02 H49 H45 H39 H34 H36 H12 H15 H42 H03 H46 H38 H19 H40 H17 H04 H05 5% djustedmortality at 365 days 1.6 Version 2020 ANNUALREPORT ANZHFR| a of plot Caterpillar 57 Figure
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77 PATIENT LEVEL AUDIT This is the 8th Facility Level Audit of Australian and New Zealand hospitals undertaking definitive management of older people with a hip fracture. The aim of the audit is to document over time the services, resources, policies, protocols and practices that exist across both countries. This year, 117 hospitals have completed the audit and the results are provided here. Comparisons, where provided, are with last year and/or the first year of patient and facility level reporting, which was 2016.
78 ANNUAL REPORT 2020 / ANZHFR FACILITY LEVEL AUDIT FACILITY
ANZHFR / ANNUAL REPORT 2020 79 80 FACILITY LEVEL AUDIT FIGURE 59 FIGURE 58 INFORMATION GENERAL RESULTS 1: ANNUAL REPORT2020 /ANZHFR
Figure 54Number ofhip fractures treated 2019calendar yea Information 1General Results Figure 54Number ofhip fractures treated 2019calendar yea Information 1General Results here. practices that existyear, This acros117 countries. both s here. people with a hip fracture. The aim of theaudit is todocument over time the services, resources, policies,protocols and practices that existyear, This acros117 countries. both s This the is 8 people with a hip fracture. The aim of theaudit is todocument over time the services, resources, policies,protocols and This the is 8 Introduction Introduction ANZHFR ANZHFR Figure 55Number ofhip fractures treated 2014-2020 Figure 55Number ofhip fractures treated 2014-2020 was 2016. was 2016.
NumberNumber of hospitals of hospitals NumberNumber of hospitals of hospitals
10 10 15 15 20 20 25 25 30 30 10 10 15 15 20 20 25 25 30 30 35 35 Comparisons Comparisons 0 0 5 5 5 5 0 0 | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 1.6 Version 2020 ANNUALREPORT | NUMBEROFHIPFRACTURES TREATED 2O14-2O2O NUMBER OFHIPFRACTURES TREATED 2O19 CALENDAR YEAR th Facility LevelNew and Facility Australian th Auditof hospitals Zealand LevelNew and Facility Australian th Auditof hospitals Zealand 0-50 0-50
0-50 0-50 , ,
where provided where provided 51-100 51-100 2014 2014 51-100 51-100
, ,
are with last year last with are year last with are 2015 2015 101-150 101-150 101-150 101-150
Number of hip fracturesof hip treated Number fracturesof hip treated Number 2016 2016 Number of hip fractures hip of Number fractures hip of Number and/ and/
hospitals have completed the au hospitals have completed the au 151-200 151-200 151-200 151-200 2017 2017 or the first year of patient and facility level reporting, which or the first year of patient and facility level reporting, which
r r 2018 2018 201-300 201-300 201-300 201-300 undertaking definitive management of older undertaking definitive management of older 2019 2019 301-400 301-400 301-400 301-400 2020 2020 dit andthe results are provided dit andthe results are provided 102 102 401+ 401+ 401+ 401+ | | | Page Page
ANZHFR Figure 56Orthogeriatric care servicemodel by hospital 2014 (22/117) were not sure frailty was if collected. not collect frailty, 17% (20/117) reported usingthe Clinical Frailty did respondedthey (62/117) 53% 2020, In assessment. for used commonly mostthe is used) (if tool which nor context, Australian numberand NewZealand the of validatedin used are toolstools butthese it is not knowidely howwn increasinglybeingThereassessmentfracture. an usedafterprognosisas hip areand inform a to planning and risk of pe older in common is Frailty know. not of hospitals, the CAM by 33% (39/117), another tool by 15% (18/117) and 9% (10/117) either did not use a tool or did hospital will use a pre auditfacility has asked for information on which validated used tool is to undertake assessment most is as a it likely bu years two hospitals submitteda response to both questions. Delirium assessment hasbeen included in the patientlevel auditfor This year, two new questions were asked to betterunderstand thetools used to assess delirium and patient frailty.All report models common most two the 28% of (33/117). hospitals A weekday orthogeriatric service liaison was reported 31% in (36/117) These of hospitals. are r arrangementsor people whohave fractured their hip, represented by the increasing numbersof ANZ hospitals reporting shared care Overthebeeight seencan years aregeriatricianslevelproviding it that greaterthe facility of audit, oversight older of practitioners, suchas orthopaedicsurgeons, anaesthetists, general physicians and general access to a geriatric medicine service must look for ways to provide orthogeriatric care that utilises alternative medic bowel andbladder management, and monitoring of cognition and planning process. Implicit in this role are many of the aspects basic of careincluding nutrition, hy preparation for surgery. They take a lead in the patient’s post improvedtermshort outcomes. has not been determined,older patients cared for by bothphysicians and surgeons have surgery more quickly and spec both involves care Orthogeriatric fracture. Research evidence supports the provision of integrated orthogeriatric care to older people who have sustained a hip m 2Service Results FIGURE 6O the twomostcommonmodelsreported. service wasreported in31%(36/117)ofhospitals.Theseare 28% ofhospitals(33/117).Aweekdayorthogeriatricliaison service. In2020,shared care arrangementswere reported in arrangements orregular inputbyanorthogeriatricliaison increasing numbersofANZhospitalsreporting shared care people whohavefractured theirhip,represented bythe that geriatriciansare providing greater oversightofolder Over theeightyearsoffacilitylevelaudit,itcanbeseen anaesthetists, generalphysiciansandpractitioners. medical practitioners,suchasorthopaedicsurgeons, ways toprovide orthogeriatriccare thatutilisesalternative have accesstoageriatricmedicineservicemustlookfor cognition andcoexistingconditions.Hospitalsthatdonot care, bowelandbladdermanagement, andmonitoringof aspects ofbasiccare including nutrition,hydration,pressure planning process. Implicitin thisrole are manyofthe post-operative medicalcare andcoordinate thedischarge preparation forsurgery. Theytakealeadinthepatient’s involved inthepreoperative optimisationofthepatientin and improved shorttermoutcomes. Thegeriatricianis both physiciansandsurgeonshavesurgerymore quickly model hasnotbeendetermined,olderpatientscared forby of orthopaedicsandgeriatricmedicinewhilethebest hip fracture. Orthogeriatric care involvesbothspecialties orthogeriatric care toolder people whohavesustaineda Research evidencesupports theprovision ofintegrated OF CARE SERVICE MODEL RESULTS 2: Number of hospitals 10 20 30 40 50 0 | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT |
t the data does not provide insight into the tools preferred by clinicians at treating hospitals. This year, This the treating preferredat hospitals. the tools providedoes theinto not data t byinsight clinicians 1 egular input by an orthogeriatric liaison service.2020, In liaison orthogeriatricby an shared egularcare arrangementsinput were reported in ORTHOGERIATRIC CARESERVICE MODEL BY HOSPITAL 2O14-2O2O ferred tool, rather than different tools for individual patients. The 4At was used by 43% (50/117) odel of care of odel 2 2014 ople who sustain a hip fracture and is associated with length of stay and complications. It is is It complications. and stay of length with associated is and fracture hip a sustain who ople The geriatricianinvolved is in the pre- 3 ed. 2015
Orthogeriatric care model by hospital
ialties of orthopaedics and geriatricmedicineand orthopaedics of whiletheialties and best model 4 2016 2017 5
- operative medical care and coordinate the discharge discharge the coordinate and care medical operative -2020 Scale, 11% (13/117) used another scale and 19% and scale another used (13/117) 11% Scale, coexisting conditions. Hospitals that do not have not do that Hospitals conditions. coexisting 2018 erative optimisation of the patient in operativein thepatient of optimisation 6 2019 7 not sure iffrailtywascollected. 11% (13/117)usedanotherscaleand19%(22/117)were 17% (20/117)reported usingtheClinicalFrailtyScale, 2020, 53%(62/117)responded theydidnotcollectfrailty, (if used)isthemostcommonlyusedforassessment.In the NewZealandandAustraliancontext,norwhichtool but itisnotknownhowwidelythesetoolsare usedin after hipfracture. There are anumberofvalidatedtools assessment ofriskandtoinformplanningprognosis complications. Itisincreasingly beingusedas an fracture andisassociatedwithlengthofstay Frailty iscommoninolderpeoplewhosustainahip or didnotknow. 15% (18/117)and9%(10/117)eitherdidnotuseatool of hospitals,theCAMby33%(39/117),anothertool individual patients.The4AT wasusedby43%(50/117) will useapreferred tool,ratherthandifferent toolsfor to undertakeassessmentasitismostlikelyahospital asked forinformationonwhichvalidatedtoolisused at treating hospitals.Thisyear, thefacilityaudithas not provide insightintothe toolspreferred byclinicians the patientlevelauditfortwoyearsbutdatadoes questions. Deliriumassessmenthasbeenincludedin patient frailty. Allhospitalssubmittedaresponse toboth understand thetoolsusedtoassessdeliriumand This year, twonewquestionswere askedtobetter 2020
practitioners. 8 dration, pressure care, 103 | |
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ANZHFR /ANNUAL REPORT2020
9. 8. 7. 6. 5. 4. 3. 2. 1. al al Other No formalserviceexists determines whichpatients arereviewed service (2015)whereaconsultsystem A medicalliaisonservice(2014)/ patients arereviewed consult systemdetermineswhich / geriatricservice(2015)wherea An orthogeriatricliaisonservice(2014) of hipfracturepatients(2-3timesweekly) physician orGPprovidesintermittentreview A medicalliaisonservicewhereageneral (2-3 timesweekly) review ofallolderhipfracturepatients geriatric medicineprovidesintermittent An orthogeriatricliaisonservicewhere working week) all olderhipfracturepatients(dailyduring physician orGPprovidesregularreviewof A medicalliaisonservicewhereageneral working week) of allolderhipfracturepatients(dailyduring geriatric medicineprovidesregularreview An orthogeriatricliaisonservicewhere medicine forallolderhipfracturepatients. admission betweenorthopaedicsandgeriatric is jointresponsibilityforthepatientfrom A sharedcarearrangementwherethere 81 FACILITY LEVEL AUDIT 82 FACILITY LEVEL AUDIT 88% (107/121)reported in2016. This isconsistentwithlastyearandanincrease from hospitals didutiliseaprotocol fortheprevention ofVTE. 2020, 93%(109/117)ofrespondents reported thattheir agreed protocols toprevent itsonsetare common.In VTE isaseriouscomplicationoflowerlimbtraumaand VENOUS THROMBOEMBOLISM(VTE) without aCT/MRIprotocol. delayed diagnosesare more likelytooccurinhospitals to surgerydueadelayeddiagnosis.Itisunknownif Zealand, and7%ofpatientsinAustralia,are delayed since Figures 24and25show12%ofpatients inNew improve thediagnosisofclinicallysuspiciousfractures, the introduction ofaprotocol maybeanopportunityto change overthepastfiveyears.Forsomehospitals, compares with50%(60/121)in2016showinglittle imaging ofasuspectedfracture wasinconclusive.This protocol orpathwaytoaccesseitherCTMRIifplain In 2020,54%(63/117)reported theavailability ofa IMAGING (MRI) COMPUTED TOMOGRAPHY (CT)/MAGNETICRESONANCE level reporting. in 2016,thefirstyearofbothpatientlevelandfacility 72% (87/121)reporting theuseofahipfracture pathway 60% forthewholeacutejourney. Thiscompares with pathway: 30%intheemergencydepartmentonlyand In 2020,90%(105/117)reported havingahipfracture HIP FRACTUREPATHWAY collaboration betweenhealthcare professionals. hip fracture, andtherefore improve communicationand specific aspectsofcare foragivencondition,suchas cost andsatisfactionofthatcare. Theyhelptosequence provision ofhealthcare thataimtoimprove thequality, Protocols andpathwaysare interventionsusedinthe ELEMENTS OFCARE PROTOCOLS AND RESULTS 3: ANNUAL REPORT2020 /ANZHFR or ‘frequently’. nerve blocksforpostoperativepainrelief ‘always’ 78% (91/117)responded thatpatientswere offered blocks preoperatively ‘always’or‘frequently’ and (107/117) responded thatpatientswere offered nerve and postoperativepainmanagement.Thisyear, 91% are offered localnerveblocksaspartofpreoperative The facilitylevelauditalsoasksrespondents ifpatients reported theuseofaprotocol orpathwayforpain. compare with2016when 61% (74/121)ofrespondents reporting apathwayinthe ED.Thisyear’s responses greatest changeintheproportion ofrespondents of hospitalsusingapathway(72%lastyear)withthe These results showanincrease intheoverallproportion department onlyand48%forthewholeacutejourney. at 84%(98/117)ofhospitals:36%intheemergency In 2020,aprotocol orpathway forpainwasavailable PAIN PATHWAY to surgeryreported inFigures 24and25. past fiveyearsandmaycontribute totheprimarydelay planned theatre list hasremained relatively steadyinthe The proportion ofANZhospitalsreporting accesstoa year butanimprovement from 39%(47/121)in2016. trauma list,forhipfracture patients. Thisissimilartolast access toaplannedoperatingtheatre list,orplanned In 2020,46%(53/117)ofrespondents reported having operated onascheduledlistindaytimeworkinghours. recommends thatolderhipfracture patientsare The ANZGuidelineforHipFracture Care inAdults PLANNED THEATRE LIST ‘always’ or‘frequently’. when 69%(84/121)reported choicewasoffered last year, itdoesrepresent anincrease from 2016 ‘always’ or‘frequently’. Whilstthisislowerthan reported routinely offering achoiceofanaesthesia of anaesthesia.In2020,77%(90/117)hospitals if hipfracture patientsare routinely offered achoice audit commencedeightyearsago.Thequestionasks This questionhasremained constantsincethe facility CHOICE OFANAESTHESIA FIGURE 62 FIGURE 61 ensures thedayofsurgery doesnotnegativelyimpact discharge. Provision ofaccesstoweekendtherapy short termoutcomesandrecovery ofmobilityafter surgery forahipfracture ismore likelytoresult inpoorer prevent complications.Low, ordelayed,mobilityafter surgery helpstorestore movementandfunction Mobilisation onthedayof,orafter, hipfracture WEEKEND THERAPY Figure 58Australian hospitals reported elements ofcare Figure 57NewZealand hospitals reported elements ofcare Figure 57NewZealand hospitals reported elements ofcare ANZHFR ANZHFR Figure 58Australian hospitals reported elements ofcare
% Proportion% Proportion of Australian of Australian hospitals hospitals % Proportion% Proportion of New of New Zealand Zealand hospitals hospitals 100 100 100 100 10 10 20 20 30 30 40 40 50 50 60 60 70 70 80 80 90 90 10 10 20 20 30 30 40 40 50 50 60 60 70 70 80 80 90 90 0 0 0 0 NEWZEALANDHOSPITALS REPORTEDELEMENTSOFCARE | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | 1.6 Version 2020 ANNUALREPORT | AUSTRALIAN HOSPITALS REPORTEDELEMENTSOFCARE Shared care MOC Shared care MOC Shared care MOC Shared care MOC protocol/pathway protocol/pathway protocol/pathway protocol/pathway 2013 2013 ED ED ED ED 2013 2013
CT protocol /MRI CT protocol /MRI CT protocol /MRI CT protocol /MRI 2014 2014 2014 2014 2015 2015
VTE protocolVTE protocolVTE VTE protocolVTE protocolVTE
2015 2015 Elements of hip fracture care Elements of hip fracture care Elements of hip fracture care Elements of hip fracture care 2016 2016 2016 2016 Pain pathway Pain pathway Pain pathway Pain pathway the pastfiveyears. is similartoprevious yearsandisrelatively unchangedin access toweekendphysiotherapyservices.Thisfigure respondents reported theirhospitalasproviding routine the rehabilitation process. In2020,82%(96/117)of
2017 2017
2017 2017 Anaesthetic choice Anaesthetic choice Anaesthetic choice Anaesthetic choice 2018 2018 2018 2018 Scheduled theatre Scheduled theatre Scheduled theatre Scheduled theatre 2019 2019 list list list list 2019 2019 ANZHFR /ANNUAL REPORT2020 Weekend therapy Weekend therapy Weekend therapy Weekend therapy 2020 2020 2020 2020 106 106 Data collection Data collection Data collection Data collection | | | Page Page
83 FACILITY LEVEL AUDIT 84 FACILITY LEVEL AUDIT reported at41%(48/117). services, theavailabilityoffracture liaisonservicesis initiatives andconsistentevidencesupportingthese successfully withOsteoporosis NZ.Despitethese available inallDistrictHealthBoards andhaspartnered a nationalapproach tomakingfracture liaisonservices with osteopeniaandosteoporosis. NewZealandhas are successfulinreducing refracture ratesinpeople management andfollowupofminimaltraumafractures Dedicated resources allocatedtotheidentification, FRACTURE LIAISONSERVICE based rehabilitation (Table 1andFigure 59). and offsite rehabilitation; 50%reported accesstohome recovery. In2020,44%reported accesstobothonsite defined care, are recommended tofacilitatefunctional rehabilitation program forthosepatientsneedingmore early dischargehome,ortoastructured Structured, multidisciplinaryprogrammes supporting encouraged asitleadstoimproved functionalmobility. Early mobilisationandrehabilitation shouldbe REHABILITATION HOSPITAL STAY BEYOND THEACUTE RESULTS 4: ANNUAL REPORT2020 /ANZHFR was reported by26%(30/117). information ontheprevention offuture fallsandfractures hospital. Theroutine provision ofindividualisedwritten this year, 56%(66/117)reported providing thisattheir fracture hasbeenseenovertheyearsofaudit, and of writteninformationontreatment andcare afterhip or theirfamilycarer. Asteadyincrease intheprovision about care shouldincludediscussionwithpatientsand/ media andappropriate languages.Allkeydecisions about hipfracture treatment andcare inarangeof recommends offering patients,ortheirfamily, information The ANZGuidelineforHipFracture Care inAdults PATIENT ANDCARERINFORMATION respectively. lower at58%(68/117),49%(57/117)and22%(26/117), osteoporosis, oracombined fallsandboneclinic,are high at91%(106/117).Accesstopublicclinicsforfalls, Again in2020,accesstoorthopaedicclinicsremains OUTPATIENT CLINICS REPORTING SPECIFICSERVICES BEYOND THEACUTE HOSPITAL STAY FIGURE 63 SPECIFIC SERVICES BEYOND THEACUTE HOSPITAL STAY TABLE 1 Routine provisionwritteninformation Access toapublicosteoporosisclinic Access toapublicorthopaedicclinic Access tohome-basedrehabilitation written informationonpreventionof Routine provisionofindividualised Access toapublicfallsandbone ANZHFR
ANZHFR fractures future falls and of prevention on written information individualised Routine provision of fractures future falls and of prevention on written information individualised Routine provision of Access torehabilitationonsite Fracture LiaisonService(FLS)
% Proportion% Proportion of hospitals of hospitals reporting reporting availability availability of services of services Access toapublicfallsclinic on treatmentandcareafter PROPORTION OFNEWZEALANDANDAUSTRALIAN HOSPITALS REPORTING 100% 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 0% future fallsandfractures | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | | ANNUAL REPORT 2020 Version 1.6 Version 2020 ANNUALREPORT | PROPORTION OFNEWZEALANDANDAUSTRALIAN HOSPITALS
onsite and offsite onsite and offsite rehabilitation rehabilitation Access to Access Access to Access health clinic hip fracture and offsite Access to home- Access to home- rehabilitation rehabilitation based based n/a# n/a#
2013 2013 2013 Fracture Liaison Fracture Liaison 72% 16% 35% 41% 15% 68% 47% n/a# n/a# Service (FLS) Service (FLS) n/a# n/a# 2014 2014
Reported services beyond the acute hospital stay Access to a public Reported services beyond the acute hospital stay Access to a public 2014 90% 15% 32% 43% 20% 64% 37% 27% n/a#
falls clinic falls falls clinic falls 2015 2015 27% 27%
2016 2016 osteoporosis clinic Access to a public osteoporosis clinic Access to a public 2015 91% 18% 40% 57% 21% 41% 41% 27% 41%
27% 27% 2017 2017
2016 Access to a public Access to a public 90% 17% 48% 64% 25% 36% 37% 27% 38% falls and bone falls and bone health clinic health clinic 2018 2018 27% 27%
2019 2019 2017 Access to a public Access to a public orthopaedic clinic orthopaedic clinic 89% 16% 40% 58% 33% 40% 33% 27% 39% 24% 24% 2020 2020 ANZHFR /ANNUAL REPORT2020
2018 written information written information Routine provision 93% 20% 44% 60% 36% 42% 36% 24% 47% Routine provision on treatment and on treatment and care aftercare hip care aftercare hip fracture fracture 22% 22% 108 108
2019 written information written information 96% 20% 50% 62% 42% 41% 41% 22% 51% Routine provision Routine provision on prevention of of individualised on prevention of of individualised future falls and future falls and | | | | fractures fractures Page Page 26% 26%
2020 91% 22% 49% 58% 41% 50% 44% 26% 56%
85 FACILITY LEVEL AUDIT APPENDIX 1 : ANZHFR STEERING
APPENDICES GROUP MEMBERSHIP
The ANZHFR is based at the Falls, Balance and Injury Research Centre at Neuroscience Research Australia (NeuRA). Members of the ANZHFR Steering Group are:
MEMBERS OF THE ANZHFR STEERING GROUP ARE: Professor Jacqueline Close, Geriatrician Co-Chair Professor Ian Harris, Orthopaedic Surgeon Co-Chair Ms Elizabeth Armstrong (Australian Registry Manager) Mr Brett Baxter (Physiotherapist, Australian Physiotherapy Association) Dr Jack Bell (Advanced Accredited Practising Dietitian, Dietitians Australia) Prof Ian Cameron (Rehabilitation Physician, Australasian Faculty of Rehabilitation Medicine) A/Prof Mellick Chehade (Orthopaedic Surgeon, Australian and New Zealand Bone and Mineral Society) Dr Owen Doran (Emergency Medicine Physician, Australasian College of Emergency Medicine) A/Prof Kerin Fielding (Orthopaedic Surgeon, Royal Australasian College of Surgeons and Osteoporosis Australia) Mr Stewart Fleming, (Webmaster) Ms Christine Gill (CEO, Osteoporosis New Zealand) Dr Roger Harris (Geriatrician, Australian and New Zealand Society for Geriatric Medicine) Dr Sarah Hurring (Geriatrician, Clinical Lead New Zealand) Mr Angus Jennings (Orthopaedic Surgeon, New Zealand Orthopaedic Association) Dr Angel Hui-Ching Lee (Geriatrician, Royal Australasian College of Physicians) Dr Catherine McDougall (Orthopaedic Surgeon, Australian Orthopaedic Association) Dr Sean McManus (Anaesthetist, Australian and New Zealand College of Anaesthetists) A/Prof Rebecca Mitchell (Injury Epidemiologist, Australian Institute Health Innovation, Macquarie University) A/Prof Marinis Pirpiris (Orthopaedic Surgeon, Victoria) Dr Gretchen Poiner (Consumer) Dr Hannah Seymour (Geriatrician, Australian and New Zealand Society for Geriatric Medicine) Ms Anita Taylor (Nurse Practitioner, Australian and New Zealand Orthopaedic Nurses Association) Ms Nicola Ward (New Zealand National Coordinator) Dr Mark Wright (Orthopaedic Surgeon, New Zealand)
ATTENDEES Ms Linda Roylance (Secretariat) Ms Karen Lee, ANZHFR Project Officer
86 ANNUAL REPORT 2020 / ANZHFR AND WEREMAINCOMMITTED TO HAS IMPROVED OVER TIME, DRIVING ANDREPORTING WITH HIPFRACTURES THAT IMPROVEMENT INTO THEFUTURE OF PEOPLE THE CARE ANZHFR /ANNUAL REPORT2020 87 FACILITY LEVEL AUDIT