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Hip FractureEnhanced Recovery Guidelines Hip Fracture – Enhanced Recovery Guidelines? Trust wide Business Group ?? LocalState Document Type: GuidelineAPPROVAL / VALIDATIONSurgery, GI and Critical Care Business GroupDATE OF APPROVAL / VALIDATIONOctober 2018INTRODUCTION DATEOctober 2018DISTRIBUTIONAnaesthetic DepartmentEmergency DepartmentTrauma and Orthopaedic DepartmentOrthogeriatric DepartmentInpatient TherapiesActive RecoveryREVIEWOriginal Issue DatePrimary Version 2.1Review Date June 2020CONSULTATION Anaesthetic DepartmentEmergency DepartmentTrauma and Orthopaedic DepartmentOrthogeriatric DepartmentInpatient TherapiesActive RecoveryEQUALITY IMPACT ASSESSMENT ? Screening □ Initial □ Full RELATED APPROVED TRUST DOCUMENTSN/AAUTHOR/FURTHER INFORMATIONSimon Ghalayini - T&O ConsultantTHIS DOCUMENT REPLACESNEW DOCUMENTDocument Change History:Issue NoPageChanges made (include rationale and impact on practice)Date1N/AN/A2Revision following document launchSeptember 2018 Introduction to the documentThis document outlines the protocols and guidelines for each stage of the Hip fracture enhanced recovery pathway at Stepping Hill Hospital.2.0 Statement of intent/purpose of the documentThis document is intended to ensure that staff involved in the care pathway of hip fracture patients are aware of and understand the enhanced recovery guidelines, and the expectations in the management of hip fracture patients at Stepping Hill Hospital. The intention is that these guidelines are followed where possible for each patient in order to minimise variation in the standard and quality of care, improve clinical outcomes, and optimise achievement of best practice tariff. As the document has been created with the help of the Trust’s partners in the Greater Manchester Orthopaedic Alliance, as well as NHS organisations elsewhere, it is anticipated this document will be shared with these organisations to edit and implement if desired.Summary of the documentThis document covers guidelines from the clinical presentation of a hip fracture patient in the emergency department, through to surgery, post-operative management, rehabilitation and discharge.Roles and ResponsibilitiesIt is the role and responsibility for all staff involved in the clinical management of hip fracture patients at Stepping Hill Hospital to be aware of these guidelines and to follow the guidelines relevant to their particular part of the pathway where they are involved in caring for hip fracture patients.Primary Care – Pre - eventReduce risk of falls.Reduce risk of osteoporosis.Identify and reduce co-morbidities & their complications.Consider factors that may delay surgery and discharge from acute care (e.g. use of medications such as anticoagulants).Emergency Department (ED) – See Appendix 4ED to assess fully including medical state.Confirmed Neck of Femur Fracture on X-Ray – referral to Orthopaedic On-Call team.Diagnosis with X-ray AP Pelvis and Lateral of injured hip.Calibrated AP of hips to be done if intra-capsular fracture.Inconclusive X-ray with clinical suspicion of Neck of Femur Fracture.Urgent CT scan requested directly by ED (ED Middle grade or ED Consultant must be involved in decision to request).Orthopaedic On-Call Team will see patient in ED and review CT Scan to assess for presence of fracture. (Radiology will formally report CT Scan within 5 days).If continued doubt remains as to presence of fracture on CT scan after review by On Call Orthopaedic team then escalate to Radiology for Urgent reporting – CT scan must have been reviewed by Orthopaedic Middle Grade or above. Radiology must be contacted for an urgent report. The requirement for an urgent radiology report will be guided by degree of?clinical urgency/ level of clinical suspicion of fracture if none seen on CT scan by Orthopaedic On-Call.MR Scan may need to be considered if continued uncertainty after X-ray and CT Scan on a case-by-case basis.Confirmed Neck of Femur Fracture.Neck of Femur ICP to be completed and followed by on call Orthopaedic Doctor.Immediate urgent referral to Orthogeriatrics or On-Call Medical team where significant co-existent medical condition present.6.1 Analgesia / other drugs in Emergency Department (ED)Minimise opiate requirements through use of:Fascia Iliaca Block performed by ED.IV Paracetamol given by ED.Reduction of blood loss following fracture:Tranexamic acid either 1g orally or 1g by slow IVI if not contraindicated.7.0 Admission and Pre – Operative careAll patients with Neck of Femur Fracture should be admitted to the Hip Fracture Unit (D2) within 4 hours of presentation.All patients admitted with Neck of Femur Fracture should be admitted under joint orthopaedic and Orthogeriatric Care.Medications including Analgesia to be prescribed onto ePMA by On-Call Orthopaedic team on or before admission to D2. For analgesia be guided by NOF protocol on ePMA.All patients must be reviewed by Orthogeriatrician within 72 hours of admission.Pre-op AMTS must be completed.Ensure Thromboprophylaxis prescribed according to thromboprophylaxis protocol if not already anticoagulated. Patients admitted during day time to receive first dose of Clexane up to 20:00hrs on day of admission. If after 20:00hrs defer Clexane until timing of planned surgery known.7.1Antihypertensive Medication – Established treatmentPost-operative hypotension is a significant problem in this group of patients.Consider omitting routine anti-hypertensives pre-operatively.Beta blockers should not be omitted.Routine drugs should not be withheld where pre-operative hypertension is a significant problem.7.2 Haemoglobin <10g/dlHb < 10 g/dl should be transfused 1- 2 units as soon as possible pre-operatively, with the haemoglobin to be rechecked following transfusion.Only in exceptional cases should surgery be delayed to await this transfusion.7.3 Atrial Fibrillation – Uncontrolled (>90bpm)Seek urgent advice from Medical On-Call at admission to establish control of AF. 7.4 Anticoagulation – Established treatment on admission (Refer to Anticoagulation Appendices)Patients normally treated with anticoagulation should have this corrected on admission according to the flow diagram in Appendix 1.All patients requiring vitamin K to reverse warfarin treatment should receive it before they leave the Emergency Department.7.5 Nottingham Hip Fracture ScoreThe Nottingham hip fracture score should be documented by the trauma nurse for each patient.It can guide discussions with the patient and their next of kin about the nature of the injury, surgery and resuscitation status. Criteria 3 points??Age 66-85 yrs. 4 points ??Age > 86 yrs. 1 point ??Male 1 point??Admission Hb ≤ 10 g/dl 1 point ??Admission AMTS ≤ 6 1 point ??Number of comorbidities ≥ 2 11 point ??Living in an institution 21 point ??Malignancy within last 20 yrs. 3Total score /10Score 0 1 2 3 4 5 6 7 8 9 10 Risk 0.7% 1.1% 1.7% 2.7% 4.4% 6.9% 11% 16% 24% 34% 45% Explanation notes 1 Comorbidities include MI, angina, AF, valvular heart disease or hypertension, CVA/TIA, COPD/asthma, diabetes or pre-existing renal failure (not AKI). 2 Respite care, nursing homes and residential homes count as institutions. Living with relatives, carers or in warden controlled accommodation does not. 3 Non-invasive skin cancer is not counted and can be excluded from the NHS.7.6 Acceptable reasons for cancellation /delay of surgeryImminent death.Correctable serious cardiac arrhythmias.Uncontrolled heart failure.Severe pneumonia.Severe uncontrolled diabetes e.g. DKA.INR = > 1.8Severe anaemia Hb < 87.7 Resuscitation statusResuscitation status should be routinely discussed as part of the admission process. All patients with capacity should be consulted.Where patients lack capacity to consent, operative risk should routinely be discussed with next of kin. For patients without capacity, a call to the next of kin to discuss risk and resuscitation status is good practice. Resuscitation status should routinely be part of this discussion.Where resuscitation status has not been discussed pre-operatively, it is reasonable for the anaesthetist to include this discussion as part of the pre-operative assessment. Any resuscitation decision made by the anaesthetic team should be reviewed by the orthogeriatric consultant at the first opportunity.Where the staff managing a patient do not reach consensus regarding the need for discussion / agreement of DNAR status, surgery should not be delayed. Resuscitation status should be routinely discussed at the theatre team huddle, and for those patients with this outstanding a clear plan made as to who will undertake this, and when it will be done.Where consensus cannot be reached with regards to a DNAR decision / discussion, the patients should remain FOR resuscitation. Documentation of this position should be entered in the case notes as evidence that resuscitation status has been considered.For patients who lack capacity, surgeon or anaesthetist should contact next of kin immediately after surgery, to offer an update, and to ask about resuscitation wishes.All patients leaving theatre recovery should have either have a documented resuscitation decision, or a clear plan as to when this will be undertaken and by whom.7.8 Length of Stay: Family and Patient ExpectationsTrauma nurse to confirm with patient and family on admission that discharge will occur as soon as safely possible. Most patients will have been discharged by Day 14. 8.0 SurgeryScheduled for planned trauma list.Perform surgery within 36 hours of presentation to ED or within 36 hours of diagnosis if existing in patient.Performed by appropriately experienced surgeon or trainee with adequate appropriate supervisionIf surgery being performed by appropriately experienced Trainee with Consultant unscrubbed, Consultant must scrub in if Guidewire not accurately placed within femoral head (for DHS or IM Nail) OR femoral head not removed (for Hemiarthroplasty) within 20 minutes of commencing Operation.Surgery to ideally allow Immediate Full Weight-Bearing post-operatively.Surgeon to populate National Hip Fracture Database Form with surgical details once surgery completed.8.1 Surgical ProcedureThis will be determined by the fracture and patient factors.Intracapsular Fracture – DisplacedCemented Hemiarthroplasty Use Heraeus Copal G + C Bone Cement. (See Copal model Excel file attachment for evidence base / cost benefit analysis) Template femoral head / stem size.Surgical approach for hemiarthroplasty – Anterolateral / Hardinge.Preferred implant Thompson’s (A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip. Bone Joint J 2018;100-B:352–60.)NB In order to reduce the risk of Bone Cement Implantation syndrome modern generation cementing technique must be employed, including:Giving adequate warning to the anaesthetist that cement insertion is about to happen.Thorough pulsatile lavage of the femoral canal.Drying of canal prior to cement insertion.Suctioning of canal at cement insertion.In hemiarthroplasty surgery avoid cement pressurisation.Total Hip Replacement Consider if:Independent outdoor walking with 1 stick or less.No cognitive impairment.Medically fit for surgery.Note potential increased risk of complications including dislocation, therefore in these patients consider if Bipolar hemiarthroplasty may be felt clinically more appropriate.Surgical Approach Total Hip Replacement – Surgeon’s usual approach for total hip replacement Follow Total Hip Replacement ERAS protocolIntracapsular Fracture – UndisplacedCannulated screw or 2 hole Dynamic Hip Screw fixation (Surgeon’s Preference)Extracapsular Fracture at or above lesser Trochanter (A1 and A2)Dynamic Hip ScrewFracture below lesser trochanterIntramedullary Device (Long) – Reconstruction NailPerform open reduction and stabilisation with appropriate clamps prior to passage of guide wire and reamingAnaesthesiaShould be carried out by consultant or suitably trained anaesthetist or specialist with similar clinical experience. Only very senior trainees should undertake these cases unsupervised.Consider Regional vs GA.Neuraxial and general anaesthesia should not be combined.Anticoagulation – Established Treatment on Admission:See Anticoagulation Appendices for guidance.Some residual anticoagulant may exist, and bleeding may be increased.Avoid neuraxial anaesthesia unless you are certain anticoagulation has been reversed (i.e. INR <1.5 if on warfarin).If Spinal:Minimise dose: suggest 2mls of 0.5% heavy Marcaine with spinal inserted fracture side down. (Senior Anaesthetist covering list to make final decision)Only intrathecal opiate to be used is Fentanyl.Surgeon to be aware that low dose spinal being used. If GA:Consider gas induction (associated with less hypotension than intravenous induction).Careful IV induction.Airway choice at the discretion of anaesthetist but consider spontaneous ventilation if possible.For all patients (including those receiving spinal anaesthesia)Either Block (e.g. fascia iliacus, lumbar plexus etc.) OR ERAS local by the surgeons.Avoid long acting opiates intra-operatively where possible.Tranexamic Acid for all procedures – by slow infusion1g IV at Induction.1g IV 8 hours post operativelyAntibiotic ProphylaxisTeicoplanin 600mg and gentamicin 3mg/kg IV at induction if has been in a residential home, nursing home or hospital in previous 12 months; otherwise Flucloxacillin 2g and gentamicin 3mg/kg IV at induction.Both teicoplanin and flucloxacillin, where given, MUST be administered slowly to prevent the risk of anaphylactoid reactions with teicoplanin and a fall in BP with flucloxacillin.No Post op dose of antibiotics even for total hip replacement.Post-Operative ThromboprophylaxisProphylactic-dose enoxaparin should be commenced at 6hr after wound closure and continue as per thromboprophylaxis protocol. (See anticoagulant guidance under 11.1 if on Warfarin/ NOACs at admission).Prescribed by surgeon before patient leaves theatre.Aim for close control of BP Ideally within 20% of baseline.Absolute hypotension i.e. systolic BP < 100 mmHg must be avoided.Pressors should routinely be drawn up for rapid administration.Consider metaraminol infusion intraoperatively.Low threshold for arterial monitoring peri-operatively especially if significant cardiovascular disease.Bone cement implantation syndrome can occur after reaming or cement insertion. A clear warning, ‘cement going in’ from the surgical team facilitates close monitoring by the anaesthetist for hypoxemia, hypotension or cardiovascular collapse.RecoveryHypotension is a significant risk post-operatively. This is more effectively treated in theatre recovery than it can be on the ward.No ephedrine or aramine must have been administered for at least 30 minutes prior to BP assessment for discharge.Patients must remain in recovery until blood pressure returns to greater than 110 systolic (or to at least 80 % of pre-operative blood pressure) consistently for a minimum of 15 minutes.All patients must have a HaemoCue measured in theatre recovery, and the result reviewed by the anaesthetist responsible for the case.10.1 Post op pain reliefRegular Paracetamol.Oxycodone MR 5 mg bd for most.Consider 10 mg bd for younger patients (< 70 years old).Oxynorm 5-10 mg PRN for breakthrough pain.NSAIDS likely to be unsuitable for majority of NOF patients but could be considered in patients with pain control issues and no contraindications.11.0 Post-Operative CarePatients return to D2.In frail patients where critical care is not appropriate extended recovery stay may be required until patient safe to go back to ward.Consideration of DNACPR status should be discussed between senior anaesthetist and surgeon prior to discharge from the recovery area.Post-operative Orthogeriatric directed multi-professional rehabilitation team care.Post-operative patient care provided by both Orthogeriatric and Orthopaedic teams – Junior staff in both orthopaedics and medicine should never be left to manage without senior support.Where senior advice is required, and the middle grade is too busy to attend, consultant advice should be sought from the most appropriate specialty.All must have Specialist Falls Assessment.Fracture Prevention assessment – Bone health and Specialist Falls assessment.Nutrition assessment during admission for all.Delirium assessment using 4AT screening tool during admission.11.1 AnticoagulationPost-surgery follow anticoagulation guidance within Anticoagulation appendix (take into account any pre-established anticoagulation therapy present at admission).Prophylaxis dose enoxaparin should be commenced at 6hr after surgery, and continued until therapeutic anticoagulation achieved (e.g. INR within therapeutic range, NOAC recommenced).If previously on Warfarin or NOAC restart anticoagulant 24-48 hours post-op if wound is dry. Warfarin can be restarted at usual maintenance dose, although consideration for loading may be given if used in the presence of a mechanical heart valve.If Clopidogrel has been withheld it should be restarted 24h post-op (assuming haemostasis).11.2 Early discharge planningHip Fracture Ward to have regular Discharge Co-Ordinator and Social Worker, who attend MDTs.Social Work Team to take responsibility for ensuring social care referrals are handled appropriately and in a timely manner.Consider Early Repatriation (once stable and appropriate) to patient’s local Trust when out of area.If patient has been admitted from a nursing home or a residential home:Home to be contacted as soon after admission as possible in order to discuss patient’s normal activities/ abilities so that early planning for discharge can commence. Home to be contacted thereafter on day 5 and day 10 to inform them of patient’s progress during their stay in hospital and agree estimated date of discharge.11.3 Length of Stay: Family expectationsPost op day 2 discuss expected date of discharge (EDD) with family engaging OT/PT re further requirements re adaptations etc.Continue discussions with family re EDD on day 5 and 10.Request relatives to bring day clothes, encourage patient to start getting dressed by day 7.11.4 Intermediate care tierRapid discharge assessment tool to start as a trial on D2 – “transfer to assess” model this will mean that patients no longer stay in hospital for assessment of their needs when home. These needs will be assessed in the environment in which the patient will be living – “home first”.Pro-active management – known issues in intermediate bed based care where not fully staffed or trained to accept NOF discharges. Start discharge conversations as soon as assessment determines patient may need intermediate care in order to agree EDD and ensure relevant equipment available.12.0 Therapy Role on D2 with Fractured Neck of Femur Patients12.1 Physiotherapy Role (Team Leader Trauma & Orthopaedics Inpatient Therapies Ext 5270) Physiotherapy assessment of all patients will commence within one day of surgery (the day of surgery or the day after surgery) following a fractured Neck of Femur and follows Physiotherapy care pathway for Fractured Neck of Femur based on NICE guidelines (see attached). The patients will begin to mobilise during that assessment if medically and physically able.Physiotherapy service provided 7 day a week including Bank Holidays.The patient’s mobility will be progressed daily as able with the appropriate walking aid. The Physiotherapy treatment will also include balance work and appropriate lower and upper limb strengthening exercises and falls management.The Physiotherapist will liaise closely with the Multi-Disciplinary Team especially the Occupational Therapist to plan and facilitate a timely discharge to the appropriate setting.12.2 Occupational Therapy (Clinical Lead Occupational Therapist Trauma and Orthopaedics Team Ext 5270)The Occupational Therapist (OT) accepts the referral of the patient within one working day of admission to the ward and follows the OT care pathway for Fractured Neck of Femurs based on NICE guidelines (see attached).Discharge planning starts with the initial assessment. The OT’s first priority is to establish the patient’s community circumstances including their home environment, activities of daily living baseline and support network including carer needs and identifies factors that will impact positively or negatively upon safe and timely discharge back to the community.Where the patient has undergone hemi or total hip replacement the OT educates the patient regarding hip precautions and implements the necessary recommendations to support joint protection for twelve weeks.The OT assesses for care, support and rehabilitation needs to minimize risk and optimize independence. Items of equipment and adaptations essential to support activities of daily living at discharge are assessed for and prescribed/recommended.While the patient remains on the ward the OT carries out functional interventions to improve skills, independence and confidence.13.0 Primary care – After DischargeFacilitate rehabilitation.Review following discharge into the community.Prevention of further events.Prevention of other co-morbidities.14.0 Primary Care – Early Supported Multidisciplinary Rehabilitation within Care HomesReduce length of stay in hospitals.Improve early return to function.Potentially reduce readmission rates.Potentially reduce requirement for NHS / social care funded residential or nursing care.Appendix 1 – Anticoagulant GuidanceACTIONS FOR THE ANTICOAGULATED PATIENTGuidelines adapted from NHS Borders existing guidelines.ON ADMISSION TO ED/WARDYou must make a plan on admission – do not delay this until the ward round the next dayWITHHOLD anticoagulant and document timing of last dose of anticoagulantIf HIGH THROMBOSIS RISK* then bridging anticoagulation may be required. Discuss with on-call haematologist, and inform on-call anaesthetist. Follow DRUG SPECIFIC ADVICE in Appendix 2 Reverse warfarin on admission. This is important. If you leave it until the next day the patient’s anticoagulation is unlikely to be reversed in time for surgery, and surgery may be delayed. If surgery on the day of admission is possible, Beriplex may be indicated to rapidly reverse warfarin and allow surgeryDo not give pre-operative prophylactic-dose enoxaparin to anticoagulated patientsDelaying surgery because of anticoagulation should only be considered when the risk from bleeding outweighs the poorer survival associated with delay (30% increase in mortality per 24h delay) INTRA-OPERATIVE CARERemember some residual anticoagulant may exist, and bleeding may be increasedAvoid neuraxial anaesthesia unless you are certain anticoagulation has been reversed (i.e. INR <1.5 if on warfarin)TRANEXAMIC ACID reduces bleeding and 1g IV should be given upon induction by the anaesthetist. Further dose 1g iv given at ClosurePOST-OPERATIVE CAREProphylaxis-dose enoxaparin should be commenced at least 6hr after surgery, and continued until therapeutic anticoagulation achieved (e.g. INR within therapeutic range, NOAC recommenced)Restart anticoagulant 24-48 hours post-op if wound is dry. Warfarin can be restarted at usual maintenance doseIf clopidogrel has been withheld it should be restarted 24h post-op (assuming haemostasis)*HIGH RISK PATIENTS* Details on following page*HIGH RISK PATIENTS*HIGH THROMBOSIS RISKHIGH BLEEDING RISKMechanical heart valve prosthesisActive VTE (DVT within 3 months, PE within 6 months)Recurrent VTE whilst anticoagulatedCardiac stent within 1 yearAcute coronary syndrome or stroke within 3 monthsTarget INR =>3Concomitant use of anticoagulants and antiplatelet agentsDual antiplateletsIntramedullary nail surgeryPathological fractureAppendix 2 - Anticoagulation Guidance - Drug Specific AdviceDRUG SPECIFIC ADVICEWARFARIN (Flow Chart Appendix 3)Check clotting screen on admissionIf not high thrombosis risk* then give 5mg vitamin K as soon as possible (e.g. in ED). Give as infusion diluted in 100ml 0.9% saline over 20 minsPlan for surgery for the day after admissionCheck INR at 6am on day of surgery so that result is back for the trauma meetingProceed with surgery if INR =<1.7 (GA if between1.5-1.7. Spinal anaesthesia will usually only be considered if INR =<1.5)If INR still >1.7 thenDo not remove from operating list and aim to rapidly correct coagulation so surgery can proceed Give a further vitamin K 2mg IV and recheck INR 4hr later. Beriplex will rapidly reverse warfarin and is indicated if surgery would otherwise be cancelledBeriplex is indicated if surgery on the day of admission is feasible. Discuss with orthopaedic/anaesthetic consultantWarfarin anticoagulation must be actively reversed. ‘Spontaneous reversal’ without active treatment is slow, unpredictable and does not reduce thrombosis riskDo not use fresh frozen plasma for reversal of warfarinDIRECT ORAL ANTICOAGULANTS (DOACs)Calculate creatinine clearance (CrCl) (online calculators widely available) and refer to table below. Do not use eGFR as this is less accurateDelay surgery from timing of the last dose of anticoagulant not the time of admissionStandard clotting tests (PT, aPTT, INR) cannot be used for measuring anticoagulant effect from rivaroxaban, apixaban and edoxaban. Only anti-Xa levels can be used (sent to MRI for processing usually result available <24hrs, can be done urgently e.g. at the weekend). Dabigatran can only be monitored with thrombin time (TT) and not other clotting tests Dabigatran can be reversed with Idarucizumab (Praxbind kept in ED) and may be indicated if delay to surgery is >24-48h (see table below). Discuss with haematology. A specific reversal agent for –aban drugs is in development but not yet availableTime from last dose of anticoagulant to surgeryCrCl greater than 30 CrCl less than 30High bleeding risk*Apixaban24h from last dose48h from last doseExtend time by 24hRivaroxaban24h from last dose48h from last doseExtend time by 24hEdoxaban24h from last dose48h from last doseExtend time by 24hDabigatranCrCl>80: 24h delayCrCl 50-80: 24-48h delayCrCl 30-50: 48-72h delayExtend time by 24hHEPARINSLMWH Prophylaxis dose:LMWH Treatment dose:Unfractionated heparin VTE prophylaxisUnfractionated heparin by infusionPlan surgery 12h from last dosePlan surgery 24h from last dosePlan surgery 6h from last doseStop infusion 6h before surgery (check aPTT not necessary)ANTIPLATELETSASPIRINCONTINUE DRUG AND DO NOT DELAY SURGERYDo not discontinue and proceed with surgery without delayCLOPIDOGREL CONTINUE DRUG AND DO NOT DELAY SURGERY. If high risk of bleeding, withhold for 24h pre-opEvidence suggests a trend towards increased bleeding risk but not to an extent significant enough to warrant delaying surgery. Withholding may lead to a 6-fold increased risk of cardiovascular complications. If the patient is high risk of bleeding then delaying surgery 24h from last dose allows transfusion of platelets DUAL ANTIPLATELETS STOP CLOPIDOGREL ON ADMISSION, CONTINUE ASPIRIN, DELAY SURGERY BY 24hLikely to be at high risk of complications (e.g. recent cardiac stent or stroke). Bleeding risk is likely to be high and platelet and blood transfusions may be required. Delay surgery 24h from last dose of medication to avoid platelet inhibition from residual drug. Delaying longer than 24h is likely to increase thrombosis riskOTHER ANTIPLATELETS E.g. ticagrelor, dipyridamole, prasugrel No guidance is available regarding bleeding risk for these drugs. Discuss with anaesthetist in first instanceSee additional reference list for source evidence.Appendix 3 – Warfarin Reversal Flowchart Action PlanYou must make a plan for anticoagulants on admission. Do not delay this until the next day!If surgery on the day of admission is possible AND only prevented by a high INR, then BERIPLEX may be indicated to reverse warfarin rapidly. Discuss with anaesthetist in the first instance, and then discuss with haematologist on callDecision to admit for surgeryStop warfarin on admissionPerform clotting screen-6985011684000HIGHAssess thrombosis risk*LOWContact on-call haematologist and discuss plan with on-call anaesthetist-262890-57150001318260-7810500Give Vitamin K 5mg IVDilute in 100ml 0.9% saline and infuse over 20 minutesTo be given as soon as diagnosis of neck of femur fracture made1090295146060011499851460600If mechanical heart valve, consider discussion with cardiologistCheck INR06.00 the next day So that result is back in time for trauma round. Organise this with HAN!11499851397100INR <=1.7*HIGH THROMBOSIS RISK1085215190500NO1847853238500YESMechanical heart valve prosthesisActive VTE (DVT within 3 months, PE within 6 months)Recurrent VTE whilst anticoagulatedTarget INR =>3Give Vitamin K 2mg IV and recheck INR 6h laterBeriplex may facilitate surgery that day: Discuss with consultant orthopaedic surgeon or anaesthetist first, and then on-call haematologistProceed with surgeryRestarting warfarin in low-risk patientsStart enoxaparin prophylaxis dose as per VTE guidelinesRestart warfarin as usual dose 24h post-op (if no wound complications)Check INR daily, continue enoxaparin until INR within target rangeAppendix 4 – Emergency Department GuidelinesAppendix 5 – NOF NICE Quality StandardsStatement 1 Adults with hip fracture are cared for within a Hip Fracture Programme at every stage of the care pathway. [2012, updated 2016] Statement 2 Adults with hip fracture have surgery on a planned trauma list on the day of, or the day after, admission. [2012, updated 2016] Statement 3 Adults with displaced Intracapsular hip fracture receive cemented hemiarthroplasty or, if they are assessed as clinically eligible, a total hip replacement. [2012, updated 2016]Statement 4 Adults with Trochanteric fractures above and including the lesser trochanter receive extramedullary implants. [2012, updated 2016] Statement 5 Adults with Subtrochanteric fracture are treated with an intramedullary nail. [new 2016] Statement 6 Adults with hip fracture start rehabilitation at least once a day, no later than the day after surgery. [2012, updated 2016]Appendix 6 - NOF NICE Quality Standards Definition of Hip Fracture ProgrammeA coordinated multidisciplinary approach ensuring continuity of care and responsibility across the clinical pathway. It covers care in all settings, including ambulances, A&E departments, radiology, operating theatres, wards and in the community and primary care, and at all stages, including diagnosis, treatment, recovery, discharge planning, rehabilitation, long-term after care and secondary prevention. It involves formal 'orthogeriatric' care, with the geriatric medical team contributing to joint preoperative patient assessment, and increasingly taking the lead in postoperative medical care, multidisciplinary rehabilitation and discharge planning.It includes all of the following: orthogeriatric assessment rapid optimisation of fitness for surgeryearly identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeingcontinued, coordinated, orthogeriatric and multidisciplinary reviewliaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services clinical and service governanceResponsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.Appendix 7 - Standards for Practice (BOAST 1 - Jan 2012)1. Secondary prevention, anti-resorptive therapy for osteoporosis and falls assessments are effective in reducing further fragility fractures and must be an integral part of the fracture care.2. Hip fractures should be managed by a multidisciplinary team including orthogeriatricians, orthopaedic surgeons, anaesthetists, nursing and allied health professionals with expertise appropriate for these frail patients.3. Patients who cannot weight-bear and who may have a hip fracture should be offered magnetic resonance imaging (MRI) if anteroposterior pelvis and lateral hip X-rays are negative; if MRI is not available within 24 hours or is contraindicated, consider computed tomography.4. Assess the patient’s pain and offer immediate analgesia on presentation at hospital and regularly as part of routine nursing observations throughout admission, including patients with cognitive impairment. Ensure analgesia is sufficient to allow movements necessary for investigations and for nursing care and rehabilitation.5. Identify and treat correctable co-morbidities immediately so that surgery is not delayed. Intravenous fluids should be administered and appropriate blood tests undertaken. Preoperative assessment should follow local protocols including for those presenting on anticoagulants.6. Perform hip fracture surgery on the day of, or the day after, admission on a planned trauma list. Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures.7. Operate on patients with the aim to allow them to fully weight bear (without restriction) in the immediate postoperative period. Offer patients’ mobilisation with a physiotherapist at least once a day and assessment on the day after surgery.8. From admission, offer patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme that includes orthogeriatric assessment, rapid optimisation of fitness for surgery, early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing.9. Assess patient’s risk of delirium and dementia by actively looking for cognitive impairment when patients first present with hip fracture and perform regular re-assessment.10. If a hip fracture complicates or precipitates a terminal illness, the multidisciplinary team should still consider the role of surgery as part of the palliative care.11. Patients should be assessed and treated for their risk of venous thromboembolism and pressure sores.12. Offer patients (or, as appropriate, their carer and/or family) verbal and printed information about treatment, care and rehabilitation.13. Each hospital should submit data to the National Hip Fracture Database to monitor its performance against national benchmarks and quality standards. ................
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