Lead researcher and geriatrician Associate Professor Jacqueline Close writes about what we need to do to ensure equality in care for these patients whose voices often go unheard.
Having had the privilege of practicing medicine and providing care to some of the most frail members of our society for 20 years, I never cease to be amazed at the diversity of hip fracture patients, each bringing with them a unique set of challenges and opportunities.
A hip fracture following a fall can be anything from a simple trip in an otherwise healthy and active person, to an event that signals the end of independent living or a terminal event in someone already nearing the end of their life.
Such is the intellectual challenge of providing care for a diverse range of our older population where patient preferences, priorities and expectations must be married with the science to optimise what is a traumatic and painful life experience for any older person.
Whilst individualised care is what we strive to deliver, there are clearly a number of systems and processes that must be in place to underpin service provision so as to give every individual the best chance of gaining meaning functional recovery.
Take time to surgical intervention as an example. The surgery offered to hip fracture patients is one of the best forms of pain relief for this condition. Unless there are medical problems that can be improved then there is no justification for delaying surgery and the scientific evidence would lead us to believe that potential harm comes from delay in the form of pressure sores, pneumonia and clots in the legs and lungs.
From a humane and scientific viewpoint it is unacceptable that surgery is delayed yet evidence from various sites across Australia highlight marked variation in achievement of the goal of timely access to surgery.
Some hospitals, including my own, prioritise the care of these patients to ensure that they are not “bumped” from operating theatre lists or repeatedly fasted and immobilised in the anticipation of surgery that then gets cancelled.
Another important area that impacts on outcome is who looks after these people. A hip fracture is rarely a fatal event. It is the medical conditions and complications that have the most influence of the final outcome, yet traditionally orthopaedic surgeons have been primarily responsible for care.
Orthopaedic surgeons are high skilled individuals whose strengths are in identifying and treating the fracture. However, few would claim to have the same level of expertise in the management of the conditions most likely to cause a poor outcome – heart failure, infection, delirium and dementia.
Evidence from our own research as well as from other centres across the world show that hip fracture patients do better when their care is provided in partnership by orthopaedic surgeons and geriatricians – fewer complications and fewer deaths.
Again this practice is not widespread across Australia but the picture is slowly changing and will be helped by the development of a national guideline for hip fracture care which is currently out for public consultation. Equally important will be the work being undertaken in some states in Australia.
Western Australia has already introduced a financial incentive to reward hospitals that provide high quality care against a number of agreed indicators whilst New South Wales is on the verge of releasing a set of standards of care for hip fracture.
Both these options offer a real opportunity to improve care of a population whose voice is not often heard.
Assoc Prof Jacqui Close trained as a geriatrician at King’s College Hospital in London. She moved to Sydney in 2006 and now combines a clinical and academic career at the Prince of Wales Hospital and Neuroscience Research Australia.
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