Balancing priorities in the management of hip fractures: guidelines versus resources.
BACKGROUND
About 60,000 patients are treated for hip fractures each year in the UK and the incidence is increasing. The majority of these patients are elderly and sick, and delay to operation may be fatal. The National Confidential Enquiry into Peri-Operative Deaths (NCEPOD) guidelines aim to improve quality of care for such patients. However, we present an audit highlighting the importance of balancing the implementation of such guidelines with available local resources to ensure that established priorities in the care of these patients remain paramount.


METHODS
The 2001 NCEPOD report recommends that pre-operative transthoracic echocardiography be performed in patients who have evidence of aortic stenosis in order to identify those requiring invasive monitoring and high dependency unit care postoperatively.


RESULTS
We have assessed the impact of the implementation of these guidelines on surgery for fractured neck of femur at our hospital, auditing both delay to surgery and the effect of the investigation on subsequent management. In the period studied prior to the introduction of the NCEPOD guidelines, no patients underwent pre-operative echocardiography. Subsequent to their introduction, 10% of patients underwent the investigation, which in the current study did not alter management but did delay surgery by 4-8 days in all cases.


CONCLUSIONS
For such guidelines to be implemented, adequate resources should first be provided. In the absence of these resources, clinicians must balance the need for adequate pre-operative assessment with the need for urgent surgery.
Guryel
E
E
Department of Orthopaedic Surgery, Princess Royal Hospital, Haywards Heath, West Sussex, UK.
Redfern
D J
DJ
Ricketts
D M
DM
D000368:Aged; D000369:Aged, 80 and over; D004452:Echocardiography / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D006292:Health Priorities; D006295:Health Resources / Q000600:supply & distribution*; D006620:Hip Fractures / Q000601:surgery*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008485:Medical Audit; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000401:mortality / Q000592:standards*; D013997:Time Factors