Hip Fracture Clinical Care Standard

Use a locally endorsed hip fracture pathway to guide the comprehensive clinical assessment and management of patients with a suspected hip fracture including: 

• screening for malnutrition, frailty, cognitive impairment and risk factors for delirium
• identifying comorbidity and medicines that may impact on time to surgery or readiness for surgery
• providing pain relief
• assessing for underlying acute and chronic medical conditions precipitating the fall,
• excluding other injuries
• conducting relevant diagnostic imaging and pathology. 

Put in place interventions to prevent or manage delirium, in accordance with the Delirium Clinical Care Standard. Document the frailty assessment and use the results to guide care planning.

Ensure the patient knows what is happening and what to expect from their treatment and recovery, and identify a substitute decision maker. Document and communicate processes as part of the patient’s comprehensive care plan to ensure effective management and clinical handover. 

For hospitals that do not provide hip fracture surgery, organise prompt transfer and initiate the care pathway locally to optimise the patient’s pre-operative condition. There is an expectation that all patients will receive surgery within 36 hours, no matter the hospital where they first present.

Ensure systems are in place to support clinicians to provide timely and effective assessment and management based on a locally endorsed hip fracture pathway. Systems should include transfer protocols including consideration of straight to ward arrangements for inter-hospital transfers.

For hospitals that do not perform hip fracture surgery, ensure that the pathway is commenced with attention to stabilising medical conditions.

For hospitals receiving transfer patients with hip fracture, ensure both hospitals are using the same pathway and that the expectations for referral and receiving of patients are clear.

When you arrive at hospital, the clinical team will assess you to see if you have a hip fracture (broken hip). They will also check any other health conditions so that you can have an operation quickly if you need one. As part of the assessment, you will need an X-ray and blood tests. Your clinician will:

• check your overall health and ability to function before your injury
• ask about any existing health conditions you may have
• ask about any medicines that you are taking that may affect your surgery
• make sure your pain is controlled
• talk to you about possible reasons for your fall
• check for any problems you may be having with your memory, thinking or communication that could mean you are at risk of delirium (a serious condition where there is a change in mental state that alters awareness, such as seeing or hearing things)
• ask if you identify as Māori or Aboriginal and Torres Strait Islander, or need access to a translator.

Your priorities and choices are important, and your clinical team will support these wherever possible. Let them know if there are family members, friends or carers that you would like to have included in decisions about your care.

For clinicians 

Consider personal biases, cultural and social factors, and communication barriers when assessing the patient. 

Ask about and document: 

• the person’s Māori or Aboriginal and Torres Strait Islander identity, to ensure that the care provided meets their needs
• the person’s preferred language and facilitate access to interpreters when required. 

In a culturally safe way, explain to the patient and their family, carer or support people the reasons for assessment, tests and interventions. Understand what is important to the person and what their goals of care are. 

Consider cultural validation and suitability when selecting cognitive screening tools. For some people from culturally and linguistically diverse groups, the Rowland Universal Dementia Assessment Scale is relevant. The Kimberley Indigenous Cognitive Assessment (KICA)32 provides a more culturally appropriate measure of cognition, which may be useful for Māori and Aboriginal and Torres Strait Islander people.

Consider how cultural factors may influence who is suited to be a substitute decision-maker. Multiple decision-makers may be required for Aboriginal and Torres Strait Islander people.

For healthcare services 

Recognise potential barriers to people accessing care, including language differences, being from a remote or vulnerable community, and a lack of cultural safety within healthcare services. Support clinicians to address potential barriers to care by having systems in place that facilitate access to Māori Health Workers, Aboriginal and Torres Strait Islander Health Workers or Practitioners, Liaison Officers, cross-cultural health workers and interpreters whenever cultural differences may be a barrier to the person’s experience and outcomes of care.

• Resources including local protocols and clinical pathways for hip fracture care have been shared by hospitals that contribute to the ANZHFR; these can be found on the ANZHFR website.
• The Australasian College for Emergency Medicine Care of older persons in the emergency department (Policy P51) relates to the recommended standards of care for older persons in the emergency department; it has been developed in consultation with, and endorsed by, the Australian and New Zealand Society for Geriatric Medicine.
• People with hip fracture have a high risk of delirium; to prevent, diagnose and manage delirium in these people, they should be treated according to the Delirium Clinical Care Standard.
• The 4AT has been validated for both cognitive impairment screening and delirium assessment, and is available in 17 languages.
• Some validated tools for cognitive impairment screening include
  • Abbreviated Mental Test Score (AMTS), incorporated in the NSW Health Delirium Screen for Older Adults (available from the Agency for Clinical Innovation)
  • Kimberley Indigenous Cognitive Assessment tool, available from the Dementia Centre for Research Collaboration.
• The Clinical Frailty Scale can predict adverse outcomes in older people in hospital, including hospital-based harm, emergency department and inpatient length of stay, the need for placement in an aged care facility, and death.

Many patients with a hip fracture will have received analgesics in the ambulance. Assess and document the patient’s pain:

• immediately upon presentation to hospital
• within 30 minutes of administering initial analgesia
• hourly until the patient is settled and pain is managed
• regularly as part of routine nursing and other clinicians’ observations throughout the admission.

Provide appropriate pain management including multimodal analgesia, and local nerve blocks as part of peri-operative pain management. A nerve block has the potential to reduce opioid dose requirements and their unwanted side effects (such as sedation, respiratory complications and delirium).

For hospitals that do not provide hip fracture surgery, arrange appropriate analgesia and if suitable, administer a nerve block prior to transfer.

Include the use of a standardised pain assessment system that:

• includes functional assessment for pain
• specifically addresses the assessment of pain for patients with cognitive impairment or those unable to communicate pain.

If opioid analgesics are used:

• prescribe immediate-release formulations at the lowest appropriate dose for a limited duration in accordance with the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard
• plan for appropriate opioid analgesic use at the transfer of care when a patient is first prescribed, supplied or administered an opioid analgesic.

Follow a weaning and cessation protocol guided by assessing the patient’s functional activity and pain scores.

Ensure pain management protocols are in place to provide pain assessment and management for patients with a hip fracture that:

• align with current guidelines
• support the appropriate use of multimodal analgesia and nerve blocks
• support appropriate prescribing of opioid analgesics in accordance with the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.

Ensure systems are in place to monitor appropriate adherence and regularly evaluate effectiveness of acute pain management.

If you have a hip fracture and come to the hospital by ambulance, you may be given medicines to relieve your pain and nausea in the ambulance. When you arrive at the hospital, a doctor, nurse or other clinician will assess your pain immediately and give you suitable medicines to relieve your pain. Your pain will be assessed and managed throughout your hospital stay. Before surgery, you are likely to be offered an injection in the groin called a ‘nerve block’. Nerve blocks can provide pain relief for several hours by numbing the area around your hip and thigh.

If you need to travel to another hospital for surgery, you will be given pain relief before you are transferred, to make you as comfortable as possible.

For clinicians 

Pain assessment and management should be done on an individual patient basis. Differences between ethnic and cultural groups should not be used to stereotype patients; these should only be used to inform of possible cultural preferences. Language should not be a barrier to appropriate assessment and management of pain. An interpreter can assist with administering pain scales and providing clinicians with useful information on cultural beliefs about expression of pain. Multilingual printed information and pain measurement scales are useful in managing patients with different cultural or ethnic backgrounds. 

Ask about and record the person’s Māori or Aboriginal and Torres Strait Islander identity with respect to providing care that meets their needs. For example, offer the involvement of a Māori Health Worker or an Aboriginal and Torres Strait Islander Health Worker, Practitioner or Liaison Officer to help with effective communication of words and concepts. Differences in non-verbal and behavioural expressions of pain may affect the clinician’s perceptions of the patient’s pain. When attempting to assess pain, verbal descriptor scales (for example, ‘none’, ‘mild’, ‘moderate’ and ‘severe’) or pain assessment tools using facial expressions are considered superior to numerical and visual analogue scales. Pain expression in Aboriginal and Torres Strait Islander people may not reflect what is expected by the clinician’s cultural background. This places the onus on the clinician to understand nuances in pain expression and beliefs within such populations.

For healthcare services 

As pain management is a critical component of care, ensure that translated resources (such as the word ‘pain’ and appropriate pain scales) that are suitable to the local population are available to aid assessment and management. Ensure that there is access to professional interpreting services, including for those who are deaf. 

Whenever cultural differences may be a barrier to the patient’s experience of care, involve people who can assist in the social aspects of care, such as Māori Health Workers or Aboriginal and Torres Strait Islander Health Workers, Practitioners and Liaison Officers; cross-cultural health workers; or translators.

• The Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard describes the key components of care that patients can expect when they are prescribed opioid analgesics for acute pain in acute care settings.
• Pain scales support the identification of symptoms and signs associated with pain in people with altered cognition; examples include
  • Pain Assessment in Advanced Dementia scale
  • Abbey pain scale.
• Some pain assessment tools use facial expressions, such as the Wong-Baker FACES pain rating scale.
• Some patients may have needs that require particular attention (for example, patients who are opioid-tolerant or have a substance use disorder, Aboriginal and Torres Strait Islander people, Māori, patients with cognitive behavioural and/or sensory impairments, and non-English speaking people); evidence-based information related to the management of acute pain in these patient groups and situations is included in the fifth edition of Acute Pain Management: Scientific Evidence, published by the Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine.
• Standard of practice in pain management for pharmacy services, Advanced Pharmacy Australia (AdPha) (formerly Society of Hospital Pharmacists of Australia)

From the time of admission, offer patients with a hip fracture a formal orthogeriatric model of care that includes:

• regular orthogeriatrician assessment including medication review
• managing patient comorbidities
• optimisation for surgery
• early identification of goals of care, in discussion with the patient and their family or support people and documented in the comprehensive care plan
• early assessment of the patient’s nutritional status using a validated assessment tool, reassessed during the course of the admission with individualised interventions when required including offering oral nutritional supplements postoperatively
• management based on initial assessment for frailty, cognitive impairment and delirium
• ongoing orthogeriatric and multidisciplinary review including reassessment of cognition, delirium and malnutrition after surgery
• assessment for venous thromboembolism (VTE) risk to determine the need for VTE prophylaxis
• discharge planning liaison with primary care, including falls prevention and secondary fracture prevention
• coordination of care to provide multidisciplinary rehabilitation aimed at increasing mobility and independence, facilitating return to pre-fracture residence and supporting long‑term wellbeing, if appropriate and clinically indicated
• early identification of most appropriate service to deliver rehabilitation, if indicated. 

Ensure systems are in place to offer patients with a hip fracture treatment that is based on an orthogeriatric model of care as recommended in the Australian and New Zealand Guideline for Hip Fracture Care. For hospitals that do not have a geriatric medicine service available, care should be shared between an orthopaedic surgeon and an anaesthetist with a physician, using the orthogeriatric model of care.

For hospitals that do not perform hip fracture surgery, it is important that the orthogeriatric model of care is commenced while patients await transfer.

If you have a hip fracture, you and your family or carer are involved in important decisions about your care from the time you are admitted to hospital. This includes working out what you would like to achieve from your care, and the best way to achieve it. For example, extra steps may need to be taken so that it is medically safe for you to have surgery or there may be different options for your surgery. Your care will be shared between healthcare providers with different areas of expertise which may include:

• specialist medical expertise
• nursing or allied health knowledge in caring for older people
• orthopaedic (bone) surgery
• rehabilitation medicine
• physiotherapy
• nutrition.

It is important that all of your health issues are taken into account, to give you the best chance of full recovery. 

Nutrition is very important to your recovery from a hip fracture. You will be assessed early in your admission to see if you are malnourished. You will be offered oral nutrition supplements to help increase your calorie and protein intake. If your clinician thinks you are malnourished, or at risk of malnutrition, they will discuss how to improve your nutrition taking into account your needs and preferences. 

There is a chance you may develop a condition called delirium after a hip fracture. Delirium causes mental and physical changes such as confusion, sleepiness or agitation, and seeing or hearing things that are not there. You will be monitored for delirium throughout your hospital stay. It is important for you and your support people to let your healthcare team know about any changes in your mental awareness, including confusion, being disoriented or memory problems. Dealing with the causes of delirium quickly will help your recovery.

For clinicians 

Attend cultural safety training provided by your healthcare service or professional organisation. 

If language or culture may be a barrier to involving patients in their care or the optimisation process for surgery, involve interpreting services, Māori Health Workers or Aboriginal and Torres Strait Islander Health Workers or Practitioners. Continuity of these services through the hip fracture journey can enhance the patient experience, and allows for appropriate planning of ongoing rehabilitation and support for discharge and the transition to home. Recognise that a history of trauma may affect behaviour, and provide trauma-aware and healing-informed care.

Language should not be a barrier to ensuring timely access to surgery. Fasting in some community groups means abstaining from specific foods only, so it may be necessary to advise the patient about what fasting means in the context of preparing for major surgery. An interpreter should be used to explain the reason for fasting to both the patient and their family when necessary. 

Ensure that Aboriginal and Torres Strait Islander and Māori people remain connected with their respective physical, spiritual and cultural connections while in the hospital, particularly if they are off Country and a long way from home. Incorporate the person’s family (whānau*), social worker and usual Community Controlled Health Service (if applicable) into care planning, to support transitions of care.

For healthcare services

Recognising a person’s culture can improve both the clinical care provided and the person’s experience of care. To help achieve this: 

• ensure that clinicians have received cultural safety training
• enable the involvement of Māori Health Workers; Aboriginal and Torres Strait Islander Health Workers or Practitioners and Liaison Officers; translators; and others who can assist in the social aspects of care when this is what the person would prefer and when cultural differences may be a barrier to their clinical care or experience of care
• establish systems for patients who identify as Māori or Aboriginal and Torres Strait Islander to identify relevant community care providers (for example, the person’s Aboriginal Community Controlled Health Organisation), and involve them in the patient’s care planning where appropriate or possible.

• People with hip fracture have a high risk of delirium; to prevent, diagnose and manage delirium in these people, they should be treated according to the Delirium Clinical Care Standard.
• The Venous Thromboembolism Prevention Clinical Care Standard supports clinicians and healthcare services to deliver high-quality care that prevents VTE from being acquired both in hospital and following discharge.
• The Commission has developed several resources for clinicians, managers and executives, governing bodies and others that can help them adopt strategies that reduce the occurrence of hospital-acquired complications such as VTE, delirium and malnutrition.
• The National Safety and Quality Health Service Standards Comprehensive Care Standard includes actions on nutrition and hydration (5.27 and 5.28), preventing falls and harm from falls (5.24 to 5.26) and preventing delirium and managing cognitive impairment (5.29 and 5.30).

Discuss treatment options with the patient. Explain the goals, benefits, risks and limitations of treatment options, taking into account the patient’s medical conditions, goals of care and prior level of function. If a hip fracture complicates or precipitates a terminal illness, consider the role of surgery as part of a palliative care approach to alleviate symptoms and minimise suffering.

If clinically indicated and in accordance with patient preferences, surgery should be performed within 36 hours of the patient’s first presentation to hospital. If a patient sustains a fracture in hospital, surgery should be performed within 36 hours of the fracture occurring. Prescribe surgical antibiotic prophylaxis and thromboprophylaxis according to current guidelines.

Ensure systems are in place for clinicians to perform hip fracture surgery within 36 hours of presentation. 

For health service organisations covering some remote areas, networks and systems should be in place to ensure coordinated inter-facility transfer of patients who sustain a hip fracture, to facilitate surgery within 36 hours of the first clinical presentation. 

Ensure that there is a palliative pathway available for patients with a hip fracture that complicates or precipitates a terminal illness.

Your clinicians will discuss the treatment options for your hip fracture, and the possible risks and benefits with you. You should have surgery within 36 hours of presenting to hospital with a hip fracture, unless your doctors advise that you wait. The same timeframes apply if you experience a hip fracture while you are in hospital. If you are in a remote location, surgery may be delayed while you are transferred to a hospital where the surgery can be done. However, you should still receive surgery as soon as possible. 

For some people a decision is made that surgery is not the best option. You may not want to have surgery, or your doctors may advise that it is better for you not have surgery at all. Your family will be involved in these decisions.
 

For clinicians

Cultural safety remains important, even during time-sensitive care. Language should not be a barrier to shared decision making or informed consent. The use of Māori Health Workers; Aboriginal and Torres Strait Islander Health Workers or Practitioners; Liaison Officers; cross-cultural health workers; and translators is strongly encouraged to help:

• patients navigate the service and their treatment options
• with translation of words and adaptations of concepts.

For healthcare services

Support clinicians to provide respectful and culturally safe care by having systems in place that facilitate involvement of Aboriginal and Torres Strait Islander Health Workers or Practitioners; Liaison Officers; cross-cultural health workers; and translators.

Improving mobility outcomes after hip fracture is key to recovery. Mobilise patients the day of, or the after hip fracture surgery, and at least once a day thereafter unless contraindicated. Mobilised means the patient manages to stand and step transfer out of bed onto a chair/commode or walk. Allow patients to bear weight as tolerated, but avoid weight‑bearing if there is a clinical concern about the fracture, the fixation or the likelihood of healing.

Additional exercises, such as training of gait, balance and functional tasks can further improve patient outcomes. For patients with conditions preventing mobilisation, arrange for tailored advice from a physiotherapist or occupational therapist.

For patients at risk of pressure injuries, conduct comprehensive skin inspections and provide pressure injury prevention and care in accordance with best-practice guidelines.

Ensure systems and protocols are in place for:

• patients to be mobilised the day of, or the day after hip fracture surgery and at least once a day thereafter, unless contraindicated
• pressure injury prevention and wound management, consistent with best-practice guidelines.

Ensure that equipment and devices are available to enable mobilisation, and decrease the risk of pressure injuries.

The aim of hip fracture surgery is to allow you to get up and put weight through your leg straight away. The day of your surgery or the day after your surgery, you will be encouraged to sit out of bed and start to walk using your full weight, unless there are good reasons for you not to. It is common to feel some pain or weakness when you start walking. Starting to move early will prevent you from losing your strength and mobility, and help you regain your independence sooner. It will also help to avoid serious complications, such as pneumonia, clots in the legs, pressure injuries to the skin and delirium.

If you are spending long periods in bed or in a chair without moving, you are at risk of developing a pressure injury. Your risk of getting a pressure injury will be assessed regularly and you will be provided with the right kind of equipment (like a mattress and/or cushion) and advice on moving about to relieve the pressure that causes the sores.

For clinicians

Language should not be a barrier to early mobilisation. Professional healthcare interpreters can help clinicians explain why mobilisation is important for rehabilitation, and to navigate any cultural beliefs that may be influencing the patient and their family (whānau). Consideration needs to be given to the development of culturally relevant goals and how these can be achieved to support the wellbeing of the patient.

• The Commission has developed several resources for clinicians, managers and executives, governing bodies and others that can help them adopt strategies that reduce the occurrence of hospital-acquired complications and provide comprehensive care, including for pressure injury.
• The National Safety and Quality Health Service Standards Comprehensive Care Standard includes actions on preventing and managing pressure injuries (5.21 to 5.23).

Assess patients with a hip fracture for their risk of another fracture. Educate them by discussing risk factors for falls and providing written information on specific exercises to improve muscle strength and balance. Where clinically indicated, discuss the need for bone protection medicines and initiate treatment prior to discharge. Where appropriate, refer to an established fracture liaison service (FLS). Ensure the management plan is included in the patient’s discharge summary and care plan.

Ensure systems are in place for routine assessment of patients’ fracture risk and follow-up for secondary fracture prevention. This includes:

• education to address modifiable risk factors including patient education materials (such as for reducing falls risk and specific exercises to improve muscle strength and balance)
• prescribing or administering bone protection medicines prior to discharge where possible
• referral where appropriate.

Where a FLS exists within the health service, establish processes to systematically identify patients after a fracture and arrange follow up, as described in the Clinical Standards for Fracture Liaison Services in New Zealand. Where no FLS exists, a model of care should include systems and resources to:

• identify at risk patients
• conduct investigations
• assess and manage future fracture risk
• refer to the appropriate treatment provider(s) for secondary fracture prevention care that cannot be provided during the hospital stay.

In Australia, this may involve liaison with Primary Health Networks to develop appropriate models of care.

People who have had a hip fracture are more likely to have another fracture in the future. Before you leave hospital, your risk of having another fracture anywhere in your body will be assessed. Your clinician will help to identify the possible reasons for your fall and ways to prevent future falls. They will also check the strength of your bones, which may be getting weaker and more likely to break easily. You may be offered bone protection medicines to improve your bone strength and reduce the chance of another fracture. You will also be given written information and advice on exercises to reduce your risk of falls or another fracture. It’s important that you continue to work on preventing another fracture after you leave hospital. Discuss your care plan with your general practitioner or ongoing clinical provider. You may be offered a follow up appointment at the hospital as part of planning to reduce your risk of another fracture.

For clinicians

Ensure that the information and education you provide is culturally safe and appropriate. Use an interpreter if needed, and provide written information in the person’s preferred language and in a way that they can understand. Apply understandings of family (whānau) and involve Māori Health Workers, Aboriginal and Torres Strait Islander Health Workers or Practitioners and Liaison Officers. Consider the home environments and lived realities of patients, including services accessible to them and community infrastructure.

For healthcare services

Written information that highlights the pathway for hip fracture care should be provided in languages that reflect the make-up of the local population. Any written material for Māori or Aboriginal and Torres Strait Islander populations should be developed in partnership with the community and people with expertise in Indigenous health issues. Validated methods for developing written information should be used to the greatest extent possible.

• The Australian and New Zealand Hip Fracture Registry fact sheet Reducing the risk of future fractures: Osteoporosis and fall prevention.
• Healthy Bones Australia resources and fact sheets about osteoporosis, treatment, diet, exercise and falls; this information can be used by clinicians in discussions with patients when developing a plan to reduce the risk of another fracture.
• The Clinical Standards for Fracture Liaison Services in New Zealand underpin a nationwide strategy to prevent older adults who sustain a fragility fracture from breaking other bones in the future.
• The Therapeutic Guidelines Osteoporosis and minimal-trauma fracture guideline includes information on assessing and interpreting bone status and preventing minimal‑trauma fracture.
• National Safety and Quality Health Service Standards Comprehensive Care Standard actions on preventing and managing pressure injuries (5.21 to 5.23), nutrition and hydration (5.27 and 5.28), preventing falls and harm from falls (5.24 to 5.26) and preventing delirium and managing cognitive impairment (5.29 and 5.30).

Develop an individualised care plan with the patient before they leave hospital (for example the ANZHFR My Hip Fracture or NZHQSC Recovering from a Hip Fracture booklets). The individualised care plan is separate to a clinical discharge summary and should:

• identify any changes in medicines, any new medicines or ongoing pain management
• identify equipment and contact details for rehabilitation services and refer as required
• describe mobilisation activities, wound care and function post-injury
• provide information and recommendations for secondary fracture prevention including contact details for services, where appropriate
• recommend bone protection medicines to the patient and their GP if they have not been started in the hospital.

Provide the care plan to the patient before they leave hospital. Include an overview of the care discussed within the discharge care summary and provide to their general practice, and other regular clinicians and care providers on discharge.

Ensure systems are in place to support clinicians to develop an individualised care plan with patients prior to discharge, and refer patients to the relevant services as required.

Ensure clinical information systems support clinicians in providing the plan to the patient, and communicating the content to their general practitioner, ongoing clinical providers, or community providers responsible for the patient clinical care (such as Aged Care Homes). Where local clinical information systems allow, upload information into the patient’s My Health Record. Sharing information on the care provided in hospital is particularly important if the patient is discharged to interim care (rehabilitation hospital or respite aged care) before returning home or consulting their usual general practitioner.

Before you leave hospital, your doctor will talk with you about your recovery and the ongoing care you will need. They will help to develop a plan with you in a format that you understand. The plan describes:

• medicines you may need to take
• information on how to prevent future fractures
• nutrition care
• rehabilitation services and equipment you require.

You will get a copy of your plan before you leave hospital. The information in your plan will also be communicated to your general practitioner and other regular clinicians and care providers. Take your plan with you to future appointments along with any questions you would like to discuss.

For clinicians

Consider cultural needs, preferences and goals and their impact on the individualised care plan. This is especially true for the discharge process and the transition to home. It is important for the care plan to reflect the lived realities of the person and consider what supports are available within the family and community. 

For Māori patients and whānau, acknowledge hauora (overall physical, mental, emotional, environmental and spiritual health) and involve Māori Health Workers to provide additional support during transition from the hospital. 

For Aboriginal and Torres Strait Islander patients and support people, ACCHOs and Aboriginal Medical Services play an important role in providing access to relevant support after discharge, especially in rural and remote areas. If the person’s usual care provider is based in an ACCHO or Aboriginal Medical Service, offer to contact the care provider to advise that the patient is being discharged and discuss suitable support arrangements. Involve an Aboriginal and Torres Strait Islander Health Worker, Practitioner or Liaison Officer when this is the patient’s preference.

For healthcare services

Ensure that services are in place to enable effective communication with patients that considers their culture and location of care. Aboriginal and Torres Strait Islander people, Māori people and whānau, and others who have completed acute treatment away from their community may need structured support to ensure that they safely return to their place of residence. Establish appropriate, culturally safe networks and arrange access to services, support and contacts for people who have been transferred from remote locations.

• ANZHFR My Hip My Voice webpage - the Hip Fracture Care Guide (translated into 15 languages), and other information for patients, carers and families. Australian and New Zealand Hip Fracture Registry
• Te Tāhū Hauora has helped to develop the Recovering from a hip fracture: Pikinga ora i tētahi whainga hope information booklet to meet the needs of the population in Aotearoa New Zealand; an important part of the booklet is for the patient to be able to work through and document a personal plan with their healthcare team before discharge from hospital.

Overall indicator

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

Information for clinicians - Hip Fracture Clinical Care Standard

Information for healthcare services - Hip Fracture Clinical Care Standard

• Shared Hospital Resources including locally developed protocols and pathways, Australian and New Zealand Hip Fracture Registry website.
• Care of older persons in the emergency department (Policy P51) Australasian College for Emergency Medicine
• Hospital-acquired complications resources including for VTE, delirium , malnutrition and pressure injury
• National Safety and Quality Health Service Standards Comprehensive Care Standard actions on nutrition and hydration (5.27 and 5.28), preventing falls and harm from falls (5.24 to 5.26) and preventing delirium and managing cognitive impairment (5.29 and 5.30). preventing and managing pressure injuries (5.21 to 5.23) 

VTE and delirium

• Venous Thromboembolism Prevention Clinical Care Standard
• Delirium Clinical Care Standard
• 4AT - validated for both cognitive impairment screening and delirium assessment, available in 17 languages.
• Some validated tools for cognitive impairment screening include:
  • Abbreviated Mental Test Score (AMTS), incorporated in the NSW Health Delirium Screen for Older Adults (available from the Agency for Clinical Innovation)
  • Kimberley Indigenous Cognitive Assessment tool, available from the Dementia Centre for Research Collaboration
• Clinical Frailty Scale  

Falls and fractures

• The Falls Guidelines
• The Clinical Standards for Australian Secondary Fracture Prevention Services (available from the Australian National SOS Fracture Alliance)
• The Therapeutic Guidelines Osteoporosis and minimal-trauma fracture guideline includes information on assessing and interpreting bone status and preventing minimal‑trauma fracture. 

Pain management 

• Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard
• Pain scales support the identification of symptoms and signs associated with pain in people with altered cognition; examples include
  • Pain Assessment in Advanced Dementia scale
  • Abbey pain scale.
  • Wong-Baker FACES pain rating scale.
• Acute Pain Management: Scientific Evidence, Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine.
• Standard of practice in pain management for pharmacy services, Advanced Pharmacy Australia (AdPha) (formerly Society of Hospital Pharmacists of Australia)

Guide for consumers - Hip Fracture Clinical Care Standard 

Further information for consumers can also be found on the ANZHFR 'My Hip My Voice' page including the 'Hip Fracture Care Guide' resource which has been translated into 15 different languages, and was developed to help consumers understand what to expect when admitted to hospital with a broken hip.

• ANZHFR My Hip My Voice webpage - the Hip Fracture Care Guide (translated into 15 languages), and other information for patients, carers and families. Australian and New Zealand Hip Fracture Registry
• Recovering from a hip fracture: Pikinga ora i tētahi whainga hope information booklet to meet the needs of people in Aotearoa New Zealand  - includes a personal plan to be developed by the patient with their healthcare team before discharge from hospital.
• Healthy Bones Australia resources and fact sheets
• Reducing the risk of future fractures: Osteoporosis and fall prevention. The Australian and New Zealand Hip Fracture Registry

The revised Standard maintains the same scope and goal of the 2016 Hip Fracture Clinical Care Standard. It is recommended that services use the 2023 version of the Standard no later than September 2024, 12 months from the release of the updated Standard. 

The following changes have been made in the updated Standard.

Changed

• Indicator 1b (now 1a) on screening for cognitive impairment to align with Indicator 1b of the Delirium Clinical Care Standard.

Added

• Indicators 2b and 2c on the proportion of patients receiving a nerve block prior to surgery and prior to transfer from another hospital, where applicable.
• Indicators 3a and 3b on assessing for clinical frailty and delirium.
• Indicator 3c on the proportion of patients receiving protein and energy oral nutritional supplements.

Retired

• Indicator 1a ‘Evidence of local arrangements for the management of patients with hip fracture in the emergency department’.
• Indicator 2a ‘Evidence of local arrangements for timely and effective pain management for hip fracture’.
• Indicator 3a ‘Evidence of orthogeriatric (or alternative physician or medical practitioner) management during an admitted patient’s hip fracture episode of care’.
• Indicator 5b ‘Proportion of patients with a hip fracture with unrestricted weight bearing status immediately post hip fracture surgery’.
• Indicator 5d ‘Proportion of patients with a hip fracture returning to pre-fracture mobility’.
• Indicator 6b ‘Proportion of patients with a hip fracture readmitted to hospital with another femoral fracture within 12 months of admission from initial hip fracture’.
• Indicator 7b ‘Proportion of patients with a hip fracture living in a private residence prior to their hip fracture returning to private residence within 120 days post separation from hospital’.

A hip fracture is a break occurring at the top of the thigh bone (femur), near the pelvis. Hip fracture is an event that often signifies underlying ill health. Most hip fractures occur in people aged 65 years and over, with an average age of 82 years across Australia and New Zealand Aotearoa. Individuals with hip fracture are over 3.5 times more likely to die within 12 months compared to non-injured individuals. This patient group also has a high hospital-acquired complication rate, resulting in patient suffering and unnecessarily high healthcare costs.

Key markers of quality of care in hip fracture such as time to surgery, complication rates, hospital readmission rates and length of stay can vary considerably between hospitals. Hip fracture patients, being vulnerable due to their age, are at risk of other common hospital-acquired complications such as those defined by the Commission. The quality of care is influenced by, among other factors, the configuration of orthopaedic and geriatric medicine services, hospital protocols and processes, and the degree to which a multidisciplinary approach to care is taken.

These considerations were fundamental to the development of the Hip Fracture Clinical Care Standard.

Read more about the scope and goal of this Standard or see further background in the Hip Fracture Clinical Care Standard.

This Standard applies to care provided in all hospital settings, including public and private hospitals and subacute facilities.

Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement. 

When implementing this Standard, healthcare services should consider:

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service. 

In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:

• hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations
• multidisciplinary teams including allied health involvement where clinically appropriate.

This Standard relates to the care that people with a suspected hip fracture should be offered, from presentation to hospital through to completion of treatment and discharge from hospital. This also includes people who sustain a hip fracture while in hospital. The target age for this clinical care standard is 50 years and older. 

The care described in this clinical care standard is also appropriate for people aged under 50 years who have a suspected hip fracture that is judged to be caused by osteoporosis or osteopenia.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting. 

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities.

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Commission wishes to acknowledge Te Tāhū Hauora The Health Quality & Safety Commission (Aotearoa New Zealand) for their collaboration on this bi-national Standard.

The Hip Fracture Clinical Care Standard has been endorsed by 22 key organisations:

• Australian and New Zealand Bone and Mineral Society
• Australian and New Zealand College of Anaesthetists
• Australian and New Zealand Falls Prevention Society
• Australian and New Zealand Hip Fracture Registry
• Australian and New Zealand Orthopaedic Nurses Alliance
• Australian Association of Gerontology
• Australian College of Emergency Medicine
• Australian College of Nurse Practitioners
• Australian College of Nursing
• Australian College of Perioperative Nurses
• Australian College of Rural and Remote Medicine
• Australasian Delirium Association
• Australian Orthopaedic Association
• Australian Physiotherapy Association
• CRANAplus
• Healthy Bones Australia
• Indigenous Allied Health Australia
• National Aboriginal Community Controlled Health Organisation
• Neuroscience Research Australia
• Royal Australasian College of Physicians
• Society of Hospital Pharmacists Australia
• Te Tāhū Hauora Health Quality & Safety Commission

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Hip Fracture Clinical Care Standard Topic Working Group provided expert advice on the development and review of the Standard. In addition, a targeted consultation process was conducted with key stakeholders.

Hip Fracture Clinical Care Standard - Topic Working Group

Many members of the topic working group were involved in the original development of the Standard in 2016. 

The role of the Topic Working Group was to:

• advise the Commission on the scope and key components of care
• advise the Commission on the key sources of evidence to inform the revisions
• recommend to the Commission strategies to support implementation
• actively support raising awareness of the updated Standard.

For those who are consumers, a key role is to advise the Commission on matters relating to their experience - whether as a patient or carer - and provide this perspective during the review of the Hip Fracture Clinical Care Standard.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence base which underpins the Hip Fracture Clinical Care Standard.

Evidence Sources - Hip Fracture Clinical Care Standard