Multi-Disciplinary Clinical Service Review: Care of Patients with Non-Ambulatory Fragility Fractures

About the Non-Ambulatory Fragility Fracture Review Service

The British Orthopaedic Association (BOA) has offered a service review for sites caring for older patients with fragility fractures for over a decade and we have reviewed 25 sites in that time.  We have had very positive feedback from reviewed sites, including:

“We think it’s a fair and impressively detailed report of our service considering the short time the team had to assess the service.  A remarkable piece of work!”
“It has already been very useful in influencing necessary changes”

The reviews are led by the BOA but have always taken a multi-disciplinary approach and the review panel is formed of senior clinicians from several specialties.  Although originally labelled a “hip fracture review”, we have always recommended that the principles of care should apply equally to all patients with similar clinical needs and the reviews are now formally targeted at the care of all patients with non-ambulatory fragility fractures (NAFFs).  This is a broad group of patients, including most elderly and frail patients who are admitted to hospital with lower limb fractures and those with upper limb fractures that disrupt mobility, for example in patients who rely on walking aids.

Often a request for a review is triggered when a site is identified as a negative outlier for mortality in the National Hip Fracture Database (NHFD) but this is not the only reason for a review and we welcome requests from all sites.

Purpose of a Review

The reviews are designed as a supportive process to help clinical and operational teams to improve care; they are not an inspection and the review team act as critical friends, not as regulators.  It is a significant undertaking to hold an in-depth review of this nature, both for the review panel and the site being reviewed.  However, such reviews have an important role to play in helping clinical teams identify areas for improvement and ultimately for patients to benefit.  We hope to develop a constructive and supportive relationship with the site throughout the process.

The full scope of the review will be agreed by the BOA and the site in advance but the following broad objectives are common to all reviews:

•    To evaluate the quality of data submitted to the National Hip Fracture Database (NHFD) and to analyse this in the context of the review parameters.
•    To assess standards of care, compared to current relevant NICE guidelines, NICE quality standards, BOA standards for trauma, AoA guidance and Best Practice Tariff for fragility hip and femur fractures.
•    To assess working practices and multi-disciplinary team function as they relate to the care of patients with non-ambulatory fragility fractures.
•    To recommend changes in the pathway of care for patients with non-ambulatory fragility fractures, to empower the team and give guidance on how to develop the service and drive quality improvement.

Structure of the Review

The review panel evaluate written information from the site in advance of a site visit and then produce a report of findings and recommendations.

The site review takes place in person over two days, with meetings with key individuals on the first afternoon and visits to the various departments the next morning, following the patients’ journey through the hospital to understand how the pathway and processes work in practice.  General feedback is provided at the end of the site visit in advance of the formal report.

Further Information

More information for sites considering a review is available on these links:

•    Information for Sites
•    Organising a Review
•    Request Form

Informal enquiries are welcome from any member of the team but the review must be commissioned by an Executive Director of the organisation, usually the Chief Executive Officer or Medical Director.

Sites that are interested in a review should e-mail their enquiry to [email protected].  The BOA Policy Team will then be in touch about the next steps.