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ANNUAL REPORT - 2O18

ANNUAL REPORT - 2O18

2O18 ANNUAL REPORT

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The ANZHFR would like to acknowledge and thank sincerely the clinical and administrative staff of the 56 hospitals that have contributed to the Patient Level Report and the 118 hospitals that contributed to the Facility Level Report. Without their support, dedication, and energy, this report would not be possible. The ANZHFR receives funding and in-kind support from Neuroscience Research Australia, UNSW Sydney, the New Zealand Accident Compensation Corporation, Amgen Australia, the Australian Commission on Safety and Quality in Health Care, and Queensland Health.

Enhancing Outcomesfor OlderPeople For enquiries or comments, please contact the ANZHFR, Neuroscience Research Australia, 139 Barker Street, Randwick NSW Australia 2031. Additional copies of this report may be accessed at www.anzhfr.org or can be requested from the ANZHFR. Extracts from this report may be reproduced provided the source of the extract is acknowledged.

Report prepared on behalf of the ANZHFR Steering Group by: Ms Elizabeth Armstrong, AHFR Manager Professor Jacqueline Close, ANZHFR Co-Chair Geriatric Medicine Professor Ian Harris AM, ANZHFR Co-Chair Orthopaedics Mr Stewart Fleming, Webmaster Report Design: patterntwo creative studio www.patterntwo.com.au Photography: Craig Fardell, Elizabeth Armstrong, Harry Constantin, Jacqueline Close Suggested citation: ANZHFR Bi-National Annual Report of Hip Fracture Care 2018. Australian and New Zealand Hip Fracture Registry, August 2018. ISBN-13: 978-0-7334-3824-0

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CONTENTS 4 CO-CHAIRS FOREWORD 6 EXECUTIVE SUMMARY 8 INTRODUCTION 10  HIP FRACTURE CARE CLINICAL CARE STANDARD Quality Statement 1: Care at presentation  Quality Statement 2: Pain management  Quality Statement 3: Orthogeriatric model of care  Quality Statement 4: Timing of surgery Quality Statement 5: Mobilisation and weight-bearing  Quality Statement 6: Minimising risk of another fracture Quality Statement 7: Transition from hospital care 12 PARTICIPATION  Patient Level Audit  Facility Level Audit 15  ANZHFR PATIENT LEVEL AUDIT 16 Data Caveats and Completeness 19 Section 1: Demographic information 26  Section 2: Care at presentation 34  Section 3: Surgery and operative care 49  Section 4: Postoperative care 61  Section 5: 30 and 120 day follow-up 77  ANZHFR FACILITY LEVEL AUDIT 78  Results 1: General information 79  Results 2: Model of care 80  Results 3: Protocols and elements of care 84  Results 4: Beyond the acute hospital stay 86 APPENDICES 86 Appendix 1: ANZHFR Steering Group 87  Appendix 2: List of abbreviations ANZHFR | ANNUAL REPORT 2018 3

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4 ANNUAL REPORT 2018 | ANZHFR CO-CHAIRS FOREWORD Welcome to our third patient level and sixth facility level report. Over the past year we have continued to see additional sites join and contribute data to the Registry. The facility level report contains information from all 116 public hospitals across Australia and New Zealand that operate on people with a hip fracture. We welcome the addition of two private hospitals that have joined us in 2017. The report also contains data from 56 hospitals contributing patient level data, a figure that has risen from 34 hospitals in the previous year and continues to increase.

We now have over 20,000 data-sets in the Registry and opportunities exist to explore this data in more detail.

For the first time we are identifying hospitals. New Zealand has elected to publish the names of all hospitals entering patient level data, whilst Australia is identifying hospitals where individual site level approval has been obtained. Pleasingly, 83% of Australian hospitals agreed to be identified in this report. Our hope is that more clinicians of all professions will see their own data and use the data to drive change at a local level. Equally we want teams to share their successes and learnings with other Registry sites. What remains apparent is the marked variation in a number of the process measures, including indicators, which have a real impact for the patient: assessment and management of pain, time to surgery and secondary fracture prevention.

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ANZHFR | ANNUAL REPORT 2018 5 It is important that the Registry evolves over time from being a quality assurance activity (provision of data) to something that drives change (quality improvement). This year we asked some additional questions of the data around access to rehabilitation services for people living in residential aged care facilities, and those with a pre- existing cognitive impairment. There is huge variation in practice across hospitals in both these areas. We cannot comment on whether the variation in practice ultimately leads to different outcomes for these individuals but this is worthy of further evaluation.

The Registry provides an ideal test bed to explore such questions in more detail. In Australia, we were fortunate enough to secure some funding from states and commonwealth governments in 2018/19 and this provides the opportunity to work more closely with sites. It is apparent from talking to sites that there is a huge amount of good work happening and the ability to share and celebrate the successes is limited. We plan to set up a series of state-level hip fracture “festivals” designed to promote good practice, learn from each other and share great ideas. We will also continue to enhance the utility of both the website and the Registry, so as to continuously provide users with information that is timely and relevant to them.

We welcome feedback and plan to continue our teleconference sessions with sites to create a peer network that allows users to ask questions about data entry and data definitions, and share solutions to identified issues.

Collaboration with states in Australia, and at national level in New Zealand, remains important as much of the quality improvement activity is generated and driven at this level. This year we have produced a state and territory level supplementary report that allows jurisdictions to compare performance against the Hip Fracture Care Clinical Care Standard. Collection and reporting of data in a consistent manner across all states and territories provides the opportunity for meaningful comparison of performance. We will continue to explore mechanisms for embedding the minimum dataset within existing medical records on both sides of the Tasman, although this is not without its challenges.

Finally, a huge thanks to all those who have provided data for the facility level and/or patient level reports. We are aware of the challenges in collecting data and the time commitment of the busy clinicians who have been diligently entering data into the Registry. We hope that this report stimulates action to drive change and that these efforts will reap dividends for patients. We will continue to engage with hospitals not currently entering data with the intent in the near future of achieving 100% coverage of all public hospitals in Australia and New Zealand operating on people with a hip fracture.

Professor Jacqui Close Geriatrician Co-Chair Australian and New Zealand Hip Fracture Registry Professor Ian Harris AM Orthopaedic Surgeon Co-Chair Australian and New Zealand Hip Fracture Registry

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6 ANNUAL REPORT 2018 | ANZHFR EXECUTIVESUMMARY The ANZHFR is a bi-national audit of hip fracture care and secondary fracture prevention in Australia and New Zealand. Its objective is to use patient level and facility level data to enable improvements to hip fracture care across both countries. This is the third report of patient level data and the sixth report of facility level data. For the first time, the patient level report uses hospital identifiers. The steps required to achieve improvement in hip fracture care were clear from the outset. A Bi-National Guideline for Hip Fracture Care, a Hip Fracture Care Clinical Care Standard, and the Registry as a mechanism for tracking performance and driving change.

The ANZHFR standardised dataset is aligned to the Hip Fracture Care Clinical Care Standard and data is collected and submitted by hospitals across Australia and New Zealand. The data are used to generate real- time feedback that contributers can use to review the hip fracture care they provide.

In September 2016, the Australian Commission on Safety and Quality in Health Care launched the Hip Fracture Care Clinical Care Standard and its accompanying resources. Importantly, the Hip Fracture Care Clinical Care Standard has been adopted by the Health Quality & Safety Commission New Zealand and this continues the bi-national collaboration commenced in 2012 to improve hip fracture care and secondary fracture prevention on both sides of the Tasman. The Registry evaluates care against the Hip Fracture Care Clinical Care Standard and its seven quality statements: care at presentation; pain management; orthogeriatric model of care; timing of surgery; mobilisation and weight-bearing; minimising the risk of another fracture; and transition from hospital care.

Over the three years of reporting, there is evidence of improvement in some aspects of hip fracture care however variation is evident and this provides a number of opportunities for quality improvement initiatives. The ANZHFR has two components: 1) data collection at the level of the patient, an audit of all people aged 50 years and over admitted to a participating hospital with a minimal trauma fracture of the hip and 2) an annual audit of facility level services and elements of hip fracture care, the facility level audit. For this report, patient level data was contributed from 56 hospitals: 15 New Zealand hospitals and 41 Australian hospitals; and facility level information was provided by 118 hospitals, two of which are private hospitals.

9408 records were contributed for the 2017 calendar year and have been used in this report: 7117 from Australia and 2291 from New Zealand. Key findings this year include: „ „ Only one in five patients in New Zealand (20%) and a little more than one in three patients in Australia (36%) had a documented assessment of cognition prior to surgery „ „ 50% and 54% of patients in New Zealand and Australia, respectively, have a documented assessment of pain within 30 minutes of presentation to the emergency department „ „ The use of nerve blocks for the management of pain is showing steady improvement in both countries.

In New Zealand, 61% of patients have a nerve block for the management of pain compared with 58% in 2017 and 51% in 2016. In Australia, 84% of patients have a nerve block for the management of pain, compared with 80% in 2017 and 59% in 2016. „ „ 40% of hospitals reported access to a planned operating theatre list or planned trauma list for hip fracture patients, unchanged over the six years of the facility level audit „ „ 54 hours is the average time patients are waiting for surgery if transferred to another hospital for their operation „ „ Fewer than one in ten patients are on active treatment for osteoporosis on admission and fewer than one in four have commenced active osteoporosis treatment prior to discharge from the operating hospital Again this year, the ANZHFR is reporting health outcomes for hip fracture patients.

Hip fractures are associated with significant loss of function and independence in daily living activities. Returning home and to similar levels of pre- injury mobility are primary goals of hip fracture treatment and rehabilitation. For the first time, the Registry has highlighted variation in access to rehabilitation for people admitted to hospital from a residential aged care facility, or who have a cognitive impairment.

Rates of follow-up continue to be variable and numbers are low for some sites so the picture of recovery after hip fracture remains incomplete. There is work to be done on expanding coverage of the Registry and improving the rate of follow-up at 30 and 120 days, especially in Australia. Data is a powerful tool for driving change when that data is credible, accessible and provided in a manner that is both timely and meaningful. Reports like this provide a snapshot in time, and sites are encouraged to use the Registry on a regular basis to evaluate the hip fracture care provided.

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ANZHFR | ANNUAL REPORT 2018 7 FACILITYLEVELDATA PATIENTLEVELREPORT of hospitals reported having a pain protocol for hip fracture patients 56% 40% of hospitals had access to planned operating lists for hip fracture patients 24% of hospitals routinely provided individualised written information on prevention of future falls and fractures HOSPITALS 118 HOSPITALS ANZ 9,408 RECORDS 53% had a documented pain assessment within 30 min of arriving at ED 8% 56 25% of patients were on active treatment for osteoporosis on discharge 32% 78% had a nerve block to manage pain before and/or after surgery 30 hours is the time to surgery unless a person is transferred and then it is 54 hours had a preoperative assessment of cognition were on active treatment for osteoporosis on admission

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8 ANNUAL REPORT 2018 | ANZHFR Hip fracture is a common and serious injury of older people. Almost everyone who breaks their hip will be admitted to hospital and nearly all will have a surgical procedure. The consequences are significant. Health and social care systems bear considerable costs associated with the acute treatment, the ongoing costs of rehabilitation, assistance with day-to-day living activities, and the impact of long-term care placement. For individuals, a hip fracture impacts mobility and function, where they live, and even their survival. Yet research shows that effective and efficient hip fracture care and secondary fracture prevention are not routinely delivered.

This care gap leaves hip fracture survivors with an increased risk of subsequent falls and fractures that are associated with increased mortality and loss of societal contributions.

The Australian and New Zealand Hip Fracture Registry (ANZHFR) was established in 2015 with the goal of using data to improve hip fracture care, and ultimately, to improve outcomes for older people who fracture their hip. The patient-level and facility-level data collected by the ANZHFR are not easily captured in existing administrative data sets and are specifically focussed on measuring care against the Australian and New Zealand Guideline for Hip Fracture Care1 and the Australian Commission on Safety and Quality in Health Care (ACSQHC) Hip Fracture Care Clinical Care Standard2 . The Standard was developed in collaboration with the Health Quality & Safety Commission New Zealand and it prioritises seven areas of hip fracture care: care at presentation; pain management; orthogeriatric model of care; timing of surgery; mobilisation and weight-bearing; minimising risk of another fracture; and transition from hospital care.

The ANZHFR consists of two components: 1) data collection at the level of the patient, the patient level audit, for all people aged 50 years and over admitted to a participating hospital with a minimal trauma fracture of the hip and 2) an annual snapshot of facility level services and elements of hip fracture care, the facility level audit. Both data collections allow progress to be mapped over time and should be used to drive change and inform ongoing improvements in the delivery of hip fracture care. Patient level data is used to generate real-time feedback to sites and there are plans to include the facility level audit in the database, but at the moment this function is not yet available.

Coverage is steadily increasing and this year, the third year of bi-national patient level reporting, data from 56 Australian and New Zealand hospitals is included. This represents a steady increase from 34 hospitals reported in 2017 and 25 hospitals in 2016, the first year of patient level reporting. Hospitals across both countries have provided facility level data for six years. PATIENT LEVEL REPORT Public and private hospitals in Australia and New Zealand are eligible to participate if they provide definitive management to people admitted with a hip fracture. People admitted to these hospitals are eligible for inclusion in the ANZHFR patient level audit if they: „ „ Are aged 50 years and over; „ „ Have fractured their hip from a minimal trauma injury; and „ „ Undergo surgical or non-surgical management of the hip fracture.

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ANZHFR | ANNUAL REPORT 2018 9 Hospitals looking to participate can contact the ANZHFR on clinical@anzhfr.org and they will be assisted through the ethics and governance approval process. Patients are able to opt-out of the Registry at any time. At December 2017, 77 hospitals in Australia and New Zealand had approvals in place to collect and submit data to the ANZHFR, although not all hospitals had implemented data collection in time to be included in this report. This represents 65% of public hospitals in Australia and New Zealand identified as undertaking definitive treatment of hip fracture patients.

This year, two private hospitals are included in the patient level report. Since patient level data collection commenced in 2015, 23 330 records have been created in the Registry: 18 424 Australian records and 4 906 New Zealand records.

For the first time, hospitals are identified in this report with a three-letter code used consistently throughout the report. New Zealand determined that all hospitals included in the patient level report would be identified. In Australia, individual sites were contacted and asked to opt-in to identified- reporting, and 34 of 41 hospitals agreed. Seven Australian hospitals not identified this year have been randomly allocated a number, also used consistently throughout, and the number has been provided to the local Principal Investigator. In this report, the patient level audit has been divided into the following sections: „ „ Demographic Information „ „ Care at Presentation „ „ Surgery and Operative Care „ „ Postoperative Care „ „ 30 and 120 Day Follow-up FACILITY LEVEL AUDIT The aim of the facility level audit is to document and monitor over time the services, protocols and practices that exist across Australia and New Zealand in relation to hip fracture care.

The first facility level audit was completed in 2013 and the audit has since been undertaken annually. Public hospitals identified as providing definitive management of hip fractures are invited to complete the survey, as are private hospitals participating in the Registry. The questions have been designed to enable comparison of services and protocols within and between States and Territories in Australia, and New Zealand. The 2018 snapshot of care is the sixth year of the audit and year-on-year results are published in this report.

In this report, the facility level audit has been divided into the following sections: „ „ General Information „ „ Model of Care „ „ Protocols and Elements of Care „ „ Beyond the Acute Hospital Stay REFERENCES 1. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. Australian and New Zealand Guideline for Hip Fracture Care: Improving Outcomes in Hip Fracture Management of Adults. Sydney: Australian and New Zealand Hip Fracture Registry Steering Group; 2014. Available at: www.anzhfr.org 2. Australian Commission on Safety and Quality in Health Care. Hip Fracture Care Clinical Care Standard.

Sydney: ACSQHC, 2016. Available at: https://www. safetyandquality.gov.au/our-work/ clinical- care-standards/hip-fracture-care-clinical- care-standard/

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10 ANNUAL REPORT 2018 | ANZHFR HIPFRACTURECARE CLINICALCARESTANDARD The Hip Fracture Care Clinical Care Standard was developed by the Australian Commission on Safety and Quality in Health Care in collaboration with consumers, clinicians, researchers and health organisations. Its goal is to improve the assessment and management of patients with a hip fracture to optimise outcomes and reduce their risk of another fracture. The Clinical Care Standard includes seven ‘quality statements’ (shown below) that describe the clinical care that a patient should be offered to support the delivery of evidence-based high-quality care.

A patient presenting to hospital with a suspected hip fracture receives care guided by timely assessment and management of medical conditions, including diagnostic imaging, pain assessment and cognitive assessment. „ „ 78% of hospitals reported having a hip fracture pathway: 56% across the whole acute patient journey and 22% in the emergency department only „ „ 55% of hospitals reported the presence of a protocol for Computed Tomography (CT) / Magnetic Resonance Imaging (MRI) if plain imaging of a suspected hip fracture is inconclusive „ „ 59% of patients in both New Zealand and Australia are documented as having no cognitive issues prior to admission „ „ 20% and 36% of patients in New Zealand and Australia, respectively, have a documented assessment of cognition using a validated tool prior to surgery A patient with a hip fracture is assessed for pain at the time of presentation and regularly throughout their hospital stay, and receives pain management including the use of multimodal analgesia, if clinically appropriate.

„ „ 56% of hospitals responded that they had a pathway for pain management in hip fracture patients: 32% across the whole acute patient journey and 24% in the emergency department only „ „ 50% and 54% of patients in New Zealand and Australia, respectively, have a documented assessment of pain within 30 minutes of presentation to the emergency department „ „ 38% and 46% of patients in New Zealand and Australia, respectively, are receiving analgesia in transit or within 30 minutes of presentation to the emergency department „ „ 36% and 66% of patients in New Zealand and Australia, respectively, receive a nerve block before surgery A patient with a hip fracture is offered treatment based on an orthogeriatric model of care as defined in the Australian and New Zealand Guideline for Hip Fracture Care.

„ „ 55% of hospitals reported an orthogeriatric service for older hip fracture patients: 32% utilising a daily geriatric medicine liaison service; 23% utilising a shared-care arrangement with orthopaedics „ „ 24% and 63% of patients in New Zealand and Australia, respectively, are assessed by a geriatrician prior to surgery QUALITY STATEMENT 1: CARE AT PRESENTATION QUALITY STATEMENT 2: PAIN MANAGEMENT QUALITY STATEMENT 3: ORTHOGERIATRIC MODEL OF CARE

ANZHFR | ANNUAL REPORT 2018 11 A patient presenting to hospital with a hip fracture, or sustaining a hip fracture while in hospital, receives surgery within 48 hours, if no clinical contraindication exists and the patient prefers surgery.

„ „ 80% and 77% of patients in New Zealand and Australia, respectively, are reported as being operated on within 48 hours of presentation to hospital „ „ 54 hours is the average time to surgery in both countries for patients transferred to the operating hospital from another hospital A patient with a hip fracture is offered mobilisation without restrictions on weight bearing the day after surgery and at least once a day thereafter, depending on the patient’s clinical condition and agreed goals of care. „ „ 87% and 89% of patients in New Zealand and Australia, respectively, are offered the opportunity to mobilise on the first day after surgery „ „ 93% and 96% of patients in New Zealand and Australia, respectively, have unrestricted weight-bearing immediately after hip fracture surgery „ „ Fewer than 3% of hip fracture patients are reported as experiencing a new stage II or higher pressure injury of the skin during their hospital stay „ „ 52% of patients were followed up at 120 days after presentation: of those followed up, 23% and 26% of patients in New Zealand and Australia, respectively, are reported as having returned to their pre-fracture mobility at 120 days after presentation to hospital Before a patient with a hip fracture leaves hospital, they are offered a falls and bone health assessment, and a management plan based on this assessment, to reduce the risk of another fracture.

„ „ 74% and 81% of patients in New Zealand and Australia, respectively, had undergone a fall-risk assessment during their inpatient stay „ „ 25% and 24% of patients in New Zealand and Australia, respectively, were receiving bone protection medication at discharge from hospital „ „ At 120 days after presentation, 38% and 30% of patients in New Zealand and Australia, respectively, were receiving bone protection medication Before a patient leaves hospital, the patient and their carer are involved in the development of an individualised care plan that describes the patient’s ongoing care and goals of care after they leave hospital.

The plan is developed collaboratively with the patient’s general practitioner. The plan identifies any changes in medicines, any new medicines, and equipment and contact details for rehabilitation services they may require. It also describes mobilisation activities, wound care and function post-injury. The plan is provided to the patient before discharge and to their general practitioner and other ongoing clinical providers within 48 hours of discharge. „ „ 5% and 28% of hospitals in New Zealand and Australia, respectively, reported providing written, individualised information on discharge that describes ongoing care, goals of care and recommendations for prevention of future falls and fractures „ „ Of those who lived at home prior to injury and followed up at 120 days after presentation, 76% and 71% of patients in New Zealand and Australia, respectively, have returned to their own home at 120 days QUALITY STATEMENT 4: TIMING OF SURGERY QUALITY STATEMENT 6: MINIMISING RISK OF ANOTHER FRACTURE QUALITY STATEMENT 7: TRANSITION FROM HOSPITAL CARE QUALITYSTATEMENT5: MOBILISATIONANDWEIGHT-BEARING

12 ANNUAL REPORT 2018 | ANZHFR PARTICIPATION REPORT ID N Austin Hospital NUMBER 187 Bankstown Lidcombe Hospital BKL 166 Blacktown Hospital NUMBER 124 Box Hill Hospital BOX 253 Cairns Hospital CNS 180 Campbelltown Hospital - - Coffs Harbour Hospital CFS 28 Concord Hospital CRG 110 Dandenong Hospital DDH 339 Fiona Stanley Hospital FSH 539 Flinders Medical Centre NUMBER 167 Footscray Hospital FOO 136 Frankston Hospital FRA 133 Gosford Hospital GOS 90 Ipswich Hospital IPS 110 John Hunter Hospital JHH 395 Joondalup Hospital NUMBER 173 Launceston Hospital LGH 122 Liverpool Hospital LIV 267 Logan Hospital LOG 109 Lyell Mcewin Hospital LMH 200 REPORT ID N Mater Hospital South Brisbane MSB 91 Nambour Hospital NBR 29 Nepean Hospital NUMBER 220 Prince Charles Hospital PCH 321 Prince of Wales Hospital POW 171 Princess Alexandra Hospital PAH 162 Qeii Hospital QII 35 Rockhampton Hospital ROK 41 Royal North Shore Hospital RNS 163 Royal Prince Alfred Hospital NUMBER 105 Sir Charles Gairdner Hospital SCG 250 St George Hospital STG 217 St Vincent’s Hospital Darlinghurst NUMBER 99 Sunshine Coast University Hospital SCU 121 Tamworth Hospital TAM 32 The Northern Hospital TNH 189 The Sutherland Hospital TSH 90 Toowoomba Hospital TWB 175 Townsville Hospital TSV 195 Westmead Hospital WMD 229 Wollongong Hospital TWH 354 PATIENTLEVELAUDIT REPORT ID N Auckland City Hospital ACH 238 Christchurch Hospital CHC 386 Dunedin Hospital DUN 131 Hawkes Bay Hospital HKB 35 Hutt Valley Hospital HUT 91 Middlemore Hospital MMH 255 North Shore Hospital NSH 361 Rotorua Hospital ROT 11 REPORT ID N Southland Hospital INV 70 Tauranga Hospital TGA 185 Waikato Hospital WKO 169 Wellington Hospital WLG 170 Whakatane Hospital WHK 21 Whanganui Hospital WAG 35 Whangarei Hospital WRE 133 NEW ZEALAND HOSPITALS AUSTRALIAN HOSPITALS

ANZHFR | ANNUAL REPORT 2018 13 New Zealand Hospitals Auckland City Hospital Christchurch Hospital Dunedin Hospital Gisborne Hospital Grey Base Hospital Hawkes Bay Hospital Hutt Hospital Rotorua Hospital Middlemore Hospital Nelson Hospital North Shore Hospital Palmerston North Hospital Southland Hospital Taranaki Base Hospital Tauranga Hospital Timaru Hospital Waikato Hospital Wairarapa Hospital Wairau Hospital Wanganui Hospital Wellington Regional Hospital Whakatane Hospital Whangarei Base Hospital NEW SOUTH WALES Armidale Hospital Bankstown Lidcombe Hospital Bathurst Hospital Blacktown Hospital Bowral Hospital Campbelltown Hospital Canterbury Hospital Coffs Harbour Hospital Concord Hospital Dubbo Hospital Gosford Hospital Goulburn Base Hospital Grafton Base Hospital Hornsby Ku-ring-gai Hospital John Hunter Hospital Lismore Hospital Liverpool Hospital Maitland Hospital Manly Hospital Manning Hospital Mona Vale Hospital Nepean Hospital Orange Health Service Port Macquarie Hospital Prince of Wales Hospital Royal North Shore Hospital Royal Prince Alfred Hospital Ryde Hospital Shoalhaven Hospital South East Regional Hospital (Bega) St George Hospital St Vincent’s Hospital Darlinghurst Sutherland Hospital Tamworth Hospital The Tweed Hospital Wollongong Hospital Wagga Wagga Rural Referral Hospital Westmead Hospital Wollongong Hospital VICTORIA Albury Wodonga Health Austin Hospital Ballarat Health Services Bendigo Hospital Box Hill Hospital Dandenong Hospital Frankston Hospital Goulburn Valley Health (Shepparton) Latrobe Regional Hospital Maroondah Hospital Mildura Base Hospital Northeast Health Wangaratta Royal Melbourne Hospital Sandringham Hospital South West Healthcare (Warrnambool) St Vincent’s Hospital The Alfred The Northern Hospital University Hospital Geelong West Gippsland Healthcare Group (Warragul) Western District Health Service (Hamilton) Western Hospital (Footscray) Wimmera Base Hospital (Horsham) FACILITYLEVELAUDIT QUEENSLAND Bundaberg Base Hospital Cairns Hospital Gold Coast University Hospital Hervey Bay Hospital Ipswich Hospital Logan Hospital Mackay Base Hospital Mater Hospital South Brisbane Nambour General Hospital Princess Alexandra Hospital QEII Jubilee Hospital Redcliffe Hospital Robina Hospital Rockhampton Hospital Sunshine Coast University Hospital The Prince Charles Hospital The Townsville Hospital Toowoomba Hospital SOUTH AUSTRALIA Flinders Medical Centre Lyell McEwin Hospital Mount Gambier and Districts Health Service Royal Adelaide Hospital The Queen Elizabeth Hospital WESTERN AUSTRALIA Albany Hospital Fiona Stanley Hospital Geraldton Hospital Joondalup Health Campus Royal Perth Hospital Sir Charles Gairdner Hospital South West Health Campus (Bunbury) TASMANIA Launceston General Hospital North West Regional Hospital Royal Hobart Hospital NORTHERN TERRITORY Royal Darwin Hospital Alice Springs Hospital AUSTRALIAN CAPITAL TERRITORY The Canberra Hospital Australian Hospitals

14 ANNUAL REPORT 2018 | ANZHFR 14 ANNUAL REPORT 2018 | ANZHFR

ANZHFR | ANNUAL REPORT 2018 15

16 ANNUAL REPORT 2018 | ANZHFR PATIENT LEVEL AUDIT DATACA VEATS ANDCOMPLETENESS Assessment of data quality involves checking the completeness, correctness (accuracy), and coverage (ascertainment) of the data held by the Registry. Completeness refers to the number of variables completed per record over the number of variables eligible to be completed for that patient. The Registry utilises automated and manual data completeness checks for each record.

When logged into the Registry users can view the percentage of variables complete per record. Figure 1 shows the average completeness of data for each participating hospital. Correctness refers to the accuracy of the data entered into each individual data field. The ANZHFR utilises data validation rules and inbuilt date/time sequence checks to ensure the integrity of its data variables. In 2017, a pilot project was undertaken to determine a consistent process for checking data quality and the findings will be used to develop a process that sites can use to ensure reliable data is held by the Registry.

Coverage refers to the proportion of all eligible hip fracture patients that are captured by the Registry. High levels of coverage allow the findings to be generalised to the whole population. If the capture rate is low, selection bias may be introduced where patients included or excluded are systematically different from each other. This may affect the generalisability of the findings.

This patient level report includes data from 56 of 118 hospitals. This year, 9408 records were contributed for the 2017 calendar year: 7117 from Australia and 2291 from New Zealand. One hospital reported in 2017 did not contribute the requisite ten records to be included in 2018. Of the 9408 records created in 2017, 4887 (52%) included 120-day follow-up data. The rate of 120-day follow up in Australia was 43% (3050 records of 7117) and in New Zealand was 80% (1837 records of 2291). The figures provided in this report have the following caveats: „ „ Figures in this report include data from Australia and New Zealand for all patients with an Emergency Department Arrival or an In Hospital Fracture or a Transfer Date in the range of the 1st January 2017 up to and including 31st December 2017 „ „ Hospitals must have contributed more than nine patient records during the relevant calendar year for inclusion in the patient level report „ „ Hospitals are identified using a hospital code.

New Zealand has elected to identify all hospitals and in Australia, individual hospital executives and the local principal investigator have elected to opt-in to identified reporting „ „ Where hospital teams have not elected to opt-in to identified reporting, a randomly assigned number has been used consistently throughout this report. The hospital identification number will be provided to the Principal Investigator listed on the ethics/ governance approval at each facility „ „ Any hospital with fewer than 10 records for any calculation has not had their data reported „ „ For 30 and 120 day outcomes, hospitals have only been reported if they have 80% or more of the patient’s followed up „ „ Where the figure was included in a previous year the averages from all years have been included for comparison The facility level report includes aggregated data only: responses were received from 118 hospitals, including two private hospitals.

ANZHFR | ANNUAL REPORT 2018 17 PATIENT LEVEL AUDIT ANZHFR Patient Level Audit FIGURE 1 DATA COMPLETENESS Figure 1 shows the average completeness of all data for each patient record, shown as an average for each site, and for each country. Completeness is defined as the proportion of fields completed 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% H07 QII H02 LMH RNS SCG H05 TSH ROK STG TWH CFS MSB POW CRG H06 FSH FRA LGH SCU DDH CNS TWB NBR LOG H01 H04 BKL LIV JHH H03 TNH TSV PCH IPS GOS WMD TAM PAH BOX FOO Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 DUN CHC TGA ROT WRE INV ACH MMH NSH HUT WLG HKB WHK WKO WAG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 DATA COMPLETENESS FIGURE1 DATACOMPLETENESS Figure 1 shows the average completeness of all data for each patient record, shown as an average for each site, and for each country.

Completeness is defined as the proportion of fields completed (questions answered) in the individual patient level data collection form. There is no clear threshold for ‘satisfactory’ completeness and 100% completeness is not always possible as some data may not be available for some patients or from some sites.

18 ANNUAL REPORT 2018 | ANZHFR “Iwouldencourageallhospitalsthat careforhipfracturepatientsto jointheANZHFR.Togetherwecan optimisethecareofpatientswith thisfracture,asI’msureyouallknow ofsomeonewhohassustained afracturedhip.Itwillalsobe beneficialtomanyofus,personally, toourownfuturehealth.” OrthopaedicClinicalNurseConsultant,Australia PATIENT LEVEL AUDIT 18 ANNUAL REPORT 2018 | ANZHFR

ANZHFR | ANNUAL REPORT 2018 19 PATIENT LEVEL AUDIT 16 SECTION 1: DEMOGRAPHIC INFORMATION FIGURE 2 SEX 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% IPS FSH RNS CRG SCG GOS LIV SCU ROK H03 BOX STG FOO QII H06 WMD CFS LGH TWH TSV PCH JHH POW CNS DDH FRA BKL H07 TSH LMH H02 LOG MSB H05 PAH TNH H04 TWB TAM H01 NBR Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 ROT INV TGA WKO CHC HKB DUN NSH ACH WLG MMH WHK WAG HUT WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 SEX Male Female Females comprised 70% and 69% of the New Zealand and Australian hip fracture patients in 2017, respectively.

The make-up of the population varies between hospitals. FIGURE2 SEX SECTION1: DEMOGRAPHIC INFORMATION

20 ANNUAL REPORT 2018 | ANZHFR PATIENT LEVEL AUDIT The average age of hip fracture patients is 84 years in both New Zealand and Australia. The median age of males is 84 years in New Zealand and 83 years in Australia and in women, the median age is 85 years in both New Zealand and Australia. The Figure shows the distribution of hip fracture patients by 10- year age bands. Whilst there is variation in the distribution between individual hospitals, the distribution of patients across the age bands in New Zealand and Australia is similar. People aged 90 years and older make up 25% of hip fracture patients in both Australia and New Zealand.

FIGURE3 AGEATADMISSION 25% of hip fracture patients are 90 years and older 18 FIGURE 3 AGE AT ADMISSION The average age of hip fracture patients is 84 years in both New Zealand and Australia. The median age of males is 84 years in New Zealand and 83 years in Australia and in women, the median age is 85 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% RNS H07 TSH FRA H05 FOO CRG SCU NBR SCG TAM STG BKL LMH LGH TWH FSH H06 BOX JHH H01 H04 GOS PCH CFS POW H03 H02 TWB DDH WMD MSB ROK LIV QII TNH IPS TSV PAH CNS LOG Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 DUN NSH ROT WAG TGA ACH INV WKO WLG MMH WRE CHC HKB HUT WHK NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 AGE AT ADMISSION 50-60 60-70 70-80 80-90 90+

ANZHFR | ANNUAL REPORT 2018 21 PATIENT LEVEL AUDIT Indigenous populations constituted less than 1% of the Australian reported data. Maori and Pacific Peoples made up 3.6% of the New Zealand reported data. The majority of New Zealand hip fracture patients report being of European origin. Equivalent data were not collected in Australia. Accuracy in reporting of Indigenous status is known to be variable. FIGURE4 NEWZEALANDETHNICITY 20 FIGURE 4 NEW ZEALAND ETHNICITY Indigenous populations constituted less than 1% of the Australian reported data. Maori and Pacific Peoples made up 3.6% of the New Zealand reported data.

The majority of New Zealand hip fracture patients report being of European origin. Equivalent data were not collected in Australia. Accuracy in reporting of Indigenous status is known to be variable.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MMH ACH HUT NSH WHK WAG WRE WLG WKO TGA INV CHC HKB DUN ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 ETHNICITY Maori Asian Other Ethnicity European Pacific Peoples Middle Eastern / Latin American / African Not elsewhere included

22 ANNUAL REPORT 2018 | ANZHFR PATIENT LEVEL AUDIT 21 FIGURE 5 USUAL PLACE OF RESIDENCE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CRG MSB SCU NBR QII CFS LMH SCG STG TWH H02 TAM TNH POW FSH H07 WMD TSH PCH RNS ROK BKL FRA H05 BOX PAH JHH H01 DDH GOS TWB H03 IPS LGH H06 TSV LIV LOG CNS H04 FOO Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WAG WKO ROT ACH CHC DUN TGA WLG WHK HUT INV NSH MMH HKB WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 USUAL PLACE OF RESIDENCE Private residence Residential aged care facility Other Not known The majority of people admitted to hospital with a hip fracture live at home: 72% of New Zealand patients and 71% of Australian patients.

However, this implies that people from residential aged care facilities are over- represented in the hip fracture population – a finding that is expected and consistent with national and international literature. There is variation seen between hospitals, which will reflect the make-up of the local population including the number of residential aged care facilities.

FIGURE5 USUALPLACEOFRESIDENCE

ANZHFR | ANNUAL REPORT 2018 23 PATIENT LEVEL AUDIT 23 FIGURE 6 PRE-ADMISSION COGNITIVE STATUS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CFS H04 MSB TWB TSH H02 CRG LMH FOO STG ROK QII SCU POW RNS H07 H05 PCH TNH FRA H01 BKL SCG LOG WMD TWH JHH IPS GOS FSH BOX NBR CNS TSV LIV PAH H06 TAM LGH DDH H03 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 ROT HUT ACH HKB WAG WKO INV TGA WHK WRE DUN NSH WLG CHC MMH NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PRE-ADMISSION COGNITIVE STATUS Normal cognition Impaired cognition or known dementia Not known Fifty nine percent of patients in both New Zealand and Australia are documented as having no cognitive issues prior to admission.

However, 39% of patients hospitalised in both countries had impaired cognition or known dementia. Cognitive status prior to admission is not known for 2% of patients. FIGURE6 PREADMISSIONCOGNITIVESTATUS 39% of hip fracture patients had impaired cognition or known dementia at presentation

PATIENT LEVEL AUDIT 24 ANNUAL REPORT 2018 | ANZHFR Updated Charts – August 2018 FOR V5 OF THE ANNUAL REPORT - PATTERNTWO FIGURE 7 PREADMISSION WALKING ABILITY – the one in the draft report is an old one that doesn’t have the new codes and the numbered hospitals. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% LMH TAM TWB MSB NBR CRG FRA TWH H02 FOO BKL LGH PAH H01 IPS PCH WMD JHH TSH RNS H05 SCU H06 TSV H07 SCG STG TNH H04 QII DDH H03 FSH LIV CFS GOS LOG CNS ROK POW BOX Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB WKO HUT ROT INV DUN WHK ACH MMH CHC NSH TGA WAG WRE WLG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PREADMISSION WALKING ABILITY Usually walks without walking aids Usually walks with either a stick or crutch Usually walks with two aids or a frame Usually uses a wheelchair or bedbound Not known Pre-admission walking ability is used to assess the outcome of treatment, as it is a surrogate marker of overall health status.

In New Zealand and Australia, 46% and 45% of hip fracture patients, respectively, walked without any assistive device prior to hospitalisation. There is variation seen between hospitals, which is likely to reflect the make-up of the local population.

FIGURE7 PREADMISSIONW ALKINGABILITY

ANZHFR | ANNUAL REPORT 2018 25 PATIENT LEVEL AUDIT The ASA grading was developed by the American Society of Anesthesiologists (ASA). It is a measure of anaesthetic risk that is often used as a general measure of physical health or comorbidity. Increasing ASA Grade is associated with mortality and morbidity risk. For patients at each hospital for whom the ASA is known, Figure 9 shows the grading of anaesthetic risk. Grade 1 is a healthy individual with no systemic disease, Grade 2 is mild systemic disease not limiting activity, and Grade 3 is severe systemic disease that limits activity but is not incapacitating.

Grade 4 indicates a patient with severe systemic disease that is a constant threat to life. ASA Grade 5 indicates that the patient is not expected to survive surgery. The ASA grades provided in Figure 9 show that most hip fracture patients have an ASA grade of 3 or higher, indicating significant comorbidities and anaesthetic risk.

27 FIGURE 8 ASA KNOWN FIGURE 9 ASA GRADE 0% 50% 100% H05 TSH ROK H03 TWH FRA CFS H06 TNH STG GOS FOO FSH WMD POW SCG LGH JHH BOX H04 LIV BKL LMH CNS CRG DDH H01 H02 H07 IPS LOG MSB NBR PAH PCH QII RNS SCU TAM TSV TWB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WRE TGA WHK CHC WAG WKO DUN HKB ROT HUT ACH INV NSH MMH WLG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 KNOWN VS UNKNOWN Known Unknown 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% H05 TSH ROK H03 TWH FRA CFS H06 TNH STG GOS FOO FSH WMD POW SCG LGH JHH BOX H04 LIV BKL LMH CNS CRG DDH H01 H02 H07 IPS LOG MSB NBR PAH PCH QII RNS SCU TAM TSV TWB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WRE TGA WHK CHC WAG WKO DUN HKB ROT HUT ACH INV NSH MMH WLG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 ASA GRADE ASA Grade 1 ASA Grade 2 ASA Grade 3 ASA Grade 4 ASA Grade 5 27 FIGURE 8 ASA KNOWN FIGURE 9 ASA GRADE 0% 50% 100% H05 TSH ROK H03 TWH FRA CFS H06 TNH STG GOS FOO FSH WMD POW SCG LGH JHH BOX H04 LIV BKL LMH CNS CRG DDH H01 H02 H07 IPS LOG MSB NBR PAH PCH QII RNS SCU TAM TSV TWB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WRE TGA WHK CHC WAG WKO DUN HKB ROT HUT ACH INV NSH MMH WLG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 KNOWN VS UNKNOWN Known Unknown 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% H05 TSH ROK H03 TWH FRA CFS H06 TNH STG GOS FOO FSH WMD POW SCG LGH JHH BOX H04 LIV BKL LMH CNS CRG DDH H01 H02 H07 IPS LOG MSB NBR PAH PCH QII RNS SCU TAM TSV TWB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WRE TGA WHK CHC WAG WKO DUN HKB ROT HUT ACH INV NSH MMH WLG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 ASA GRADE ASA Grade 1 ASA Grade 2 ASA Grade 3 ASA Grade 4 ASA Grade 5 FIGURE8 ASAKNOWN FIGURE9 ASAGRADE

PATIENT LEVEL AUDIT 26 ANNUAL REPORT 2018 | ANZHFR 29 SECTION 2: CARE AT PRESENTATION FIGURE 10 TRANSFERRED FROM ANOTHER HOSPITAL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BKL CFS CRG H01 H04 NBR QII TSH WMD BOX STG H07 PAH FOO H03 SCG IPS MSB RNS H05 LOG TNH GOS LGH POW FRA JHH LIV DDH H02 SCU H06 LMH TWH FSH PCH ROK TSV CNS TAM TWB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 ACH HKB MMH WAG WHK NSH WLG HUT WKO TGA CHC DUN INV WRE ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 TRANSFERRED FROM ANOTHER HOSPITAL Transferred from another hospital Not transferred FIGURE1O TRANSFERREDFROMANOTHERHOSPITAL There is considerable variation between sites in the proportion of patients transferred in from other hospitals prior to definitive treatment.

This variation reflects differences in geography, service delivery, and the role delineation of the hospital. It also impacts on time to surgery when the period spent in the transferring hospital and the time spent in transition is included. SECTION2: CAREAT PRESENTATION

ANZHFR | ANNUAL REPORT 2018 27 PATIENT LEVEL AUDIT 31 FIGURE 11 AVERAGE LENGTH OF STAY IN THE EMERGENCY DEPARTMENT (ED) H06 TWH WMD BOX H05 H01 H04 LIV FOO FRA LGH LOG TNH BKL CFS H02 JHH LMH POW STG TSH DDH GOS H03 NBR PAH QII RNS CNS H07 MSB PCH SCG TAM CRG FSH IPS SCU TWB ROK TSV Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 MMH INV NSH HKB WKO ACH DUN HUT ROT TGA WAG WLG WRE CHC WHK NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 0 2 4 6 8 10 12 14 Hours AVERAGE LENGTH OF STAY IN THE EMERGENCY DEPARTMENT Average length of stay in ED Median time in ED Average length of stay in the Emergency Department (ED) decreased slightly between 2016 and 2017 in both countries, but variation in length of stay between hospitals remains.

The median length of stay in ED did not change between 2016 and 2017 in both Australia (6 hours) and New Zealand (5 hours). FIGURE11 A VERAGELENGTHOFSTAYINTHEEMERGENCYDEPARTMENT(ED)

PATIENT LEVEL AUDIT 28 ANNUAL REPORT 2018 | ANZHFR The type of ward used for hip fracture patients varies between sites due to factors such as the size and the role of the hospital. Despite this, the proportion of patients admitted to a specific hip fracture or orthopaedic ward in 2017 was 98% and 89%, respectively, in New Zealand and Australia. This is similar to previous years. FIGURE12 W ARDTYPEFROMTHEEMERGENCYDEPARTMENT 33 FIGURE 12 WARD TYPE FROM THE EMERGENCY DEPARTMENT 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% WMD TWH LIV GOS H05 CRG JHH H01 H04 H02 RNS BOX STG H07 TSH H06 QII H03 LGH TNH BKL MSB LOG LMH IPS PAH POW NBR CNS DDH SCG TWB SCU TSV FRA FSH PCH CFS FOO ROK TAM Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB TGA WAG MMH DUN NSH HUT WKO ACH CHC WLG WRE INV ROT WHK NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WARD TYPE FROM THE EMERGENCY DEPARTMENT Hip fracture unit/Orthopaedic ward/preferred ward Outlying ward HDU / ICU / CCU Other/Not known

ANZHFR | ANNUAL REPORT 2018 29 PATIENT LEVEL AUDIT There is considerable variation seen between hospitals in the proportion of patients who have a documented assessment of pain within 30 minutes of arrival in the ED, varying from 0% to nearly 100%. On average, 50% and 54% of the New Zealand and Australian hip fracture patients, respectively, have a documented assessment of pain within 30 minutes of presentation. FIGURE13 PAINASSESSMENTINTHEEMERGENCYDEPARTMENT(ED) 35 FIGURE 13 PAIN ASSESSMENT IN THE EMERGENCY DEPARTMENT (ED) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SCG WMD TNH NBR H01 H06 LIV FSH SCU JHH BKL QII TSV LOG FRA H02 TSH DDH RNS LMH POW FOO ROK MSB TWB CNS STG H03 TAM IPS H05 TWH GOS CFS LGH PCH H04 BOX PAH CRG H07 Aus Avg 2017 NSH DUN WLG HKB WKO CHC MMH WAG TGA ACH WHK HUT INV ROT WRE NZ Avg 2017 PAIN ASSESSMENT IN THE EMERGENCY DEPARTMENT Documented assessment of pain within 30 minutes of ED presentation Documented assessment of pain greater than 30 minutes of ED presentation Pain assessment not documented or not done Not known

PATIENT LEVEL AUDIT 30 ANNUAL REPORT 2018 | ANZHFR It can be seen that 38% and 46% of the New Zealand and Australian hip fracture patients, respectively, received analgesia either in transit (by paramedics) or within 30 minutes of arrival at the ED. FIGURE14 PAINMANAGEMENTINTHEEMERGENCYDEPARTMENT(ED) 37 FIGURE 14 PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT (ED) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TNH NBR TSV H06 SCG QII LMH LOG FSH LIV SCU TAM POW TSH DDH FRA JHH TWB H01 MSB H02 H03 RNS H07 PCH STG WMD BKL CFS CNS IPS FOO ROK GOS TWH LGH H04 H05 BOX PAH CRG Aus Avg 2017 NSH DUN CHC WKO WLG HKB INV TGA HUT WAG WRE WHK ROT MMH ACH NZ Avg 2017 PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT Analgesia given within 30 minutes of ED presentation Analgesia provided by paramedics Analgesia given more than 30 minutes after ED presentation Analgesia not required Not known 37 E 14 PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT (ED) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TNH NBR TSV H06 SCG QII LMH LOG FSH LIV SCU TAM POW TSH DDH FRA JHH TWB H01 MSB H02 H03 RNS H07 PCH STG WMD BKL CFS CNS IPS FOO ROK GOS TWH LGH H04 H05 BOX PAH CRG g 2017 NSH DUN CHC WKO WLG HKB INV TGA HUT WAG WRE WHK ROT MMH ACH g 2017 PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT Analgesia given within 30 minutes of ED presentation Analgesia provided by paramedics Analgesia given more than 30 minutes after ED presentation Analgesia not required Not known FIGURE 14 PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT (ED) 0% 10% 20% 30% 40% 50% 60% 70% TNH NBR TSV H06 SCG QII LMH LOG FSH LIV SCU TAM POW TSH DDH FRA JHH TWB H01 MSB H02 H03 RNS H07 PCH STG WMD BKL CFS CNS IPS FOO ROK GOS TWH LGH H04 H05 BOX PAH CRG Aus Avg 2017 NSH DUN CHC WKO WLG HKB INV TGA HUT WAG WRE WHK ROT MMH ACH NZ Avg 2017 PAIN MANAGEMENT IN THE EMERGENCY DEPAR Analgesia given within 30 minutes of ED presentation Analgesia provided by paramedics Analgesia given more than 30 minutes after ED presen Analgesia not required Not known

ANZHFR | ANNUAL REPORT 2018 31 PATIENT LEVEL AUDIT FIGURE15 USEOFNERVEBLOCKS 39 FIGURE 15 USE OF NERVE BLOCKS Nerve blocks are used to manage pain in the acute fracture setting and particularly in ED when a new hip fracture patient may be moved a number of times in order to investigate, assess and manage the 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BKL ROK MSB TSH STG LGH H04 H06 CRG LIV FRA IPS LMH H05 CFS CNS TSV QII DDH H02 TNH POW TWH NBR GOS TAM H03 RNS PCH H01 SCU SCG TWB LOG BOX JHH FOO H07 WMD FSH PAH Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 CHC NSH DUN WAG MMH ACH WRE WHK WKO HKB INV TGA HUT WLG ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 USE OF NERVE BLOCKS Both Nerve block administered before arriving in OT Nerve block administered in OT Neither Not known Nerve blocks are used to manage pain in the acute fracture setting and particularly in ED when a new hip fracture patient may be moved a number of times in order to investigate, assess and manage the fracture.

The Registry does not record where the nerve block was administered prior to surgery, but for most hospitals this is likely to be in the ED. In 2017, there was an increased uptake in nerve blocks in both New Zealand and Australia compared to 2016. In New Zealand, 36% of patients had a nerve block administered before surgical intervention. In Australia, 66% of patients received a nerve block before surgical intervention. There is marked variation in practice across hospitals.

PATIENT LEVEL AUDIT 32 ANNUAL REPORT 2018 | ANZHFR 41 FIGURE 16 PREOPERATIVE MEDICAL ASSESSMENT 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MSB ROK TAM CFS H06 QII LGH BKL FRA CNS BOX LIV WMD H03 TSV FSH TWH FOO JHH RNS GOS TWB H01 PAH H04 TSH LOG CRG H05 IPS STG H02 DDH H07 TNH PCH POW SCG LMH NBR SCU Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 INV HKB ROT WHK NSH WAG TGA WRE WLG DUN HUT WKO ACH CHC MMH NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PREOPERATIVE MEDICAL ASSESSMENT Geriatrician / Geriatric Team Physician / Physician Team GP Specialist Nurse No assessment conducted Not known Twenty-four percent of patients in New Zealand are seen by a geriatrician prior to surgery.

In Australia, 63% of patients are seen by a geriatrician prior to surgery. As more hospitals contribute data to the Registry this proportion may drop, as these sites may not have geriatric medicine services available.

FIGURE16 PREOPERATIVEMEDICALASSESSMENT

ANZHFR | ANNUAL REPORT 2018 33 PATIENT LEVEL AUDIT 43 FIGURE 17: PRE-OPERATIVE COGNITIVE ASSESSMENT The Hip Fracture Care Clinical Care Standard recommends use of a validated tool to assess and document cognition prior to surgical intervention. In New Zealand, 20% of patients had their cognition 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% H04 QII DDH H06 H07 WMD BOX TAM LGH TNH STG CFS H05 FRA RNS FOO CNS H03 TWB TSV PCH JHH BKL MSB TWH H02 H01 TSH IPS ROK GOS LOG POW FSH LIV SCG LMH NBR PAH CRG SCU Aus Avg 2017 Aus Avg 2016 HKB NSH INV TGA DUN CHC WRE WKO HUT WHK ACH ROT WLG WAG MMH NZ Avg 2017 NZ Avg 2016 PRE-OPERATIVE COGNITIVE ASSESSMENT Cognition assessed using validated tool and recorded Cognition not assessed The Hip Fracture Care Clinical Care Standard recommends use of a validated tool to assess and document cognition prior to surgical intervention.

In New Zealand, 20% of patients had their cognition assessed using a validated tool prior to surgery, and in Australia, 36% of patients had their cognition assessed and recorded, an improvement from 2016. FIGURE17 PREOPERATIVECOGNITIVEASSESSMENT

PATIENT LEVEL AUDIT 34 ANNUAL REPORT 2018 | ANZHFR 45 SECTION 3: SURGERY AND OPERATIVE CARE FIGURE 18 TREATED WITH SURGERY 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH IPS H03 TAM CNS LIV POW PAH STG H05 DDH RNS TWB PCH SCU LGH H01 BOX QII TSV FSH TSH FOO H07 JHH H04 H06 BKL SCG FRA H02 GOS MSB LOG TNH CFS CRG LMH NBR ROK WMD Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK ROT HUT WAG WRE TGA CHC MMH WLG NSH DUN ACH HKB INV WKO NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 TREATED WITH SURGERY Yes No FIGURE18 TREATEDWITHSURGERY It is anticipated that nearly all patients with a hip fracture will be treated surgically with a view to optimising function and/or alleviating pain.

The data presented in Figure 18 show some variation between hospitals, which may reflect differences in clinical management and in the populations treated. Non-operative treatment may be a reasonable option in some circumstances, such as for patients at high risk of perioperative mortality or those with stable undisplaced fractures who are able to mobilise. SECTION3: SURGERYAND OPERATIVECARE

ANZHFR | ANNUAL REPORT 2018 35 PATIENT LEVEL AUDIT 47 FIGURE 19 CONSULTANT SURGEON PRESENT DURING SURGERY 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MSB QII PCH LMH IPS WMD TWB H06 BKL FSH SCU CRG GOS PAH SCG NBR CNS LIV LOG TSV POW RNS H05 H01 FRA LGH TWH H02 DDH JHH FOO TSH ROK H03 BOX STG H07 TNH CFS H04 TAM Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 CHC TGA WKO MMH HUT DUN ACH WLG INV HKB WRE NSH ROT WAG WHK NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 CONSULTANT SURGEON PRESENT DURING SURGERY Yes No Not known In both countries, the level of consultant supervision has increased each year since 2015.

The high institutional variation seen in the proportion of surgical procedures that were supervised by a consultant likely reflects differences in staff levels, staff seniority and theatre availability. Hip fracture surgery that is performed on scheduled operating lists is more likely to have a consultant present compared to cases performed on emergency lists (which are associated with unpredictable start times and after-hours surgery). The ANZ Guideline for Hip Fracture Care recommends performing hip fracture surgery on scheduled operating lists. FIGURE19 CONSULTANTSURGEONPRESENTDURINGSURGERY

PATIENT LEVEL AUDIT 36 ANNUAL REPORT 2018 | ANZHFR This year, Figure 20 excludes patients transferred into the treating hospital, reflecting the journey of a patient initially presenting to the treating hospital. Time to theatre is calculated by measuring the difference between the date and time of presentation to the operating hospital and commencement of anaesthesia. The median time between initial presentation and surgery has increased each year since 2015 and is currently 30 hours. The Hip Fracture Care Clinical Care Standard states that surgery should be performed within 48 hours of presentation because early surgery is thought to reduce morbidity, hasten recovery and reduce length of stay.

The average or mean (the end of the orange bar) is the average time to theatre and is longer than the median due to some patients waiting many days before undergoing surgery. It is important to note that small numbers of patients and a few outliers can significantly alter the average time to surgery.

FIGURE2O A VERAGETIMETOSURGERYEXCLUDINGTRANSFERREDPATIENTS FIGURE 20 AVERAGE TIME TO SURGERY EXCLUDING TRANSFERRED PATIENTS 0 10 20 30 40 50 60 70 TWH LIV IPS CNS TSH DDH H06 MSB NBR PAH H01 QII H05 BKL BOX FOO GOS LOG STG PCH POW FRA TWB WMD SCU TNH CRG H03 H04 H07 LGH TAM TSV JHH LMH RNS ROK CFS FSH SCG H02 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK HKB WAG DUN TGA WRE WKO INV HUT CHC MMH NSH WLG ACH ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 Hours AVERAGE TIME TO SURGERY EXCLUDING TRANSFERRED PATIENTS Average time to surgery Median time to surgery

PATIENT LEVEL AUDIT ANZHFR | ANNUAL REPORT 2018 37 51 FIGURE 21 AVERAGE TIME TO SURGERY TRANSFERRED PATIENTS ONLY Figure 21 shows that the time to surgery is longer for patients who are transferred in from other hospitals.

This measure takes into account the time spent at the (initial) transferring hospital and shows the treatment delays that result from systems that do not deliver patients directly to treating hospitals, or do not have expedited pathways for the transfer of hip fracture patients. The average time to surgery for transferred patients is 54 hours in both countries, higher than the 39 hours in New Zealand and the 37 hours in Australia for non-transferred patients.

PULLOUT 54 HOURS IS THE AVERAGE TIME TO SURGERY FOR TRANSFERRED PATIENTS 0 10 20 30 40 50 60 70 80 90 100 JHH TWH RNS DDH H06 TAM H02 LMH CNS PCH TWB SCU SCG LIV ROK POW TSV FSH FRA Aus Avg 2017 NSH DUN CHC WRE INV NZ Avg 2017 Hours AVERAGE TIME TO SURGERY TRANSFERRED PATIENTS ONLY Time to surgery Median time to surgery Figure 21 shows that the time to surgery is longer for patients who are transferred in from other hospitals. This measure takes into account the time spent at the (initial) transferring hospital and shows the treatment delays that result from systems that do not deliver patients directly to treating hospitals, or do not have expedited pathways for the transfer of hip fracture patients.

The average time to surgery for transferred patients is 54 hours in both countries, higher than the 39 hours in New Zealand and the 37 hours in Australia for non-transferred patients. FIGURE21 A VERAGETIMETOSURGERYTRANSFERREDPATIENTSONL Y “Ifracturedmyleftfemurin2O16.Theaccident occurredatourfarm:threehoursdrivefrom Sydney.Idon’tquiteknowhowbutmyshoe seemedtosticktothetiledfloor.Ifellheavilyand withoneleggoingoffatastrangeangle;itwas clearIhadbrokensomething.

Thetwo-kilometredrivefromthehouseinthe ambulancealongaroughtracktothepublic roadwasextremelypainfuldespitethefactthat Iwasloadedwithopiates. TheaccidentoccurredonaFridayandbecauseI chosetoreturntoSydneyforsurgeryIspentthe nextcoupleofdaysinthelocalhospitalbefore beingtransferred.Itwasnotacomfortable perioddespitethededicatedcareofthestaff.” 54 is the average time to surgery for transferred patients HOURS

PATIENT LEVEL AUDIT 38 ANNUAL REPORT 2018 | ANZHFR Figures 22 and 23 include patients admitted directly to the operating hospitals and those patients transferred in.

Figure 22 shows that most patients were treated within 48 hours of presentation to the operating hospital but there is considerable variation in the reasons provided for any delays beyond 48 hours. Figure 23 provides useful information for sites wishing to improve the proportion of patients treated within 48 hours as it highlights modifiable causes for surgical delay. FIGURE22 SURGERY WITHIN48HOURS FIGURE23 REASONFORDELAY>48HOURS 52 FIGURE 22 SURGERY WITHIN 48 HOURS FIGURE 23 REASON FOR DELAY > 48 HOURS 0% 50% 100% TWH LIV CNS TWB IPS DDH TSH NBR PCH GOS H01 PAH TAM SCU FOO STG QII BKL H05 H06 FRA WMD LOG MSB POW LGH TNH ROK BOX H03 H04 CRG JHH H07 TSV LMH RNS H02 FSH SCG CFS Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB WHK WAG DUN WRE TGA WKO HUT CHC INV WLG NSH MMH ACH ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 SURGERY ≤ 48 HOURS 48 hours 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH LIV CNS TWB IPS DDH TSH NBR PCH GOS H01 PAH TAM SCU FOO STG QII BKL H05 H06 FRA WMD LOG MSB POW LGH TNH ROK BOX H03 H04 CRG JHH H07 TSV LMH RNS H02 FSH SCG CFS Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB WHK WAG DUN WRE TGA WKO HUT CHC INV WLG NSH MMH ACH ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 REASON FOR DELAY > 48 HOURS Delay due to theatre availability Delay due to surgeon availability Delay due to patient deemed medically unfit Delay due to issues with anticoagulation Other type of delay Not known 52 FIGURE 22 SURGERY WITHIN 48 HOURS FIGURE 23 REASON FOR DELAY > 48 HOURS 0% 50% 100% TWH LIV CNS TWB IPS DDH TSH NBR PCH GOS H01 PAH TAM SCU FOO STG QII BKL H05 H06 FRA WMD LOG MSB POW LGH TNH ROK BOX H03 H04 CRG JHH H07 TSV LMH RNS H02 FSH SCG CFS Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB WHK WAG DUN WRE TGA WKO HUT CHC INV WLG NSH MMH ACH ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 SURGERY ≤ 48 HOURS 48 hours 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH LIV CNS TWB IPS DDH TSH NBR PCH GOS H01 PAH TAM SCU FOO STG QII BKL H05 H06 FRA WMD LOG MSB POW LGH TNH ROK BOX H03 H04 CRG JHH H07 TSV LMH RNS H02 FSH SCG CFS Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB WHK WAG DUN WRE TGA WKO HUT CHC INV WLG NSH MMH ACH ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 REASON FOR DELAY > 48 HOURS Delay due to theatre availability Delay due to surgeon availability Delay due to patient deemed medically unfit Delay due to issues with anticoagulation Other type of delay Not known

ANZHFR | ANNUAL REPORT 2018 39 PATIENT LEVEL AUDIT Figures 24 and 25 are new figures for this report and provide a comparison between countries for the reasons for surgical delay. Fifty-one percent of patients in both countries are delayed to surgery due to two modifiable reasons: the availability of operating theatres or issues with anticoagulation. FIGURE24 REASONFORDELAY>48HOURSNEWZEALAND FIGURE25 REASONFORDELAY>48HOURSAUSTRALIA 51% of patients are delayed to surgery for two modifiable reasons Delay due to patient deemed medically unfit Delay due to issues with anticoagulation Delay due to surgeon availability Delay due to theatre availability Not known Other type of delay 30% 16% 2% 35% 12% 5% Delay due to patient deemed medically unfit Delay due to issues with anticoagulation Delay due to surgeon availability Delay due to theatre availability Not known Other type of delay 28% 26% 1% 25% 10% 10%

PATIENT LEVEL AUDIT 40 ANNUAL REPORT 2018 | ANZHFR 55 FIGURE 26 TYPE OF ANAESTHESIA 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TSV H04 SCU H02 MSB IPS LOG JHH GOS ROK SCG DDH H01 LGH TWB STG NBR BOX TNH QII H07 FSH TWH CFS TAM LMH FRA CNS PCH H06 PAH FOO TSH CRG WMD LIV H03 BKL RNS POW H05 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB WHK ROT ACH MMH WLG WRE DUN TGA INV NSH HUT WAG CHC WKO NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 TYPE OF ANAESTHESIA Spinal / regional anaesthesia Other General anaesthetic General and spinal / regional anaesthesia Not known The majority of people undergoing operative intervention for a hip fracture have a general anaesthetic with or without regional anaesthesia: 69% in New Zealand and 73% in Australia.

Marked variation is noted between hospitals and is likely to reflect the personal preference of the anaesthetist or the department. FIGURE26 TYPEOFANAESTHESIA

ANZHFR | ANNUAL REPORT 2018 41 PATIENT LEVEL AUDIT OPERATIONS BY TYPE OF FRACTURE The term “hip fracture” is used to describe different types of fracture of the proximal (upper) femur. The types of hip fracture are classified by the location of the fracture. Classification of the type of hip fracture is important, as it will determine the most appropriate management of the fracture. The fracture locations and terms used by the ANZHFR are shown in Diagram 1. Diagram 1: Zones of hip fracture The types of fracture seen at each site (Figure 27) are consistent with expectations in that between 5% and 10% are subtrochanteric, and the remainder are divided fairly evenly between intertrochanteric and intracapsular (subcapital) fractures.

Sites with wide variation from the average are likely to reflect low numbers of cases from those sites. Alternatively, this variation may highlight issues relating to the classification or coding of the type of fracture.

Different fracture types are generally treated by different surgical techniques. Fractures occurring in the intracapsular area (neck of femur) usually undergo an arthroplasty (replacement) or insertion of screws. Hemiarthroplasty involves removing the head of the femur (ball of the hip joint) that has broken away from the shaft of the bone and replacing it with an artificial (metal) ball that is held in place by a connected stem that sits inside the upper end of the femur (thigh bone). A total hip arthroplasty involves the same procedure, but also involves replacing the socket of the hip joint.

Fractures that occur in the extracapsular region (intertrochanteric) generally undergo internal fixation with an intramedullary nail or a sliding hip screw and plate.

Figures 28 and 29 show the proportions of intracapsular (subcapital) fractures treated with various techniques, reported separately for undisplaced and displaced femoral neck (intracapsular/sub-capital) fractures. Note that undisplaced fractures (Figure 28) are often treated by inserting screws across the fracture (“cannulated screws”) rather than replacing the broken part of the bone (“arthroplasty”). Although the proportion of displaced intracapsular fractures treated with total hip arthroplasty is increasing, hemiarthroplasty remains the most common treatment for this fracture type. Figure 30 provides information on the variation in surgical treatment for intertrochanteric fractures.

These fractures are usually treated by internally securing (fixing) the fractures using metallic devices, rather than replacing the broken part (arthroplasty). There is variation in the use of the two most common types of implant: a sliding hip screw and an intra-medullary nail. The ANZHFR does not distinguish between simple and comminuted or unstable fracture types and this may influence the choice of implant. Comparative studies have not shown large differences in the outcomes between these two devices (and this is reflected in the recommendations within the ANZ Guideline for Hip Fracture Care), but intramedullary fixation is recommended for subtrochanteric fractures and this recommendation appears to have been followed as seen in Figure 31.

The ANZ Guideline for Hip Fracture Care recommends the use of cemented stems for hip arthroplasty. Figures 32 and 33 show the rates of cement use reported by sites for hemiarthroplasty and total hip arthroplasty. NOTE: hospitals with fewer than ten (10) cases of the type of surgery have not been reported in Figures 27 to 33. FIGURES27,28,29,30,31,32AND33 Pelvis Femoral Head Intracapsular Region Subtrochanter Region Lesser Trochanter Greater Trochanter Femoral Shaft 5cm Extracapsular Region Pelvis Femoral Head Intracapsular Region Subtrochanter Region Lesser Trochanter Greater Trochanter Femoral Shaft 5cm Extracapsular Region

42 ANNUAL REPORT 2018 | ANZHFR 59 FIGURE 27 FRACTURE TYPE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% H05 GOS BKL TSH H07 TWH TNH FRA FOO TSV WMD JHH CFS STG SCU TAM RNS TWB H02 MSB LMH H01 CNS NBR PAH LIV H06 H04 DDH PCH FSH SCG H03 POW BOX CRG IPS LGH ROK LOG QII Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 ROT WAG WKO ACH HUT WLG MMH CHC WRE NSH INV TGA WHK DUN HKB NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 FRACTURE TYPE Intracapsular - displaced Intracapsular - undisplaced / impacted Intertrochanteric (incl basal / basicervical) Subtrochanteric FIGURE27 FRACTURETYPE PATIENT LEVEL AUDIT

ANZHFR | ANNUAL REPORT 2018 43 PATIENT LEVEL AUDIT 60 FIGURE 28 PROCEDURE TYPE FOR INTRACAPSULAR FRACTURES UNDISPLACED/IMPACTED 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TAM QII NBR GOS CFS BKL FSH BOX LGH MSB TSV WMD FRA H01 DDH LIV TWB PCH STG POW RNS H02 CNS TSH JHH PAH FOO H04 LOG SCU TNH SCG H06 H03 TWH CRG ROK LMH IPS H07 H05 Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK ROT INV NSH DUN TGA HKB WLG WAG MMH CHC WKO HUT ACH WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PROCEDURE TYPE FOR INTRACAPSULAR FRACTURES UNDISPLACED / IMPACTED Hemiarthroplasty Total hip replacement Cannulated screws Sliding hip screw Intramedullary nail Other Not known FIGURE28 PROCEDURETYPEFORINTRACAPSULARFRACTURESUNDISPLACED/IMPACTED

44 ANNUAL REPORT 2018 | ANZHFR 61 FIGURE 29 PROCEDURE TYPE FOR INTRACAPSULAR FRACTURES DISPLACED 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TAM ROK QII H05 CFS RNS FOO CRG H02 H03 MSB FRA GOS JHH H07 TWH H04 CNS H06 NBR SCU WMD LIV SCG STG TNH TSV TWB FSH LMH H01 LGH DDH BKL POW PCH BOX TSH IPS LOG PAH Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK WAG HKB CHC HUT TGA MMH ACH WRE DUN NSH INV WKO WLG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PROCEDURE TYPE: INTRACAPSULAR FRACTURES DISPLACED Hemiarthroplasty Total hip replacement Cannulated screws Sliding hip screw Intramedullary nail Other Not known FIGURE29 PROCEDURETYPEFORINTRACAPSULARFRACTURESDISPLACED PATIENT LEVEL AUDIT

ANZHFR | ANNUAL REPORT 2018 45 PATIENT LEVEL AUDIT FIGURE 30 PROCEDURE TYPE FOR INTERTROCHANTERIC FRACTURE INCLUDING BASAL/BASICERVICAL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% QII H02 JHH PAH H01 GOS WMD TAM TSH POW STG RNS LMH SCG FSH IPS H06 TWH PCH ROK H05 CRG BKL CNS H07 H04 H03 FOO TNH TSV SCU LIV CFS BOX FRA NBR DDH LOG LGH TWB MSB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HKB ROT WHK WAG WRE MMH WLG INV HUT CHC WKO ACH DUN NSH TGA NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PROCEDURE TYPE FOR INTERTROCHANTERIC FRACTURE INCLUDING BASAL / BASICERVICAL Sliding hip screw Intramedullary nail Cannulated screws Hemiarthroplasty Total hip replacement Other Not known FIGURE3O PROCEDURETYPEFORINTERTROCHANTERIC FRACTUREINCLUDINGBASAL/BASICERVICAL

46 ANNUAL REPORT 2018 | ANZHFR PATIENT LEVEL AUDIT FIGURE 31 PROCEDURE TYPE FOR SUBTROCHANTERIC FRACTURE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TSH TAM ROK RNS QII PAH NBR LOG LGH IPS H04 H03 H01 FOO CFS H05 FRA GOS SCU H07 LMH TWH CNS BKL CRG H02 STG MSB JHH DDH PCH TWB TSV LIV BOX FSH H06 POW SCG TNH WMD Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WLG WAG INV HUT HKB WRE ACH NSH TGA DUN WKO CHC MMH NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PROCEDURE TYPE: SUBTROCHANTERIC FRACTURE Intramedullary nail Sliding hip screw Hemiarthroplasty Cannulated screws Total hip replacement Other Not known FIGURE31 PROCEDURETYPEFORSUBTROCHANTERICFRACTURE

ANZHFR | ANNUAL REPORT 2018 47 PATIENT LEVEL AUDIT FIGURE 32 HEMIARTHROPLASTY: USE OF CEMENT 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TAM NBR CFS PAH H01 CRG TWH H06 GOS H05 TSH LGH LMH SCU STG JHH H07 LOG CNS IPS BOX H03 FRA TNH BKL H02 H04 FOO TSV POW LIV PCH FSH DDH MSB QII RNS ROK SCG TWB WMD Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK WAG ROT INV NSH TGA CHC WLG ACH HUT DUN HKB MMH WKO WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 HEMIARTHROPLASTY: USE OF CEMENT Cemented Uncemented FIGURE32 HEMIARTHROPLASTY:USEOFCEMENT

PATIENT LEVEL AUDIT 48 ANNUAL REPORT 2018 | ANZHFR 67 FIGURE 33 TOTAL HIP REPLACEMENT: USE OF CEMENT 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TWB TSV TSH TNH TAM SCU ROK QII NBR MSB LMH IPS H07 H06 H04 H01 FRA FOO CRG CFS BKL PAH GOS CNS STG POW LGH LOG H02 BOX JHH H03 DDH FSH H05 LIV PCH RNS SCG WMD Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK WAG TGA ROT INV HUT HKB WKO NSH ACH DUN WRE WLG CHC MMH NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 TOTAL HIP REPLACEMENT: USE OF CEMENT Cemented Uncemented FIGURE33 TOTALHIPREPLACEMENT:USEOFCEMENT

ANZHFR | ANNUAL REPORT 2018 49 PATIENT LEVEL AUDIT Previously, post- operatively, many patients were not permitted to weight bear fully for fear of disturbing the surgical fixation. However, there is little evidence to support this, and allowing immediate unrestricted weight bearing after surgery permits easier rehabilitation and earlier restoration of function. The ANZ Guideline for Hip Fracture Care and the Hip Fracture Care Clinical Care Standard both recommend that patients be allowed full weight bearing without restriction immediately after surgery. Figure 34 shows that all but a small proportion of patients are allowed full weight bearing after surgery.

68 SECTION 4: POSTOPERATIVE CARE FIGURE 34 WEIGHT BEARING STATUS AFTER SURGERY 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% QII CFS FRA TWH TSH LGH RNS ROK H06 CNS STG JHH H03 LOG H05 IPS POW H01 TWB H04 FOO TAM BOX H07 CRG TNH BKL GOS MSB DDH SCG H02 WMD TSV PCH SCU LIV FSH LMH NBR PAH Aus Avg 217 Aus Avg 2016 Aus Avg 2015 WHK WAG NSH CHC DUN WKO TGA MMH ACH WLG HUT WRE HKB INV ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 WEIGHT BEARING STATUS AFTER SURGERY Unrestricted weight bearing Restricted / non weight bearing Not known SECTION4: POSTOPERATIVE CARE FIGURE34 WEIGHTBEARINGSTATUSAFTERSURGERY

PATIENT LEVEL AUDIT 50 ANNUAL REPORT 2018 | ANZHFR 70 FIGURE 35 FIRST DAY MOBILISATION 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% QII TWH RNS STG H05 JHH TSH TWB H06 DDH FRA CNS LGH BOX CFS IPS TAM TNH LIV BKL POW ROK TSV LOG CRG H07 SCG GOS H03 LMH H02 PAH H04 FOO PCH SCU H01 FSH MSB NBR WMD Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK DUN ROT CHC WKO TGA ACH WLG HKB HUT WRE INV NSH MMH WAG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 FIRST DAY MOBILISATION Opportunity given day 1 post surgery Opportunity not given day 1 post surgery Not known Quality statement 5 of the Hip Fracture Care Clinical Care Standard promotes early mobilisation of patients after hip fracture surgery.

All hip fracture patients should be given the opportunity to sit out of bed and start to mobilise the day after surgery unless there is a specific documented contraindication. In New Zealand and Australia, 87% and 89%, respectively, of patients are given the opportunity to mobilise the day after surgery. FIGURE35 FIRSTDAYMOBILISATION

ANZHFR | ANNUAL REPORT 2018 51 PATIENT LEVEL AUDIT FIGURE 36 ASSESSED BY GERIATRIC MEDICINE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MSB QII ROK TAM CFS H06 LGH WMD TSH FRA CNS TWH GOS BOX LIV TWB RNS STG FSH TSV H03 FOO BKL CRG H01 IPS POW LOG DDH H04 JHH H05 PAH H07 SCG PCH H02 LMH NBR SCU TNH Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WHK ROT WAG HKB TGA NSH CHC DUN WRE WLG ACH WKO MMH HUT INV NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 ASSESSED BY GERIATRIC MEDICINE Yes No No geriatric medicine service available Not known FIGURE36 ASSESSEDBYGERIATRICMEDICINE Quality statement 3 of the Hip Fracture Care Clinical Care Standard promotes the orthogeriatric model of care where physicians (usually geriatricians) provide medical support for hip fracture patients in partnership with the orthopaedic surgeons.

Service models differ across hospitals with some offering a true shared-care approach whilst others operate on a consult basis – see facility level information in this report.

In New Zealand, 80% of hip fracture patients saw a geriatrician at some stage in their acute hospital stay compared to 92% in Australia. As more hospitals join the Registry we may see a drop in this proportion as smaller sites and non-metropolitan sites are likely to have less access to a geriatrician.

PATIENT LEVEL AUDIT 52 ANNUAL REPORT 2018 | ANZHFR 74 FIGURE 37 PRESSURE INJURIES OF THE SKIN 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% QII GOS LOG TWH FRA ROK LIV STG LGH TSH FOO CFS H03 TAM IPS H06 POW H01 CNS SCU TSV PCH LMH TWB JHH RNS BOX FSH H07 MSB H04 WMD PAH DDH TNH SCG BKL CRG H02 H05 NBR Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 HUT WLG ACH INV TGA WAG CHC ROT HKB DUN WKO WHK WRE MMH NSH NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 PRESSURE INJURIES OF THE SKIN No Yes Not known FIGURE37 PRESSUREINJURIESOFTHESKIN Pressure injury of the skin is a potentially preventable complication of hip fracture care.

As a complication it is associated with delayed functional recovery and an increased length of stay. In New Zealand and Australia, 3.6% and 2.0% of patients, respectively, are documented as having sustained a pressure injury.

ANZHFR | ANNUAL REPORT 2018 53 PATIENT LEVEL AUDIT 77 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MSB PCH TWB TAM QII ROK CFS TSH TWH STG H03 FRA LGH RNS H05 TNH CNS FOO BOX POW H02 GOS JHH LOG H01 H07 H06 LIV TSV BKL PAH IPS SCU H04 CRG FSH DDH LMH NBR SCG WMD Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WAG WLG HKB WHK ROT HUT TGA CHC WRE DUN ACH WKO NSH INV MMH NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 SPECIALIST FALLS ASSESSMENT Yes - Performed during admission Yes - Awaits falls clinic assessment Yes - Further intervention not appropriate No Not relevant Not known FIGURE38 SPECIALISTFALLSASSESSMENT A minimal trauma fracture is a strong predictor of risk of a second fracture.

Quality statement 6 of the Hip Fracture Care Clinical Care Standard requires that each hip fracture patient is assessed in relation to future fall and fracture risk and that a plan is put in place to manage risk.

The ANZ Guideline for Hip Fracture Care recommends that hip fracture patients should be assessed for falls risk: this should consist of an assessment by a suitably trained health professional and cover fall history, risk factors for falls, including medication review, and formulation of a future plan to prevent further falls. In New Zealand, 74% of patients are reported to have undergone a falls assessment during their in-patient stay. In Australia, 81% of patients underwent a fall risk assessment during their in-patient stay.

PATIENT LEVEL AUDIT 54 ANNUAL REPORT 2018 | ANZHFR Substantial variation is seen in mean and median length of stay (LOS) in the acute ward in both New Zealand and Australia.

The median LOS in New Zealand is 7.3 days and 59% of patients are transferred to rehabilitation. In Australia, the median length of stay in the acute ward is 7.7 days and 51% are transferred to rehabilitation. A multitude of factors contribute to acute length of stay including access to subacute facilities or services in the community that can deliver home-based rehabilitation. Average total length of stay is the preferred measure but because of the movement of patients between hospitals, including to the private sector, this is not currently available. Use of linked hospitalisation data in the future will provide a better overall picture.

0 2 4 6 8 10 12 14 16 18 BKL CRG H05 LIV GOS H04 H06 IPS H01 PCH STG TWH JHH NBR POW TSH CFS CNS DDH H02 LGH MSB QII WMD H07 LOG RNS TSV TWB FOO FRA PAH SCU TAM TNH BOX H03 LMH ROK FSH SCG Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 TGA WHK HKB NSH WRE DUN INV MMH CHC HUT WAG WKO ACH WLG ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 Days ACUTE LENGTH OF STAY Average LOS Median LOS 0% 50% 100% BKL CRG H05 LIV GOS H04 H06 IPS H01 PCH STG TWH JHH NBR POW TSH CFS CNS DDH H02 LGH MSB QII WMD H07 LOG RNS TSV TWB FOO FRA PAH SCU TAM TNH BOX H03 LMH ROK FSH SCG Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 TGA WHK HKB NSH WRE DUN INV MMH CHC HUT WAG WKO ACH WLG ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 DISCHARGE TO REHABILITION Discharged to rehabilitation Other discharge 0 2 4 6 8 10 12 14 16 18 BKL CRG H05 LIV GOS H04 H06 IPS H01 PCH STG TWH JHH NBR POW TSH CFS CNS DDH H02 LGH MSB QII WMD H07 LOG RNS TSV TWB FOO FRA PAH SCU TAM TNH BOX H03 LMH ROK FSH SCG Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 TGA WHK HKB NSH WRE DUN INV MMH CHC HUT WAG WKO ACH WLG ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 Days ACUTE LENGTH OF STAY Average LOS Median LOS 0% 50% 100% BKL CRG H05 LIV GOS H04 H06 IPS H01 PCH STG TWH JHH NBR POW TSH CFS CNS DDH H02 LGH MSB QII WMD H07 LOG RNS TSV TWB FOO FRA PAH SCU TAM TNH BOX H03 LMH ROK FSH SCG Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 TGA WHK HKB NSH WRE DUN INV MMH CHC HUT WAG WKO ACH WLG ROT NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 DISCHARGE TO REHABILITION Discharged to rehabilitation Other discharge FIGURE39 ACUTELENGTHOFSTAY(LOS) FIGURE4O DISCHARGETOREHABILITATION

ANZHFR | ANNUAL REPORT 2018 55 PATIENT LEVEL AUDIT 82 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% FOO RNS TWH TAM CNS TSV H07 H03 FRA H04 H06 LGH H05 PAH TNH SCG ROK DDH LOG QII IPS JHH FSH H01 TWB STG BOX LMH CFS LIV PCH POW TSH CRG WMD BKL H02 SCU GOS NBR MSB Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 ACH CHC INV WKO MMH HUT WRE WLG DUN TGA NSH WHK ROT HKB WAG NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 DISCHARGE DESTINATION FROM THE ACUTE WARD Private residence (including unit in retirement village) Residential aged care facility Rehabilitation unit - public Rehabilitation unit - private Other hospital / ward / specialty Other Not known Deceased FIGURE41 DISCHARGEDESTINATIONFROMTHEACUTEW ARD

56 ANNUAL REPORT 2018 | ANZHFR PATIENT LEVEL AUDIT “Weareusingthedatatoscopethe opportunitiesforprovidingrehabilitation topatientswhodischargetoresidential careandidentifyingthevolumeofworkthis wouldinvolve.Ourstaffaredoingagreat jobcollectingthisdataandInowfeelthatwe canmakethemostofthisrichinformationto generatenewknowledgeinhipfracturecare. Wenowhaveclinicallyrelevantinformationto addtoexistingdatabases.” Geriatrician,NewZealand 56 ANNUAL REPORT 2018 | ANZHFR

ANZHFR | ANNUAL REPORT 2018 57 PATIENT LEVEL AUDIT 83 FIGURE 42 RESIDENTIAL AGED CARE TO REHABILIATION (PUBLIC OR PRIVATE) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% H02 IPS NBR TWB LMH MSB LOG SCU TSH DDH BOX WMD PCH BKL STG H01 QII POW LGH CRG JHH FSH LIV CFS ROK TAM SCG H04 TSV CNS H05 H03 PAH FRA TNH GOS H06 H07 FOO TWH RNS Aus Avg 2017 WHK ROT HKB WAG WRE WLG HUT MMH TGA NSH DUN WKO INV CHC ACH NZ Avg 2017 RESIDENTIAL AGED CARE TO REHAB (PUBLIC OR PRIVATE) To rehabilitation Not to rehabilitation FIGURE42 RESIDENTIALAGEDCARETOREHABILIATION(PUBLICORPRIV ATE) Overall, 45% of people from residential aged care are transferred for rehabilitation after their acute care for their hip fracture in New Zealand.

This contrasts with 18% of hip fracture patients in Australia. Wide variation in practice is evident. More work is needed in this area to explore why the variation exists and more importantly, the impact it has on the individual longer term.

PATIENT LEVEL AUDIT 58 ANNUAL REPORT 2018 | ANZHFR 85 FIGURE 43 IMPAIRED COGNITION BEFORE ADMISSION AND DISCHARGED TO REHABILIATION 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CFS ROK TAM NBR MSB TWB LMH SCU WMD BKL H02 STG TSH BOX LGH DDH CRG LOG IPS SCG H01 QII TSV JHH LIV POW CNS H06 PAH PCH FSH GOS H03 FRA H05 H04 TNH H07 TWH RNS FOO Aus Avg 2017 HKB ROT WHK WAG WLG TGA DUN WRE NSH MMH WKO HUT INV CHC ACH NZ Avg 2017 IMPAIRED COGNITION BEFORE ADMISSION AND DISCHARGED TO REHABILITATION To rehabilitation Not to rehabilitation FIGURE43 IMPAIREDCOGNITIONBEFOREADMISSIONANDDISCHARGED TOREHABILIATION Overall, 55% of people with pre-existing cognitive impairment were transferred for rehabilitation after their acute care in New Zealand.

This contrasts with 34% of hip fracture patients with pre-existing cognitive impairment in Australia. Wide variation in practice is evident. More work is needed in this area to explore why the variation exists and more importantly, the impact it has on the individual longer term.

ANZHFR | ANNUAL REPORT 2018 59 PATIENT LEVEL AUDIT FIGURE44 BONEPROTECTIONMEDICATIONONADMISSION 88 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% DDH SCU WMD CRG MSB GOS NBR QII CFS BOX H06 H03 ROK TAM TWH SCG FOO LIV LGH FRA BKL FSH CNS STG PAH TSH TWB H05 H02 TNH H01 POW JHH H07 H04 RNS TSV LMH PCH LOG IPS Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WAG DUN WLG ACH WHK HUT NSH HKB CHC TGA WKO ROT WRE MMH INV NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 BONE PROTECTION MEDICATION ON ADMISSION Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and / or vitamin D only No bone protection medication Not known The majority of people admitted with a hip fracture were not on any form of pharmacological treatment for bone health prior to their fracture despite evidence in the literature demonstrating that up to 50% of these people will have already sustained a minimal trauma fracture.

In New Zealand, 37% of people were recorded as on calcium and/or vitamin D at admission whilst 8% were recorded as taking active treatment for osteoporosis above and beyond calcium and/or vitamin D. In Australia, 36% of people were recorded as on calcium and/or vitamin D at admission whilst 9% were recorded as taking active treatment for osteoporosis above and beyond calcium and/or vitamin D. These proportions suggest a significant and ongoing care gap in secondary fracture prevention in both countries.

88 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% DDH SCU WMD CRG MSB GOS NBR QII CFS BOX H06 H03 ROK TAM TWH SCG FOO LIV LGH FRA BKL FSH CNS STG PAH TSH TWB H05 H02 TNH H01 POW JHH H07 H04 RNS TSV LMH PCH LOG IPS us Avg 2017 us Avg 2016 us Avg 2015 WAG DUN WLG ACH WHK HUT NSH HKB CHC TGA WKO ROT WRE MMH INV NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 BONE PROTECTION MEDICATION ON ADMISSION Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and / or vitamin D only No bone protection medication Not known 0% 10% 20% 30% 40% 50% 60% 70% DDH SCU WMD CRG MSB GOS NBR QII CFS BOX H06 H03 ROK TAM TWH SCG FOO LIV LGH FRA BKL FSH CNS STG PAH TSH TWB H05 H02 TNH H01 POW JHH H07 H04 RNS TSV LMH PCH LOG IPS Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WAG DUN WLG ACH WHK HUT NSH HKB CHC TGA WKO ROT WRE MMH INV NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 BONE PROTECTION MEDICATION ON ADMISSIO Yes - Bisphosponates, strontium, denosumab or teripa Yes - Calcium and / or vitamin D only No bone protection medication Not known

PATIENT LEVEL AUDIT 60 ANNUAL REPORT 2018 | ANZHFR 91 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% WMD DDH CRG MSB H01 SCU H06 LIV GOS NBR CFS ROK SCG TAM BOX TWB TNH H07 TWH FRA H04 FOO LGH H03 H05 POW TSH TSV QII PCH JHH CNS IPS FSH STG BKL LOG RNS H02 LMH PAH Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WLG HKB NSH DUN WHK WAG WKO ROT HUT ACH TGA INV MMH CHC WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 BONE PROTECTION MEDICATION ON DISCHARGE Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and / or vitamin D only No bone protection medication Not known Quality statement 6 of the Hip Fracture Care Clinical Care Standard requires an assessment and management plan for future fracture prevention including initiation of treatment for osteoporosis in hospital, where appropriate.

The Registry is able to capture this in the acute setting but information on new treatments initiated on transfer to another facility such as a subacute hospital is not available and so the data reported here may underestimate the number of people treated for osteoporosis.

In New Zealand, 25% of hip fracture patients left hospital on a bisphosphonate, denosumab or teriparatide compared to 8% on admission. In Australia, 24% of patients left hospital on a bisphosphonate, denosumab or teriparatide compared to 9% on admission. Whilst not always possible to initiate treatment in the acute setting, the data continues to highlight a significant care gap and missed opportunity to improve bone health and contribute towards secondary fracture prevention. FIGURE45 BONEPROTECTIONMEDICATIONONDISCHARGE 0% 10% 20% 30% 40% 50% 60% 70% 8 WMD DDH CRG MSB H01 SCU H06 LIV GOS NBR CFS ROK SCG TAM BOX TWB TNH H07 TWH FRA H04 FOO LGH H03 H05 POW TSH TSV QII PCH JHH CNS IPS FSH STG BKL LOG RNS H02 LMH PAH Aus Avg 2017 Aus Avg 2016 Aus Avg 2015 WLG HKB NSH DUN WHK WAG WKO ROT HUT ACH TGA INV MMH CHC WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 BONE PROTECTION MEDICATION ON DISCHARGE Yes - Bisphosponates, strontium, denosumab or teriparitid Yes - Calcium and / or vitamin D only No bone protection medication Not known 91 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% WMD DDH CRG MSB H01 SCU H06 LIV GOS NBR CFS ROK SCG TAM BOX TWB TNH H07 TWH FRA H04 FOO LGH H03 H05 POW TSH TSV QII PCH JHH CNS IPS FSH STG BKL LOG RNS H02 LMH PAH us Avg 2017 us Avg 2016 us Avg 2015 WLG HKB NSH DUN WHK WAG WKO ROT HUT ACH TGA INV MMH CHC WRE NZ Avg 2017 NZ Avg 2016 NZ Avg 2015 BONE PROTECTION MEDICATION ON DISCHARGE Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and / or vitamin D only No bone protection medication Not known

ANZHFR | ANNUAL REPORT 2018 61 PATIENT LEVEL AUDIT Figures 46 and 47 show the rate of 30-day and 120-day follow-up for each hospital. Follow-up is undertaken by sites by telephone and the variation reflects local differences in resources and prioritisation, as this task requires the use of local staff to contact patients and is labour-intensive. SECTION5: 3OAND12ODAY FOLLOW-UP “WhatIdidnotappreciatewasthevaluethatthefollow-up phonecallshaveonindividualpatients.Itmademerealise wedischargethesepatientsafterabigoperationand oftenlonglengthofstay,withnofollowup,justagood-bye. Thefollow-upallowsthepatienttofeelvaluedandlistened to,proudtotelltheirachievements.” ANZHFRHipFractureCoordinator In New Zealand 88% of patient records had 30-day follow up data and 80% had data for 120-days.

In Australia, 54% of patient records had 30-day follow up data and 43% had data for 120-days. For figures 48 to 58, hospitals are reported only if they have followed up 80% or more of eligible patients.

PATIENT LEVEL AUDIT 62 ANNUAL REPORT 2018 | ANZHFR 94 FIGURE 46 FOLLOW-UP AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% RNS QII H07 H02 CRG POW LGH BOX TWH STG SCU FSH TSH NBR SCG LOG H05 H06 GOS CFS IPS ROK LMH MSB BKL CNS TSV PAH DDH JHH TWB WMD FRA FOO PCH LIV H04 TNH TAM H01 H03 Aus Avg 2017 Aus Avg 2016 DUN WAG ACH WHK WLG WKO TGA NSH MMH HUT CHC INV ROT WRE HKB NZ Avg 2017 NZ Avg 2016 FOLLOW-UP AT 30-DAYS 30-day follow-up No 30-day follow-up FIGURE46 FOLLOWUPAT3O-DAYS

ANZHFR | ANNUAL REPORT 2018 63 PATIENT LEVEL AUDIT 95 FIGURE 47 FOLLOW-UP AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TSH STG SCG RNS QII NBR LIV LGH H07 H02 CRG CFS BOX TWH POW SCU FSH LOG H05 H06 LMH GOS MSB IPS ROK PCH DDH BKL PAH TSV CNS JHH H01 FRA TWB FOO H04 H03 WMD TAM TNH Aus Avg 2017 Aus Avg 2016 DUN ROT WAG ACH WHK WKO WLG WRE MMH TGA CHC NSH HUT HKB INV NZ Avg 2017 NZ Avg 2016 FOLLOW-UP AT 120-DAYS 120-day follow-up No 120-day follow-up FIGURE47 FOLLOWUPAT12O-DAYS

PATIENT LEVEL AUDIT 64 ANNUAL REPORT 2018 | ANZHFR Figures 48 and 49 show that at 3O- and 12O-days, the rate of reoperation was low.

FIGURE48 REOPERATIONAT3ODAYS 96 Figures 48 and 49 shows that at 30- and 120-days, the rate of reoperation was low. FIGURE 48 REOPERATION AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LOG NBR POW QII TWH SCG SCU STG TSH TWH LMH TWB TAM CNS TNH TSV PCH BKL H04 JHH LIV PAH DDH FOO FRA H01 H03 MSB ROK WMD Aus Avg 2017 DUN HUT WKO TGA CHC WRE INV WLG MMH NSH ACH HKB ROT WAG WHK NZ Avg 2017 REOPERATION AT 30-DAYS No reoperation at 30-days Reoperation at 30-days

ANZHFR | ANNUAL REPORT 2018 65 PATIENT LEVEL AUDIT FIGURE49 REOPERATIONAT12O-DAYS 97 FIGURE 49 REOPERATION AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG RNS QII POW NBR LOG LMH LIV LGH H07 H02 GOS FSH CRG CFS BOX TAM CNS TWB H06 IPS H01 PCH TNH H04 JHH DDH PAH H03 TSV WMD BKL FOO FRA H05 MSB ROK Aus Avg 2017 ACH DUN ROT WAG WHK WKO WLG WRE CHC TGA INV MMH HUT NSH HKB NZ Avg 2017 REOPERATION AT 120-DAYS No reoperation at 120-days Reoperation at 120-days

PATIENT LEVEL AUDIT 66 ANNUAL REPORT 2018 | ANZHFR FIGURE5O BONEPROTECTIONMEDICATIONAT3O-DAYS Figures 50 and 51 show that most patients are not provided with medication to prevent further fractures at 30 or 120 days after admission to hospital.

There is considerable variation between hospitals and the data suggests minimal improvement in the care gap in secondary fracture prevention seen at discharge from hospital. FIGURE 50 BONE PROTECTION MEDICATION AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LOG NBR POW QII RNS SCG SCU STG TSH TWH DDH WMD MSB ROK H01 FRA LIV TAM H04 TWB H03 TNH BKL CNS TSV JHH PCH FOO LMH PAH Aus Avg 2017 DUN HKB WLG ACH WHK WAG NSH WKO ROT TGA HUT INV MMH CHC WRE NZ Avg 2017 BONE PROTECTION MEDICATION AT 30-D Yes - Bisphosponates, strontium, denosumab or te Yes - Calcium and/or vitamin D only No bone protection medication Not known 98 ONE PROTECTION MEDICATION AT 30-DAYS 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BONE PROTECTION MEDICATION AT 30-DAYS Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and/or vitamin D only No bone protection medication Not known 98 FIGURE 50 BONE PROTECTION MEDICATION AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LOG NBR POW QII RNS SCG SCU STG TSH TWH DDH WMD MSB ROK H01 FRA LIV TAM H04 TWB H03 TNH BKL CNS TSV JHH PCH FOO LMH PAH Aus Avg 2017 DUN HKB WLG ACH WHK WAG NSH WKO ROT TGA HUT INV MMH CHC WRE NZ Avg 2017 BONE PROTECTION MEDICATION AT 30-DAYS Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and/or vitamin D only No bone protection medication Not known

ANZHFR | ANNUAL REPORT 2018 67 PATIENT LEVEL AUDIT FIGURE 51 BONE PROTECTION MEDICATION AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LIV LMH LOG MSB NBR POW QII RNS ROK SCG SCU STG TSH TWH DDH WMD FRA H04 TAM H01 CNS H03 TWB BKL TNH JHH TSV FOO PCH PAH Aus Avg 2017 ACH DUN ROT WAG WHK WKO WLG WRE HKB NSH TGA HUT MMH INV CHC NZ Avg 2017 BONE PROTECTION MEDICATION AT 120-DAYS Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and/or vitamin D only No bone protection medication Not known FIGURE51 BONEPROTECTIONMEDICATIONAT12O-DAYS FIGURE 50 BONE PROTECTION MEDICATION AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LOG NBR POW QII RNS SCG SCU STG TSH TWH DDH WMD MSB ROK H01 FRA LIV TAM H04 TWB H03 TNH BKL CNS TSV JHH PCH FOO LMH PAH Aus Avg 2017 DUN HKB WLG ACH WHK WAG NSH WKO ROT TGA HUT INV MMH CHC WRE NZ Avg 2017 BONE PROTECTION MEDICATION AT 30-D Yes - Bisphosponates, strontium, denosumab or te Yes - Calcium and/or vitamin D only No bone protection medication Not known ONE PROTECTION MEDICATION AT 30-DAYS 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BONE PROTECTION MEDICATION AT 30-DAYS Yes - Bisphosponates, strontium, denosumab or teriparitide Yes - Calcium and/or vitamin D only No bone protection medication Not known “IworkasaFractureLiaisonNurseandtheRegistryhashighlighted agapinourpatient’safter-hospitalbonehealthcare.Ourpatient’s arenowfollowed-upbytheFracturePreventionService.Ireallydo lovethisroleandtheoutcomeofmakingadifference.” FractureLiaisonNurse

PATIENT LEVEL AUDIT 68 ANNUAL REPORT 2018 | ANZHFR FIGURE 52 UNRESTRICTED WEIGHTBEARING AT 30 DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG RNS QII POW NBR LOG LGH IPS H07 H06 H05 H02 GOS FSH FRA CRG CFS BOX PCH H03 MSB H04 DDH H01 CNS ROK FOO TAM TWB WMD BKL TNH JHH LIV LMH PAH TSV Aus Avg 2017 DUN WHK WAG HKB CHC HUT TGA MMH WKO WLG ACH NSH WRE INV ROT NZ Avg 2017 UNRESTRICTED WEIGHT BEARING AT 30 DAYS Unrestricted weight bearing Restricted / non weight bearing Not known FIGURE52 UNRESTRICTEDWEIGHTBEARINGAT3O-DAYS Figure 52 shows that a small proportion of patients remain with weight bearing restrictions at 30-days post-operatively.

This is likely to be because weight-bearing restrictions are usually applied for a period of at least 6 weeks post-surgery.

ANZHFR | ANNUAL REPORT 2018 69 PATIENT LEVEL AUDIT FIGURE53 UNRESTRICTEDWEIGHTBEARINGAT12O-DAYS FIGURE 53 UNRESTRICTED WEIGHTBEARING AT 120 DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG RNS QII POW NBR LOG LMH LGH LIV H07 H02 FSH FRA CRG CFS BOX MSB CNS DDH H01 H04 IPS H03 FOO ROK TWB WMD PCH TAM H06 BKL TNH JHH GOS H05 PAH TSV Aus Avg 2017 ACH DUN ROT WAG WHK WKO WLG WRE HKB CHC HUT MMH TGA NSH INV NZ Avg 2017 UNRESTRICTED WEIGHT BEARING AT 120 DAYS Unrestricted weight bearing Restricted / non weight bearing Not known Figure 53 shows a small proportion of patients still have weight bearing restrictions at 120-days, which is not usually recommended.

This may reflect lack of orthopaedic review and continuation of previously applied restrictions.

PATIENT LEVEL AUDIT 70 ANNUAL REPORT 2018 | ANZHFR Figure 54 shows that of the group of patients who were living at home prior to admission, approximately two-thirds had returned to their place of residence at 30-days after admission. FIGURE54 RETURNTOPRIV ATERESIDENCEAT3O-DAYS 105 FIGURE 54 RETURN TO PRIVATE RESIDENCE AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LOG NBR POW QII RNS SCG SCU STG TSH TWH LMH JHH MSB H01 H04 CNS TNH FRA TWB PCH H03 TAM TSV FOO BKL DDH LIV WMD PAH ROK Aus Avg 2017 DUN ACH TGA MMH WKO HUT NSH CHC INV WHK WAG HKB WRE WLG ROT NZ Avg 2017 RETURN TO PRIVATE RESIDENCE AT 30-DAYS Return to private residence at 30-days Not returned to private residence at 30-days

ANZHFR | ANNUAL REPORT 2018 71 PATIENT LEVEL AUDIT Being able to return home after a hip fracture is one of the most important outcomes for a patient following a hip fracture. Of those who lived at home prior to hip fracture, and were followed-up, 76% of patients in New Zealand and 71% of patients in Australia returned to their own home at 120-days after their hip fracture surgery. FIGURE55 RETURNTOPRIV ATERESIDENCEAT12O-DAYS 107 FIGURE 55 RETURN TO PRIVATE RESIDENCE AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG ROK RNS QII POW NBR MSB LOG LMH LIV LGH IPS H07 H06 H05 H02 GOS FSH CRG CFS BOX H04 CNS H01 DDH H03 FOO PCH TWB TAM BKL FRA JHH TNH TSV WMD PAH Aus Avg 2017 Aus Avg 2016 WRE WLG WKO WHK WAG ROT DUN ACH HKB NSH CHC TGA MMH INV HUT NZ Avg 2017 NZ Avg 2016 RETURN TO PRIVATE RESIDENCE AT 120-DAYS Return to private residence at 120-days Not returned to private residence at 120-days

PATIENT LEVEL AUDIT 72 ANNUAL REPORT 2018 | ANZHFR FIGURE 56 RETURN TO PRE-ADMISSION MOBILITY AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG ROK RNS QII POW NBR MSB LOG LMH LIV LGH IPS H07 H06 H05 H02 GOS FSH CRG CFS BOX TAM FOO TSV PCH WMD CNS FRA H03 TWB BKL JHH TNH DDH PAH H01 H04 Aus Avg 2017 Aus Avg 2016 WRE WLG WKO WHK WAG ROT DUN ACH MMH HKB CHC NSH TGA HUT INV NZ Avg 2017 NZ Avg 2016 RETURN TO PRE-ADMISSION MOBILITY AT 120-DAYS Return to preadmission walking ability 120-days Not returned to preadmission walking ability 120-days FIGURE56 RETURNTOPREADMISSIONMOBILITYAT12O-DAYS From a patient perspective, the recovery of function including mobility is a critical outcome following a hip fracture.

Mobility at 30-days after presentation is not reported as this is early in the course of recovery. Of those followed up at 120-days in 2017, 23% of patients in New Zealand and 26% of patients in Australia had returned to their pre-injury level of mobility. The data should be interpreted with caution, as the overall number followed-up is relatively small and those followed up represent a variable percentage of all hip fractures at each site. Nonetheless, the impact of a hip fracture appears substantial at 120-days. FIGURE 56 RETURN TO PRE-ADMISSION MOBILITY AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG ROK RNS QII POW NBR MSB LOG LMH LIV LGH IPS H07 H06 H05 H02 GOS FSH CRG CFS BOX TAM FOO TSV PCH WMD CNS FRA H03 TWB BKL JHH TNH DDH PAH H01 H04 Aus Avg 2017 Aus Avg 2016 WRE WLG WKO WHK WAG ROT DUN ACH MMH HKB CHC NSH TGA HUT INV NZ Avg 2017 NZ Avg 2016 RETURN TO PRE-ADMISSION MOBILITY AT 120-DAYS Return to preadmission walking ability 120-days Not returned to preadmission walking ability 120-days

PATIENT LEVEL AUDIT “In2O17,Ifellheavilybackwards whenhandfeedingcattle.The resultingcompressedfractureofa vertebra(L3)healedquitereadily buttheimpactonmylowerback, alreadyarthriticanddegenerating, wasquiteprofound.Iwaschecked severalyearsagoforosteoporosis, afterIbrokemyhip,andIwasfine butImentionthisbecauseIhaveto wonderiftherehasbeenachange andIneedtobereassessed.” ANZHFR | ANNUAL REPORT 2018 73

PATIENT LEVEL AUDIT 74 ANNUAL REPORT 2018 | ANZHFR Figure 57 shows the survival (proportion of patients still alive) at 30 days from hospital presentation.

The survival at 30 days in 2017 was 95% for New Zealand and 94% for Australian hospitals. The high variation between hospitals is likely to represent random variation due to the low number of patients followed up at 30 days in some hospitals. FIGURE57 SURVIV ALAT3O-DAYS 111 FIGURE 56 SURVIVAL AT 30-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% TWH TSH STG SCU SCG RNS QII POW NBR LOG LGH IPS H07 H06 H05 H02 GOS FSH CRG CFS BOX DDH MSB H03 PAH PCH H01 TAM FOO LMH TWB CNS JHH H04 TNH FRA BKL WMD TSV LIV ROK Aus Avg 2017 Aus Avg 2016 WAG DUN ROT WHK WLG WRE WKO CHC HKB HUT MMH NSH ACH TGA INV NZ Avg 2017 NZ Avg 2016 SURVIVAL AT 30-DAYS Survived at 30-days Not survived at 30-days

ANZHFR | ANNUAL REPORT 2018 75 PATIENT LEVEL AUDIT Survival at 120-days post-surgery is over 90%, but the accuracy of survival data and possible selection bias in those followed up means that these figures should be interpreted with caution. In the future, data linkage with mortality data may increase the accuracy of reporting survival after-hip fracture, and increase the efficiency of the Registry. FIGURE58 SURVIV ALAT12O-DAYS 113 FIGURE 57 SURVIVAL AT 120-DAYS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BOX CFS CRG FSH GOS H02 H05 H06 H07 IPS LGH LIV LMH LOG MSB NBR POW QII RNS ROK SCG SCU STG TSH TWH H03 TAM JHH BKL PCH TNH PAH H04 FRA DDH WMD H01 FOO TSV TWB CNS Aus Avg 2017 ACH DUN ROT WAG WHK WKO WLG WRE HUT INV TGA MMH NSH HKB CHC NZ Avg 2017 SURVIVAL AT 120-DAYS Survived at 120-days Not survived at 120-days

76 ANNUAL REPORT 2018 | ANZHFR 76 ANNUAL REPORT 2018 | ANZHFR

ANZHFR | ANNUAL REPORT 2018 77

FACILITY LEVEL AUDIT 78 ANNUAL REPORT 2018 | ANZHFR RESULTS1: GENERAL INFORMATION Hospitals were asked to categorise how many hip fractures were treated in the 2017 calendar year: 0-50 hip fractures; 51-100; 101-150; 151-200; 201-300; 301-400; and 401+. See Figure 59. Seventy percent of hospitals (81/118) reported treating more than 100 hip fracture patients during 2017 (Figure 60). FIGURE59 NUMBEROFHIPFRACTURESTREATED2O18 FIGURE6O NUMBEROFHIPFRACTURESTREATED2O14-2O18 ANZHFR Facility Level Audit RESULTS 1: GENERAL INFORMATION Hospitals were asked to categorise how many hip fractures were treated in the 2017 calendar year: 0- 50 hip fractures; 51-100; 101-150; 151-200; 201-300; 301-400; and 401+.

See Figure 58. Seventy percent of hospitals (81/118) reported treating more than 100 hip fracture patients during 2017 (Figure 58).

FIGURE 58 NUMBER OF HIP FRACTURES TREATED 2018 FIGURE 59 NUMBER OF HIP FRACTURES TREATED 2014-2018 5 10 15 20 25 30 0-50 51-100 101-150 151-200 201-300 301-400 401+ Number of hospitals Number of hip fractures NUMBER OF HIP FRACTURES TREATED IN AUSTRALIAN AND NEW ZEALAND HOSPITALS 2018 5 10 15 20 25 30 0-50 51-100 101-150 151-200 201-300 301-400 401+ Number of hospitals Number of hip fractures NUMBER OF HIP FRACTURES TREATED IN AUSTRALIAN AND NEW ZEALAND HOSPITALS 2014-2018 2014 2015 2016 2017 2018 1 ANZHFR Facility Level Audit RESULTS 1: GENERAL INFORMATION Hospitals were asked to categorise how many hip fractures were treated in the 2017 calendar year: 0- 50 hip fractures; 51-100; 101-150; 151-200; 201-300; 301-400; and 401+.

See Figure 58. Seventy percent of hospitals (81/118) reported treating more than 100 hip fracture patients during 2017 (Figure 58).

FIGURE 58 NUMBER OF HIP FRACTURES TREATED 2018 FIGURE 59 NUMBER OF HIP FRACTURES TREATED 2014-2018 5 10 15 20 25 30 0-50 51-100 101-150 151-200 201-300 301-400 401+ Number of hospitals Number of hip fractures NUMBER OF HIP FRACTURES TREATED IN AUSTRALIAN AND NEW ZEALAND HOSPITALS 2018 5 10 15 20 25 30 0-50 51-100 101-150 151-200 201-300 301-400 401+ Number of hospitals Number of hip fractures NUMBER OF HIP FRACTURES TREATED IN AUSTRALIAN AND NEW ZEALAND HOSPITALS 2014-2018 2014 2015 2016 2017 2018

ANZHFR | ANNUAL REPORT 2018 79 FACILITY LEVEL AUDIT RESULTS2: MODEL OFCARE Orthogeriatric care involves a shared care arrangement for hip fracture patients between the specialties of orthopaedics and geriatric medicine.The geriatrician is involved in the pre-operative optimisation of the patient in preparation for surgery and then takes a lead in the post-operative medical care and coordinates the discharge planning process.

Implicit in this role are many of the aspects of basic care including nutrition, hydration, pressure care, bowel and bladder management, and monitoring of cognition and coexisting conditions. Hospitals that do not have access to a geriatric medicine service must look for ways to provide a model of orthogeriatric care that utilises alternative medical practitioners, such as orthopaedic surgeons, anaesthetists, physicians, and general practitioners.

In 2018, shared care arrangements were present in 23% (27/118) of hospitals. The most common model for provision of care is an orthogeriatric liaison service, which occurs in 32% (38/118) of hospitals (Figure 61). Both results are similar to the previous year and indicate 55% of hip fracture patients have access to an orthogeriatric service at least daily during the working week. FIGURE61 MODELOFCAREFOROLDERHIPFRACTUREPATIENTS2O14-2O18 1.  A shared care arrangement where there is joint responsibility for the patient from admission between orthopaedics and geriatric medicine for all older hip fracture patients.

2.  An orthogeriatric liaison service where geriatric medicine provides regular review of all older hip fracture patients (daily during working week) 3.  A medical liaison service where a general physician or GP provides regular review of all older hip fracture patients (daily during working week) 4.  An orthogeriatric liaison service where geriatric medicine provides intermittent review of all older hip fracture patients (2-3 times weekly) 5.  A medical liaison service where a general physician or GP provides intermittent review of hip fracture patients (2-3 times weekly) 6.  An orthogeriatric liaison service (2014) / geriatric service (2015) where a consult system determines which patients are reviewed 7.  A medical liaison service (2014) / medical service (2015) where a consult system determines which patients are reviewed 8.  No formal service exists 9. Other RESULTS 2: MODEL OF CARE Orthogeriatric care involves a shared care arrangement for hip fracture patients between the specialties of orthopaedics and geriatric medicine.The geriatrician is involved in the pre-operative optimisation of the patient in preparation for surgery and then takes a lead in the post-operative medical care and coordinates the discharge planning process.

Implicit in this role are many of the aspects of basic care including nutrition, hydration, pressure care, bowel and bladder management, and monitoring of cognition and coexisting conditions. Hospitals that do not have access to a geriatric medicine service must look for ways to provide a model of orthogeriatric care that utilizes alternative medical practitioners, such as orthopaedic surgeons, anaesthetists, physicians, and general practitioners. In 2018, shared care arrangements occurred in 23% (27/118) of hospitals. The most common model fo provision of care is an orthogeriatric liaison service, which occurs in 32% (38/118) of hospitals (Figure 59).

Both results are similar to the previous year and indicate 55% of hip fracture patients have access to an orthogeriatric service at least daily during the working week.

FIGURE 60 MODEL OF CARE FOR OLDER HIP FRACTURE PATIENTS 2014-2018 1. A shared care arrangement where there is joint responsibility for the patient from admission between orthopaedics and geriatric medicine for all older hip fracture patients. 2. An orthogeriatric liaison service where geriatric medicine provides regular review of all older hip fracture patients (daily during working week) 3. A medical liaison service where a general physician or GP provides regular review of all older hip fracture patients (daily during working week) 4. An orthogeriatric liaison service where geriatric medicine provides intermittent review of all older hip fracture patients (2-3 times weekly 5.

A medical liaison service where a general physician or GP provides intermittent review of hip fracture patients (2-3 times weekly) 6. An orthogeriatric liaison service (2014) / geriatric service (2015) where a consult system determines which patients are reviewed 7. A medical liaison service (2014) / medical service (2015) where a consult system determines which patients are reviewed 8. No formal service exists 5 10 15 20 25 30 35 40 45 50 1 2 3 4 5 6 7 8 9 Number of hospitals Model of care by hospital MODEL OF CARE FOR OLDER HIP FRACTURE PATIENTS AUSTRALIAN AND NEW ZEALAND HOSPITALS 2014-2018 2014 2015 2016 2017 2018

FACILITY LEVEL AUDIT 80 ANNUAL REPORT 2018 | ANZHFR RESULTS3: PROTOCOLSAND ELEMENTSOFCARE Systems and protocols can support clinicians to provide hip fracture patients with high quality care. Investigation, assessment and management of a patient’s injury and their medical conditions must be provided in a timely and effective way throughout a patient’s admission. Health services are encouraged to develop protocols aligned with the ANZ Guideline for Hip Fracture Care and the Hip Fracture Care Clinical Care Standard.

Figure 62 shows responses from all hospitals in Australia and New Zealand on the presence of protocols and elements of care.

Figures 63 and 64 show the reported elements of care for each country for a six-year period. HIP FRACTURE PATHWAY In 2018, 78% (92/118) reported having a pathway for hip fracture patients: 22% in the emergency department only and 56% for the whole acute journey. Whilst similar to 2017, there has been a steady increase in the proportion of hospitals that report a pathway for the management of a patient with a hip fracture through the whole acute journey. COMPUTED TOMOGRAPHY (CT) / MAGNETIC RESONANCE IMAGING (MRI) In 2018, the presence of a protocol or pathway to access either CT or MRI for inconclusive plain imaging of hip fracture was available in 55% (65/118) of hospitals, similar to 2017.

This question was first asked in 2014 with 46% (54/117) of sites reporting presence of a protocol: in 2013, the audit question listed MRI as the only imaging modality hence comparison must be done with caution. The absence of substantial change in this area over the six years of the facilities audit provides services an opportunity for improving the quality of assessment at a person’s presentation to hospital. VENOUS THROMBOEMBOLISM (VTE) This question has remained constant over the six years of the audit. In 2018, 87% (103/118) of respondents said “yes” when asked if their hospital had a VTE protocol.

This is similar to 91% (109/120) in 2017 and 88% (107/121) in 2016.

PAIN PATHWAY In 2018, a protocol or pathway for pain was available at 56% (66/118) of hospitals: 24% in the emergency department only and 32% for the whole acute journey. This is similar to the previous year and continues to show little change over the six years of the facilities audit. The facilities audit also asks respondents if patients are offered local nerve blocks as part of preoperative and postoperative pain management. In 2018, 89% (105/118) responded that patients were offered nerve blocks preoperatively “always” or “frequently” and 81% (95/118) responded that patients were offered nerve blocks for postoperative pain relief “always” or “frequently”.

CHOICE OF ANAESTHESIA This question has remained constant since 2014, and asks if hip fracture patients are routinely offered a choice of anaesthesia. In 2018, 76% (90/118) of hospitals were reported as routinely offering a choice of anaesthesia “always” or “frequently”, similar to 2017 at 73% (88/120). PLANNED THEATRE LIST In 2018, 40% of respondents reported having access to a planned operating theatre list or planned trauma list for hip fracture patients. This is similar to previous years: 39% (47/120) in 2017; 39% (47/121) in 2016; 40% (48/120) in 2015 and 42% (49/117) in 2014. WEEKEND THERAPY In 2018, 85% (100/118) of hospitals reported having routine access to weekend therapy services, predominantly physiotherapy services (80%).

There has been a steady increase over the six years of the facilities audit. Mobilisation on the day of, or day after, hip fracture surgery helps patients restore movement and function and prevent complications. Provision of access to weekend therapy provides the opportunity to mobilise early and ensures that the day of surgery doesn’t impact the rehabilitation process.

ANZHFR | ANNUAL REPORT 2018 81 FACILITY LEVEL AUDIT FIGURE62 PRESENCEOFPROTOCOLSFORELEMENTSOFHIPFRACTURECARE2O13-2O18 FIGURE63 NEWZEALANDHOSPITALSREPORTEDELEMENTSOFCARE2O13-2O18 FIGURE 61 FIGURE 62 PRESENCE OF PROTOCOLS FOR ELEMENTS OF HIP FRACTURE CARE 2013-2018 10 20 30 40 50 60 70 80 90 100 % Proportion of hospitals Elements of hip fracture care PRESENCE OF PROTOCOLS FOR ELEMENTS OF HIP FRACTURE CARE AUSTRALIA AND NEW ZEALAND 2013-2018 2013 2014 2015 2016 2017 2018 FIGURE 62: NEW ZEALAND HOSPITALS REPORTED ELEMENTS OF CARE 2013-2018 FIGURE 63: AUSTRALIAN HOSPITALS REPORTED ELEMENTS OF CARE 2013-2018 10 20 30 40 50 60 70 80 90 100 % Proportion of New Zealand hospitals Elements of hip fracture care NEW ZEALAND HOSPITALS: REPORTED ELEMENTS OF HIP FRACTURE CARE YEAR-BY-YEAR COMPARISON 2013-2018 2013 2014 2015 2016 2017 2018 AUSTRALIAN HOSPITALS: REPORTED ELEMENTS OF HIP FRACTURE CARE YEAR-BY-YEAR COMPARISON 2013-2018

82 ANNUAL REPORT 2018 | ANZHFR FACILITY LEVEL AUDIT FIGURE64 AUSTRALIANHOSPITALSREPORTEDELEMENTSOFCARE2O13-2O18 FIGURE 62: NEW ZEALAND HOSPITALS REPORTED ELEMENTS OF CARE 2013-2018 FIGURE 63: AUSTRALIAN HOSPITALS REPORTED ELEMENTS OF CARE 2013-2018 10 20 30 40 50 60 70 80 90 100 % Proportion of New Zealand hospitals Elements of hip fracture care NEW ZEALAND HOSPITALS: REPORTED ELEMENTS OF HIP FRACTURE CARE YEAR-BY-YEAR COMPARISON 2013-2018 2013 2014 2015 2016 2017 2018 10 20 30 40 50 60 70 80 90 100 % Proportion of Australian hospitals Elements of hip fracture care AUSTRALIAN HOSPITALS: REPORTED ELEMENTS OF HIP FRACTURE CARE YEAR-BY-YEAR COMPARISON 2013-2018 2013 2014 2015 2016 2017 2018

FACILITY LEVEL AUDIT ANZHFR | ANNUAL REPORT 2018 83

FACILITY LEVEL AUDIT 84 ANNUAL REPORT 2018 | ANZHFR RESULTS4: BEYONDTHEACUTE HOSPITALSTAY The Facilities Audit asked respondents to report on access for hip fracture patients to rehabilitation services and publicly funded outpatient clinics for the management of their injury and the prevention of future falls and fractures. Information from the 2018 audit is provided below with comparison to previous years in Table 1 and Figure 65. REHABILITATION In 2018, 36% (42/118) of responding hospitals reported access to both onsite and offsite rehabilitation services, a small increase from 33% reported in 2017.

Access to onsite rehabilitation only is reported by 39% (46/118), and access to offsite rehabilitation only was reported by 25% (30/118). Access to an early, supported home- based rehabilitation service was reported by 42% (50/118) of hospitals this year.

FRACTURE LIAISON SERVICE (FLS) Dedicated resources allocated to the identification, management, and follow-up of minimal trauma fractures has been shown to reduce re-fracture rates in people with osteopenia and osteoporosis. The availability of fracture liaison services remains limited, however, the small but steady increase seen in previous years has continued and access to a FLS was reported by 36% (43/118) of hospitals. Of these services, 30% (35/118) were for patients with any minimal trauma fracture (including hip fracture) and 7% (8/118) were specifically for hip fracture patients only.

OUTPATIENT CLINICS In 2018, variable access to public outpatient clinics was again observed and this provides opportunity to health services to review services to increase access for hip fracture patients.

There is widespread access to orthopaedic clinics at most sites – 93% (110/118). However, access to clinics targeting secondary fracture prevention, and the prevention of future falls and fractures, remains limited. In 2018, access to a public falls clinic is reported at 60% (71/118), access to an osteoporosis clinic at 44% (52/118), and access to a combined falls and bone health clinic at 20% (24/118). PATIENT AND CARER INFORMATION Hip fracture patients and their carers must be active partners in any decisions made about their care and recovery from injury. Information and advice on treatment and recovery, and the prevention of future falls and fractures, should be provided verbally and in writing.

In 2018, 47% (55/118) of hospitals responded “yes” to the provision of written information to patients about their hip fracture treatment, an increase from 39% in 2017. Only 24% (28/118) of respondents said they provided written information to patients on discharge that included recommendations for future falls and fracture prevention (not the same as a discharge summary): 5% (1/21) hospitals in New Zealand and 28% (27/97) in Australia.

ANZHFR | ANNUAL REPORT 2018 85 FACILITY LEVEL AUDIT TABLE1 REPORTEDSERVICESA V AILABLEBEYONDTHEACUTEHOSPITALSTAY AUSTRALIANANDNEWZEALANDHOSPITALS2O13-2O18 2013 (n = 116) 2014 (n = 117) 2015 (n = 120) 2016 (n = 121) 2017 (n = 120) 2018 (n = 118) Access to rehabilitation onsite and offsite Onsite 30% Offsite 23% Both 47% Onsite 37% Offsite 26% Both 37% Onsite 38% Offsite 21% Both 41% Onsite 41% Offsite 22% Both 37% Onsite 42% Offsite 25% Both 33% Onsite 39% Offsite 25% Both 36% Access to home-based rehabilitation 68% 64% 41% 36% 40% 42% Fracture Liaison Service (FLS) 15% 20% 21% 25% 33% 36% Access to a public falls clinic 41% 43% 57% 64% 58% 60% Access to a public osteoporosis clinic 35% 32% 40% 48% 40% 44% Access to a public falls and bone health clinic 16% 15% 18% 17% 16% 20% Access to a public orthopaedic clinic 72% 90% 91% 90% 89% 93% Routine provision written information on treatment and care after hip fracture n/a 27% 41% 38% 39% 47% Routine provision of individualised written information on prevention of future falls and fractures n/a n/a 27% 27% 27% 24% n/a = not asked FIGURE65 REPORTEDAV AILABLESERVICESBEYONDTHEACUTEHOSPITALSTAY AUSTRALIANANDNEWZEALANDHOSPITALS2O13-2O18 FIGURE 64: FIGURE 65 REPORTED AVAILABLE SERVICES BEYOND THE ACUTE HOSPITAL STAY AUSTRALIAN AND NEW ZEALAND HOSPITALS 2013-2018 10 20 30 40 50 60 70 80 90 100 Access to rehabilitation onsite and offsite Access to home-based rehabilitation Fracture Liaison Service (FLS) Access to a public falls clinic Access to a public osteoporosis clinic Access to a public falls and bone health clinic Access to a public orthopaedic clinic Routine provision written information on treatment and care after hip fracture Routine provision of individualised written information on prevention of future falls and fractures % Proportion of hospitals reporting availability of services Reported services beyond the acute hospital stay REPORTED SERVICES BEYOND THE ACUTE HOSPITAL STAY AUSTRALIAN AND NEW ZEALAND HOSPITALS 2013-2018 2013 2014 2015 2016 2017 2018

86 ANNUAL REPORT 2018 | ANZHFR THE ANZHFR is based at the Falls, Balance and Injury Research Centre at Neuroscience Research Australia (NeuRA) MEMBERS OF THE ANZHFR STEERING GROUP ARE: Professor Jacqueline Close, Geriatrician Co-Chair Professor Ian Harris, Orthopaedic Surgeon Co-Chair Dr Laura Ahmad (Geriatrician, RACP) Ms Elizabeth Armstrong (Australian Registry Manager) Dr John Barry (Anaesthetist, ANZCA) Mr Brett Baxter (Physiotherapist, APA) Prof Ian Cameron (Rehabilitation Physician, AFRM) A/Prof Mellick Chehade (Orthopaedic Surgeon, ANZBMS) Dr Owen Doran (Emergency Medicine Physician, ACEM) A/Prof Kerin Fielding (Orthopaedic Surgeon, RACS) Mr Stewart Fleming (Webmaster) Ms Christine Gill (CEO, Osteporosis New Zealand) Dr Roger Harris (Geriatrician, ANZSGM) A/Prof Raphael Hau (Orthopaedic Surgeon, Victoria) A/Prof Rebecca Mitchell (Injury Epidemiologist, AIHI) Dr Kris Dalzell (Orthopaedic Surgeon, NZOA) Ms Chris Pegg (New Zealand Registry Manager) Dr Gretchen Poiner (Consumer Representative) Dr Hannah Seymour (Geriatrician, ANZSGM) Dr Ralph Stanford (Orthopaedic Surgeon, AOA) Ms Anita Taylor (Nurse Practitioner, ANZONA) ATTENDEES Ms Linda Roylance (Secretariat) APPENDIX1: ANZHFRSTEERING GROUP APPENDICES

ANZHFR | ANNUAL REPORT 2018 87 ACEM Australasian College of Emergency Medicine AFRM Australasian Faculty of Rehabilitation Medicine AIHI Australian Institute of Health Innovation ANZ Australia and New Zealand ANZBMS Australian and New Zealand Bone and Mineral Society ANZCA Australian and New Zealand College of Anaesthetists ANZHFR Australian and New Zealand Hip Fracture Registry ANZONA Australian New Zealand Orthopaedic Nurses Association ANZSGM Australian and New Zealand Society for Geriatric Medicine AOA Australian Orthopaedic Association APA Australian Physiotherapy Association ASA American Society of Anesthesiologists AUS Australia CCU Coronary Care Unit CT Computed Tomography ED Emergency Department FLS Fracture Liaison Service GP General Practitioner HDU High Dependency Unit ICU Intensive Care Unit MRI Magnetic Resonance Imaging NZ New Zealand NZOA New Zealand Orthopaedic Association OA Osteoporosis Australia ONZ Osteoporosis New Zealand OT Operating Theatre RACP Royal Australasian College of Physicians RACS Royal Australasian College of Surgeons VTE Venous Thromboembolism APPENDICES APPENDIX2: LISTOF ABBREVIATIONS

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