The 2011 National Hip Fracture Database (NHFD) Report has shown our institute has the fewest number of patients meeting the 36-hour target to theatre in the UK (9%) but well above the national average for review by geriatrician (42.5%) at 76%. We believe our timely medical input means patients' are more physiologically normalised prior to surgery. We aimed to review our postoperative results to see if our patients had significantly different morbidity and mortality compared to the rest of the UK. We reviewed 152 patients between the period September 2009 and September 2010. All of the patients were prospectively identified and their information was added to our hip fracture database. Using the auditing software we reviewed the patients' outcomes and compared them to national averages using figures from the NHFD. Of the 152 patients identified 13% met the 36-hour target. The average time to theatre for the study group was 89 hours. 83% of the group had a pre-operative assessment by a geriatrician. The primary reason for surgical delay was a lack of space on a theatre list (61.2%) followed by being medical unfit (16.4%). The average length of acute hospital stay was 16.4 days matching the national average while 30 Day mortality at 7.9% was (0.5%) lower than NHFD figures. We continue to try and improve our time to surgery for hip fracture patients and accept this is mostly related to limited theatre access. Deficient resources due to Northern Ireland's exclusion from the best practice tariff means we are unable to compete with the top performing units in the NHFD. While it makes humanitarian sense to expedite surgery, evidence used to determine the 36-hour target is quoted as “low quality” or “very low quality”. Our data shows no significant difference in outcomes compared to national figures

We have a national UK database for hip fracture outcome. It has been developed synchronously with an agreed care pathway that is multi-disciplinary, including surgeons, anaesthetists, geriatricians, osteoporosis experts, healthcare managers and lay charities. Care has been improved and audit established for future evolution. The database started in 2007 and now includes 85 units. The synchronous care pathway deals with falls and osteoporosis prevention, perioperative multi-disciplinary care, rehabilitation and outcome results. Key issues are avoidance of delay and cancellation of surgery and how we deal with patients with medical co-morbidities. Outcome is analysed prospectively to take account of co-morbidities and variations in surgical techniques. The care pathway and data base are now universally accepted as a national priority with advice for all UK trauma units to participate. Of the 121 registered units, only 85 actively contribute data. The cost and staff needs for data input are now accepted. To date, 12,983 clinical cases have been entered. Variation of trauma theatre list operating time per head of population and other related resource has been highlighted. This has been accepted by politicians and health managers. The NHS Institute of Improvement has started a rapid improvement plan to support units with poor resource/audit outcome. It is early days in terms of validity of outcome data for technical variations in treatment eg. fixation/replacement/use of bone cement. We have a national increase in resouce for hip fractures. We now have some logic to interaction between surgeons and medics/managers. Objectively struggling units get active support. We accept the possible lack of validity of some outcome data. Some units who look bad on paper should not be disadvantaged

Purpose. Hip fractures are the most common injury requiring hospitalization in both men and women over the age of 65. There is significant mortality associated with hip fracture and delay to surgical treatment increases this rate. We undertook an ethnographic study exploring organizational barriers to timely hip fracture surgery. Method. Using purposive sampling, over 30 interviews were conducted at a large teaching hospital with various professionals involved in the process of getting a patient from ED to surgery and to surgical discharge. This included anaesthetists, surgeons, emergency and internal medicine physicians, nurses, social workers and senior administrative personnel. An additional twelve patient interviews were conducted and reported separately. Following transcription of each tape, a small study team met over the course of several months to read and discuss each transcript in detail. A coding template was developed and each transcript coded with emerging themes noted. Results. Several important themes emerged which impact time to hip fracture surgery. We have classified these as: 1) issues related to inter and intra-professional collaboration; 2) social admissions or “failure to cope” (FTC) patients who are referred to surgical orthopaedic ward beds; 3) difficulties in discharge to rehabilitation; and 4) the disconnect between hospital administration's discourse of efficiency while insufficient resources choke optimal patient flow of care. Conclusion. Inter and intra-professional collaboration has been recognized as central to the provision of excellent, patient-centred care yet not often been studied empirically. Our study revealed obstacles at several stages that stretched from admission at the ED to post-surgical discharge. Tensions were reported between medical, anaesthetic and surgical specialists in relation to consults, anticoagulation and pre-op testing that frustrated attempts to operate within the current Ontario wait time standard of 48 hours. Competition for scarce hospital beds also increased this tension and sense of frustration. In addition, non-operative fracture patients are often referred from ED to orthopaedic surgical wards, thus further delaying access for patients requiring emergent hip fracture surgery due to lack of surgical bed availability. On the basis of these findings our team hopes to advance recommendations designed to address these issues and improve wait times that will be applicable to other hospitals. These recommendations may include the inclusion of a geriatrician or hospitalist on orthopaedic wards as well as harmonized guidelines and care pathways. In addition, we are adding to the understanding of the social organization of acute care in complex and demanding environments