Differences between hip fracture guidelines

Abstract

We were pleased that the different clinical guidelines related to proximal femoral fractures have been compared and examined 1, but suggest that the nature of the patient cohort has hampered research, and therefore the production of coherent guidance. We agree with the authors that the 6-year time span of the guidelines considered is very likely to have thrown up differences, particularly in areas where improvements in care have been addressed through a multidisciplinary approach, such as peri-operative analgesia. Many randomised controlled trials (RCTs) have struggled with trial design, recruitment, bias and issues surrounding consent and capacity 2, to the extent that they may not be included in any rigorous Cochrane review. The largest UK-based study on anaesthesia for hip fracture has been underway in Peterborough for the last three years and is very unlikely to find any meaningful difference, owing to all these inherent problems 2. Instead, the use of prospective observational studies has been proposed to collate data about anaesthetic management, to inform and/or promote future research. Data about the mode of anaesthesia has recently started to be collected by the National Hip Fracture Database (NHFD) 3. Of real concern in the NHFD's 2012 report was the finding that 6.5% of 59 000 patients received combined spinal and general anaesthesia. More recently still, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) has funded a sprint audit (‘ASAP’), for the NHS Hip Fracture Perioperative Network (HiPeN), in collaboration with the NHFD, to collect peri-operative management information on more than 10 000 hip fracture patients 4. Anaesthetists in Scotland cannot contribute to this audit, but many have contacted HiPeN about collecting local data. Kearns et al. mention newer papers that have not been considered, possibly due to their publication date. We can confirm, for example, that the meta-analysis by Luger et al. 5 was not considered by NICE owing to the timings of the meetings. However, other papers were quoted inappropriately: the FOCUS study (quoted as reference 41) concerns transfusion policies in a rehabilitation, rather than a peri-operative setting, and so is of limited relevance to inclusion in future guidelines, excepting its implication that [haemoglobin] should be measured in the recovery room because of peri-operative blood loss equivalent to a mean of 2.5 g.dl−1 haemoglobin. Inevitably, as a result of ASAP, the recent AAGBI guidelines 6 will be submitted to a form of continuous improvement 7 through review, in the same way that the NICE guidance is already under review, less than two years since publication. Finally, we would like to suggest that from a medicolegal point of view, the guidelines most likely to be referred to in determining the peri-operative standard of care given by anaesthetists are those provided by the specialty itself, in this case the AAGBI guidelines 6.