An end of surgery care bundle should be completed for all patients.

 

Rationale

Care bundles remind clinicians about important aspects of care that are often overlooked in the postoperative care unit, and which can delay re-enablement [57, 58].

Approximately 50% of hip fracture patients reach the recovery room with a core temperature <36.5%, delaying their return to the ward and causing discomfort [59].

Approximately 90% of hip fracture patients are anaemic after surgery, having lost a mean of 2.5g/dl blood perioperatively (more in extracapsular/pathological fractures). Approximately 20% have a postoperative [Hb]<8g/dl on day 1 postoperatively, and 15% of patients have their [Hb] measured later than day 1. Postoperative measurement of [Hb] (Hemocue, FBC, blood gas) identifies patients that would otherwise experience a period of avoidable anaemia of a degree that may impair recovery and remobilisation.

Renal dysfunction (eGFR<60) on admission to hospital is seen in approximately 40% of hip fracture patients [60], and impairs clearance of opioids (halve dose, double interval) and some sedatives, increasing the likelihood of confusion. Similarly, tramadol should be avoided in hip fracture patients, due to the potential for it causing confusion.

Postoperative fluid therapy should focus on nursing staff encouraging oral fluid intake. If this is unlikely to happen, then appropriate intravenous fluids need to be prescribed.

The loss of functional aids (hearing, visual, teeth) is a common but totally avoidable cause of postoperative confusion, communication problems and poor nutrition, delaying rehabilitation.

With good orthogeriatric and anaesthetic care, high dependency facilities are rarely needed, but their use should be considered with every hip fracture patient if a sustained improvement in condition might be brought about beyond that which the orthogeriatricians think that they can deliver on an orthopaedic ward.

 

Evidence

1. Stolbrink M, McGowan L, Saman HH et al. The Early Mobility Bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay. Journal of Hospital Infection 2014; 88: 34-9.

2. Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA, Quiney N; ELPQuiC Collaborator Group. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. British Journal of Surgery 2015; 102: 57-66.

3. National Institute for Health and Clinical Excellence. The management of inadvertent perioperative hypothermia in adults. 2008. https://www.nice.org.uk/guidance/cg65/resources/cg65-perioperative-hypothermia-inadvertent-full-guideline2 (accessed 01/01/2016).

4. White SM, Rashid N, Chakladar A. An analysis of renal dysfunction in 1511 patients with fractured neck of femur: the implications for peri-operative analgesia. Anaesthesia 2009; 64: 1061-5.