Pre‐operative echocardiography for hip fractures: time to make it a standard of care

Management of older people with hip fractures in Belfast has continuously developed and improved since the inception of our orthogeriatric service in 1997, using ‘performance by the aggregation of marginal gains’ as our focus, to borrow the mantra of British Cycling’s Perforance Director David Brailsford [1]. One of the earliest issues we addressed with this approach was the management of previously undiagnosed heart murmurs. Patients with hip fractures were often subjected to long preoperative delays for various reasons. Often a murmur was detected on admission but a transthoracic echocardiogram (TTE) was not requested. Further delays were then added following pre-operative assessment by the anaesthetic team and a request for a TTE when surgery was eventually scheduled. In 2001, we adopted a policy that a TTE should be obtained for all patients with hip fractures and previously undiagnosed murmurs detected on auscultation. We did so in order to comply with the two recommendations for older people with aortic stenosis made in the Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) published that year [2]. These were: (i) whenever possible the anaesthetist of a patient with aortic stenosis should obtain a pre-operative echocardiogram of the aortic valve; and (ii) the availability of the echocardiography service for patients pre-operatively should be accorded an appropriate priority in the funding and development plans of hospitals. From 2001 to 2005, a TTE to investigate an undiagnosed heart murmur was requested in 908 out of 3997 (23%) consecutive patients with hip fractures in our unit [3]. Our ability to obtain these investigations was initially facilitated by long delays to theatre, but with communication, feedback and service development we now have access to a rapid bedside echocardiography service. In an analysis of the 272 patients in whom the TTE detected aortic stenosis, we found significant trends towards general anaesthesia over spinal anaesthesia, and use of invasive monitoring of intra-operative blood pressure, as the severity of the aortic stenosis increased, with no significant trend towards a higher 30-day mortality [3]. Over the past decade, management of hip fracture has been improved by national guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) and the British Orthopaedic Association ⁄ British Geriatrics Society that have been published on the basis of national audits of hip fracture management in Scotland (Scotttish Hip Fracture Audit) and the rest of the UK (National Hip Fracture Database (NHFD)), respectively [4–6]. These guidelines focus on optimising the management of older patients with hip fractures while minimising delays to theatre. Guidelines have also been produced by the National Institute for Health and Clinical Excellence (NICE) [7]. As delays to theatre have been markedly reduced, controversy surrounding the necessity for TTE has emerged since such a request may lead to a delay to operative fixation of the fracture. This may now be perceived as being extremely costly in England as any delay to surgery beyond 36 hours from admission will deny the treating hospital the Best Practice Tariff (BPT) for hip fractures, which now equates to £1335 (€1706; $2102) above base tariff for each patient whose care meets BPT criteria defined by the NHFD. What evidence is there to suggest that hip fracture units should ensure that patients with previously undiagnosed murmurs should have a TTE performed before surgery? Should this be available in all hip fracture units? Anaesthesia 2012, 67, 1189–1201