Keywords

1.1 Introduction

In many parts of the world, fragility fractures are the most common reason for admission to acute orthopaedic trauma units. The care of people following fragility fractures is provided in a variety of care settings including pre-hospital and emergency care, acute hospitals, outpatient/ambulatory clinics, rehabilitation, primary care and community/home care. Such care is often a complex, medium- to long-term undertaking with several phases from acute care through to rehabilitation and secondary fracture prevention. Often, a fragility fracture has a substantial impact on older peoples’ longer term function, place of residence and quality of life. A hip fracture, for example, has been described as a ‘life-breaking’ event [1], reflecting its serious impact on the lives of individuals and their families. Sometimes, fragility fractures lead to the end of life. It is vital that care following a fragility fracture is swift and evidence informed. Nursing care has a huge impact on the outcomes for individuals whether it be their quality of life, where they live after the fracture or whether they survive.

Avoiding these devastating impacts drives the need to prevent fractures through secondary fracture prevention. This prevention care is lifelong and usually delivered and monitored by a primary care team including general practitioners, nurses, physiotherapists and other specialist practitioners. The pathway of care is, therefore, far from static and involves the collaboration of many individuals and agencies.

Although not all people who sustain fragility fractures are ‘older’ (some are fit and active, in their 60s, 50s or even 40s, and still in the workforce), most are elderly and often frail and/or living with sarcopenia. Many, especially those in younger age groups, have suffered a fracture that can be treated as an outpatient. However, such injuries are important warning signs that the underlying cause may be fragile bones caused by osteoporosis—often previously undiagnosed—that requires treatment to prevent further fractures.

If left untreated, osteoporosis and associated bone fragility can, ultimately, lead to significant injuries such as hip or femoral fractures, which will require hospital admission and surgery and severely threaten an individual’s health and well-being, often becoming a precursor to declining function and even death from the complications of the injury and surgery. This can be illustrated by a patient story:

Sofia’s story

I’m 78 now. Seven years ago, I was totally independent in my life, I fell and broke my left hip. They fixed it and I went home after 5 days. To be honest, I was never really the same after that. My walking seemed less steady, and I found it hard to walk far, or up the hill.

When I came out of hospital my general practitioner sent me for a bone scan. I was told I had osteoporosis. My Mum had it, so I suppose I wasn’t surprised, but I didn’t really understand the difference between osteoporosis and osteoarthritis. They put me on a drug for it. I’ve taken it every week since. After a year I had another bone scan. But I never got the results, and no one followed it up. I suppose I didn’t take it seriously.

Over the last few years, I’ve noticed my spine has got quite curved. Sometimes my back aches. I think this has made my walking less steady. This has been worse since Covid—I stopped going out for quite a while and now it’s hard to leave my home. I’ve been thinking I should talk to my doctor about seeing a specialist, but I haven’t got around to it.

Recently, I fell again. I fractured my right femur, my right wrist, and the top of my right arm near the shoulder. The orthopaedic surgeon fixed my femur with a nail and my wrist with a plate. The fracture at the top of my arm has been left to heal on its own. It took me 4 weeks to get home as it’s been so hard to get standing and walking again. I was so worried I might have to go into a home. It’s been so much worse than last time.

The osteoporosis team came to see me in hospital. They said they thought I needed to start on some injections. I have a telephone appointment next week.

Loss of bone strength (bone fragility) due to osteoporosis, and consequent fragility fractures, often occurs in older people who are frail. They can then become frail or frailer following the fracture because of the physiological response to the tissue trauma, surgery and subsequent complications related to a sedentary lifestyle and the immobility that follows the fracture. Frailty is a complex geriatric syndrome linked with ageing, multiple health problems and physical and mental decline. It is recognised as a significant factor in adding complexity of needs to an already challenging clinical situation. This is reflected in the four Fs of orthogeriatric/fragility fracture care outlined in Fig. 1.1.

Fig. 1.1
A chart of the interconnection of four factors: frailty, fragility, fractures, and falls, with frailty and falls being linked, while fragility and fractures are also connected.

The four ‘Fs’ of orthogeriatric/fragility fracture care

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All these issues lead to significant challenges for clinical teams in every care setting. The main focus of this chapter is to introduce the reader to orthogeriatric and fragility fracture care. The aims are to both familiarise the reader with the multiple topics covered in this book and support the interdisciplinary care team in achieving optimal recovery of independent function and quality of life, with no further fractures for all people with fragility fractures.

1.2 Learning Outcomes

At the end of the chapter, and following further study, the practitioner will be able to

  • Explore the causes and impacts of osteoporosis and fragility fractures.

  • Outline the principles and challenges of fragility fracture and orthogeriatric care.

  • Explain the elements of evidence-based pathways of care following fragility fracture.

  • Outline the need for development of healthcare practitioner roles in fragility fracture care.

  • Discuss the nature of fragility fracture care from an interdisciplinary perspective.

1.3 Fragility Fracture and Orthogeriatric Care

Fragility fractures are defined by the International Osteoporosis Foundation [2]:

Fragility fractures, which result from low energy trauma, such as a fall from standing height or less, are a sign of underlying osteoporosis. A patient who has sustained one fragility fracture is at high risk of experiencing secondary fractures, especially in the first 2 years following the initial fracture.

Although the care of patients with fragility fractures has taken place for centuries, as long as osteoporosis has existed, the concepts of orthogeriatric care and fragility fracture care have relatively recently been discussed. Consequently, we want to be clear about what we mean by these terms:

Orthogeriatric care is a specialised sector of healthcare that combines the skills of orthopaedic care as well as acute and rehabilitation care of older people who have suffered fragility fractures admitted to acute hospitals. This involves working as part of an interdisciplinary healthcare team who have expertise in geriatric medicine (although not specifically a geriatrician as they do not exist everywhere) and orthopaedic surgery as part of a team of allied health professionals with specialist expertise in aspects of the patient journey from injury to rehabilitation and fracture prevention.

Fragility fracture care is a specialised sector of healthcare that focuses on any person who has sustained a fragility fracture and has health and care needs that involve management of the fracture as well as prevention of future fractures. This care may take place in acute, rehabilitation and community settings and involves an interdisciplinary team approach, collaborating with other experts in fracture management, rehabilitation and secondary fracture prevention.

These two are not independent or exclusive of each other; practitioners in different parts of the fragility fracture journey may focus on one or the other or even both in their clinical practice, depending on their role and the setting in which they work. What is important is that these two facets of care of patients with fragility fracture require both fundamental and specialist skills and knowledge.

Osteoporosis and falls are more widely considered in Chaps. 2 and 4. The Fragility Fracture Network (FFN) has outlined four pillars of effective care and management of fragility fractures, listed in Box 1.1.

Box 1.1 The Fragility Fracture Network’s (FFN) four pillars of fragility fracture care [3, 4]

Pillar 1: Acute care

Pillar 2: Rehabilitation

Pillar 3: Secondary prevention

Pillar 4: Policy

1.3.1 Pillar 1: Acute Care

Many fractures, including those sustained due to fragile or osteoporotic bones, require acute care from an orthopaedic trauma team to manage the fracture and monitor its repair/healing. If there is a relatively minor fracture (such as an uncomplicated fracture of the wrist) and the patient is otherwise fit and well, treatment can usually be provided without hospital admission, and in some areas across the world the treatment is managed in primary care. It is essential, however, that emergency care, fracture clinic and primary care teams recognise and act on the need to investigate the bone health of the patient. Secondary fracture prevention is the responsibility of all healthcare teams with the aim of minimising or deleting the treatment gap that is so prevalent in all parts of the globe. All teams are responsible for identifying whether osteoporosis is a cause of the fracture and ensuring that steps are taken to treat the cause according to contemporary evidence. Secondary fracture prevention is further discussed in relation to Pillar 3 below and in detail in Chaps. 2 and 5.

Vertebral fractures rarely lead to acute hospital admission but are worthy of mention here. They are common and have a significant impact, leading to further fractures, significant pain, loss of function and mobility, increased risk of falls, reduced quality of life and, even, death due to the impact of spinal curvature on the function of associated organs. However, the fracture usually occurs without symptoms, and most go undiagnosed.

The most severe injuries such as, but not exclusively, hip, femur and pelvis fractures require hospitalisation for assessment and management of the fracture. The most common of these is hip fracture (sometimes known as proximal femur fracture). In almost all cases, surgery is the most effective way to treat hip fractures as internal stabilisation of the fracture facilitates:

  1. (a)

    Managing the acute pain from the injury

  2. (b)

    Enabling the patient to mobilise early to avoid an extensive period of immobility

The management of these fractures, particularly hip fracture, is discussed in detail in Chaps. 7–12 where every aspect of the management of such injuries and care following surgery is considered.

It is increasingly common for patients admitted to hospital with a fragility fracture to have sustained a peri-prosthetic fracture (a fracture sustained around arthroplasty implants of the hip and knee), reflecting the more widespread use of hip and knee arthroplasty for the management of arthritis.

Any fracture that requires orthopaedic surgery places significant physiological and psychological stress on the patient, leading to significant anxiety, reduction in function and mobility, loss of independence and complications that can result in death.

Although this book is aimed at all health professionals providing care to patients with fragility fractures, nurses are the professional group who often provide care over the whole 24-h period, and the ones present in acute, primary and secondary care, making a significant contribution to positive outcomes. Consequently, nurses are the largest group of health professionals in the orthogeriatric team. They are also likely to work across organisational boundaries, acting as links between the patient’s family and local community, the hospital, the outpatient/ambulatory setting and other health and social care organisations. They are also instrumental in rehabilitation and fracture prevention pathways. It is important to acknowledge, however, that not all care is provided by nurses and that there are many other healthcare professionals and other workers who contribute to interdisciplinary patient care.

1.3.1.1 Acute Orthogeriatric Care

There are several different models of acute hospital care for patients with significant fragility fractures. Hospitalisation ideally involves admission to an orthopaedic trauma unit, but the unique needs of this group of largely frail and vulnerable patients are increasingly recognised and high standards of care are needed for all patients in every setting to ensure optimum outcomes. This is leading to the global development of ‘enhanced care’ units, often known as orthogeriatric units or hip fracture wards/units, where there is access to specialist medical, surgical, therapy and nursing care that includes geriatricians and other members of an interdisciplinary team with advanced skills in caring for patients with highly complex needs following a fracture. Depending on the local population size, these wards or units could be an entire ward dedicated to orthogeriatric care, or a section of an orthopaedic/surgical ward where dedicated beds are allocated to this group and the care staff have developed the special skills required to provide optimum care.

Orthogeriatrics is an established speciality in hip fracture care ... [in some countries …], it involves the collaboration of orthopaedic surgeons working in partnership with geriatricians to provide medical care, which meets the best interests of the older person following hip fracture. But as the services have evolved the term ‘orthogeriatrics’ has come to describe an interdisciplinary team, caring, most often on an orthopaedic ward, for older people following hip fracture. They work collaboratively across the disciplines of surgery, medicine, anaesthesia, allied health professionals and nursing in providing specialist care [5].

It is widely accepted that hospitalised patients following a fragility fracture have highly complex care needs that require a team approach. No single healthcare profession can provide care in isolation, but patients’ outcomes are improved if there is full collaboration across all disciplines making up the ‘orthogeriatric’ team [6] as well as involvement of patients and families in care and decision-making. Complexity of patient needs following hip fracture, high prevalence of such injuries, time spent in an acute hospital and healthcare costs mean that the focus of inpatient care tends to relate predominantly to this group. Around the world, how hospitalised patients are managed depends on local organisation of healthcare and the resources available. For example, in many countries, individuals are co-managed by orthopaedic surgeons and geriatricians, but the absence or limited numbers of geriatricians in some parts of the world means that other medical practitioners are more likely to be involved, including rehabilitation specialists and/or internal medicine physicians. In many higher income countries, where hip fracture and other fragility fracture management is audited against evidence-based standards, outcomes following fragility fracture have significantly improved over the last few decades. In many other countries, however, these standards are yet to be incorporated into clinical practice. In some locations, for example, surgical fixation can be delayed for up to 2 weeks, despite best practice standards that recommend surgery within 1–2 days.

Many established orthogeriatric units use the interdisciplinary team approach. This model involves a lead clinician who is most often a physician, geriatrician or orthopaedic surgeon, collaborating with specialist nurses and allied health professional team members. There are highly developed local pathways and protocols of care to standardise and improve care and ensure effective communication between all team members and other specialists. This co-working has led to value-based care in action and improvement in patient outcomes, patient and family experiences and clinical team members’ work experience. The concept of interprofessional care is essential for ensuring that individuals’ needs drive clinical care, and the incorporation of evidence-based practice is central to assessment and intervention [7].

Most practitioners providing care for people with fragility fractures in the acute phase will have extensive orthopaedic knowledge and skills but may have limited knowledge and skills specifically relating to the specialist care of older people. Globally, there are too few geriatricians and physicians specialising in the health of older people to provide clinical leadership for all patients with significant fragility fractures—especially in Asia and Latin America where fracture cases are set to rise to epidemic levels. Because of this gap, orthogeriatric competencies based on comprehensive geriatric assessment (CGA) and management of frailty (Chaps. 3 and 6) must be developed in other practitioners. These practitioners may be from professions such as nursing, physiotherapy, occupational therapy and pharmacy, but who are led and educated by geriatricians wherever possible. In situations where geriatricians are not available, remote peer mentoring from advanced practitioners at a distance can be used to upskill local team members.

As the person travels through their journey towards rehabilitation, their care needs alter. As they move on from acute settings (for example, when they are assessed in secondary fragility fracture care services or bone health clinics), the team involved in their care need to be specialists in community rehabilitation, bone health, chronic health conditions, palliative care and self-management support models of care. It is the role of clinical leaders to ensure that there are sufficient educational opportunities to guarantee that the care patients receive is age sensitive and reflects their individual needs.

One of the key challenges in providing interdisciplinary orthogeriatric care is also the biggest opportunity for nurses. Interdisciplinary orthogeriatric care can be fragmented and less effective if it is not managed or coordinated effectively. Nurses’ 24-h presence, detailed knowledge and involvement in care pathways make them ideal care coordinators. The complex care requirements of orthogeriatric patients mean that care should be led by those who are experts in the field, with an intuitive understanding of need. In some settings, care and its coordination are led by a specialist nurse or coordinator such as a hip fracture nurse specialist, elderly/elder care nurse specialist, trauma nurse coordinator, nurse practitioner or advanced nurse practitioner.

This model of professional expertise is also critical to the development of secondary fragility fracture prevention teams such as fracture liaison services. These are commonly coordinated by nurses (although this role can also be done by other professional groups such as therapists and other allied health practitioners) to close the gap between the fracture and access to secondary fragility fracture prevention services. Expertise in fragility fracture prevention that includes medical and conservative care needs such as fall risk/prevention and nutrition is imperative for coordinators of secondary fracture prevention care. An understanding and knowledge of how to utilise behaviour change models of care are also needed so that the patient and family are not only core team members in their care planning and implementation, but also have a clear and heard voice in their health improvement journey. Employing behaviour change theoretical models of care aids in long-term positive outcomes as the person and their family will have had input into exploring what they are able to do to manage their bone health. These concepts are further discussed in Chap. 5.

In some countries, interdisciplinary collaborative working has supported the development of advanced nursing roles (often operationalised as clinical nurse specialists, nurse practitioners or physicians’ assistants) who have a variety of skills that are complementary to the interdisciplinary team and which enhance patient care. Continuity of care should be provided so that communication between individual professional groups, patients and carers is central to care provision, providing high-quality care and excellent patient experience and ensuring that all care needs of individuals are addressed.

1.3.2 Pillar 2: Rehabilitation

Evidence-informed rehabilitation that considers local cultural needs is needed following many fragility fractures. Such rehabilitation will support people in recovering their function, independence and quality of life once the acute phase of care is subsiding. Rehabilitation starts immediately following the fracture, so this is not something that can be postponed until the person meets a specific rehabilitation professional or team. The individual’s needs are assessed and planned for from admission to hospital with all team members responsible for working towards individual goals to achieve best possible long-term outcomes. Rehabilitation is considered in more detail in Chaps. 8 and 14.

1.3.3 Pillar 3: Secondary Prevention

People who sustain any fragility fracture underestimate their risk of osteoporosis, and they are usually unaware of the presence of this chronic disease until a fragility fracture occurs. Unless screening using bone densitometry becomes a normal part of primary care in people at most risk (men and women aged 50 years or more), primary prevention (before a fracture occurs) is mostly infeasible. This has created a significant ‘treatment gap’ between those individuals who require medical and conservative management of osteoporosis and those individuals who actually receive treatment to prevent future fractures [8].

A fundamental pillar of effective fragility fracture care is comprehensive secondary prevention after every fracture, addressing falls risk as well as bone health. Secondary prevention involves identifying those who have osteoporosis immediately following presentation with a low trauma fracture (hopefully a less significant fracture such as a wrist fracture) so that osteoporosis can be treated and future fractures are prevented (see Chaps. 2 and 5).

Secondary fragility fracture prevention services (sometimes known as fracture liaison services (FLSs)) are interdisciplinary services that optimise the ‘case finding’ of those who have sustained a first, or ‘signal’, fragility fracture, as well as those who have had previous fractures but have not gained access to evidence-informed care to prevent further factures. Such services are coordinated by a lead clinician, and the fracture prevention team work together to optimise the management of re-fracture prevention, including osteoporosis, over the short and long terms [9]. Such services and pathways are discussed in detail in Chap. 5.

This approach has been demonstrated to optimise osteoporosis treatment and thus reduce the incidence of re-fracture. Collaboration across the healthcare sector is imperative. However, this important aspect of care cannot simply be delegated to a fracture prevention service since such services are currently not commonplace across the world. The epidemic of fragility fractures worldwide means that a few expert teams cannot make enough difference globally, so there is a need to focus on global policy and change.

1.3.4 Pillar 4: Policy

The fact that fragility fracture care is not optimal or standardised either across the globe or even within many higher income countries led the Fragility Fracture Network (FFN) to instigate a global ‘Call to Action’ [3]. The Call to Action aims to improve the care of people presenting with fragility fractures through a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures. There has been a repeated call on governments to urgently address the human and economic toll that fragility fractures are placing on societies through the formation of interdisciplinary national alliances to promote policy change. Quality of care is defined as: “… the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with evidence-based professional knowledge, spanning health promotion, prevention, treatment, rehabilitation and palliation through the provision of evidence-based care that takes into consideration the needs and preferences of service users—patients, families and communities” [10].

For meaningful policy change to take place, all stakeholders across fragility fracture care and linked sectors need to be involved in engaging with policymakers to seek improvements in care [11]. This includes the involvement of all health professionals in global, regional, national and local networks and all professional organisations. For nurses and other care providers, this also means speaking out about the needs for improvements in care through ensuring that there are adequate resources and education for clinicians. Further discussion of these issues is included in Chap. 18.

1.4 Interdisciplinary Care

There is strength in a team that is much more than the sum of its parts. The fundamental principle of orthogeriatric care and management of fragility fractures is the interdisciplinary approach. People presenting with fragility fractures need the simultaneous application of the skill sets of orthopaedic surgeons and geriatric physicians, but an effective interdisciplinary team is much broader. It includes other medical professionals such as emergency physicians, anaesthetists, endocrinologists, rheumatologists, rehabilitation specialists and primary care teams collaborating with other health professionals such as nurses, physiotherapists, occupational therapists, nutritionists and psychologists. Interdisciplinary care involves clinicians from different disciplines or professional groups sharing skills and working together, each drawing on their own disciplinary knowledge and working in the best interests of patients and their families.

In an interdisciplinary approach, nurses and other health professionals work collaboratively with medical and therapy colleagues, keeping people at the centre of the planning and provision of high-quality evidence-based care which not only reflects orthogeriatric knowledge and skills, but is also provided in a way that demonstrates that the care provided is integrated, compassionate, dignified, person-centred and holistic (see Chaps. 17 and 18).

Few orthogeriatric teams are yet working in a truly interdisciplinary manner. Table 1.1 provides an overview of the meaning of common terms relating to different styles of collaborative professional working.

Table 1.1 Common terms relating to team collaboration in healthcare [12]
Full size table

For orthogeriatric care to be an effective model everywhere in the world, it is essential to move towards a more interdisciplinary approach with the aim of transdisciplinary collaboration (Table 1.1). Although interdisciplinary care is not yet common, it is achievable. Interprofessional collaboration as a basis for interdisciplinary care helps minimise undesirable events, improve teamwork and communication and improve patient outcomes. Major factors that affect collaboration include communication, respect and trust, unequal power among team members, understanding other team members’ professional roles, and task prioritising. Despite many years of professional working relationships between nurses, therapists and doctors, for example, an understanding of each other’s roles, values and beliefs could be improved in many teams.

The FFN Call to Action (CtA) [3, 4] identified the core values of an interdisciplinary approach to fragility fracture management. The development of the CtA identified that patients with a fragility fracture can expect that they are cared for in an interprofessional manner across the continuum of care. Nurses, as well as other health professionals, are actively involved in the management of care in the first three clinical pillars and should be active in national alliances as well as Global FFN, promoting these values. However as identified by Marsh et al. [13]:

Despite the fact that nurses are actively involved globally in the multidisciplinary teams, for the management of fragility fractures. It depends on attitudes to nurses, and what they may be capable of, which varies widely across the globe. In some developed economies, nurses are significantly empowered, based on models of advanced training, protocol-driven care and supervision by appropriate medical specialists. This includes, in many locations, the ability to order investigations and treatments within protocols. By contrast, there are many countries where such autonomy would be anathema. What is very clear, and needs to be asserted as frequently as possible, is that the volume of fragility fracture-related work—already now but more so in the future—is such that it cannot realistically be delivered without enhanced nurse input. There is no prospect that there will be (1) enough geriatricians on the planet to deliver orthogeriatric surveillance of all older fracture inpatients on a daily basis or (2) enough endocrinologists for every fragility fracture patient to be assessed for secondary prevention by a doctor.

For nurses, there are three major questions regarding the interdisciplinary management of fragility fractures

  1. 1.

    What role do nurses play in the multidisciplinary team, and does this meet the criteria for an interdisciplinary team?

  2. 2.

    How do nurses identify and develop their orthogeriatric and fragility fracture professional knowledge and skills to demonstrate interdisciplinary nursing knowledge that relates to orthopaedic knowledge and skill, older persons’ care, osteoporosis and management of fragility fracture care?

  3. 3.

    What does advanced professional nursing practice look like, and how should nurses act as coordinators of care in all parts of the ‘acute care–rehabilitation–secondary prevention’ pathway?

1.5 The Key Role of Nurses in Orthogeriatric and Fragility Fracture Care

The introductory chapter to the first edition of this book provided an overview of the nature of nursing. It identified that nursing is both a caring art and a science that encompasses a distinct body of knowledge, separate from that of medical or allied health professional colleagues. Knowledge is specific information about something, and caring is behaviour that demonstrates compassion and respect for another, but these simplified concepts do not truly reflect the synthesis of both knowledge and the art of caring that makes orthogeriatric nursing unique [14]. It is important, however, to acknowledge that not all ‘care’ is provided by those professionals who are identified as nurses and that, in the future, the boundaries of care giving roles are likely to be more flexible. For these reasons, this book, although focused on nursing (because a significant amount of fragility facture/orthogeriatric care is provided by them), aims to broaden its relevance to all healthcare professionals who provide care in any part of the world.

Health professionals caring for those who have sustained a fragility fracture are required to provide evidence-based care and coordinate interdisciplinary care. Care also needs to be multi-specialist in the sense that it brings together the skills and knowledge of acute orthopaedic trauma care, acute geriatric care, rehabilitation and palliative care. This requires both advanced knowledge and enhanced skills. However, this is not the complete picture; those with fragility fractures also need skilled and professional care in community and outpatient settings with a focus on bone health and future fracture prevention. These practitioners need diverse skill sets, working at different levels from novice through to expert [15]. Nurses and other practitioners need to perceive and act on patients’ care needs holistically and use this to help them to provide high-quality care. This book has been written by a group of experts, predominantly nurses but also including other members of the team, each with skills and knowledge in specific aspects of fragility fracture care. It is the synthesis of this knowledge and the associated evidence that informs and leads the practice discussed within these chapters that epitomises this evolving care speciality.

Each contributor in this second edition has a different clinical background reflecting the interprofessional working required to care for orthogeriatric and fragility fracture patients across healthcare settings globally. This has offered the opportunity for the book to truly bring together a depth of experience of interdisciplinary practice and to acknowledge the need for practice development across a world where local practice varies according to social, cultural and political influences.

1.6 Safe and Effective Clinical Care

Nursing is broad and complex, and the nursing profession has traditionally had difficulty in articulating its unique benefits. Indicators of care quality include nurse-sensitive patient outcomes such as patient comfort and quality of life, risk, outcomes and safety, patient empowerment and patient satisfaction [16]. Hip fracture is known to carry a high incidence of morbidity, mortality and long-term functional disability, challenging the interdisciplinary team to manage complex multi-factorial issues relating to, for example, advancing age, frailty, existing and evolving comorbidities, and cognitive dysfunction. These underlying issues are significantly impacted by nursing care interventions in the perioperative period and beyond [17].

More specific indicators of nursing quality of care include healthcare-associated infection, pressure ulcers, falls, drug administration errors and patient satisfaction [18, 19]. But an approach to quality that focuses on patient safety can neglect other aspects of clinical effectiveness and the impact on quality of care or patient experience.

In orthogeriatric care, a starting point might be to work on the development of nurse-sensitive indicators for pain, delirium, pressure ulcers/injuries, hydration and nutrition, constipation, prevention of secondary infections and venous thromboembolism (VTE) [20]. While many of these complications are discussed in more detail within other chapters, it is important to include evidence-based care and management strategies that coexist with medical models of care, reducing the risk of developing complications, morbidity and mortality while improving recovery, maintaining functional ability and improving patient outcomes and experiences. Pain management, nutrition and hydration, remobilisation, rehabilitation and motivation are all central to prevention of complications following hip fracture, and each of these are both interdisciplinary and nursing care priorities and considered in more detail in later chapters.

Comprehensive assessment of the older person with a fragility fracture, especially hip fracture, is central to effective, evidence-based care in the emergency, perioperative and recovery periods (Chap. 6), and an understanding of frailty and sarcopenia underpins all of this (Chap. 3). Many aspects of care are discussed, but pain management, complication prevention, remobilisation, nutrition, hydration, wound management and pressure ulcer prevention are singled out for specific attention in this book because they are so central to improving patient outcomes. Delirium (Chap. 12) and other cognitive impairments such as dementia are, like depression and other aspects of mental health, major barriers to recovery and rehabilitation following fragility fracture. In some instances, hip fracture may be the beginning of the final phase of a person’s life and sensitive palliative care, with effective symptom control and emotional and psychological support for patients and their families being essential.

Quality indicators within the standards that underpin hip fracture audit have already had a significant impact on the quality of medical and surgical care. However, these currently only briefly consider nursing indicators. Specific indicators of the value of nursing care must be identified and ways to measure them developed. The overall contribution of healthcare delivery is often measured in terms of health status, outcomes, readmissions rates, length of stay, complication rates and mortality [15], but these do not necessarily help to capture the specific contribution of nursing and other members of the interdisciplinary team. Length of stay can be a misleading measure for success given concerns about early discharge when patients still need expert care.

1.7 Education for Orthogeriatric Care

Despite the high incidence of fragility fracture globally and their presence in a wide variety of healthcare settings, practitioners have rarely received formal education in the care and management of this group of patients with complex needs, and the centrality of the nursing role is not well recognised in the literature. Practitioners need multiple orthogeriatric specialist skills that combine orthopaedic care expertise with age-sensitive care of the older person in acute healthcare involving in-depth appreciation of the theory underpinning care. This includes a deep understanding of how both age and frailty, as well as skeletal fragility and injury, impact the planning and implementation of care. There is, consequently, an important education and skill gap, and at present there are limited education resources available to support professional development of specialist orthogeriatric nurses and other practitioners. Education needs to involve sharing of knowledge and skills nationally and internationally as an integral part of the development of orthogeriatric practice.

Summary of Key Points

  • Fragility fractures are common globally, and their care, especially in older people, is often complex; involving three main clijncial pillars: acute care, rehabilitation and secondary fracture prevention.

  • The underlying causes of fragility fractures are osteoporosis and associated bone fragility with fractures often precipitated by a fall.

  • Globally, not all who suffer a fragility fracture receive optimum care in some or all phases.

  • People are usually unaware that they have osteoporosis until they have a first fracture—this fracture should lead to a referral to secondary prevention services often known as a fracture liaison service.

  • Orthogeriatrics is a model of care that involves interdisciplinary collaboration in optimising care in the acute care of older people with significant fractures including specialist and advanced skills.

  • Practitioners need to develop their practice through knowledge sharing and skill development through training.

1.8 Further Study

Returning to Sofia’s story at the beginning of this chapter and reviewing what you have learned from this chapter, consider how her care might have been improved, based on the three clinical pillars, discussed above in relation to both her initial hip fracture and her more recent injuries from the perspectives of; (1) acute care, (2) rehabilitation and (3) secondary fracture prevention.

As you read some of the material in the following chapters, compare Sofia’s experience to other cases presented in the subsequent chapters. Return to your reflections on Sofia’s experiences, and consider how this relates to the care pathways in your own clinical setting.