Title : Improving documentation in hip fracture clerking: A quality improvement project
Abstract:
Background & Aims: Neck of Femur (NOF) fracture patients require prompt assessment on admission to enable safe, timely transfer to theatre, in line with NICE guidance and the Best Practice Tariff standard of surgery within 36 hours. NICE recommends early identification of correctable comorbidities, such as anaemia, electrolyte imbalance, arrhythmia and chest infection, to avoid surgical delay. Incomplete clerking and delayed interpretation of bloods, ECG and chest X-ray can lead to missed comorbidities, prolonged pain, delayed theatre access and increased mortality. At Wythenshawe Hospital, use of an existing tick-box clerking proforma by orthopaedic SHOs raised concerns about incomplete documentation. This quality improvement project aimed to improve completeness of NOF admission documentation using a standardised proforma, support multidisciplinary input from orthogeriatrics and physiotherapy, and reduce delay to theatre.
Methods: A baseline retrospective review of 44 patients admitted with hip fractures in December 2023 assessed documentation of key admission assessments, including interpretation of chest X-ray, ECG and bloods, chest auscultation, resuscitation status, ceiling of care discussion, and proforma use. Using a PDSA methodology, three interventions were introduced: an educational session for orthopaedic clerking clinicians; a Hip Fracture Clerking Cheat Sheet; and a revised clerking proforma incorporating delirium (4AT) screening and additional prompts for reviewing bloods, ECG, chest X-ray and resuscitation status, reflecting NICE guidance on comorbidity optimisation. Departmental teaching was delivered to resident doctors and the wider multidisciplinary team on proforma use, standards and initial audit findings. A second audit cycle then reviewed NOF admission notes against the same domains.
Results: Documentation improved across nearly all domains. Proforma use rose to 94.7% from 55%. ECG interpretation improved to 57.9% from 20%, blood test interpretation to 39.5% from 25%, chest X-ray interpretation to 47.4% from 27%, chest auscultation to 84.2% from 64%, and resuscitation status documentation to 52.6% from 30%. Delirium (4AT) screening, newly introduced, was completed in 76.3% of admissions. Ceiling of care discussion remained the weakest domain, improving only marginally to 26.3% from 23.7%.
Conclusion: Simple, targeted interventions: including education, a quick reference cheat sheet, and a revised, guideline-aligned proforma produced clear improvements in hip fracture admission documentation across nearly all domains, supporting earlier comorbidity optimisation and more timely progression to theatre. Ceiling of care discussion remains challenging and warrants senior-led prompts, such as incorporation into post-take ward round practice. Induction packs and six-monthly re-audit will help embed and sustain these changes, particularly as new trainees rotate through the department.
