Adherence to referral pathway of hip fractures: A clinical audit

Introduction: Hip fracture is a significant cause of morbidity and mortality, mostly in elderly patients; especially if treatment is delayed. Hip fractures are commonly occult on plain radiographs in osteoporotic or obese patients. Therefore, the National Institute for Health and Care Excellence (NICE) guidance has sought to identify the most cost-effective imaging strategies to ensure this does not happen. Accordingly, an imaging reference pathway has been developed by King's College Hospital, UK. This study aims to evaluate the level of adherence to the pathway and identify poorly performed steps.
Methods: Retrospective data from 112 patients investigated for hip fractures over five months at the Radiology Department, of King’s College Hospital (KCH) were analysed. The assessment focused on various steps in the referral pathway, including the time taken for each imaging modality, reporting findings, time to diagnosis, and surgical intervention.
Results: Results showed that 21.4% of patients had hip fractures identified via plain radiography. In cases where radiographs were negative further imaging with MRI was suggested in 75%. However, only 19.6% of patients underwent CT or MRI to exclude occult hip fractures. Only 6% of patients with negative X-ray findings had an MRI. MRI was underutilized despite its recommendation. Notably, all identified hip fractures were initially detected via plain radiography, while occult fractures found in CT or MRI were confined to the pelvic or sacral region.
Although there were delays in reporting times for radiographs clinical decisions were often made without waiting for reports. Surgical intervention occurred within 48 hours for 67.8% of patients, with delays attributed to valid reasons.
Conclusions: Adherence to referral pathway of hip fractures was satisfactory in King’s College Hospital while the main deficiency identified was preferring CT over MRI as the second-line imaging method in identifying occult hip fractures. Unexpectedly, all hip fractures were identified by plane radiography while occult fractures identified in CT or MRI were pelvic or sacral fractures.