RecommendationSchedule hip fracture surgery on a planned trauma list
Relative values of different outcomesMortality, reoperation rate, dislocations, length of stay in secondary care and wound infection were considered the main outcomes. Complications, pain and functional status were also considered.
Trade off between clinical benefits and harmsNo RCTs were identified evaluating a planned trauma list. Evidence is extrapolated from the surgeon seniority data. This shows a significantly higher reoperation rate with unsupervised/junior orthopaedic surgeons with less than 3 years experience than senior more experienced surgeons. There was no statistically significant difference in dislocation rates. No other outcomes were reported.
Economic considerationsA planned trauma list consists of a period of time allocated to the surgical management of patients with unplanned admissions following musculoskeletal injury. For this period there will be an adequate operating theatre, with supporting equipment including an image intensifier. The responsible senior surgical, anaesthetic and theatre staff will have work plan allocating time to the list to carry out procedures or supervise their junior staff. Thus, a planned trauma list implies allocation and involvement of senior staff, who will either carry out the necessary procedures in the operating theatre or will adequately supervise the junior staff.

The GDG suggested that a possible comparator for a planned trauma list could be a general emergency theatre, shared by many different specialities, often occurring outside of normal working hours and staffed by trainees.

If we consider the case of a planned trauma list where operations are performed by a consultant surgeon and a consultant anaesthetist and if we take as comparator a general emergency theatre where both surgeon and anaesthetist are registrars, and we assume no other difference in the professional grade of the remaining staff involved in the operation, then the planned trauma list would result in an additional personnel cost per hour of £94 over the general emergency theatre. In particular, the personnel cost per hour for a planned trauma list with a consultant surgeon and consultant anaesthetist correspond to £337, and for a general emergency list with a registrar surgeon and a registrar anaesthetist (and with a consultant surgeon and consultant anaesthetist on call), to £243 (please see Appendix H section 20.2 for further details). However, there is great uncertainty as to whether there are other differences in other categories of costs (e.g. overheads, diagnostic devices, etc) between a planned trauma list and a general emergency theatre,and therefore our estimate should be considered only as an approximation of the overall cost difference between a planned trauma list and a general emergency theatre. Furthermore, there is uncertainty around the right baseline intervention as after the introduction of the BPT for hip fracture, senior staff should be performing the surgery. In particular, the GDG noted that it is not clear as to what we should consider as the usual alternative to a planned trauma list, as it is quite uncertain what could represent the “baseline” case for a hospital, and this can change depending on the type of hospital. It was also pointed out that since the introduction of the Best Practice Tariff (BpT) for hip fracture in April 2010 the hospitals that do not have planned trauma list in place on a daily basis would however have employed relevant senior staff (consultant surgeons and anaesthetist) to meet the tariff's requirements, and therefore senior staff are already part of the comparator.

Nevertheless, the GDG thinks that these potential additional personnel costs of a planned trauma list would be at least partially off-set by savings due to lower re-operation rates and by a higher number of patients operated per hour.
Quality of evidenceNo RCTs were identified evaluating a planned trauma list. There is extrapolated evidence from surgeon seniority showed no evidence for the majority of the outcomes and only very low quality evidence from non-randomised studies for two outcomes: reoperation rate and dislocations. The recommendation is based on a consensus agreement within the GDG.
Other considerationsWe have specified in the recommendation that surgery for hip fractures should occur on a planned trauma list. To establish a scheduled trauma list management and clinicians are required to provide adequate facilities and staff for it to run. For a planned list it is necessary to have a chain of responsibility to a consultant surgeon and consultant anaesthetist who have time in their programs to execute that responsibility. To run a planned trauma list requires ready access to an image intensifier and radiographer. The nursing team would need to be appropriate to the work planned for that theatre. The recommendation therefore recognises the need for adequate seniority of the surgeon but makes what we believe to be a reasonable assumption that this recognition should also apply to the rest of the operating theatre team caring for the hip fracture patient.

The GDG noted that there is high uncertainty regarding the implementation costs linked with this recommendation, as these costs will vary depending on the current set up and infrastructure of each hospital . For example, the GDG recognised that smaller hospitals may not currently provide this service at weekends.

This recommendation is in line with the British Orthopaedic Association's Advisory book on consultant trauma and orthopaedic services 38. The GDG consider this recommendation a key priority for implementation.

From: 9, Surgeon seniority

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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