Completion of Treatment Escalation Plans and Resuscitation Discussions in Frail and Elderly Patients With Hip Fractures

Background Hip fractures disproportionately occur in frail and elderly patients and carry high mortality even with optimal management. The British Orthopaedic Association recommends that all frail and elderly trauma patients have ceilings of treatment (CoTs) and appropriateness of cardiopulmonary resuscitation (CPR) decided pre-operatively. Our hospital documents these treatment escalation plans (TEPs) within the Resuscitation Council UK's Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. Methods We sampled the hip fracture population at Burton Hospital orthopaedic ward on random days between October and November 2024. We separately collected data on other patients with a ReSPECT form to see whether omissions on these forms were specific to the hip fracture group or replicated more widely. Results We collected data for 42 patients, including 33 patients admitted with hip fractures and nine non-hip fracture patients. We found that 20 (61%) hip fracture patients had a ReSPECT form that documented the appropriateness of CPR. However, only nine (45%) of these documented an appropriate CoT. This left only nine (27%) hip fracture patients with a full TEP. Out of all decisions documented, 16 (80%) were endorsed by a consultant. In the non-hip fracture group, we found that many ReSPECT forms also lacked a CoT. There was no significant difference in the completion of a CoT on ReSPECT forms between the hip fracture and non-hip fracture groups (p=0.69). Conclusion We found that many patients with a hip fracture did not have a documented recommendation on the appropriateness of CPR, and even fewer had a decision documented on the appropriateness of escalation. This meant that neither area met the standard of 100% set for our audit. This was in part due to the incompletion of the clinical recommendations section on the ReSPECT forms, which we highlight is an often-omitted section in our hospital. Review of the escalation plan within a comprehensive geriatric assessment, and increasing clinician education on TEPs, may help to improve the number of complete treatment escalation plans made.