Getting It Right Beyond the Hip: Transforming Care for Non-Ambulatory Fragility Fracture Patients

Introduction: The Getting It Right First Time (GIRFT) Non-Ambulatory Fragility Fracture (NAFF) Pathway and British Orthopaedic Association Standards for Trauma (BOAST) recommend comprehensive orthogeriatric care for older adults with NAFFs. To address historical gaps in care, a dedicated NAFF service was established at the Royal Preston Hospital, aiming to provide comprehensive geriatric assessment within 72 hours of injury, including falls assessment, establishment of ceilings of care, and optimisation of bone health.

Methods: A quality improvement audit was conducted over three cycles spanning 12 months. Baseline data was collected in May 2025 before service implementation. Following introduction of the NAFF service, patients were identified using the daily major trauma list and, from November 2025, a dedicated electronic NAFF whiteboard. Subsequent audit cycles were completed in December 2025 and May 2026 to evaluate service impact and sustainability.

Results: 32 patients were identified at baseline, 68 in Cycle 2, and 51 in Cycle 3, including patients highlighted on non-orthopaedic wards via the NAFF whiteboard. The proportion reviewed by a geriatrician within 72 hours increased from 53.1% to 83.8% and 94.1%, respectively. Documentation of delirium assessment improved overall from 3.0% to 62.7%, falls assessment from 34.0% to 88.2%, Clinical Frailty Score from 53.0% to 82.4%, osteoporosis assessment from 40.6% to 56.9%, and documented DNACPR decisions from 9.4% to 43.1%. Mean length of stay was 11.75, 15.4, and 11.39 days across the three cycles. Bone protection at discharge increased from 43.7% to 51.0% while inpatient mortality remained low (3.0%, 2.9%, and 5.9%).

Conclusion: Implementation of a dedicated NAFF service improved timely orthogeriatric review and comprehensive geriatric assessment. The NAFF whiteboard identified 20 additional patients in December 2025 and 17 in May 2026 who would otherwise have been missed. Ongoing evaluation will assess effects on clinical outcomes, length of stay, mortality, and osteoporosis management.