Table 1.

Summary of CPGs of hip fracture management

	NICE 2017 [17] (NICE 2011 [176] update version)	Scottish Standards of care for hip fracture patients [20], 2018	SIGN 2009 [19]	Mak et al. [22], 2010
Mobilization	1.7.1 Mobilisation on the day after surgery (2011)	Standard 8 Mobilisation has begun by the end of the first day after surgery and every patient has physiotherapy assessment by end of day two.	8.5 Early mobilization	18. Mobilisation
	1.7.2 at least once a day and ensure regular physiotherapy review (2011)		- If the patient’s overall medical condition allows, mobilisation and multidisciplinary rehabilitation should begin within 24 hours postoperatively. (Good practice points)	- Early assisted ambulation (begun within 48 hours of surgery) accelerates functional recovery.
Weight-bearing	1.6.1 Operate on patients with the aim to allow them to fully weight bear (without restriction) in the immediate postoperative period. (2011)	-	- Weight-bearing on the injured leg should be allowed, unless there is concern about quality of the hip fracture repair (e.g., poor bone stock or comminuted fracture). (Good practice points)	-
Multidisciplinary	1.8.1 From admission, offer patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme. (2011)	Standard 7: Every patient who is identified locally as being frail, receives comprehensive geriatric assessment within three days of admission.	9.2.3 Medical management and rehabilitation	19. Rehabilitation
	- Rehabilitation after hip fracture incorporating the following core components of assessment and management: medicine; nursing; physiotherapy; occupational therapy; social care. Additional components may include: dietetics, pharmacy, clinical psychology.	Standard 11: Every patient’s recovery is optimised by a multi-disciplinary team approach such that they are discharged back to their original place of residence within 30 days from the date of admission.	- A multidisciplinary team should be used to facilitate the rehabilitation process.	- Patients with hip fracture should be offered a coordinated multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their prefracture living arrangements.
		Standard 9: Every patient has a documented Occupational Therapy Assessment commenced by the end of day three post admission.		- Early multidisciplinary daily geriatric care reduces in hospital mortality and medical complications in older patients with hip fracture, but does not reduce length of stay or functional recovery.
Comorbidities and complications	Referral to Clinical guideline (CG103)	Standard 7: Every patient who is identified locally as being frail, receives comprehensive geriatric assessment within three days of admission: falls history and assessment including an ECG and lying and standing blood pressures, assessment of co-morbidities and functional abilities, medication review, cognitive assessment, nutritional assessment, assessment for sensory impairment, continence review, assessment of bone health and discharge planning.	8.1 Pain relief	5. Thromboprophylaxis
	Delirium: prevention, diagnosis and management		- Regular assessment and formal charting of pain scores should be adopted as routine practice in postoperative care. (Recommendation B)	- Low molecular weight heparin and mechanical devices
	Referral to NICE guideline (NG89)			6. Pressure gradient stockings
	Venous thromboembolism in over 16s			8. Type of analgesia
	Referral to Clinical guideline (CG146)		8.7 Urinary catheterization	- Femoral nerve block
	Osteoporosis: assessing the risk of fragility fracture		- Urinary catheters should be avoided except in specific circumstances. (Good practice points)	- Intrathecal morphine
	Referral to Clinical guideline (CG32)	Standard 10: Every patient who has a hip fracture has an assessment of, or a referral for, their bone health prior to leaving the acute orthopaedic ward.	- When patients are catheterised in the postoperative period, prophylactic antibiotics should be administered to cover the insertion of the catheter. (Good practice points)	15. Urinary catheterisation
	Nutrition support for adults			- Intermittent catheterization is preferable
				16. Nutritional status
				- Protein and energy supplement
			9.2.1 Nutrition	17. Reducing postoperative delirium
			- Supplementing the diet of hip fracture patients in rehabilitation with high energy protein preparations containing minerals and vitamins should be considered. (Recommendation A)	- Prophylactic low-dose haloperidol
				20. Osteoporosis treatment
			- Patients’ food intake should be monitored regularly, to ensure sufficient dietary intake. (Good practice points)	- Vitamin D supplementation, annual infusion of zoledronic acid
Community care	1.8.5 Only consider intermediate care (continued rehabilitation in a community hospital or residential care unit) if length of stay and ongoing objectives for intermediate care are agreed. (2011)		9.4 Discharge management	19. Rehabilitation
			- Supported discharge schemes with liaison nurse follow up can monitor patient progress at home and help to alleviate some of these fears.	- A program of accelerated discharge and home-based rehabilitation may lead to functional improvement, greater confidence in avoiding subsequent falls, improvements in health-related quality of life and less caregiver burden.
	1.8.6 Patients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme. (2011)		- Liaison between hospital and community (including social work department) facilitates the discharge process.	- Extended outpatient rehabilitation that includes progressive resistance training can also improve physical function and quality of life compared with home exercise alone.

CPG, clinical practice guideline; NICE, National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network.