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In-hospital Associated with Fractured Neck of Femur

Basic Facts

Stage of development


Potential or current usage

This measure is used as the basis of calculating an unequivocal measure of harm associated with in-hospital falls at a national level. It is part of the Quality and Safety Marker set and should be used alongside its related process and outcome markers

Brief overview of the measure

General description

This measure was selected to provide baseline information about the national occurrence of in-hospital falls associated with fractured neck of femur (FNOF), enabling the calculation of changes over time in this number.

Rationale for selection

Fractured neck of femur in older people is associated with increased mortality, loss of independence and likelihood of longer hospital stays.

Type of measure


Domain(s) of quality


Application and interpretation of the measure

Stated intent of the measure

To measure national occurrence of fractured neck of femur associated with in-hospital falls in order to measure the impact of the nation-wide implementation of the falls risk assessment and appropriate care planning in DHBs.

Caveats - Considerations

The caveats of this measure are the relatively small number of fractured necks of femur, and reliance on NMDS data. There are too few events to present meaningful data at the local level using standard approaches. However, the use of statistical control charts, with a Poisson distribution, is being explored for presenting local-level data. As we are reliant on NMDS data we are dependent on good recording. While there is a general view that not all in hospital falls are recorded, there is greater confidence about consistent recording of in-hospital FNOFs. As part of testing this has been compared with those reported under the Serious and Sentinel Event reporting programme and there is a reasonable degree of consistency.

Links to other measures

This measure is part of the Quality and Safety Marker for falls set and should be used alongside its related process and outcome markers

Level of health care delivery/setting

This measure is focused on falls inside inpatient healthcare facilities. It excludes aged care facilities

Target population

This measure focuses on the total population.

Stratification by vulnerable populations

There can be wide variation in hospital stay outcomes by admission type, the type of healthcare received, and by patient factors such as co-morbidities. However, the purpose of this analysis was on estimating a national occurrence to establish a baseline, so this does not standardise or stratify. It is notable that a vast majority of events occur to patients aged 75 and over.

Calculation of the measure

Output of calculation

The output of the calculation is the number of falls associated with fractured femur which took place during an inpatient stay in a healthcare facility.

Numerator description

The numerator is a count of in-hospital events where a fall was recorded within the start and end of the hospital stay which was recorded as being in hospital and where a secondary diagnosis of fractured neck of femur was recorded. Identifying these patients using NMDS, and excluding patients where (e.g.) the patient was admitted with a fractured neck of femur requires an involved 4 stage process. The introduction of present on admission flags post July 2012 will make the identification of these cases considerably easier. The four stages are: • create spells • identify spells with an in hospital fall • identify spells with fractured neck of femur which occurred during the spell • confirm event during which fracture neck of femur occurred and association with recorded fall In detail Create spells • The nature of older people falling in hospital is such that a fall which results in a fracture which requires orthopaedic intervention will often result in two or more separate events in NMDS. In order to avoid inappropriately excluding fractured neck of femur and to accurately calculate deaths and associated bed days it is necessary to link events which form a continuous stay within hospital (even if there is more than one hospital involved). • This is done by grouping on pseudonymised patient ID number and the event start and end date. Where the latter are continuous (i.e. there is no break between the end of one event and the start of the next) these are counted as a continuous “spell” and given a unique spell ID. • Through identifying maximum event end and minimum event start values we create spell start and end dates. All three new flags are linked the NMDS as new fields. Identify spells with an in hospital fall – Step 1 Identify recorded fall: select records with code W0* or W1* in Fields ecode01-15 – Step 2 Identify recorded fall during hospital stay: select records with code W0* or W1* in field ecodeX AND date in accdatex lying within the parameters of spell start and end dates Identify spells with fractured neck of femur which occurred during the spell • From recorded falls subset , select records where S720* or S271* is recorded in at least one field from Diag02 to Diag25 Confirm event during which fracture neck of femur occurred and association with recorded fall • Mark specific event as the fall event where the following criteria are met • The fall event is recorded as being in hospital (Y9222) – tested by ensuring that the Y9222 code has the same date as the fall code (W0* and W1*) • The fall event is ONLY attributed to the event during which the fall took place, regardless as to whether the fall is recorded in this event or not. Thus if the fall is recorded against an Orthopaedic event but its dates lie within those of the previous Medical event in the spell it will be counted against the Medical event not Orthopaedic one. This matters as a good proportion of the patients in this set fall and injure themselves in different hospitals to the one they are operated on. This means that there will only be one attributed fall per spell • The fall event is before any recorded surgical repair of the hip. If it is later than this it is taken to be a fall post fracture and excluded Exclusions • If the principal diagnosis of the first event within the spell is S720* or S271* • If the fall takes place within an aged care facility (Y9214) even though the aged care event is being paid for by the DHB (often as step down care following an acute admission) and thus included in NMDS. This excludes in the region of 30-40 further falls associated with FNOF. There are of course many more falls resulting in fractured neck of femur within aged care facilities.

Denominator description

As a straightforward count there is no denominator

Denominator exclusions

As a straightforward count there is no denominator

Time period

12 months – set for financial year in baseline

Data source

National minimum dataset (NMDS), available from the Ministry of Health.

Method of extraction

NMDS data were imported into Microsoft Access 2010. Queries were developed separately for extracting denominator data and numerator data. Calculations were undertaken in Microsoft Excel 2010. This approach could be adapted to be undertaken more easily through SAS.

Appraisal of the measure

Availability of evidence to support application of the measure

Measure is formulated on and underpinned by an evidence based clinical practice guideline.

Evidence of feasibility and reliability of implementation

Reliability - The measure has been demonstrated to be reliable (i.e. free from random error)., Interpretation - The measure allows unambiguous interpretation of better or worse performance., Data extraction - Data collection specifications for the measure are well defined., Data sources - Required data elements for the measure can be obtained from existing data sources., Availability of data - Required data elements for the measure can be gathered during routine practice activities, IT software - Existing IT software is sufficient for data collection., Validity - The measure has been demonstrated to be valid (i.e. it measures what it purports to).

Development approach

Total for 2010/11 compared with Serious and Sentinel event reporting. This showed that with one exception the number of events were within 2-3 SSE reports for every DHB and for about half of DHBs identical. Isolation of these cases is feasible from NMDS and will become easier and more reliable with the implementation of the present on admission flag.

Other items

Owner details

Reference number


Date of entry to library

2012-10-29 13:59:28

Owner (Organisation name)

Health Quality and Safety Commission

Owner (Email contact)