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Delayed discharges post hip fracture have been shown to expose patients to increased perioperative morbidity and mortality rates, as well as reduced rehabilitation potential and less chance of returning home on discharge. This has significant cost implications for the health service and justifies the introduction of hospital bypass protocols for patients with hip fractures.

As the incidence of fragility fractures continues to rise, healthcare professionals will encounter patients with fractures in a variety of clinical settings such as falls clinics, intermediate care services and acute medical wards. Older people with fragility fractures are a diverse group, and their care needs are complex. Although some have comparatively few health problems, many have a series of interconnected illnesses and psychological and social problems requiring a range of therapeutic interventions. The primary focus of care is to meet the needs of the older person following skeletal trauma throughout their care pathway and ensure that they receive the same high standard of specialist care within orthopaedic services as they would within a setting specialising in the care of older people. The central philosophy should be holistic care using a person-centred approach that brings the various aspects of specialist care together.'Geriatric syndrome' is a term often used to refer to common health problems in older adults that do not fit into distinct organ-specific disease categories and that have multifactorial causes; this includes problems such as frailty, cognitive impairment, delirium, incontinence, malnutrition, falls, gait disorders, pressure ulcers, sleep disorders, sensory deficits, fatigue and dizziness. These are common in older adults and can have a major impact on quality of life (QoL) and disability [1]. Geriatric syndromes can best be identified by a comprehensive multidisciplinary

Background The Irish Hip Fracture Database is a national clinical audit developed to improve fracture care and outcomes. Lack of integration with other databases, such as a National Death Register makes determination of longer term outcomes challenging. In hospital mortality is one quality indicator that can be very accurately measured. We sought to determine in-hospital mortality in the Irish Hip Fracture Cohort between 2013 and 2017 and to determine which factors most influenced this outcome with particular reference to the IHFD quality standards. Methods A secondary analysis of the 15,603 patients in the IHFD between 2013 and 2017 was conducted. Descriptive and analytical statistics were produced. Results In-hospital mortality was 4.5% for the 5 years. Univariate logistic regression revealed 11 statistically significant predictors of in-hospital mortality of which only 4 (age, gender, pre-fracture mobility, mobilised day of/after surgery) remained significant after multivariate analysis. The most striking finding was that those patients not mobilised on the day of/after surgery were 46% more likely to die in hospital (OR 1.46, p<0.000, 95% CI 1.25-1.70). Conclusion Measuring care is challenging and often one standard cannot reflect all aspects. The ability to be mobilised on the day of or day after surgery is a good composite measure of both patient and organisational factors in hip fracture care: timely surgery, adequate pain relief, prevention of delirium, admission to a ward with philosophy, skills and resources to encourage early mobility. While early mobility has always been encouraged this data suggests its adoption as a formal standard to which all units must comply.

Fragility fracture audit is key to understanding fragility fracture management, identifying areas for its improvement and measuring the impact of clinical initiatives and service change. Hip fracture can be considered a marker for fragility fractures, and hip fracture audits indirectly show strengths and weaknesses of fragility fracture care overall. Notably, where effective hip fracture care exists, this has a favourable impact on the care of other fragility fractures. Early established audits, clinically led, have used clinical standards and feedback on compliance with them to improve care and outcomes. Although data collection, analysis and feedback require investment, the cost per case amounts to only a very small fraction of the cost of care per case. More recently established audits have also proved effective, and increasingly international collaboration on hip fracture audit is now emerging: an important development in view of demographic projections reflecting first-generation mass ageing in a number of large nations. Parallel developments such as fracture liaison services promote both primary and secondary fracture prevention. In future, automated data collection using reliable electronic health records may facilitate audit and international collaboration and enabling instructive comparisons and, eventually, multinational hip fracture-related clinical and epidemiological research.