# Use of Pre-operative Echocardiograms in Traumatic Neck of Femur Fracture Patients: A Two-Cycle Quality Improvement Project

## TL;DR

This study shows that educating hospital staff about guidelines for pre-surgery heart scans in hip fracture patients reduced unnecessary scans without causing delays.

## Contribution

The novel contribution is demonstrating how targeted education and guideline dissemination can improve adherence to appropriate echocardiogram use in hip fracture surgery.

## Key findings

- Educational interventions increased appropriate echocardiogram requests from 33.3% to 94.1%.
- Echocardiograms influenced anaesthetic decisions in 23.5% of cases, showing clinical value when appropriately used.
- Surgery was not delayed in any patient during both audit cycles.

## Abstract

Background

Hip fractures are among the most common causes of hospital admission in elderly patients. National Institute for Health and Care Excellence (NICE) recommends surgery within 24-48 hours in such patients; however, pre-operative transthoracic echocardiography (TTE) is occasionally requested inappropriately, risking delays in surgery without improving outcomes. Delays to hip fracture surgery are associated with increased morbidity and mortality, with each 24-hour delay linked to worse clinical outcomes, underscoring the importance of timely operative intervention. This quality improvement project (QIP) evaluated the use of pre-operative echocardiograms in patients with neck of femur fractures, aiming to reduce unnecessary requests, prevent surgical delays, and ensure consistent acknowledgement of TTE results by anaesthetists at a district general hospital in the United Kingdom.

Materials and methods

A two-cycle Plan-Do-Study-Act (PDSA) audit was conducted at a district general hospital. Multiple guidelines were studied, and local trust guidelines regarding the use of pre-operative echocardiograms were selected as a standard that defined appropriate TTE indications. In Cycle 1 (March-April 2024), baseline compliance with three standards was assessed, which included: avoidance of surgical delay, appropriateness of echocardiogram requests and anaesthetic acknowledgement of TTE reports. Interventions included teaching sessions, posters outlining guideline criteria, and dissemination of audit findings. Cycle 2 (July-October 2024) re-evaluated compliance following these measures.

Results

In Cycle 1, 12 patients were identified using our inclusion criteria who underwent TTE. Surgery was not delayed in any case (12/12, 100%). Only 4/12 (33.3%) TTE requests met guideline criteria, and 10/12 (83.3%) reports were acknowledged by anaesthetists. In Cycle 2, following interventions, 17 patients were identified using our inclusion criteria who underwent TTE. Again, surgery was not delayed in any case (17/17, 100%). Guideline adherence improved markedly, with 16/17 (94.1%) appropriate requests, but acknowledgement of reports fell to 12/17 (70.6%). In 4/17 (23.5%) cases, TTE findings led to changes in anaesthetic management, including invasive monitoring and optimisation of cardiac status. The reduction in documented acknowledgement may reflect a higher threshold for what clinicians considered necessary to formally record following improved guideline adherence. Importantly, in 4/17 (23.5%) of cases, echocardiography directly influenced anaesthetic decision-making, supporting its role as a clinically valuable investigation when appropriately targeted.

Conclusion

Targeted educational interventions and dissemination of local guidelines reduced inappropriate echocardiogram requests in hip fracture patients without delaying surgery. However, inconsistent documentation of anaesthetic acknowledgement remains a concern. Ongoing interventions, including the implementation of mandatory electronic sign-off of echocardiogram reports within the patient record, are planned to sustain improvements and optimise perioperative communication.