Improving care in the Emergency Department of patients presenting with suspected neck or femur fractures; a prospective quality improvement study

Mrs Claire Lobb1, Dr Laura Scott1, Professor Peter Cameron1, Mrs Emma McKeown1

1Alfred Health, Prahran, Australia


This prospective quality improvement project plans to introduce & evaluate the implementation of a Suspected Neck of Femur Fracture (SNOFF) pathway in the emergency department to improve timely, quality care for these patients. The aim is to reduce waiting times to simple analgesia to within 30 minutes of arrival with x-ray and diagnosis within 1 hour and femoral nerve block (FNB) and referral to orthopaedic and orthogeriatric teams within 2 hours.


All patients presenting to ED with an isolated SNOFF will be streamed to the Fast Track area of the department between the hours of 0700-2100 hrs and out of these hours and if the patient has other suspected injuries or abnormal vital signs the patient will be streamed to the rapid intervention and treatment zone of the department.

The Nurse practitioner team in the department are championing the care of the SNOFF patient in the fast track area and will be responsible for early activation of the NOFF powerplan on Firstnet. The NOFF powerplan has been developed to streamline the care set for pharmacotherapy, diagnostic imaging and referrals for the treating clinician.

An emergency doctor will then perform the FNB once diagnosis of a NOFF has been confirmed to provide the patient with the gold standard of analgesic care.


Data of baseline demographics and times to analgesia, diagnostics, FNB & specialist team referral has been collected pre these developments and will be compared on completion of the project to evaluate if times and delivery of care has improved.


It is expected that by implementing these changes and streamlining the timely quality care for these patients it will significantly improve their outcomes. It is expected they will require less opiate analgesia, thereby reducing distress and potential delirium by providing early and effective analgesia.


Claire is an experienced nurse practitioner working in a major metropolitan emergency department. She has been endorsed since 2015 after undertaking an 18 month candidacy program at the Alfred Hospital.

The nurse practitioner team at The Alfred work predominantly in the fast track area providing clinical leadership and autonomous care for patients. The NP team constantly looks to expand their scope of practice in order to enhance the care they deliver. This QI project is one such example whereby they have completed additional education and training to manage the care of patients presenting with suspected neck of femur fractures and hip/pelvic injuries.