ED Fractured Neck of Femur
Fast Track Admission Protocol
ONLY PATIENTS WITH CLINICALLY OBVIOUS
NECK OF FEMUR FRACTURE
FORM TO BE COMPLETED IN ITS ENTIRETY
Majors triage and IC actions
Yes No
1. Identification of likely NOF#
Patient Details
2. IVA, Bloods sent inc G+S, analgesia,
XR ordered and ECG performed
3. Decision to FASTTRACK or NOT to be
made EARLY in IC once medical
checklist complete)
Date of Arrival:
Time of Arrival:
Next of Kin contacted: Y
Time
N
15mins
30mins
60mins
FAST TRACK  NON FAST TRACK 
Medical Checklist to complete EARLY in IC
SEWS > 3 at any point whilst in ED
HR <60 or >100 or SBP <110 or RR < 9 or > 20
BM < 4 or >15 or Temp <36 or >38 or Sats <90 on air
4AT>3 or evidence of head injury or focal neurology
History of collapse prior to injury or long lie
Chest pain/ palpitations or SOB at any point
Ischaemic ECG or significant arrhythmia
Significant respiratory compromise acute or chronic
Warfarin / coagulopathic
Current malignancy or immunosuppressed
Other significant associated injuries
No
Yes
If YES to ANY MUST HAVE early Senior
ED review (Reg or Cons)
SENIOR ED REVIEW DECISION
Name of reviewer :
WARD FIT (to Continue FAST TRACK) 
Needs Ortho Reg Review (to Exit FAST
TRACK) 
HDU required (to Exit FAST TRACK) 
FAST TRACK Process in IC/HD (ward in <2 hours)
Analgesia delivered, pt comfortable
EM Medical assessment (exit FASTTRACK if concerned)
Consider fluid status and start IVF if required or NBM
NOF# confirmed + CXR complete (add full femur views if
comminuted or subtrochanteric or ?pathological)
ED senior clinician review and agree
Orthopaedic team informed and bed booked
Inspect pressure areas and manage (nursing staff)
Early frailty Checklist to be completed overleaf
Time
Name of Clinician
Reason for delay?
NON FAST TRACK Process in IC/HD (4 hour target)
Analgesia delivered, pt comfortable
EM Medical assessment
Consider fluid status and start IVF if required or NBM
NOF# confirmed + CXR complete
Orthopaedic Reg review after ED senior discussion
Bed booked in ortho or other as appropriate
Inspect pressure areas and manage (nursing staff)
Early Frailty Checklist to be completed overleaf
Time
Name of Clinician
Reason for delay?
NOF # Checklist Version 070714
Early Frailty Checklist to be completed in IC
(will still require formal assessment at ward level during clerk in)
Yes (any yes then ward nurse
to flag for early MOE)
Age ≥ 75 years
Significantly underweight; cachexia or current malignancy
Cardiac disease of any form
Chronic respiratory disease
Chronic kidney disease
Diabetes or immunocompromised
Documented dementia or Parkinson’s disease
Cerebrovascular disease
Alcohol >20 units a week
On warfarin or steroids
Recurrent falls or admissions
POC, care home, IPCC or dependent on a carer
4AT to be performed in IC
[1] ALERTNESS
This includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy
during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with
speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating.
Normal (fully alert, but not agitated, throughout assessment)
0
Mild sleepiness for <10 seconds after waking, then normal
0
Clearly abnormal
4
[2] AMT4
Age, date of birth, place (name of the hospital or building), current year.
No mistakes
0
1 mistake
1
2 or more mistakes/untestable
2
[3] ATTENTION
Ask the patient: “Please tell me the months of the year in backwards order, starting at December.”
To assist initial understanding one prompt of “what is the month before December?” is permitted.
Months of the year backwards
Achieves 7 months or more correctly
0
Starts but scores < 7 months / refuses to start
1
Untestable (cannot start because unwell, drowsy, inattentive)
2
[4] ACUTE CHANGE OR FLUCTUATING COURSE
Evidence of significant change or fluctuation in: alertness, cognition, other mental function
(eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs
No
0
Yes
4
4 or above: possible delirium +/- cognitive impairment
1-3: possible cognitive impairment
0: delirium or severe cognitive impairment unlikely
(but delirium still possible if [4] information incomplete)
NOF # Checklist Version 070714
4AT SCORE
No