Editor,—In 1996 we described a system of fast tracking admission of patients with a proximal femoral fracture to the ward where definitive management could begin.¹ This system had benefits for all those involved, not least the patients who are mostly elderly women at risk of developing pressure sores.

Since we published the paper a number of changes have occurred at our hospital which reflect changes occurring in many hospitals in the NHS: the number of acute orthopaedic beds on the hospital site fell from 75 to 60; the number of acute admissions, particularly medical, has continued to rise; and improved resources and initiatives for managing emergency admissions have suffered at the expense of initiatives for reducing waiting lists.

In January 1999 we reviewed the length of stay in the accident and emergency (A&E) department for 25 consecutive patients over 65 years of age who were admitted with a proximal femoral fracture and compared them with figures for patients who were fast tracked in our original paper (fig 1). Although the 1995 figures were for patients who were fast tracked, the mean time for patients who could not be admitted because of the unavailability of an orthopaedic bed had still been only 4 hours and 8 minutes. The average length of stay has risen sharply with 40% of patients now staying in the A&E department for more than seven hours.

This apparent breakdown of a quality improvement initiative is an example of how emergency patients are suffering because of reduced numbers of acute hospital beds and a reduction in resources available for acute cases. In 1998 there were 812 cases of proximal femoral fracture over the age of 65 years admitted to our hospital. We advocate the availability of three dedicated beds each day for the management of patients with a proximal femoral fracture. The predictability of numbers and almost uniformity of presentation makes a fast track system for this type of injury eminently suitable. It is important, however, that hospital management work alongside clinicians in providing the necessary resources to develop a fast track service for this vulnerable group of patients.

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Figure 1

Length of stay in the A&E department for patients admitted with a proximal femoral fracture.