Table 1 Statements in each round and level of agreement

Generic

1.1 Optimal care for the management of older people with frailty, non-weight bearing after lower limb fracture should comply with current national guidelines for the care of patients with fragility fractures with respect to osteoporosis detection and management; falls risk reduction, and nutrition (R1, 98%).

1.2. Irrespective of the place of care, patients require access to a multi-professional team including orthopaedic surgeons and physicians, nurses and rehabilitation professionals with expertise in geriatric care. They will take an approach based on, or compatible with, comprehensive geriatric assessment – covering 1.3a symptoms 1.3b physical functioning 1.3c continence 1.3d activity – previous and current, personal and instrumental ADL 1.3e management of co-pathology beyond osteoporosis 1.3f skin integrity 1.3 g a medication review 1.3 h cognition 1.3i affect 1.3j social network 1.3 k environment 1.3 l personal factors (e.g. religious or cultural needs/ requirements) (R1, 98%).

1.3. Inpatient care for these patients should be via an orthogeriatric service (R1, 95%).

1.4. Osteoporosis management and falls risk reduction should be co-ordinated by a fracture liaison service (R1, 84%).

1.5. The daily requirements for protein, calories, vitamins and other vital nutrients for each individual patient should be estimated, and a dietary plan to meet those requirements produced (R1 90%).

1.6 Vitamin D levels should be checked in all patients, and corrected if abnormal, according to locally agreed guidelines (R2, 89%).

1.7. Nutritional supplements should not be routinely offered (R2, 74%).

1.8. Nutritional supplements should only be offered to individual patients after a clinical assessment indicates nutritional needs that cannot be met by dietary means alone (R2, 86%)

1.9. Protein supplementation should only be offered to individual patients after a clinical assessment indicates a need that cannot be met by dietary means alone (R2, 83%).

1.10. Calorific supplements should only be offered to individual patients after a clinical assessment indicates nutritional needs that cannot be met by dietary means alone (R2, 85%).

1.11. Multivitamin supplements should only be offered to individual patients after a clinical assessment indicates nutritional needs that cannot be met by dietary means alone (R2, 77%).

2.Non-weight bearing period

2.1. At the onset of the period of NWB, a personalised programme of activity and exercise should be devised, agreed and recorded: 2.1a to reduce sedentary behaviour 2.1b to include a daily range of motion exercises for the lower limb joints 2.1c to include daily aerobic fitness exercises 2.1d to include daily strength exercises for all limbs (R1,98%).

2.2. At onset of the period of NWB, thromboembolism prevention management should be reviewed, and should comprise 2.2a mobilization 2.2b mechanical (e.g. compression hosiery if tolerated) 2.2c low dose heparinoid unless contraindicated (R1, 96%).

2.3. At onset of the period of NWB, plans for the monitoring and management of any wound, fixation device or limb casting during the period of non-weight bearing should be recorded (R1,99%).

2.4. At the onset of the period of NWB, plans for the duration of the period of non-weight bearing, or the decision-making process to define it, should be recorded (R1,99%).

2.5. At the onset of the period of NWB, specific plans for the consequences of the personal ADL limitations imposed by the requirement for non-weight bearing such as upon skincare, continence, toileting and dressing should be recorded (R1, 97%).

2.6. At onset of the period of NWB, a personalised plan based on the above assessments of where the above care should be delivered should be recorded (R1, 97%).

2.7. During the period of NWB, access to equipment and professional input should be sufficient to deliver care as defined by 1.1–1.2 and 2.1–2.6 and to plan 2.8–2.11 (R1, 100%).

2.8. By the end of the period of NWB, a personalised programme of activity and exercise and where it should be conducted should be recorded (R1, 99%).

2.9. By the end of the period of NWB, plans for the monitoring and management of any aspect of fracture / injury care (wound, fixation device or limb casting) should be recorded (R1, 100%).

2.10. By the end of the period of NWB, plans for addressing on-going personal and instrumental ADL limitations should be recorded (R1. 100%).

2.11. By the end of the period of NWB, plans for addressing on-going pain should be recorded (R1. 99%).

2.12. By the end of the period of NWB, plans for management of osteoporosis should be recorded (R1,96%).

2.13. All care plans listed above should be developed with the patient, with a family member or caregiver if requested by the patient or in those patients lacking sufficient mental capacity to do so (R1,99%)