Causes and Effects of Surgical Delay in Patients With Hip Fracture A Cohort Study
ABSTRACT The clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups.
To assess the effect of surgical delay on hospital outcomes according to the cause of delay.
Prospective cohort study.
A hip fracture unit in a university hospital in Spain.
2250 consecutive elderly patients with hip fracture.
Time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications.
Median time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found.
This was a single-center study without postdischarge follow-up.
The reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.
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ABSTRACT: The effect of patient characteristics and organizational and system factors on time to surgery were studied using Emilia Romagna Region database and hospital survey. The results showed that the implementation of a Hip Fracture Program significantly increased the probability of early surgery while single intervention had only slight effect The purpose of this study is to evaluate the effect of formal Hip Fracture Program (HFP) on timing of surgery in hip fracture older patients. This is a retrospective cohort study based on Emilia Romagna administrative databases. Data on organizational and system factor were also obtained through a hospital survey. A multilevel logistic regression analysis was carried out to assess the effect of covariates on early surgery, taking into account patient level, hospital level, and trust level variability. From 1 January to 31 December 2011, 5,520 subjects over 65 years old underwent surgical repair for hip fracture in Emilia Romagna. The mean waiting time to surgery was 3.4 +/- 12.3 days, and the overall percentage of patients operated within 2 days was 52.2 %. In the adjusted multilevel logistic model, significant risk factors affecting the timing of surgical intervention at patient level were age, comorbidity, day of admission, and antiplatelet or warfarin therapy while no significant single variables were found at hospital level including dedicated operation theater, hospital volume, dedicated orthogeriatric beds, and geriatrician involvement. The most significant variable was the implementation of HFP at trust level that increased three times the probability of early surgery after adjusting for confounding variables (OR 3.216, 95 % CI 0.582-6.539). Several modifiable organizational factors may affect the proportion of patients with hip fracture undergoing early surgery. This study suggests that the development and the implementation of an evidence-based HFP at trust level are a key point of the strategy of quality of care.Osteoporosis International 07/2014; 25(11). DOI:10.1007/s00198-014-2803-5 · 4.17 Impact Factor
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ABSTRACT: Objectives: To describe the clinical profile, patterns of care and mortality rates of aged patients who have undergone hip fracture surgical repair. Design: Retrospective patient record study. Setting: A public university hospital in Rio de Janeiro, Brazil. Participants: 352 patients aged 60 and older who underwent surgery for hip fracture between 1995-2000. Measurements: Sociodemographic data, type of fracture, cause of fracture, time from fracture to surgery, physical status, Charlson comorbidity index, type of surgery and anesthesia, access to in-hospital physiotherapy, use of antibiotic and thromboembolism prophylaxis, and mortality within one year after hospital admission. Results: Among 352 subjects, 74.4% were women. The mean age overall was 77.3 years. Very long delays from the time of fracture to hospital admission (mean 3 days) and from hospital admission to surgery (mean 13 days) were observed. Most femoral neck fractures (82.7%) were managed by hip arthroplasties, while 92.8% of the intertrochanteric fractures underwent internal fixation procedures. Less than 10% of patients received in-hospital physiotherapy. Mortality rates 30 days, 90 days and one year after hospital admission were 3.4%, 8.0% and 13.4%, respectively. Conclusion: Our study provides evidence within the context of a developing country of major gaps in the quality of care of vulnerable older adults who suffered a hip fracture. Our findings suggest that hip fracture has not been treated as an urgent condition or a priority within the Brazilian public healthcare system. Further research should address current patterns of care for hip fracture in Brazil and in other developing countries.
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ABSTRACT: Die allgemeinen und speziellen Komplikationen bei Patienten mit hüftnahen Frakturen, wie auch die in der Folge resultierende Beeinträchtigung der Mobilität und der kognitiven Funktion, lassen sich durch einen strukturierten Ablauf von Diagnostik, Therapie und Rehabilitation, basierend auf einem multidisziplinären Behandlungspfad, reduzieren.In der initialen Phase liegt der Fokus nach der Sicherung der Diagnose und dem Einleiten einer adäquaten Schmerztherapie auf der Erfassung der allgemeinen Risikofaktoren, der kognitiven Funktion und einem geriatrischen Screening. Die Indikation zur Operation und die Festlegung der Operationsmethode (totale oder teilweise Hüftprothese, Osteosynthese) werden von unfallchirurgischer Seite vorgegeben. Die unfallchirurgische Therapieentscheidung orientiert sich, abgesehen vom Frakturtyp, am Alter des Patienten, seiner kognitiven Funktion, der vorbestehenden Mobilität bzw. dem funktionellen Anspruch und der Operationstauglichkeit. Im Mittelpunkt der anästhesiologischen Evaluierung steht die Risikostratifzierung für den Patienten hinsichtlich der Operationstauglichkeit und die Frage, ob wesentliche Grunderkrankungen in einem definierten Zeitraum (24 bis maximal 48 h) verbessert werden können. Die präoperative Diagnostik und eventuell erforderliche Interventionen sind interdisziplinär zu koordinieren. Postoperativ erfolgt eine weitere Evaluierung hinsichtlich der Lebensumstände des Patienten vor dem Sturzereignis, des Ernährungszustandes, des weiteren Versorgungsbedarfs sowie hinsichtlich sturzspezifischer Medikamente, die Osteoporosetherapie und ein Delir-Screening.Wiener Medizinische Wochenschrift 10/2013; 163. DOI:10.1007/s10354-013-0249-6