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Oakley B, Nightingale J, Moran CG, Moppett IK. Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study. BMJ Open 2017; 7:e014190. [PMID: 28167748 PMCID: PMC5293976 DOI: 10.1136/bmjopen-2016-014190] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual. SETTING A single university-affiliated teaching hospital. PARTICIPANTS 2541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality. RESULTS The introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p=0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9-21) pre-BPT vs 14 days (IQR 11-22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44 hours pre-BPT (IQR 24-44) vs 23 hours post-BPT (IQR 17-30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p<0.005). There was a survival benefit at 1 year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival. CONCLUSIONS The introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes.
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Affiliation(s)
- B Oakley
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Nightingale
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - CG Moran
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - IK Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, Nottingham, UK
- Department of Anaesthesia, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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White SM, Pateman J. A method of recording electronic anaesthetic monitor data for research. Anaesthesia 2017; 72:267-269. [PMID: 28093744 DOI: 10.1111/anae.13794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S M White
- Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, Brighton, UK
| | - J Pateman
- Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, Brighton, UK
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Porter CJ, Moppett IK, Juurlink I, Nightingale J, Moran CG, Devonald MAJ. Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury. BMC Nephrol 2017; 18:20. [PMID: 28088181 PMCID: PMC5237525 DOI: 10.1186/s12882-017-0437-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/04/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Hip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture. METHODS An observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures - development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay. RESULTS Data were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67). CONCLUSIONS Acute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important.
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Affiliation(s)
- Christine J. Porter
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
| | - Iain K. Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, Nottingham, NG7 2RD UK
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Irene Juurlink
- Information and Computer Technology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jessica Nightingale
- Department of Orthopaedic Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christopher G. Moran
- Department of Orthopaedic Trauma, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark A. J. Devonald
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
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Odor PM, Chis Ster I, Wilkinson I, Sage F. Effect of admission fascia iliaca compartment blocks on post-operative abbreviated mental test scores in elderly fractured neck of femur patients: a retrospective cohort study. BMC Anesthesiol 2017; 17:2. [PMID: 28125964 PMCID: PMC5267435 DOI: 10.1186/s12871-016-0297-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/21/2016] [Indexed: 11/10/2022] Open
Abstract
Background Post-operative cognitive impairment is common in elderly patients following surgery for hip fracture, with undertreated pain being an important etiological factor. Non-opioid based analgesic techniques, such as nerve blocks, may help reduce the risk of cognitive complications. The aim of this study was to investigate whether receiving a fascia iliaca compartment block (FICB) as part of a pre-operative analgesic regime increased the odds of high post-operative abbreviated mental test scores (AMTS) when compared with conventional analgesia without a nerve block. Methods A retrospective data analysis of a cohort of 959 patients, aged ≥ 65 years with a diagnosis of hip fracture and admitted to a single hospital over a two-year period was performed. A standardized analgesic regime was used on all patients, and 541/959 (56.4%) of included patients received a FICB. Provision of the FICB was primarily determined by availability of an anesthetist, rather than by patient status and condition. Post-operative cognitive ordinal outcomes were defined by AMTS severity as high (score of ≥9/10), moderate, (score of 7–8) and low (score of ≤6). A multivariable ordinal logistic regression analysis was performed on patient status and clinical care factors, including admission AMTS, age, gender, source of admission, time to surgery, type of anesthesia and ASA score. Results Admission FICB was associated with higher adjusted odds for a high AMTS (score of ≥9) relative to lower AMTS (score of ≤8) than conventional analgesia only (OR = 1.80, 95% CI 1.27–2.54; p = 0.001). Increasing age, lower AMTS on admission to hospital, and being admitted from a residential or nursing home were associated with worse cognitive outcomes. Mode of anesthesia or surgery did not significantly influence post-operative AMTS. Conclusion Post-operative AMTS is influenced by pre-operative analgesic regimes in elderly patients with hip fracture. Provision of a FICB to patients on arrival to hospital may improve early post-operative cognitive performance in this population.
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Affiliation(s)
- Peter M Odor
- Perioperative Medicine Fellow, University College London Hospital, London, UK.
| | - Irina Chis Ster
- Senior Lecturer in Biostatistics, Institute of Infection and Immunity, St. George's University of London, London, UK
| | - Iain Wilkinson
- Consultant, Orthogeriatrics, East Surrey Hospital, Redhill, Surrey, UK
| | - Frederic Sage
- Consultant, Department of Anaesthesia, East Surrey Hospital, Redhill, Surrey, UK.
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Godai K. Ultra-low dose spinal anaesthesia for hip fracture surgery. Anaesthesia 2016; 72:126. [PMID: 27988956 DOI: 10.1111/anae.13770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- K Godai
- Kagoshima University, Kagoshima, Japan
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White S. Duration of low-dose spinal anaesthesia for hip fracture surgery. Anaesthesia 2016; 72:127-128. [DOI: 10.1111/anae.13777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S. White
- Royal Sussex County Hospital; Brighton UK
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Jakobsson J, Johnson MZ. Perioperative regional anaesthesia and postoperative longer-term outcomes. F1000Res 2016; 5:F1000 Faculty Rev-2501. [PMID: 27785357 PMCID: PMC5063036 DOI: 10.12688/f1000research.9100.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 12/14/2022] Open
Abstract
Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks-that is, spinal and epidural blocks-are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.
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Affiliation(s)
- Jan Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden
| | - Mark Z. Johnson
- Department of Anaesthesia & Critical Care, Mater Misercordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Affiliation(s)
- S Q M Tighe
- Countess of Chester Hospital Foundation NHS Trust, Chester, UK.
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110
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White SM. Ultra-low dose intrathecal anaesthesia for hip fracture surgery - a reply. Anaesthesia 2016; 71:1243-4. [PMID: 27611046 DOI: 10.1111/anae.13614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- S M White
- Royal Sussex County Hospital, Brighton, UK.
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Abstract
The treatment of hip fractures in the elderly represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed. Open reduction and internal fixation versus arthroplasty remain the two major categories of treatment. While the indications and treatment algorithms still remain controversial, the overall goal for these patients is early mobilization and prevention of morbidity and mortality. The use of preoperative, regional anesthesia has aided in this effort. The purpose of this review article is to examine the various treatment modalities for hip fractures in the elderly and discuss the most recent evidence in the face of a rapidly aging population.
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Affiliation(s)
- Joshua C Rozell
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hasenauer
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek J Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
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White SM, Griffiths R, Moppett IK. Standardising anaesthesia for hip fracture surgery. Anaesthesia 2016; 71:1391-1395. [DOI: 10.1111/anae.13593] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton East Sussex UK
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; University of Nottingham; Nottingham UK
- Department of Anaesthesia; Queen's Medical Centre; Nottingham University Hospitals NHS Trust; Nottingham UK
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113
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Affiliation(s)
- S M White
- Royal Sussex County Hospital, Brighton, UK.
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Affiliation(s)
- M D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Marufu TC, White SM, Griffiths R, Moonesinghe SR, Moppett IK. Prediction of 30-day mortality after hip fracture surgery by the Nottingham Hip Fracture Score and the Surgical Outcome Risk Tool. Anaesthesia 2016; 71:515-21. [DOI: 10.1111/anae.13418] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 12/01/2022]
Affiliation(s)
- T. C. Marufu
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre; University of Nottingham; Nottingham UK
- Department of Anaesthesia; Nottingham University Hospitals NHS Trust; Nottingham UK
| | - S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton UK
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - S. R. Moonesinghe
- UCLH Surgical Outcomes Research Centre; University College London Hospitals; NIAA Health Services Research Centre; Royal College of Anaesthetists; London UK
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre; University of Nottingham; Nottingham UK
- Department of Anaesthesia; Nottingham University Hospitals NHS Trust; Nottingham UK
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