The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study

Implementation of a Dedicated Orthopaedic Trauma Room in Hip and Femur Fracture Care: A 17-Year Analysis

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on hip and femur fracture care.

DESIGN

A retrospective cohort study. Setting: Level 1 trauma center. Patients: 2928 patients with femoral neck, pertrochanteric, and femoral shaft and distal femur (FSDF) fractures.

INTERVENTION

Implementation of a DOTR.

MAIN OUTCOME MEASURES

Hospital length of stay (LOS), emergency department (ED) LOS, intensive care unit (ICU) LOS, and time to operating room (TTOR).

RESULTS

Implementation of a DOTR resulted in significant improvement in TTOR for all patient groups ( P < 0.05). We found shorter TTOR for pertrochanteric ( P < 0.001), femoral neck ( P = 0.039), and FSDF groups ( P = 0.046). Total hospital LOS was shorter for patients with pertrochanteric ( P < 0.001) and femoral neck fractures ( P = 0.044). Patients with pertrochanteric hip fractures demonstrated shorter ICU LOS ( P < 0.001). No LOS improvements were observed among patients in the FSDF group. ED LOS was significantly longer in all patient groups ( P < 0.001).

CONCLUSIONS

Implementation of a DOTR was associated with shorter TTOR, shorter hospital and ICU LOS, and longer ED LOS. There was a greater number of patients transferred into the investigating institution and fewer patients transferred out. These data support the utility of a DOTR as it relates to an improvement in hospital stay-related outcomes in patients with fractures of the hip and femur. Our results suggest that a DOTR in a Level I trauma hospital is associated with improvement in patient care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

Background

Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses.

Methods

This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders.

Results

A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia.

Conclusions

Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups.

Level of evidence: Therapeutic/Care Management, level III

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

PURPOSE

Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients.

METHODS

All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference.

RESULTS

259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0.

CONCLUSION

An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.