The effect of indirect admission via hospital transfer on hip fracture patients in Ireland

The Impact of Hospital Transfers on Surgical Delay and Associated Postoperative Outcomes for Hip Fracture Patients in Scotland: A Cohort Study

Background/Objectives: Hip fractures exert a substantial burden on hospital systems. Within Scotland 20% of the population resides rurally, warranting investigation of how this impacts prompt access to surgical care. This study aims to determine whether indirect hospital admission via hospital transfer affects the likelihood of surgical management within 36 h for hip fracture patients. Methods: A retrospective cohort study was performed. This used Scottish Hip Fracture Audit data including patients aged ≥50 split into two propensity matched groups based on their transfer status. Descriptive analysis compared patient characteristics. Regression assessed achieving surgery within 36 h of admission in the unmatched and matched cohorts. Secondary outcomes included time to surgery, mortality, mobilization, returning to residence and length of stay. A sensitivity analysis was undertaken to assess for residual confounding effects. Results: The unmatched analysis included 20,132 patients. Transfer patients were younger (p = 0.007) and less-comorbid (p < 0.001). In the matched population, 711 (63.6%) transfer patients had surgery with 36 h of presentation to hospital, compared to 852 (75.3%) non-transfer patients. Transfer patients had 43% reduced odds of timely surgery (OR (95% CI) 0.57 (0.48 to 0.69); p < 0.001). No disparities emerged in mortality, mobilisation or returning to residence., Transfer patients experienced a significant increase in length of stay in hospital (median (IQR) 16 (8 to 33) vs. 13 (8 to 30); p = 0.024). Conclusions: Hospital transfer is associated with significantly reduced odds of timely surgery, a longer time to surgery and longer length of stay. Development of structured network pathways that minimize delay to transfer are required to potentially optimize outcomes and reduce associated cost.

[Translated article] Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early

INTRODUCTION

Pre-operative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge.

MATERIAL AND METHODS

A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA≤II were included for analysis and divided according to their post-operative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year post-operative mortality rates; 30-day post-operative hospital readmission rate; and medical or surgical cause were recorded.

RESULTS

In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% versus 4.1%, p=.16) and 1-year post-operative (4.3% versus 16.3%, p=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% versus 16.3%, p=.037).

CONCLUSIONS

In the present study, the early discharge group obtained better results 30-day and 1-year post-operative mortality indicators, as well as readmission for medical reasons.

Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early

INTRODUCTION

Preoperative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge.

MATERIAL AND METHODS

A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA ≤II were included for analysis and divided according to their postoperative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year postoperative mortality rates; 30-day postoperative hospital readmission rate; and medical or surgical cause were recorded.

RESULTS

In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% vs 4.1%, P=.16) and 1-year postoperative (4.3% vs 16.3%, P=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% vs 16.3%, P=.037).

CONCLUSIONS

In the present study, the early discharge group obtained better results 30-day and 1-year postoperative mortality indicators, as well as readmission for medical reasons.

Development of a Frailty Index in the Irish Hip Fracture Database

INTRODUCTION

In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score.

MATERIALS AND METHODS

A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC).

RESULTS

From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p < 0.001) independently of age and sex. AUC analyses showed that the FI score, added to age, sex, and ASA score, significantly improved the prediction of delirium and new nursing home admission (p < 0.05), and especially prolonged LOS and inpatient mortality (p < 0.001).

CONCLUSIONS

A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.

Network Analysis Examining Intrahospital Traffic of Patients With Traumatic Hip Fracture

INTRODUCTION

Increased intrahospital traffic (IHT) is associated with adverse events and infections in hospitalized patients. Network science has been used to study patient flow in hospitals but not specifically for patients with traumatic injuries.

METHODS

This retrospective analysis included 103 patients with traumatic hip fractures admitted to a level I trauma center between April 2021 and September 2021. Associations with IHTs (moves within the hospital) were analyzed using R (4.1.2) as a weighted directed graph.

RESULTS

The median (interquartile range) number of moves was 8 (7-9). The network consisted of 16 distinct units and showed mild disassortativity (-0.35), similar to other IHT networks. The floor and intensive care unit (ICU) were central units in the flow of patients, with the highest degree and betweenness. Patients spent a median of 20-28 hours in the ICU, intermediate care unit, or floor. The number of moves per patient was mildly correlated with hospital length of stay (ρ = 0.26, p = .008). Intrahospital traffic volume was higher on weekdays and during daytime hours. Intrahospital traffic volume was highest in patients aged <65 years ( p = .04), but there was no difference in IHT volume by dependent status, complications, or readmissions.

CONCLUSIONS

Network science is a useful tool for trauma patients to plan IHT, flow, and staffing.

Instant messaging apps and data protection: combining to improve hip fracture care?

Introduction

The General Data Protection Regulation (GDPR) continues to have implications for how healthcare information is managed and shared. This presents challenges as telemedicine plays a more central role in service healthcare service provision, particularly since the beginning of 2020. We aim to measure how improved communication through a GDPR-compliant messaging app can influence time-dependent key performance indicators for hip fracture management in a tertiary-referral trauma hospital.

Methods

Using an instant messaging service, a hip fracture group was created and access was provided to all stakeholders in hip fracture care—trainee and consultant emergency physicians and orthopaedic surgeons, as well as advanced nurse practitioners, bed managers, ward managers and theatre managers. Irish Hip Fracture Database (IHFD) standard compliance was compared from April to December 2017 and April to December 2018.

Results

Two periods in 2017 and 2018 saw 121 and 122 hip fracture patients admitted, respectively. Mean time to admission to an orthopaedic ward in 2017 was 47 ± 42.9 h and 33.3 ± 42 h in 2018 (P = 0.5). Mean time to surgery in 2017 was 83.66 ± 53.46 h and 39.11 ± 10.84 h in 2018 (p = 0.026).

Conclusions

Irish Hip Fracture Database Standards present a challenge to orthopaedic departments competing with other hospital specialties for access to beds and theatre space. The introduction of a GDPR-compliant social media messaging service has contributed to significantly reducing the time to surgery for these patients. Streamlining communication through messaging services has and continues to be vital to improving care for hip fracture patients, both in the healthcare environment and beyond.

Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database

Hip fractures continue to be one of the most serious and costly injuries suffered by older people globally. This paper describes the development of a national hip fracture audit and summarises the first 6 years of data from the Republic of Ireland. This can help inform care, standards and outcomes of hip fracture patients.

INTRODUCTION

Ireland has one of the highest standardised rates of hip fracture in the world behind northern European countries. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive clinical and organisational improvements in quality and effectiveness of hip fracture care. This paper describes the progression of the IHFD between 2013 and 2018 and identifies trends and areas for improvement.

METHODS

The IHFD is a clinically led, web-based audit, with data collected through the national Hospital Inpatient Enquiry (HIPE) electronic system, the principal source of information from publicly funded acute hospitals in Ireland. Eligible cases are aged ≥ 60 years with hip fracture as defined by IHFD or with other specified hip fracture excluding periprosthetic fractures. As of 2015, all 16 trauma-receiving hospitals within Ireland submitted data. Demographics and adherence to six national quality standards are described.

RESULTS

A total of 17,983 cases were included in the analysis. National coverage has increased from 63% in 2013 to 99% in 2018. Demographic characteristics are unchanged, but higher levels of comorbidity are seen. Internal fixation and hemiarthroplasty are the most common modes of surgical repair with two-thirds of cases receiving spinal rather than general anaesthesia. Increasingly patients are being assessed by a geriatrician (11% in 2013 to 69% in 2018) and receive a bone health assessment (65% in 2013 to 84% in 2018).

CONCLUSION

While some hip fracture standards have improved, further improvements are required to compare favourably internationally. Reduction of surgical delay and ensuring early mobilisation post-operatively are immediate priorities for the IHFD.