Improvements in pain relief, handling time and pressure ulcers through internal audits of hip fracture patients

Pressure Injury Prevalence and Risk Factors: A National Multicenter Analytical Study

PURPOSE

The purpose of this study was to determine the point prevalence (PP) of general pressure injuries (PIs), hospital-acquired PIs, PI-related risk factors, and PI preventive interventions performed by nurses.

DESIGN

Descriptive, multicenter, prospective, analytical study.

SUBJECTS AND SETTING

The sample comprised 5088 patients cared for in 13 hospitals in 12 geographic regions of Turkey. Data were collected between November 5, 2018, and July 17, 2019.

METHODS

The study was carried out in 2 stages. First, nurses who collected data were trained in the diagnosis of PI, risk assessment, staging, and prevalence studies, and informed about the purpose and methods of the study, including data collection. Second, nurses and researchers who had received training related to data collection for this study conducted a PP study for PIs in their inpatient clinics using the ASSIST II method. The PI Prevalence Study Tool and the Braden Scale for Predicting Pressure Sore Risk were also used during data collection.

RESULTS

The PP of general PIs was 9.5%; the prevalence of PIs with hospitalization in intensive care units was 43.2%; medical device-related pressure injuries prevalence was 10.7%. We found that 65.1% of the PIs were acquired after hospital admission.

CONCLUSIONS

Similarities exist between PI prevalence in Turkey and reported PI prevalence rates worldwide. However, the prevalence of nosocomial PIs related to intensive care units and the prevalence of all nosocomial injuries were higher than rates previously reported. Based on results, there is a need to develop strategies to reduce the prevalence of nosocomial PIs.

Time-to-treatment is a risk factor for the development of pressure ulcers in elderly patients with fractures of the pelvis and acetabulum

INTRODUCTION

Fractures of the pelvis and acetabulum are associated with pain and immobilization and, hence, pose the risk of developing a pressure ulcer - especially in elderly patients. In the literature, information on risk factors for the occurrence of pressure ulcers related to geriatric pelvic or acetabulum fractures is missing.

METHODS

Consecutive in-hospital patients aged 55 years or older treated for closed pelvis and/or acetabulum fractures between 2013 and 2017 were retrospectively identified from an institutional prospective database. Epidemiologic characteristics and patient specifics with special focus on the time from admission to treatment, duration of hospitalization and comorbidities were retrospectively assessed by chart review.

RESULTS

During the evaluated interval, 407 patients with isolated fractures of the pelvis or acetabulum (mean age 78 years, range 55 to 101 years, 69,3% female) were treated. A new pressure ulcer that developed during the hospitalization was observed in 46/407 patients (11.3%). This included pressure ulcers of stage 1 in 18/46 cases (39%), stage 2 in 24/46 cases (52%), and stage 3 in 4/46 cases (9%). No stage 4 ulcers were seen in this cohort. The mean duration of hospitalization was longer in patients with a pressure ulcer (25 days, SD 17) than in patients with no ulcers (12 days, SD 9; p < .001). Patients who developed a pressure ulcer, had waited significantly longer for treatment of their pelvis/acetabulum fracture when compared to patients without an ulcer (5 days, SD 5 vs. 3 days SD 4, p = =.001). A logistic regression analysis confirmed "time to treatment" as an independent risk factor for the occurrence of a pressure ulcer during hospitalization. In an analysis adjusted for the confounders age, male gender, diabetes and malignancy, the odds ratio to develop a pressure ulcer remained 1.10 (CI 1.03 to 1.19; c-value = 0.774, p = .008) for each day of waiting treatment.

CONCLUSION

"Time to treatment" is an independent risk factor for the occurrence of a pressure ulcer during hospitalization after a pelvis/acetabulum fracture in elderly patients. Each day of waiting treatment increases the risk of developing a pressure ulcer by 10%.

The impact of care process development and comorbidity on time to surgery, mortality rate and functional outcome for hip fracture patients: a retrospective analysis over 19 years with data from the Swedish National Registry for hip fracture patients, RIKSHÖFT

Abstract

For a long time the attention given to the hip fracture patient group was minor and without any certain consideration to their frailty. To improve the care for these patients Skane University Hospital in Lund has during the past 19 years worked actively with developing the care. This paper aims to describe what impact the care process development has had on functional outcome and mortality, as well as to analyze the impact of comorbidity and fracture type.

Methods

Patients older than 50 years with non-pathological cervical and trochanteric hip fracture admitted between Jan 1st 1999 and Dec 31st 2017 were included and data was retrieved from the National Quality Register for hip fracture patients, RIKSHÖFT. Variables regarding patient characteristics, fracture type, operation method, lead-times and outcome were analyzed. For comparison Fischer’s exact test and Spearman’s rank correlation coefficient was used for the categorical data and Pearson correlation coefficient for the continuous. To further analyze the effect over time a linear regression model was used.

Results

A total of 7827 patients were included. A significant shift in the overall morbidity was seen, with an increase in patients of higher ASA grade. No correlation was seen between outcome and the care process development. The mortality rate for the group as a whole the mortality rate had decreased over time. The total length of stay had decreased significantly over time. There was no statistically significant change in mortality rate over time when relating it to time-to-surgery.

Conclusions

Although the patients display a higher morbidity over time, the mortality rate has not changed significantly, which might indicate an effect of the care process development.

The care process development does not seem to impact on outcome as much as other factors.

This study supports the possibility to create a more specific algorithm for hip fracture patients, taking specific subgroups into consideration.

Evaluating the Effects of a Pressure Injury Prevention Algorithm

OBJECTIVE

To evaluate the effect of a pressure injury prevention algorithm on pressure injury prevention.

DESIGN, SETTING, AND PARTICIPANTS

This intervention study was conducted in the anesthesiology and reanimation ICU (ARICU) of a university hospital. The study included two sample groups (nurses and patients). All patients older than 18 years (prealgorithm, n = 80; postalgorithm, n = 74) in the ARICU who verbally consented were included in the study. All 15 nurses who worked in the ARICU during the postalgorithm period agreed to participate in the study.

INTERVENTIONS

The study was performed in four phases. In the first phase, pressure injury incidence was evaluated in the ARICU (prealgorithm period; April 1 to September 30, 2016). At the same time, a pressure injury prevention algorithm was developed. In the second phase, ARICU nurses were provided education on how to prevent pressure injury and use the pressure injury prevention algorithm. In the third phase, the nurses provided care based on the pressure injury prevention algorithm (postalgorithm period; November 1, 2016, to April 30, 2017). In the fourth phase, the incidence of pressure injury in the pre- and postalgorithm periods was compared, and the effectiveness of the algorithm was evaluated.

MAIN RESULTS

The pressure injury incidence was 46.10 per 1,000 patient-days in the prealgorithm period and 9.21 per 1,000 patient-days in the postalgorithm period. The decline was statistically significant (z = 9.590, P < .001).

CONCLUSIONS

Nursing education and the evidence-based pressure injury prevention algorithm reduced pressure injury rates. Further study of this algorithm in other ICUs and among various care populations is recommended to fully establish its efficacy.

Hip fractures - Treatment and functional outcome. The development over 25 years

BACKGROUND

Nearly 18,000 individuals suffer from hip fracture in Sweden each year. The choice in operation method for femoral neck fractures has changed over the years as well as the overall management. Functional outcome after hip fracture is affected by several factors and the overall functional level for old people in Sweden has improved over the last decades.

OBJECTIVE

To describe and analyse the functional outcome and choice of operation method for hip fracture patients between 1988 and 2012.

PATIENTS AND METHODS

All patients with cervical or trochanteric hip fracture treated at Lund University Hospital from 1988 until 2012 were collected from the National Quality Register for hip fracture patients, RIKSHÖFT. Patients younger than 50 years and those with pathological fractures were excluded. Data regarding patient characteristics, fracture type, operation method and housing, walking ability and use of walk aids prefracture and at 4-months follow-up was retrieved and analysed.

RESULTS

For this study 8723 patients were included with a mean age of 81.6 (men 79.3, women 82.5). The mean age significantly increased over the period studied. Sliding hip screw dominates as method of choice for the trochanteric fractures. For the cervical fractures there is a clear shift from osteosynthesis to arthroplasty. There is a significant decrease in functional outcome at follow-up compared to prefracture. No significant trend change can be seen over 25 years. Functional outcome are worse for the patients with trochanteric fracture.

CONCLUSION

Although there have been changes in operation methods for hip fractures and the management has developed, our study does not show any effect on functional outcome over a 25-year period. The medical condition of these patients with increasing age seems to counteract efforts to improve the care.

Ultrasound-guided femoral nerve blocks are not superior to ultrasound-guided fascia iliaca blocks for fractured neck of femur

OBJECTIVE

To determine if an ultrasound-guided femoral nerve block (FNB) is superior to an ultrasound-guided fascia iliaca compartment block (FICB) in providing pain relief to patients with a neck of femur or proximal femoral fracture.

METHODS

A double-blind randomised controlled trial was conducted. All participants received two blocks, one active and one placebo. An active FICB was administered to 52 participants and 48 participants received an active FNB.

RESULTS

Analysis was completed on data collected from 100 participants. Most patients were elderly and the majority were female. Both FICB and FNB achieved clinically significant mean reductions in pain scores (2.62 for FICB and 2.3 for FNB). There was no significant difference in reduction in pain scores between the two cohorts, P = 0.408.

CONCLUSIONS

Ultrasound-guided FNB is not superior to ultrasound-guided FICB, with both facilitating an equivalent analgesia effect in patients with a neck of femur or proximal femur fracture.

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

INTRODUCTION

The number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.

AIM

To investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.

PATIENTS AND METHODS

In this randomised controlled trial involving patients aged ≥70years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.

RESULTS

The study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9)years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12h compared with controls (p<0.001 and p=0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3±4.0 vs. 5.7±5.2mg, p<0.001) and in the subgroup with dementia (2.1±3.3 vs. 5.8±5.0mg, p<0.001).

CONCLUSION

Patients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.

Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial

INTRODUCTION

Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality.

METHODS

The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group).

RESULTS

Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p<0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p=0.07); proportion operated within 24h (79% PFTC, 75% A&E; p=0.34); length of stay (p=0.34); post-operative complications (p=0.75); and 4 month mortality (18% PFTC, 15% A&E p=0.58).

CONCLUSION

PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded.

Radiographers' self-assessed level and use of competencies-a national survey

OBJECTIVES

To describe radiographers' self-assessed level and use of competencies as well as how sociodemographic and situational factors are associated with these competencies, particularly related to work experience.

METHODS

A cross-sectional design was employed. Radiographers (n = 406) completed the self-administered 28-item questionnaire encompassing two dimensions: 'Nurse-initiated care' and 'Technical and radiographic processes'. The level of competencies was rated on a 10-point scale and the frequency of use on a 6-point scale.

RESULTS

Most competencies received high ratings both in terms of level and frequency of use. In 'Nurse-initiated care' the competency 'Adequately informing the patient' was rated the highest, while 'Identifying and encountering the patient in a state of shock' and 'Participating in quality improvement regarding patient safety and care' received the lowest ratings. In 'Technical and radiographic processes' the highest rated competencies were 'Adapting the examination to the patient's prerequisites and needs' and 'Producing accurate and correct images'. The lowest frequency of use was 'Preliminary assessment of images'.

CONCLUSION

The main findings underline the radiographers' high competency in both 'Nurse-initiated care' and 'Technical and radiographic processes'. The lower rated competencies emphasise the importance of continuous professional education and quality improvement.

MAIN MESSAGES

• Assessing radiographers' clinical competencies is fundamental for ensuring professional standards. • Most competencies received high ratings both in the nursing and in the radiographic dimensions. • The highest rated competencies focussed on information and adaptability to the patients needs. • The lowest rated competencies focussed on encountering the patient in shock and image assessments. • Age, years in present position and work place only explained a relatively small part of competency.

The Patient's View of Nursing Care after Hip Fracture

Background. The pathway for patients with a hip fracture described in this study is a fast track. Many studies have focused on prevention of various complications but, so far, the patient's view of nursing care has not been highlighted. Aim. The aim of the study is to illuminate the patient's view on nursing care when treated for a hip fracture. Method. Ten patients were interviewed. A content analysis design was conducted. Findings. From the analysis, four main categories emerged: waiting times; pain/pain relief and mobilisation; attitude/information and sense of security; complications. Conclusion. Patients generally felt satisfied with the nursing provided. The staff created a feeling of security and showed interest and empathy for the patient. However, patients experienced a stressful waiting for surgery, and patients who developed confusion waited more than 24 hours for surgery. Therefore, waiting time must be decreased. Furthermore, patients' descriptions of a variety of pain problem show, for example, that good collaboration between the nurse and physiotherapist is critical for achieving good pain relief before mobilisation. Nursing staff need to be attentive and should elicit the patient's feelings through patient-focused communication in order to relieve anxiety about going home.

Fast-track care for patients with suspected hip fracture

Patients over 65 years of age with suspected hip fracture following low-energy trauma often wait a long time for examinations, X-rays, tests and surgery. There may be a connection between long waiting times and complications, including severe pain, mental confusion, infection, pressure sores, and longer hospital stays. This study examines whether implementing prehospital preoperative procedures might lead to reduced waiting times, less postoperative pain, fewer complications and shorter length of care for this patient group. To "fast-track" care for hip fracture patients, the ambulance nurse starts the preoperative procedure (usually performed in the accident and emergency department [A&E]) and transfers patients directly to radiology, bypassing A&E. Results from the fast-track care group were compared to results from a control group, who had been admitted to A&E in the usual way. The study group experienced fewer complications and shorter hospital stays compared to the control group. This finding suggests that fast-track care for hip fracture patients can minimise complications, heighten priorities, and decrease overall length of care. Greater awareness of risk factors for hip fracture patients amongst hospital staff leads to improved patient care. Fast-track care may also decrease the workload in A&E and thus release more time for other patients.

An audit of hip fracture services in the Mater Hospital Dublin 2001 compared with 2006

BACKGROUND

Evidence-based practice supports the provision of integrated geriatric multidisciplinary care for older people with hip fractures.

AIMS

To show that introduction of orthogeriatric services resulted in improved care and better patient outcomes.

METHODS

We compared two audits: a 2001 audit of 103 patients over the age of 65 years with hip fracture and a 2006 audit on 98 admissions using the same parameters.

RESULTS

Inpatient mortality dropped from 20% to 8%. Discharge to home increased from 8% to 18% and to nursing home fell from 25% to 21%. Prescription of perioperative antibiotics, DVT prophylaxis and osteoporosis medications improved. There were no significant differences in age or sex but there were significantly higher levels of disability in the 2001 group.

CONCLUSION

Following introduction of an orthogeriatric service, improvements in mortality and discharge destination occurred. This may have been influenced by higher proportions of disability among the 2001 cohort.

Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review

BACKGROUND

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.

METHODS

The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.

RESULTS

Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.

CONCLUSIONS

Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Pressure ulcers in elderly patients with hip fracture across the continuum of care

OBJECTIVES

To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period.

DESIGN

Prospective cohort study.

SETTING

Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged.

PARTICIPANTS

Hip fracture patients aged 65 and older who underwent surgery for hip fracture.

MEASUREMENTS

A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission.

RESULTS

In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3-3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1-4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8-2.3) and 1.3 (95% CI=0.8-2.1), respectively.

CONCLUSION

Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital-APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.

Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.

Malnutrition in hip fracture patients: an intervention study

AIMS

To investigate whether a nutritional intervention in older women and men with femoral neck fracture had an effect on postoperative complications during hospitalization and on nutritional status at a four-month follow-up.

METHODS

The design was a randomized controlled trial. The present study sample consisted of 157 patients aged 70 years and above with femoral neck fracture. The nutritional intervention included, among other things, a nutritional journal to detect nutrition deficiencies and protein-enriched meals for at least four days postoperatively. Further, at least two nutritional and protein drinks were served each day during the whole hospitalization and other factors that would influence the patient's nutrition were also considered and dealt with. Postoperative complications were registered and patients were assessed using the Mini Nutritional Assessment (MNA) scale, including body mass index (BMI), on admission and at a four-month follow-up.

RESULTS

Malnutrition was common and low MNA scores were associated with postoperative complications such as delirium and decubitus ulcers. There were significantly fewer days of delirium in the intervention group, seven patients in the intervention group developed decubitus ulcers vs. 14 patients in the control group and the total length of hospitalization was shorter. There were no detectable significant improvements regarding nutritional parameters between the intervention and the control group at the four-month follow-up but men improved their mean BMI, body weight and MNA scores in both the intervention and the control groups while women deteriorated in both groups.

CONCLUSIONS

Malnutrition was common among older people with hip fractures admitted to hospital. The nutritional intervention might have contributed to the patients suffering fewer days with delirium, fewer decubitus ulcers and shorter hospitalization but did not improve the long-term nutritional status, at least not in women.

RELEVANCE TO CLINICAL PRACTICE

This nutritional intervention, which was included in a multifactorial multidisciplinary intervention, is inexpensive and relatively easy to implement. It has significant effects on complications but no long-term effect on nutritional parameters, at least not in women.

Pressure Ulcers and Prolonged Hospital Stay in Hip Fracture Patients Affected by Time-to-Surgery

BACKGROUND

Hip fractures are associated with high morbidity. Pressure ulcer formation after hip surgery is often related to delayed patient mobilization. The objectives of this study were to determine whether time-to-surgery affects development of pressure ulcers postoperatively and, thus, length of hospital stay.

PATIENTS AND METHODS

We performed a retrospective analysis of consecutive hip fracture patients, aged 60 years and above, who underwent surgery between 1995 and 2001. The primary outcome was in-hospital development of pressure ulcers. The secondary outcome measure was the overall length of hospital stay. Analyses were adjusted for relevant confounders.

RESULTS

Of the 722 patients enrolled, 488 patients (68%) received surgery at 12 h after admission. Approximately 30% (n = 214) developed pressure ulcers during admission, whilst 19% of patients operated within 12 h of admission developed pressure ulcers. Time-to-surgery was an independent predictor of both development of pressure ulcers (OR = 1.7, 95% confidence interval [CI] = 1.2-2.6; p = 0.008) and length of hospital stay (11.3 vs 13.3 days in the early and the late surgery group, respectively, p = 0.050). Furthermore, development of pressure ulcers was associated with prolonged postoperative hospital stay (19.5 vs 11.1 days for patients with and without pressure ulcers, respectively, p = 0.001) INTERPRETATION: : In hip fracture patients, time-to-surgery was an independent predictor of both postoperative pressure ulcer development and prolonged hospital stay. These data suggest that the implementation of an early surgery protocol following admission for hip fractures may reduce both the postoperative complications and overall hospital stay.