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Almilaji O, Ayis S, Goubar A, Beaupre L, Cameron ID, Milton-Cole R, Gregson CL, Johansen A, Kristensen MT, Magaziner J, Martin FC, Sackley C, Sadler E, Smith TO, Sobolev B, Sheehan KJ. Frequency, duration, and type of physiotherapy in the week after hip fracture surgery - analysis of implications for discharge home, readmission, survival, and recovery of mobility. Physiotherapy 2023; 120:47-59. [PMID: 37369161 DOI: 10.1016/j.physio.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/06/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE To examine the association between physiotherapy access after hip fracture and discharge home, readmission, survival, and mobility recovery. METHODS A 2017 Physiotherapy Hip Fracture Sprint Audit was linked to hospital records for 5383 patients. Logistic regression was used to estimate the association between physiotherapy access in the first postoperative week and discharge home, 30-day readmission post-discharge, 30-day survival and 120-days mobility recovery post-admission adjusted for age, sex, American Society of Anesthesiology grade, Hospital Frailty Risk Score and prefracture mobility/residence. RESULTS Overall, 73% were female and 40% had high frailty risk. Patients who received ≥2 hours of physiotherapy (versus less) had 3% (95% Confidence Interval: 0-6%), 4% (2-6%), and 6% (1-11%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 3% (0-6%) lower adjusted probability of readmission. Recipients of exercise (versus mobilisation alone) had 6% (1-12%), 3% (0-7%), and 11% (3-18%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 6% (2-10%) lower adjusted probability of readmission. Recipients of 6-7 days physiotherapy (versus 0-2 days) had 8% (5-11%) higher adjusted probability of survival. For patients with dementia, improved probability of survival, discharge home, readmission and indoor mobility recovery were observed with greater physiotherapy access. CONCLUSION Greater access to physiotherapy was associated with a higher probability of positive outcomes. For every 100 patients, greater access could equate to an additional eight patients surviving to 30-days and six avoiding 30-day readmission. The findings suggest a potential benefit in terms of home discharge and outdoor mobility recovery. CONTRIBUTION OF THE PAPER.
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Affiliation(s)
- Orouba Almilaji
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK; Department of Health Service Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Salma Ayis
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - Aicha Goubar
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - Lauren Beaupre
- Department of Physical Therapy, Faculty of Rehabilitation Medicine University of Alberta,Canada
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health,University of Sydney, Australia
| | - Rhian Milton-Cole
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translation Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Antony Johansen
- Cardiff Trauma Unit, University Hospital of Wales, Cardiff, UK
| | - Morten Tange Kristensen
- Department of Physical & Occupational Therapy, Copenhagen University Hospital - Bispebjerg and Frederiksberg, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Finbarr C Martin
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - Catherine Sackley
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK; Faculty of Environmental and Life Sciences, School of Health Sciences, University of Southampton, UK & Southern Health NHS Foundation Trust, UK
| | - Euan Sadler
- Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Toby O Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Katie J Sheehan
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK.
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Goubar A, Ayis S, Beaupre L, Cameron ID, Milton-Cole R, Gregson CL, Johansen A, Kristensen MT, Magaziner J, Martin FC, Sackley C, Sadler E, Smith TO, Sobolev B, Sheehan KJ. The impact of the frequency, duration and type of physiotherapy on discharge after hip fracture surgery: a secondary analysis of UK national linked audit data. Osteoporos Int 2022; 33:839-850. [PMID: 34748023 PMCID: PMC8930962 DOI: 10.1007/s00198-021-06195-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022]
Abstract
UNLABELLED Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture. INTRODUCTION To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital. METHODS We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death. RESULTS The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19-1.30) and 1.26 (95% CI 1.19-1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18-1.52) and 1.33 (95% CI 1.12-1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08-1.15) and 1.10 (95% CI 1.05-1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge. CONCLUSION We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6-7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.
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Affiliation(s)
- A Goubar
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - S Ayis
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - L Beaupre
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - I D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - R Milton-Cole
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - C L Gregson
- Musculoskeletal Research Unit, Translation Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - A Johansen
- Cardiff Trauma Unit, University Hospital of Wales, Cardiff, UK
| | - M T Kristensen
- Department of Physical & Occupational Therapy, Copenhagen University Hospital - Bispebjerg and Frederiksberg, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - J Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - F C Martin
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
| | - C Sackley
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK
- Faculty of Medicine, University of Nottingham, Nottingham, UK
| | - E Sadler
- Faculty of Environmental and Life Sciences, School of Health Sciences, University of Southampton, Southampton, UK
| | - T O Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - K J Sheehan
- Department of Population Health Sciences, School of Population and Environmental Sciences, King's College London, London, UK.
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Iyengar KP, Khatir M, Mohamed MKA, Kariya AD, Jain VK, Sangani C, Adam RF, Suraliwala K. Characteristics and clinical outcomes of hip fracture patients during the first lockdown of COVID-19, lessons learnt: A retrospective cohort analysis. J Perioper Pract 2021; 31:446-453. [PMID: 34388942 DOI: 10.1177/17504589211026067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The management of hip fracture patients has been challenging across the UK in the wake of emergency coronavirus disease 2019 guidelines. AIMS This retrospective, observational cohort study analyses the impact of the first lockdown during the early part of the coronavirus disease 2019 pandemic on the management of hip fracture patients at a district general hospital in the UK. METHODS Comparative analysis to assess hip fracture patients treated at this Trust between 1 April to 31 May 2019 and 1 April to 31 May 2020 was undertaken. The primary outcome measures appraised were 30 and 60-day mortality and the secondary outcome measure included time to surgery. RESULTS There was a higher 30 and 60-day mortality rate in the first lockdown period at 8.1% and 13.5%, respectively, compared to 1.96% and 5.88% in 2019. A significantly lower proportion of hip fracture patients at 59.46% were operated within the 36h target time frame during the first lockdown. CONCLUSION In our Trust, hip fractures were treated as obligatory injuries. However, the mortality was higher in the 2020 cohort with a significant reduction in patients achieving the recommended '36 hours' time to surgery target and accruement of Best Practice Tariff. Enhanced infection control strategies have prepared us for the future.
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Affiliation(s)
| | | | | | | | - Vijay Kumar Jain
- Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Riad F Adam
- Southport and Ormskirk NHS Trust, Southport, UK
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Lawrence JE, Cundall-Curry D, Stewart ME, Fountain DM, Gooding CR. The use of an electronic health record system reduces errors in the National Hip Fracture Database. Age Ageing 2019; 48:285-290. [PMID: 30395143 DOI: 10.1093/ageing/afy177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/31/2018] [Accepted: 10/14/2018] [Indexed: 12/24/2022] Open
Abstract
AIM to compare the validity of data submitted from a UK level 1 trauma centre to the National Hip Fracture Database (NHFD) before and after the introduction of an electronic health record system (EHRS). PATIENTS AND METHODS a total of 3224 records were reviewed from July 2009 to July 2017. 2,133 were submitted between July 2009 and October 2014 and 1,091 between October 2014 and July 2017, representing data submitted before and after the introduction of the EHRS, respectively. Data submitted to the NHFD were scrutinised against locally held data. RESULTS use of an EHRS was associated with significant reductions in NHFD errors. The operation coding error rate fell significantly from 23.2% (494/2133) to 7.6% (83/1091); P < 0.001. Prior to EHRS introduction, of the 109 deaths recorded in the NHFD, 64 (59%) were incorrect. In the EHRS dataset, all the 112 recorded deaths were correct (P < 0.001). There was no significant difference in the error rate for fracture coding. In the EHRS dataset, after controlling for sample month, entries utilising an operation note template with mandatory fields relevant to NHFD data were more likely to be error free than those not using the template (OR 2.69; 95% CI 1.92-3.78). CONCLUSION this study highlights a potential benefit of EHR systems, which offer automated data collection for auditing purposes. However, errors in data submitted to the NHFD remain, particularly in cases where an NHFD-specific operation note template is not used. Clinician engagement with new technologies is vital to avoid human error and ensure database integrity.
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Affiliation(s)
- John E Lawrence
- Department of Trauma and Orthopaedic Surgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
| | - Duncan Cundall-Curry
- Department of Trauma and Orthopaedic Surgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
| | - Max E Stewart
- School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Daniel M Fountain
- Department of Neurosciences, Division of Neurosurgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Christopher R Gooding
- Department of Trauma and Orthopaedic Surgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
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Whitehouse MR, Berstock JR, Kelly MB, Gregson CL, Judge A, Sayers A, Chesser TJ. Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures: a prospective national registry study. Bone Joint J 2019; 101-B:83-91. [PMID: 30601043 DOI: 10.1302/0301-620x.101b1.bjj-2018-0601.r2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. PATIENTS AND METHODS Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors. RESULTS The use of short and long intramedullary nails was associated with an increase in 30-day mortality (adjusted odds ratio (OR) 1.125, 95% confidence interval (CI) 1.040 to 1.218; p = 0.004) compared with the use of sliding hip screws (12.5% increase). If this were causative, it would represent 98 excess deaths over the four-year period of the study and one excess death would be caused by treating 112 patients with an intramedullary nail rather than a sliding hip screw. CONCLUSION There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of a trochanteric fractures of the hip.
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Affiliation(s)
- M R Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK; Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - J R Berstock
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK; Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - M B Kelly
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - C L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK; Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - A Judge
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK; Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - A Sayers
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK; Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - T J Chesser
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Dick AG, Davenport D, Bansal M, Burch TS, Edwards MR. Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era? Geriatr Orthop Surg Rehabil 2017; 8:161-165. [PMID: 28835873 PMCID: PMC5557200 DOI: 10.1177/2151458517722104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/31/2017] [Accepted: 06/14/2017] [Indexed: 11/15/2022] Open
Abstract
Introduction: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. Methods: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. Results: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Conclusion: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.
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Affiliation(s)
- Alastair G Dick
- King's College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, United Kingdom
| | - Dominic Davenport
- King's College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, United Kingdom
| | - Mohit Bansal
- King's College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, United Kingdom
| | - Therese S Burch
- King's College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, United Kingdom
| | - Max R Edwards
- King's College Hospital NHS Foundation Trust, Princess Royal University Hospital, Orpington, United Kingdom
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Middleton M, Wan B, da Assunçao R. Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models. Age Ageing 2017; 46:465-470. [PMID: 27974304 DOI: 10.1093/ageing/afw232] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Indexed: 12/13/2022] Open
Abstract
Background our orthopaedic trauma unit serves a large elderly population, admitting 400-500 hip fractures annually. A higher than expected mortality was detected amongst these patients, prompting a change in the hip fracture pathway. The aim of this study was to assess the impact of a change in orthogeriatric provision on hip fracture outcomes and care quality indicators. Patients and Methods the hip fracture pathway was changed from a geriatric consultation service to a completely integrated service on a dedicated orthogeriatric ward. A total of 1,894 consecutive patients with hip fractures treated in the 2 years before and after this intervention were analysed. Results despite an increase in case complexity, the intervention resulted in a significant reduction in mean length of stay from 27.5 to 21 days (P < 0.001), a significant reduction in mean time to surgery from 41.8 to 27.2 h (P < 0.001) and a significant 22% reduction in 30-day mortality (13.2-10.3%, P = 0.04). After controlling for the effects of age, gender, American Society of Anesthesiology (ASA) Grade and abbreviated mental test score (AMTS), the effect of integrating orthogeriatric services into the hip fracture pathway significantly reduced the risk of mortality (odds ratio 0.68, P = 0.03). Conclusions changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly improved mortality and performance indicators. This is the first study to directly compare two accepted models of orthogeriatric care in the same hospital.
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Affiliation(s)
- Mark Middleton
- Trauma and Orthopaedics, Epsom and St Helier University Hospital NHS Trust, Carshalton, Surrey SM5 1AA, UK
| | - Bettina Wan
- Department of Medicine for Elderly, University College London Hospital, London, UK
| | - Ruy da Assunçao
- Department of Orthopaedic and Trauma Surgery, Western Sussex Hospitals NHS Trust, Worthing, West Sussex, UK
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Shenouda M, Silk Z, Radha S, Bouanem E, Radford W. The Introduction of a Multidisciplinary Hip Fracture Pathway to Optimise Patient Care and Reduce Mortality: A Prospective Audit of 161 Patients. Open Orthop J 2017; 11:309-315. [PMID: 28567160 PMCID: PMC5420169 DOI: 10.2174/1874325001711010309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/05/2017] [Accepted: 03/09/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Hip fractures are a major cause of morbidity and mortality in the elderly. A new patient pathway was introduced in our institution to facilitate rapid preoperative assessment, acute physician involvement and early surgery for patients with hip fractures. We sought to assess its impact on patient care and outcomes. MATERIALS AND METHODS Prospective audit of 161 patients admitted with a proximal femoral fracture in the six months before (92 patients) and after (69 patients) implementation of the pathway. Data included: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; inpatient mortality rate. RESULTS In the six months after introduction of the pathway, there was an increase in patients who received pre-operative medical assessment (85% after vs. 19% before, p=0.0001). Average TtG decreased (19 vs. 91 hours, p=0.0001), as did LOS (19.5 vs. 24.8 days, p=0.029) and mortality (4 vs. 14%, p=0.0336). There was an increase in patients returning to their original place of accommodation (80% vs. 57%, p=0.0069). There was a reduction in mean TtS (31 vs. 37 hours, p=0.0663), although this was not statistically significant. DISCUSSION AND CONCLUSIONS Rapid medical optimisation and prompt surgery significantly improve outcomes in patients with hip fractures. By involving an acute medical team in patient care from the point of admission, we have significantly improved our inpatient mortality and increased the proportion of patients returning to their preoperative place of accommodation, thereby maintaining patient independence and reducing the financial and logistical burden on social care.
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Affiliation(s)
- Michael Shenouda
- Department of Trauma and Orthopaedics, Chelsea & Westminster NHS Foundation Trust, London, UK
| | - Zacharia Silk
- Department of Trauma and Orthopaedics, Chelsea & Westminster NHS Foundation Trust, London, UK
| | - Sarkhell Radha
- Department of Trauma and Orthopaedics, Chelsea & Westminster NHS Foundation Trust, London, UK
| | - Emer Bouanem
- Department of Trauma and Orthopaedics, Chelsea & Westminster NHS Foundation Trust, London, UK
| | - Warwick Radford
- Department of Trauma and Orthopaedics, Chelsea & Westminster NHS Foundation Trust, London, UK
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Sayers A, Whitehouse MR, Berstock JR, Harding KA, Kelly MB, Chesser TJ. The association between the day of the week of milestones in the care pathway of patients with hip fracture and 30-day mortality: findings from a prospective national registry - The National Hip Fracture Database of England and Wales. BMC Med 2017; 15:62. [PMID: 28343451 DOI: 10.1186/s12916-017-0825-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 02/21/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Recent publications indicate increased mortality in patients admitted to hospital at the weekend, but these findings may be subject to inadequate adjustment for case-mix and the complexities of resource provision. Hip fractures generally occur in a frail comorbid population with a consistent diagnosis precipitating admission as an emergency. We therefore aimed to examine the association between the day of the week of milestones in the care pathway and 30-day mortality in this population. METHODS Using data from a prospective national database of hip fractures, we investigated the association between day of the week of admission, surgery, inpatient stay, and discharge (care pathway milestones) and 30-day mortality using generalised linear models. Data was collected between January 1, 2011, and December 31, 2014, on 241,446 patients. An incremental case-mix adjustment strategy was performed using patient characteristics, non-surgical interventions, surgical interventions and discharge characteristics. RESULTS The day of admission was not associated with 30-day mortality. Sunday surgery (OR, 1.094; 95% CI, 1.043-1.148; P < 0.0001) and a delay to surgery of more than 24-hours (OR, 1.094; 95% CI, 1.059, 1.130; P < 0.0001) were both associated with a 9.4% increase in 30-day mortality. Discharge from the hospital on a Sunday (OR, 1.515; 95% CI, 1.224, 1.844; P < 0.0001) or out-of-hours discharge (OR, 1.174; 95% CI, 1.081, 1.276; P < 0.0001) were associated with a 51.5% and 17.4% increase in 30-day mortality, respectively. Mortality during the inpatient stay was 5.6% lower (IRR, 0.944; 95% CI, 0.909, 0.980; P = 0.003) at the weekend compared to weekdays. CONCLUSIONS There is limited evidence of a generalised weekend effect in patients admitted to hospital for hip fracture. Optimising resource utilisation is an essential element of planning and delivering healthcare services. Interventions that lead to surgery within 24-hours of admission are justified. Factors such as Sunday operations, discharge and out-of-hours discharge require further investigation.
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Abstract
INTRODUCTION In April 2012, the activation of the regional trauma networks in England was carried out to improve the organisation of trauma care. NHS Trusts that could meet the highest standard of care to complex trauma were designated Major Trauma Centres (MTCs). MTCs receive patients fulfilling certain triage criteria, as well as secondary transfers from nearby trauma units. While complex trauma care is streamlined with this new organisation, the impact this would have on the rest of the trauma workload within MTCs as well as non-MTC hospitals is uncertain. We investigate whether the management of hip fracture cases had suffered as a result of a trauma unit becoming a MTC. METHODS Summary data was collated from the National Hip Fracture Database website for the periods of April 2011-April 2012 (the 'pre-MTC' activation period) and April 2012-April 2013 (the 'post-MTC' activation period). As our primary outcome, we compared the time to surgery within 36h between MTCs and non-MTCs for the periods detailed above. Other outcome measures were: reasons for delay to surgery, length of acute stay, proportion of cases meeting Best Practice Tariff criteria. RESULTS A total of 54,897 and 55,998 fNOF patients were included for all hospitals in England in the pre- and post-MTC periods respectively. For MTCs, a weighted mean average of 66.6% patients had surgery within 36h in the pre-MTC period versus 71.4% of patients in the post MTC period (p<0.0001). For non-MTCs, a weighted mean average of 70.0% of patients had surgery within 36h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p<0.0001). Non-MTCs in both pre- and post-MTC activation periods were therefore better in percentage of patients receiving surgery within 36h. DISCUSSION The data presented suggests that the creation of MTCs has not had a deleterious effect on the management of hip fracture patients. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, in conjunction with the development of regional Major Trauma Networks.
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Affiliation(s)
- Ken Wong
- Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom.
| | - James Rich
- Cambridge University Medical School, University of Cambridge, United Kingdom.
| | - Grace Yip
- Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom.
| | - Constantinos Loizou
- Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom.
| | - Peter Hull
- Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom.
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Patel NK, Sarraf KM, Joseph S, Lee C, Middleton FR. Implementing the National Hip Fracture Database: An audit of care. Injury 2013; 44:1934-9. [PMID: 23680283 DOI: 10.1016/j.injury.2013.04.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/21/2013] [Accepted: 04/13/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hip fractures are common injuries in the elderly, with significant associated morbidity and mortality rates. The National Hip Fracture Database (NHFD) was implemented to audit care according to national standards thus improving its clinical and cost-effectiveness. PATIENTS AND METHODS We retrospectively examined the care pathway for all hip fractures after its introduction at our centre over 1 year, with an audit of care according to the BOA-BGS 'Blue Book' guidelines. Data between the first (period 1: initial audit) and second (period 2: re-audit) six months of the study period were compared. RESULTS There were 372 patients (28% male, 72% female) in total with 190 in period 1 and 182 in period 2. For all patients, the median age was 85 years (range 33-101) and the median time to surgery was 24.5h (1-519.3), with 251 (67.5%) within 36h. Surgical delay was mainly due to lack of theatre space (37.6%) and medical reasons (54.7%). The median length of stay was 11 days (2-92) and the inpatient mortality rate was 6.2% (23). When comparing the two study periods, there were significantly more patients undergoing falls (p<0.01) and bone protection (p<0.01) assessments in period 2. Lack of theatre space was a significantly less common (p<0.01), with a significantly shorter median time to surgery (p=0.01) and length of stay (p<0.01) in period 2. More patients were discharged to rehabilitation units and the mortality rate was non-significantly lower in period 2 (7.4% vs. 5%). The best practice tariff was met in 45.3% and 70.3% (p<0.001) of patients in periods 1 and 2 respectively providing a total income of £95230.00 (GBP). CONCLUSIONS Implementing the NHFD has led to an improvement the quality of hip fracture care according to national guidelines. More patients were assessed by an orthogeriatrician, with a shorter time to surgery and length of stay following re-audit. There is potential for an improvement in mortality rates as well as significant financial income for hospitals.
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Affiliation(s)
- Nirav K Patel
- Department of Trauma and Orthopaedic Surgery, Kingston Hospital, Galsworthy Road, Kingston-upon-Thames KT2 7QB, UK.
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