Do-Not-Resuscitate status is an independent risk factor for patients undergoing surgery for hip fracture

Brovman, Ethan Y.; Pisansky, Andrew; Beverly, Anair; Bader, Angela M.; Urman, Richard D.

doi:10.5312/wjo.v8.i12.902

Cited by 15 publications

(17 citation statements)

References 41 publications

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“…9 There are few studies addressing how a DNR/DNI designation may influence prognosis in hip fracture patients. 10 However, one recent study evaluated more than 9000 patients using a national database and found that DNR was independently associated with mortality after surgical treatment of a hip fracture. Many risk factors of postoperative morbidity and mortality after hip fracture surgery are well documented, but almost all studies fail to evaluate or even mention DNR/DNI status.…”

Section: Introductionmentioning

confidence: 99%

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

Bosch

Nathan

et al. 2021

Journal of Clinical Orthopaedics and Trauma

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Background: The purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis. Methods: A retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables.Results: The DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p ¼ 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p ¼ 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p ¼ 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p ¼ 0.892). Conclusions: In our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.

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Section: Introductionmentioning

confidence: 99%

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

Bosch

Nathan

et al. 2021

Journal of Clinical Orthopaedics and Trauma

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“…Some clinicians also worry that by recording a DNAR decision, this may compromise other aspects of the patient's care. This is not unreasonable as systematic reviews have shown that surgical patients with DNARs have a worse mortality even when adjusted for other risk factors [12][13][14]. However, analysis has shown that in the hip fracture subgroup, DNAR is not an independent mortality risk factor [15].…”

Section: Discussionmentioning

confidence: 99%

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards

Heylen

Kemp

MacDonald

et al. 2021

Arch Orthop Trauma Surg

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Introduction The majority of neck of femur (NOF) fracture patients are frail and at a higher risk of cardiac arrest. This makes discussion of treatment escalation vital to informed care. The optimal time for these discussions is prior to admission or trauma. However, when this has not occurred, it is vital that these discussions happen early in the patient's admission when family is often present and before further deterioration in their condition. We undertook a service evaluation to evaluate and discuss the effect of clinician education on improving rates of timely discussion amongst orthopaedic doctors. Materials and methodsThe first cycle included 94 patients. Their notes were reviewed for presence of a ReSPECT (Recommend Summary Plan for Emergency Care and Treatment) form prior to operation and whether this it countersigned by a consultant. Following this, clinician education was undertaken and a re-audit was carried out involving 57 patients. Results ReSPECT form completion rates rose from 23% in cycle 1-32% in cycle 2 following intervention. The proportion which consultants signed rose from 41% to 56% following intervention. Conclusion This project demonstrates how a basic education program can prove limited improvements in the rates of timely resuscitation discussions. We discuss a current lack in quality research into educational programs for discussion of treatment escalation for orthopaedic trainees. We suggest there is room to improve national best practice guidelines and training to ensure these discussions are carried out more frequently and to a better standard.

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“…To take a similar example, past literature has demonstrated a strong association between do-not-resuscitate (DNR) status and adverse outcomes. [20][21][22][23][24] In all likelihood, the DNR status does not directly cause worse outcomes so much as it marks a sick and vulnerable population. Selection bias at the individual patient level may contribute to an association between comanagement and worse outcomes.…”

Section: Discussionmentioning

confidence: 99%

Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality mprovement Project

Maxwell

Mirza

2019

J Hosp Med

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H ip fractures are a large source of morbidity and mortality in the United States, with >1.5 million patients affected every year. 1 These patients are primarily older adults with a significant burden of associated medical comorbidities. 2 The outcomes of nonoperative management are poor with regard to mortality, 3 although operative management of hip fractures remains associated with a high rate of morbidity and mortality compared with several other surgical procedures, substantial resources remain devoted to the operative repair of hip fractures and to process improvement strategies for perioperative care.Medical comanagement involves having a second nonsurgical primary team-often an internist, a hospitalist, a geriatrician, or an anesthesiologist-who would follow the patient during the hip fracture admission, and provide daily care di-rected toward both the hip fracture and its associated management challenges and the patient's underlying comorbidities. This includes taking a primary or shared role in daily rounding, writing progress notes, writing orders, managing medications and therapies, disposition planning, and discharge. One argument for this practice has centered around an efficiency proposition for surgeons to spend more of their time operating and less time in these tasks of acute care management. The primary argument, though, for medical comanagement has been an outcomes proposition that frail, elderly patients with significant medical comorbidities benefit from a nonsurgeon's focused attention to their coexisting medical problems and the interaction with the surgical issues posed by operative intervention for hip fracture. A number of previous studies have demonstrated an association between comanagement and improved perioperative outcomes. 4,5 However, the most convincing improvements in several studies have been process indicators (eg, time from admission to surgery, length of stay, nurse/surgeon satisfaction) without significant differences in mortality or major morbidity. [6][7][8] Several studies were methodologically limited due to the use of historical controls, 9,10 and several were conducted in focused clinical settings (eg, a sin-

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Do-Not-Resuscitate status is an independent risk factor for patients undergoing surgery for hip fracture

Cited by 15 publications

References 41 publications

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

Pre-operative resuscitation discussion with patients undergoing fractured neck of femur repair: a service evaluation and discussion of current standards

Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality mprovement Project

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