Pre-operative echocardiogram in hip fracture patients with cardiac murmur- an audit

Abstract

BackgroundAll hip fracture patients with a cardiac murmur have an echocardiogram as a part of their preoperative work-up in our unit. We performed a retrospective audit to assess the impact of obtaining a pre-operative echocardiogram on the management of hip fracture patients.MethodsAll hip fracture patients (N = 349) between 01/06/08 and 01/06/09 were included in the study. 29 patients had pre-operative echocardiogram (echo group). A computer generated randomised sample of 40 patients was generated from N, 'non-echo' group. Data was obtained from medical records and the Hospital Information Support System (HISS). The groups were compared using Student's t test. Approval was obtained locally from the clinical governance department for this project.ResultsAge and gender distribution were similar in both groups. Indication for echo was an acute cardiac abnormality in 4 cases. 25 patients had echo for no new cardiac problem (indication being cardiac murmur in 23 patients and extensive cardiac history in 2 cases). Cardiology opinion was sought in 5 cases. No patient required cardiac surgery or balloon angioplasty preoperatively. Patients having pre-operative echo had significant delay to surgery (average 2.7 days, range 0-6 days) compared to 'non-echo' group (average 1.1 days, range 0-3 days), (p < 0.001). There was no significant difference in length of stay (p = 0.14) and mortality at 30 days (p = 0.41) between the groups.ConclusionWe have developed departmental guidelines for expediting echo requests in hip fracture patients with cardiac murmur. A liaison has been established with our cardiology department to prioritise such patients on the Echocardiography waiting list, to prevent unnecessary avoidable delay. Careful patient selection for pre-operative echocardiography is important to avoid unnecessary delay to surgery.

Effect of Preoperative Transthoracic Echocardiogram on Mortality and Surgical Timing in Elderly Adults with Hip Fracture

“…There was also had no cardiac intervention in those small groups. 18 Other studies have also shown that TTE is not efficacious in predicting cardiac risk in individuals undergoing noncardiac surgery.…”

“…Another study found a 1-day-longer stay, with a greater treatment cost of approximately $6,000. 18 Finally, unnecessary testing can result in excessive intervention, as the fact that five participants in the TTE+ group (vs 1 in the TTEÀ) received cardiac catheterization based on TTE wall motion abnormalities exemplifies. No participant received angioplasty or stents or required further surgical cardiac intervention.…”

The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retrospective cohort study

“…Cardiac conditions associated with the highest rates of mortality in non‐cardiac surgery include aortic stenosis [13], cardiac failure [5] and pulmonary hypertension [14], all of which are more reliably assessed using echocardiography than clinical examination alone [15, 16]. Transthoracic echocardiography (TTE) is a useful non‐invasive investigation for screening and assessment of cardiac disease and risk, but is not always available before surgery and an associated delay of several days may be common [17–19]. Hence, it is frequently omitted [20] and decision‐making is based on clinical assessment alone, which may be less accurate [15–17, 21].…”

Financial impact and effect on the outcome of preoperative tests for at‐risk older hip fracture patients

“…These additional tests were found to be time-consuming, thus prolonging time to surgery and increasing hospital expenses. [1][2][3][4][5] We support the contention that the outcome of atrisk patients will be improved in all the American Society of Anesthesiology Physical Status (ASA) classes in a medical facility that permits early access to surgical intervention. 6 The efforts required to expedite the preparation of this population for prompt surgery are worth the final result of an increased survival rate.…”

“…Most of the reported studies involved the patient's cardiac assessment. 1,[3][4][5]10 Medical expenses associated with a patient's evaluation can have a significant impact on the hospital budget. Several studies reported that those expenses can greatly increase after major surgical procedures in various communities up to 32%, with a low intervention rate if at all in this older population.…”