Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway

Background: A geriatric hip fracture clinical pathway, led by an orthopedic surgeon, was developed in 2007. This clinical pathway team is multidisciplinary and consists of surgeons, physicians, anesthetists, nurses, physiotherapists, occupational therapists, medical social workers, dieticians as well as voluntary support groups. Methods: From early 2007 onward, all patients older than 65 years with acute isolated hip fractures were included. During the whole inpatient treatment, all relevant data were captured prospectively. The data in 2006, before the implementation of the clinical pathway, were collected retrospectively through computer record system. A study of the length of stay in acute and rehabilitation hospital and also the short-term mortality rate was carried out to compare the difference before and after the implementation of the pathway. Results: From 2007 onward, more than 1300 hip fractures were treated. After the implementation of the pathway, the preoperative length of stay was markedly shortened by 4 days, from an average of 6.1 days in 2006 to 1.5 days in 2011 (P < .05). The postoperative length of stay and the overall acute hospital length of stay also improved significantly. The length of stay in rehabilitation hospital was also significantly shorter in the 4-year period. Although the number of hip fractures increased annually with increased age and number of comorbidities each year, the inpatient mortality rate showed a gradual decrease from 2.7% in 2006 to 1.25% in 2010. The 30 days mortality rate also showed a decrease from 3.65% in 2006 to 2.75% in 2010. Conclusion: Geriatric hip fracture clinical pathway is an excellent approach to the geriatric hip fracture service. The most significant improvement is the dramatic shortening of the length of hospital stay. Our success in the past 5 years has proven its value and sustainability.

Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

The Effectiveness of a Geriatric Hip Fracture Clinical Pathway in Reducing Hospital and Rehabilitation Length of Stay and Improving Short-Term Mortality Rates

Lau

Fang

Leung

2013

“…As the addition of a trauma room has been shown to dramatically decrease the volume of overnight surgeries and complications, and as the institution of a hip fracture pathway for medical management has been shown to decrease perioperative morbidity, their results might not demonstrate as clear an effect of DTG versus NTG hip fracture repair. [42][43][44][45] In our cohort, institution of a hip fracture pathway as well as provision of a dedicated trauma room occurred prior to data collection, thus eliminating these factors as confounding variables.…”

Section: Discussionmentioning

confidence: 99%

Surgical Time of Day Does Not Affect Outcome Following Hip Fracture Fixation

Switzer

Bennett

Wright

et al. 2013

Background: Due to the need for medical optimization and congested operating room schedules, surgical repair is often performed at night. Studies have shown that work done at night increases complications. The primary aim of our study is to compare the rates of complications and 30-day mortality between 2 surgical times of day, daytime group (DTG, 07:00-15:59) and nighttime group (NTG,. Methods: Retrospective chart review from 2005 through 2010. Setting: Level 1 Trauma Center. Participants: 1443 patients with hip fracture, age 50 years with isolated injury and surgical treatment of the fracture. Main Outcomes and Measures: Thirty-day mortality and complications: myocardial infarction, cardiac event, stroke, central nervous system event, pneumonia, urinary tract infection, postoperative wound infection, and bleeding requiring transfusion of 3 or more red blood cell units. Results: A total of 859 patients met the inclusion criteria; 668 patients in the DTG and 191 patients in the NTG. The 30-day mortality was 7.8%. The complication rate was 28%. No difference was found in 30-day mortality or complication rate based on the time of day the surgery was performed (P ¼ 1.0 and P ¼ .92, respectively). This remained unchanged when controlling for health status and surgical complexity. Age (odds ratio ¼ 1.03/year), Charlson Comorbidity Index (CCI; odds ratio ¼ 1.21), and American Society of Anesthesiologists (ASA; odds ratio ¼ 1.85) score were predictive of adverse outcomes. Conclusion: Surgical time of day did not affect 30-day mortality or total number of complications. Age, ASA score, and CCI were associated with adverse outcomes.

“…This model of care has previously been shown to decrease length of stay (LOS), re-admission rates, complications, costs of care, and in-hospital mortality. 25,[31][32][33][34][35][36] …”

mentioning

confidence: 99%

The 1-Year Mortality of Patients Treated in a Hip Fracture Program for Elders

Schnell

Friedman

Mendelson

et al. 2010

379

231

Comanagement of geriatric hip fracture patients with standardized protocols has been shown to improve short-term outcomes after surgery. A standardized, patient-centered, comanaged Hip Fracture Program for Elders is examined for 1-year mortality. Patients 60 years of age who were treated in the Hip Fracture Program for Elders were comanaged by orthopaedic surgeons and geriatricians. Data including age, place of origin, procedure, length of stay, 1-year mortality, Charlson score, and activities of daily living (ADLs) were retrospectively collected. A total of 758 patients 60 years of age with hip fractures between April 15, 2005, and March 1, 2009, were included. Their data were analyzed, and the Social Security Death Index and the hospital data system were searched for mortality data. Seventy-eight percent were female, with a mean age of 84.8 years. The mean Charlson score was 3. Fifty percent were admitted from an institutional setting. The overall 1-year mortality was 21.2%. Age (odds ratio [OR] ¼ 1.03, 95% confidence interval [CI] ¼ 1.00-1.05; P ¼ .02), male gender (OR ¼ 1.55, 95% CI ¼ 1.01-2.36; P ¼ .04), low Parker mobility score (OR ¼ 2.94, 95% CI ¼ 1.31-6.57; P ¼ .01), and a Charlson score of 4 or greater (OR ¼ 2.15, 95% CI ¼ 1.30-3.55; P ¼ .002) were predictive of 1-year mortality. ADL dependence was a borderline predictor, as was medium Parker mobility score. Prefracture residence and moderate comorbidity (Charlson score of 2-3) were not independently predictive of mortality at 1 year after adjusting for other characteristics. A comprehensive comanaged hip fracture program for elders not only improves the short-term outcomes but also demonstrates a low 1-year mortality rate, particularly in patients from nursing facilities.Keywords geriatric trauma, systems of care, fragility fractures, hip, fractures, mortality Hip fractures in older adults are a leading public health concern. The incidence of hip fractures has been declining over the past decade; however, the total number of fractures has grown exponentially. 1 The number of hip fractures in the United States could total 840 000 by the year 2040.2,3 Older adults are the fastest growing segment of the US population. The population aged 65 years and older is predicted to more than double by 2050, increasing from 39 million today to 89 million. 4 It has been estimated that 1 in 3 women and 1 in 12 men will sustain a hip fracture in their lifetime.5 It has been reported that 86% of hip fractures occur in individuals aged 65 years and older. Hip fractures are associated with significant morbidity, mortality, loss of independence, and financial burden. [6][7][8][9][10][11][12] In usual care, the reported 1-year mortality after sustaining a hip fracture has been estimated to be 14% to 58% (Table 1). 1,7,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] The relative risk of mortality in the elderly patient population increases 4% per year. 30 The first year after a hip fracture appears to be the most critical time. A recent meta-ana...