Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority

Abstract

257Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority Background: Existing literature demonstrating the negative impact of delayed hip fracture surgery on mortality consists largely of observational studies prone to selection bias and may overestimate the negative effects of delay. We conducted an intervention study to assess initiatives aimed at meeting a 48-hour benchmark for hip fracture surgery to determine if the intervention achieved a reduction in time to surgery, and if a general reduction in time to surgery improved mortality and length of stay. Methods:We compared time to surgery, length of stay and mortality between pre-and postintervention patients with a hip fracture using the Kaplan-Meier estimator and Cox proportional hazards model adjusting for age, sex, comorbidities, type of surgery and year. Results:We included 3525 pre-and 3007 postintervention patients aged 50 years or older. The proportion of patients receiving surgery within the benchmark increased from 66.8% to 84.6%, median length of stay decreased from 13.5 to 9.7 days, and crude in-hospital mortality decreased from 9.6% to 6.8% (all p < 0.001). Conclusion:Coordinated, region-wide efforts to improve timeliness of hip fracture surgery can successfully reduce time to surgery and appears to reduce length of stay and adjusted mortality in hospital and at 1 year.

In-hospital mortality after hip fracture by treatment setting

“…15 However, between 6% and 10% of patients do not receive surgery, in some cases because of death while waiting for surgery. 16,17 To better understand the risk of in-hospital death by treatment setting, outcomes of both surgical and nonsurgical care should be considered. Therefore, we conducted this study to compare the risks of in-hospital death, overall and after surgery, between teaching hospitals and community hospitals of various bed capacities providing hip fracture care in Canada.…”

Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes

“…Although the change we studied had fewer com ponents than the intervention package introduced in 2008, it was nonetheless composite and, moreover, built upon prior measures that had already improved timeliness and related outcomes. 4 This inhibits generalization of the findings to other potential consolidations of orthopedic surgery. However, it is important to recognize that the regionalization of surgery is never a simple, single-component intervention.…”

“…Studies have shown that timely access to hip fracture surgery decreases mortality and may have posi tive impacts on length of stay (LOS) in hospital and surgical complications. [1][2][3][4] The Canadian Institute for Health Information has set a national benchmark for hip fracture repair to 48 hours from time of admission to hospital. 3 Consolidation or regionalization of surgical care is common in many Western countries and is widely considered to be best practice.…”

“…4 The proportion of patients receiving surgery within the 48-hour benchmark rose from 67% before 2008 to 85% after 2008, with concomitant decreases in LOS and mortality. 4 It should be noted that the 2008 intervention was well established before the present study's "preintervention" period began.…”

Mortality effects of timing alternatives for hip fracture surgery

“…63 We studied delays that occurred after admission to hospital; data on time between injury and arrival at the hospital and in the emergency department were not available. 64 It is possible the overall time from injury to surgery, and therefore exposure to immobilization and inflammation, was similar for inpatient day 1 and 2. We were unable to differentiate between surgeries done during and after working hours, because the data on timing of surgery on an hourly basis were not available.…”