The implementation of a clinical pathway enhancing early surgery for geriatric hip fractures: how to maintain a success story?

Abstract

Background Timing of surgery in geriatric hip fracture treatment remains controversial. Early surgery is acknowledged as quality indicator and NICE guidelines recommend surgery within 0 to 48 hours from admission. In 2014 we implemented the indicator early surgery in our institution, enhancing operative treatment within the next calendar day. We aimed to evaluate the implementation, define the room for improvement and provide strategies to maintain the quality indicator. Methods Clinical outcome of 744 patients (January 2011 -December 2013) before early surgery was implemented, was compared to 817 patients (June 2014 -May 2017) after implementation of early surgery with a follow-up of 6 months. Data-analysis was done by Pearson's Chi-square test and MannWhitney U test. Results Early surgery was achieved in 47.6% and 85.7% in the preimplementation and postimplementation group, respectively (P < 0.001). Both 30-days and 6-months mortality were similar (6.0% vs. 5.4%, P = 0.573 and 18.7% vs. 16.9%, P = 0.355, preimplementation vs. postimplementation, respectively). Early surgery resulted in a significantly shorter total length-of-stay (14 vs. 12 days, P < 0.001, preimplementation vs. postimplementation, respectively). Early surgery did not reduce the readmission rate. Conclusions The indicator early surgery has been successfully implemented. Early surgery resulted in a significantly shorter LOS. No significant reduction in 30-days and 6-months mortality, and 90-days readmission was observed. In order to maintain early surgery, continuous engagement and monitoring is required by all shareholders involved and if necessary, adjustment of the clinical route is appropriate.

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures

“…190 studies underwent full-text review, and 69 studies were selected for final analysis ( Figure and eAppendix 3 in the Supplement ). 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 …”

“…190 studies underwent full-text review, and 69 studies were selected for final analysis (Figure and eAppendix 3 in the Supplement). Among the final 69 improvement programs, 49 programs significantly decreased TTS 33,35,38,41,[43][44][45][46][47][48][49][51][52][53][54]56,57,[59][60][61][62][65][66][67][68][69][70][71][72][74][75][76][79][80][81][82][85][86][87][88]91,94,96,97,99,101,103 and 20 programs 39,40,42,50,…”

Effect of Early Mobilization on Hip and Lower Extremity Postoperative: A Literature Review

“…Mobilization that is carried out more than 24 hours is a predictor of an increase in the complication risk (9). The increase in the cost of hospitalization is also largely determined by the lengthening of the patient's length of stay after femoral fracture surgery (29).…”

Effect of Early Mobilization on Hip and Lower Extremity Postoperative: A Literature Review

“…Mobilization that is carried out more than 24 hours is a predictor of an increase in the complication risk (8). The increase in the cost of hospitalization is also largely determined by the lengthening of the patient's length of stay after femoral fracture surgery (25).…”