Prospective Audit of Hip Fractures – South Wales, United Kingdom

Rupali D Shah, School of Clinical Medicine, Cardiff University, UK
Thomas I Lemon, School of Clinical Medicine, Cardiff University, UK
James Cordell-Smith, Department of Trauma and Orthopaedics, Royal Gwent Hospital, Newport, UK

ABSTRACT

Objective: To assess whether patients who required surgery for hip fractures were being operated on within 48 hours of admission (NICE guideline). To determine cause of delays and also analyse other patient information (for example, mobility status, length of stay and discharge destination).

Methods: Data was collected prospectively from patients at the Royal Gwent Hospital (RGH), Newport.

Results: Data from 25 patients was collected and analysed (15F:10M).Mean age of the patients was 80.5years (±11.3). 4% of patients were delayed to surgery due to institutional factors and 36% due to patient factors.

Conclusion: Most patients were operated on within the recommended time.

INTRODUCTION

Hip fractures are fractures that occur between the femoral head and approximately 5cm below the lesser trochanter [1]. It is an acute injury associated with severe pain, inability to weight bear or walk with the affected limb [2]. Hip fractures are a major health issue due to an ageing population. The incidence of hip fractures is estimated at 70-75,000 annually in the UK. It is predicted that by 2015, the incidence will have increased to 91,500 annually [4]. Incidence increases with age and doubles every decade after the age of 50 [3]. Hip fracture is a very common “geriatric syndrome” and imposes a high cost not only to the individual, but also the community [5].

Risk factors for hip fracture include:

• Genetic: Family history, Caucasians at higher risk

• Osteoporosis and increased age

• Sedentary lifestyle

• Smoking

• Excessive alcohol consumption

• Mental impairment

• Medications (e.g. anticonvulsants, corticosteroids)

• Osteomalacia (Vitamin D deficiency, malabsorption, liver disease)

• Cardiovascular diesase and arrhythmias

• Impaired vision

• Imparied coordination

• Underlying bone disease

• Endocrine abnormalities (hyperthyroidism, hyperparathyroidism, hypercortisolism)

Diagnosis of hip fractures is based on clinical findings and radiographs (usually anteroposterior and lateral). Magnetic Resonance Imaging (MRI) can be used for diagnosis of occult fractures [6].

The main aim of treatment is to get the patient to the same level of function as before the injury. Surgery and early mobilisation are very effective for functional recovery [4,6].

The main complications of hip fractures occur due to immobility, for example, bronchopneumonia, deep vein thrombosis (DVT), skin ulceration and rhabdomyolysis [6]. Complications of the fracture itself include avascular necrosis (AVN) and secondary osteoporosis. Postoperative death is usually as a result of patient co-morbidities.

There are many classifications of hip fractures for example, the A0 and Garden classification. Figure 1 shows a simple classification of hip fractures, and figure 2 shows the Garden classification.

Figure 1. Basic anatomy of the femur, showing the basic anatomy (femoral head and the trochanters)

Figure 2. The Garden classification of hip fractures A- Stable fracture: there is an incomplete break and minimal displacement of the neck of femur (NOF). B- Complete fracture through the NOF, however there is no displacement. C- Complete fracture and there is partial displacement. D- Complete fracture with complete displacement. There is no engagement of the 2 fragments

Management depends on the location of the fracture and degree of displacement if present [6] (summarised in table 1).

Table 1: Conservative and Surgical management of hip fractures. *Complications of fracture healing include non-union, painful joint and limited movement.

The National Institute for Clinical Excellence (NICE) suggests patients with hip fractures should be operated on within 48 hours of admission. There is empirical evidence suggesting an increase in the odds of mortality by 41% (in 30 days) and 32% (in one year) due to operative delay in patients with hip fractures [8].

OBJECTIVES

The aim of the study was to investigate whether patients who required surgery for hip fractures were being operated on within 48 hours of admission (guideline suggested by NICE for the management of hip fractures). The study also looked at patient co-morbidities, length of stay in hospital, discharge destination and mobility status pre and post-operatively.

METHODS

An audit proforma was designed. The sample included patients requiring surgery for hip fractures who were admitted to the Royal Gwent Hospital. The study involved gathering information directly (from patients) and indirectly (examining patient notes).

Most retrospective studies do not look at the patient journey throughout the hospital admission. Prospective studies aim to capture more patient oriented information. For this reason, a prospective study design was chosen.

This study was approved by the medical school projects committee.

RESULTS

Data was collected from 25 patients who were admitted between 04/05/2012 and 04/06/2012. 15 of these patients were female and 10 male (3F:2M). One of the patients included in the study died 11days after the operation. As such, only half their data was available for analysis. During the time of analysis of results, 7 patients were still inpatients in the hospital; 1 of the 7 patients was under the care of the medical team due to other co-morbidities. The data are summarised in tables 2-8.

Table 2. Mean age of patients at point of data collection

Table 3. Mean number of major co-morbidities

Table 4. Reasons for delay to surgery. More than one factor could have contributed. All but one of the delays was due to patient factors (no space on trauma list)

Table 5. Mobility status of patients pre and post-operatively. *One patient died 11 days after surgery and mobility at discharge could not be measured as some patients were inpatients.

Table 6. Mobility changes seen in patients at discharge. *Mobility was described as “improved” if they were previously bedbound and required a mobility aid to mobilise at discharge or if they previously used a zimmer- frame and mobilised with a walking stick at the time of discharge.
**Mobility was said to have “decreased” if patients who used to walk independently required mobility aids during discharge or became immobile, or if they used mobility aids prior to the fracture and were immobile at time of discharge.

Table 7. Discharge destination

Table 8. Length of Stay (LOS) in hospital

DISCUSSION

In this study, 60% of patients were operated on within 48 hours and 36% were not due to various patient factors (table 4). 4% were not operated on within 48 hours due to lack of space on a trauma list. Of the 60% operated on within 48 hours, 4% could have been operated on sooner, had it not been for a delay in blood transfusion. Similar results were obtained by Fantini et al [8]. Delays in surgeries due to lack of theatre space could be overcome by having more trauma lists. However, this would bring in the controversial cost-effective debate. More research into the cost-effectiveness of having more trauma lists would be beneficial. A 2007 study carried out estimated the cost of running an operating theatre (for a day) at £4,800 and estimated the staffing cost at £530 per list [10]. Delays to surgery are related to increased length of stay in hospital and other costs to the patient’s health [14].

Delays due to patient factors (which could not be modified) are unavoidable. American Society of Anaesthologists (ASA) Score would be useful in determining whether patients were fit for surgery and could illuminate causes of delays to surgery [8,11].

Patient demographics, such as mean age calculated in this study (80.5years(±11.3)) was similar to ones calculated in studies by Fantini et al [8] and Taylor & Narin [12]. Studies by Fantini et al8, Sanchez-Crespo et al [11] and Taylor & Narin [12] have shown the female percentage of patients to be between 71.4% and 81.6% in their studies. 60% of the patients in this study were female. This may have been due to the limited sample size.

The mean number of major co-morbidities per patient for all patients was 2.9(±1.7). The number of co-morbidities has been linked to survival by Kim et al [16]. Hommel et al [13] noted that there was a longer time to surgery for patients with more co-morbidities. This study concluded that there was no relationship between the mean number of major co-morbidities and delay to surgery.

Studies have shown the relationship between length of stay (LOS) and delay to surgery. However this study did not find such a relationship. The mean LOS for patients who were delayed was 13.8 days (±5.3) and mean LOS for patients who were not delayed to surgery was 14.4 days (±6.9). The average LOS for the patients who were discharged was 13.8 days (±5.3) and another patient who was delayed passed away. This could be attributed to the small sample size and also the fact that 7 patients were still inpatients while the report was being written. Hommel et al [13] and Orosz et al [14] concluded that a delay to surgery increased LOS. Studies could be done in the future to analyse mobility status or mobility progression after surgery and how this relates to the LOS or analyse the impacts of complications in surgery on LOS. The average length of follow up was 17.8 days (±7.5). As mentioned previously, one patient passed away and 9 patients were still in patients whilst data was being analysed.

Discharge destinations included the patient’s own home, residential homes and rehabilitation hospitals. During data collection, it was noted that there may have been a delay in discharge due to a lack of available bed space in rehabilitation hospitals. This increased the LOS of some patients. Future investigations could look further into the relationship between available bed space at the rehabilitation hospital and LOS.

Mobility status was analysed in the study (table 5 & 6). 11.76% of patients had improved mobility, 52.94% regained the same level of mobility and 35.29% had decreased mobility. The apparent decrease in mobility seen in some patients following surgery is unlikely to be a true reflection of the effect surgery has. It is reasonable to assume an increase to optimal mobility will be achieved in the near future, since the decrease in mobility is likely to represent the patient recovering from the trauma of surgery; Umarji et al [17] concluded that deterioration in mobility was due to acquired illness whilst in hospital. The improved mobility seen in this study could be attributed to patients who may have been less mobile in the community being encouraged to mobilise in hospitals. Further studies could investigate the type of operation with mobility status at discharge and in the long-run, and information could also be analysed about the time taken to regain the level of mobility.

The main limitation of this study was the time frame analysed which led to a small sample size. A larger sample size would increase the strength of the conclusions attained in this study. To determine whether the 48 hour operative target is being attained, other studies can be carried out in the future. This study could also potentially be re-audited.

CONCLUSIONS

Overall, this study concludes that the recommended guidelines for the surgical management of hip fractures are being complied with in the RGH. Further audits focusing on delays due to co-morbidities or delays encountered with different types of procedures (for example intramedullary nailing and hemiarthroplasty) could be carried out. Studies could be carried out to investigate the best strategies for improving the outcome of hip fractures and to look at reducing length of stay in hospital.

References: 

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