Fractured neck of femur: an audit of preoperative management

1
Fractured neck of femuran audit of
pre-operative management

• Matthew Gwinnutt
• University of Birmingham Medical School

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Fractured neck of femuran audit of
pre-operative management

• In the UK
• 70,000 hip fractures annually
• 120,000 cases per year by 2015
• 75 of patients are over 75 years of age
• 80 are female
• Average stay in hospital is 30 days
• 30-day mortality approximately 10
• Hip fractures account for 20 all orthopaedic bed
  occupancy

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Fractured neck of femuran audit of
pre-operative management

• Scottish Intercollegiate Guidelines Network
  (SIGN)
• Assessment, within 1 hour of arrival in the
  Emergency Department (ED)
• Early diagnosis
• Adequate analgesia before transfer of the patient
  from the ED
• Rapid transfer to the ward - fast tracking
• Minimise the delay to definitive surgery
• A multidisciplinary team approach
• Postoperative care and rehabilitation

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Fractured neck of femuran audit of
pre-operative management

• Minimise the delay to definitive surgery
• Operate as soon as possible, within 24 hours of
  admission during daytime working hours, including
  weekends
• Medical conditions delaying surgery increase
  30-day mortality by a factor of 2.5
• Non-medical delays cause
• Distress to the patient
• Increased morbidity and mortality
• Reduced chance of successful fixation and
  rehabilitation
• Reduced functional recovery
• Increased risk of DVT and PE
• Prolonged hospital stay

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Fractured neck of femuran audit of
pre-operative management

• Prospective audit, Oct 2007 Feb 2008
• All admissions to DGH with fractured neck of
  femur who underwent surgery
• Permission obtained from hospital Research and
  development department
• Data collected from clinical notes
• Admission and operation times
• Medical interventions performed pre-operatively
• Pre-op blood pressure, heart rate, urea
• Date of discharge
• In hospital mortality
• 3 month mortality
• Statistical evaluation of the effect of
  pre-operative variables on outcomes using t-test

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Fractured neck of femuran audit of
pre-operative management

• 66 patients
• Male 13 (20)
• Female 53 (80)
• Mean age 82yr (range 62 96yr)
• Type of surgical intervention

1
3
2
Dynamic hip screw (DHS) 32 (48.5)
Hemiarthroplasty 33 (50)
Total hip replacement (THR) 1 (1.5)
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Results

• Time to surgery
• 0 12hr 5 patients (7.6)
• 12 24hr 20 patients (30.3)
• 24 48hr 19 patients (28.8)
• gt48hrs 22 patients (33.3)
• Reasons for delay of gt24 hr

Treatment of Infection or arrhythmia 11 patients
Scheduling 27 patients

• INR correction
• 3 patients

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Results

• Differences in heart rate and blood pressure with
  delay

24hrs

• Heart rate
• lt24hrs 81bpm
• gt24hrs 82bpm
• p0.47

• Mean Arterial Pressure
• lt24hrs 96mmHg
• gt24hrs 94mmHg
• p0.32

24hrs
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Results
Effect of delay in surgery on length of stay
postoperatively
24hrs

• Mean post-op length of stay
• lt24hrs group 19.5 days
• gt24hrs group 19.0 days
• p 0.45

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Results

• Mortality
• In total 6 patients (9) died within 3 months of
  surgery
• 4 of these (6.5) were before discharge from
  hospital
• 3 / 4 were operated on lt24hrs after admission
• 2 died after discharge
• 1 was operated lt24hrs after admission
• None of the patients who died
• Waited gt48hrs from admission for surgery
• Were treated for a co-existing medical condition

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Conclusions

• In a DGH a significant proportion (approx 60) of
  patients wait longer than 24hrs before surgery
• Commonest reason for delay was lack of theatre
  time
• In the DGH studied, evidence suggests that
  delaying surgery does not increase mortality or
  length of stay
• Small sample size
• Fitter patients
• Close attention to pre-op care medical care
  cancels out the impact of delayed surgery
• Potential for distress to patient and impact on
  functional outcome
• More research needed to determine optimum
  management eg. National Hip Fracture database.