August 07, 2018
By Linda Carroll
(Reuters Health) - Seniors are more likely to survive a hip fracture if the break is repaired the day they're admitted to the hospital or the following day at the latest, a new study finds.
"The bottom line is that all patients should have hip fracture surgery within two days of hospitalization," said the study's lead author, Boris Sobolev, a professor at the University of British Columbia in Canada. "It's critical to reduce mortality because if the patients have surgery within two days there is less exposure to inflammation."
Another danger of waiting longer before hip fractures are repaired is that patients will spend more time bedridden, Sobolev said. "Lying in bed that long could lead to thrombosis and other complications."
The researchers analyzed data from 139,119 patients age 65 and older who had surgery for a first hip fracture at 144 hospitals in Canada from 2004 through 2012.
Altogether, 32,120 (23.1%) underwent surgery on admission day, 60,505 (43.5%) on inpatient day 2, 29,236 (21.0%) on day 3 and 17,258 (12.4%) after day 3.
Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3, they report in CMAJ, August 7.
The investigators project an additional 10.9 deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5%.
"This has been a question for a long time in the hip fracture world," said Dr. Samir Mehta, chief of the orthopedic trauma and fracture service at the University of Pennsylvania in Philadelphia. "Historically, we didn't understand how important it was to get the fracture fixed and the patient up and (moving)."
But that's been changing, said Mehta, who wasn't involved with the new study.
"We have a dedicated geriatric hip fracture program," Mehta said. "One thing we know is that the patient has to be medically optimized first. But we also know that lying in bed for more than 24 hours is bad. We published a study six or seven years ago on a year's-worth of hip fracture repairs with a zero complication rate, but readmissions to the hospital (happened because of) issues such as congestive heart failure or worsened dementia - not because the hip rebroke."
That experience, Mehta said, taught him that time was of the essence when it came to hip fractures. Because his hospital has a dedicated team performing geriatric hip fracture repairs, it doesn't matter when a patient shows up, "our goal from time of admission to surgery is 24 hours," he said. "We have about an 85 to 90 percent success rate. Our average is 18 hours."
In practice, that means if a patient shows up at 10 PM and is ready for surgery by morning, "we bump whoever is the first elective (nonemergency) surgery and the hip fracture is done first thing in the morning," Mehta said.
It helps to have an alert system for everyone on the team. "We took a page from stroke care," he said. "When a hip fracture comes in, an alert goes to all our phones."
That's how things work at the University of Pittsburgh, too. "It's a little easier for me since I'm a dedicated orthopedic trauma surgeon," said Dr. Ivan Tarkin, who is chief of orthopedic trauma at the University of Pittsburgh. "I can prioritize which cases are the most important. I can put an older patient with a hip fracture ahead of someone with a more routine injury."
"We run 24/7," Tarkin said. "I'd argue that at a tertiary care center it's easier to find the resources to take care of these patients in an efficient way."
Still, there are many institutions where patients may wait longer than 48 hours, especially when hospitals don't have a dedicated team. "I've pushed for this at various hospitals that do hip fractures, said Dr. Erik Zeegen, chief of joint replacement surgery at the University of California, Los Angeles. Zeegen is not affiliated with the new research. "It's not universally adopted at this point in time, but it should be. The problem is it requires a lot of resources. You're really talking about money to support all of this."
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