Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium

Factors involved in the development of hospital-acquired conditions in older patients in acute care settings: a scoping review

BACKGROUND

Older patients hospitalized in acute care settings are at significant risk of presenting hospital-acquired conditions. Healthcare professionals should consider many factors involved in the development of such conditions, including factors related to the patients, as well as those related to the processes of care and the structure of hospitals. The aim of this study was to describe and identify the factors involved in the development of hospital-acquired conditions in older patients in acute care settings.

METHODS

A scoping review was performed based on a structured search in eight databases in September 2022. Data were extracted with an extraction tool and classified into categories. Mapping and a narrative summary were used to synthetize data.

RESULTS

A total of 237 articles were included in the scoping review. Functional decline and delirium were the most frequent hospital-acquired conditions studied. Among all categories, factors related to the patients provided most of the data, whereas factors related to the processes of care and the structure of hospitals were less frequently explored. In most articles, one or two categories of factors were retrieved; fewer articles examined factors among three categories. Personal factors, medications, and the human and work environment were the most frequent subcategories of factors retrieved, whereas social factors, hydration and nutrition, and organizational factors were less common.

CONCLUSIONS

The development of hospital-acquired conditions in older patients in acute care settings involves many factors related to the patients, as well as to the processes of care and the structure of hospitals. Prevention of hospital-acquired conditions must involve to consider the complexities of older patients and of acute care hospitals. Not considering all categories of factors might affect the implementation of new practices of care and interventions.

Incidence of urinary incontinence after hip fracture surgery and associated risk factors: a prospective study

BACKGROUND

The contribution of the postoperative process to developing or worsening urinary incontinence (UI) after hip fracture surgery (HFS) remains unclear. We aimed to evaluate UI incidence and worsening among older patients undergoing HFS, and explore associated risk factors.

METHODS

This prospective cohort study included patients ≥ 75 years admitted between October 2019 and October 2021 to the Traumatology Service of three hospitals in the Consorci Sanitari de Alt-Penedès i Garraf (Barcelona, Spain) with hip fracture requiring surgical treatment. UI was assessed using the first two questions of the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) at baseline and at days 30 (± 3 days) and 90 (± 3 days) after HFS. Surgery-related data and post-surgical complications were recorded.

RESULTS

A total of 248 patients with a mean (SD) age of 85.8 (6.78) years were included; 77.8% were female and 154 (62.1%) had UI at baseline. After HFS, 3.24% experienced urinary tract infections (UTIs), 3.64%, acute urinary retention (AUR), 8.57%, constipation, and 53.9%, prolonged catheterization (> 24 h). Fifty-eight patients without baseline UI developed UI at 30 days, resulting in a UI incidence of 61.7% (95% CI 51.1-71.54) between days 0 and 30. Of the 248 patients, 146 (59.1%) experienced worsening of UI. AUR and UTIs were identified as risk factors for UI development and worsening after HFS, respectively.

CONCLUSION

The incidence of UI in older patients after HFS is significant. Patient management protocols should consider AUR and UTIs to reduce or eliminate the incidence of UI in older patients undergoing HFS.

Inclusion of frailty improved performance of delirium prediction for elderly patients in the cardiac intensive care unit (D-FRAIL): A prospective derivation and external validation study

BACKGROUND

The elderly patients admitted to cardiac intensive care unit (CICU) are at relatively high risk for developing delirium. A simple and reliable predictive model can benefit them from early recognition of delirium followed by timely and appropriate preventive strategies.

OBJECTIVE

To explore the role of frailty in delirium prediction and develop and validate a delirium predictive model including frailty for elderly patients in CICU.

DESIGN

A prospective, observational cohort study.

SETTINGS

CICU at China-Japan Friendship Hospital from March 1, 2022 to August 25, 2022 (derivation cohort); CICU at Beijing Anzhen Hospital affiliated to Capital Medical University from March 14, 2023 to May 8, 2023 (external validation cohort).

PARTICIPANTS

A total of 236 and 90 participants were enrolled in the derivation and external validation cohorts, respectively. Participants in the derivation cohort were assigned into either the delirium (n = 70) or non-delirium group (n = 166) based on the occurrence of delirium.

METHODS

The simplified Chinese version of the Confusion Assessment Method for the Diagnosis of Delirium in the Intensive Care Unit was used to assess delirium twice a day at 8:00-10:00 and 18:00-20:00 until the onset of delirium or discharge from the CICU. Frailty was assessed using the FRAIL scale during the first 24 h in the CICU. Other possible risk factors were collected prospectively through patient interviews and medical records review. After processing missing data via multiple imputations, univariate analysis and bootstrapped forward stepwise logistic regression were performed to select optimal predictors and develop the models. The models were internally validated using bootstrapping and evaluated comprehensively via discrimination, calibration, and clinical utility in both the derivation and external validation cohorts.

RESULTS

The study developed D-FRAIL predictive model using FRAIL score, hearing impairment, Acute Physiology and Chronic Health Evaluation-II score, and fibrinogen. The area under the receiver operating characteristic curve (AUC) was 0.937 (95% confidence interval [CI]: 0.907-0.967) and 0.889 (95%CI: 0.840-0.938) even after bootstrapping in the derivation cohort. Inclusion of frailty was demonstrated to improve the model performance greatly with the AUC increased from 0.851 to 0.937 (p < 0.001). In the external validation cohort, the AUC of D-FRAIL model was 0.866 (95%CI: 0.782-0.907). Calibration plots and decision curve analysis suggested good calibration and clinical utility of the D-FRAIL model in both the derivation and external validation cohorts.

CONCLUSIONS

For elderly patients in the CICU, FRAIL score is an independent delirium predictor and the D-FRAIL model demonstrates superior performance in predicting delirium.

Urinary tract infection in patients with hip fracture

INTRODUCTION

Urinary tract infection (UTI) is a frequent complication of hip fractures. The Danish national clinical guideline for hip fracture recommends early and systematic mobilisation after surgery and that indwelling catheters are not used perioperatively.

AIMS

The aim of this study was to describe the number of patients who received nursing care to prevent UTIs in accordance with the recommendations from the national Danish clinical guidelines. Specifically, the aim was to report the number of patients developing UTIs during admission, have indwelling catheters removed and being mobilised with 24 hours after surgery.

METHODS

This prospective study included 65 patients. Data were collected on mobilisation and catheter use with a chart designed for this study. Sterile intermittent catheterisation was used to collect urine samples on admission and at discharge. Urine samples were sent for analysis at the microbiology laboratory. The urine sample was positive for UTI if the test showed 10⁴ CFU/ml bacteria.

RESULTS

A total of five patients contracted nosocomial UTI during their hospital stay (7.7%), while 29.2% of patients had a positive urine culture on admission and were treated for UTI. At discharge, 20% of the patients had a positive urine sample but no symptoms. Postoperatively, 52.3% of the patients were mobilised within 24 hours.

CONCLUSION

The incidence of nosocomial UTI was similar to what has been found in other studies (95% [CI], 0.03-0.17]). The percentage of patients with nosocomial UTI was 7.7%. Nursing care related to hygienic performance of catheterisation or intermittent catheterisation adhered to the Danish national clinical guidelines, and 52.3% of the patients were mobilised within 24 h after surgery, which showed low adherence to the guidelines.

Pull the Foley: Improved Quality for Middle-Aged and Geriatric Trauma Patients Without Indwelling Catheters

INTRODUCTION

Urinary tract infection (UTI) complications are often attributed to the inappropriate use of urinary catheters.

PURPOSE

We sought to examine the effectiveness of a hospital-wide policy aimed at reducing the use of indwelling Foley catheters.

METHODS

We completed a retrospective review of prospectively collected data on 577 hip and femur fracture patients aged 55 years and older who were operatively treated at a Level 1 trauma center between October 2014 and March 2019. New standard-of-care guidelines restricting the use of indwelling Foley catheters were implemented starting January 2018, and we compared perioperative outcomes between cohorts.

RESULTS

Over a 50% absolute reduction in indwelling Foley catheter use and a near 30% relative reduction in hospital-acquired UTI were achieved. Postpolicy cohort patients without indwelling Foley catheters experienced lower odds of hospital-acquired UTI, higher odds of home discharge, as well as decreased time to surgery, shorter length of stay, and lower total inpatient cost compared with those with indwelling Foley catheters.

CONCLUSIONS

The policy of restricting indwelling Foley catheter placement was safe and effective. A decrease in indwelling Foley catheter use led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes.

Holistic Management of Older Patients With Hip Fractures

As the silver tsunami hits the world, older patients with hip fractures are expected to increase to 6.3 million by the year 2050, of which the majority will occur in Asia. The estimated global cost of hip fractures in the year 2050 is estimated to reach U.S. $130 billion. Hence, in addition to implementation of prevention strategies, it is important to develop an optimal model of care for older patients with hip fracture to minimize the huge medical and socioeconomic burden, especially in rapidly aging nations. This review summarizes the complications of hip fractures, importance of comprehensive geriatric assessment, and multidisciplinary rehabilitation, as well as predictors of rehabilitation outcome in older patients with hip fracture.

Postoperative delirium after hip surgery is a potential risk factor for incident dementia: A systematic review and meta-analysis of prospective studies

BACKGROUND

Although a few trials have explored the relationship between postoperative delirium (POD) and incident dementia in patients with hip surgery, the numbers of participants in each study are relatively small. Thus, we performed a meta-analysis to examine whether POD after hip surgery is a risk factor for incident dementia.

METHODS

Six prospective cohort studies investigating the development of incident dementia in patients with POD after hip surgery were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- and random- effect models.

RESULTS

POD significantly increased the risk of incident dementia and cognitive decline (overall odds ratio [ORs] = 8.957; 95 % confidence interval [CI], 5.444-14.737; P <  0.001 in fixed-effects model; overall ORs = 8.962; 95 % CI, 5.344-15.029; P <  0.001 in random-effects model). A publication bias was not evident in this study.

CONCLUSIONS

Our meta-analysis revealed that POD after hip surgery is a risk factor for incident dementia. Early identification of cognitive function should be needed after surgery and appropriate prevention and treatment for dementia will be required, especially in cases with POD.

Increased risk of mortality after postoperative infection in hip fracture patients

BACKGROUND

Postoperative infection is a common complication in hip fracture patients and the risk appears to have increased during the last decade. However, the impact of infection on mortality after hip fracture surgery remains unclear.

PURPOSE

We aimed to examine the association between infection (any, as well as specific infections), with all-cause mortality following hip fracture surgery.

METHODS

Using Danish nationwide registries, we conducted a population-based cohort study on 74,771 hip fracture patients ≥65 years old operated from 2005 to 2016. We included hospital-treated infection as a time-varying exposure, and calculated 30-days mortality rate per 1000 person-years (PY). We used time-varying Cox Proportional Hazard Regression to compute 30-days adjusted hazards ratios (aHRs) with 95% confidence interval (CI) comparing the mortality of hip fracture patients with and without infections. We adjusted for sex, age, comorbidities, medication use, and marital status.

RESULTS

Within 30 days of surgery, 9592 (12.8%) patients developed a hospital-treated infection. Among these, 30-days mortality was 8.43 per 1000 PY compared with 3.34 among patients without infection (aHR = 2.72, 95% CI: 2.56-2.88). For patients who developed pneumonia, aHR was 4.18 (95% CI: 3.91-4.48), whereas the aHR was 8.86 (95% CI: 7.88-9.95) for patients who developed systemic sepsis. For patients who sustained reoperation due to infection, aHR was 2.95 (95%CI: 1.88-4.64). The mortality was higher in infected vs. non-infected patients irrespective of patients' age, sex and comorbidity.

CONCLUSION

Infection within 30 days of hip fracture surgery is associated with substantially increased mortality risk. Further research should improve our knowledge about patients at increased risk and prevention measures for specific infections.

Fascia iliaca compartment block as a preoperative analgesic in elderly patients with hip fractures - effects on cognition

BACKGROUND

Impaired cognition is a major risk factor for perioperative delirium. It is essential to provide good pain control in patients with hip fractures and especially important in patients with severely impaired cognitive status, as they receive less pain medication, have poorer mobility, poorer quality of life and higher mortality than patients with intact cognition. The purpose of this study was to examine the association between preoperative pain management with nerve blocks and cognitive status in patients with hip fractures during the perioperative period.

METHODS

One hundred and twenty-seven patients with hip fractures participating in a double-blind, randomised, controlled trial were included in this study. At hospital admission, a low-dose fascia iliaca compartment block (FICB) was administered as a supplement to regular analgesia. Cognitive status was registered on arrival at hospital before FICB and on the first postoperative day using the Short Portable Mental Status Questionnaire.

RESULTS

Changes in cognitive status from arrival at hospital to the first postoperative day showed a positive, albeit not significant, trend in favour of the intervention group. The results also showed that patients with no or a moderate cognitive impairment received 50% more prehospital pain medication than patients with a severe cognitive impairment. FICB was well tolerated in patients with hip fractures.

CONCLUSION

Fascia iliaca compartment block given to patients with hip fractures did not affect cognitive status in this study. Patients with a cognitive impairment may receive inadequate pain relief after hip fracture and this discrimination needs to be addressed in further studies.

TRIAL REGISTRATION

EudraCT number 2008-004303-59 date of registration: 2008-10-24.

Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery.

Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used.

Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium.

Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period.

Risk factors for onset of delirium after neck of femur fracture surgery: a prospective observational study

BACKGROUND

Delirium is a common complication after surgery in the elderly that leads to increased length of stay and other adverse outcomes. The aim of this study was to better understand the exact causes of post-operative delirium in patients undergoing surgery for neck of femur (NOF) fractures.

METHODS

We performed a prospective cohort study of 381 consecutive patients undergoing surgery for NOF fractures at a single institution. Baseline cognitive status and risk factors were recorded on admission. Post-operative cognitive status was assessed at regular intervals until discharge. Binary logistic regression was performed to identify independent predictors of delirium.

RESULTS

Patients who developed post-operative delirium (n = 70) were significantly older (average age 83 vs. 78, p = 0.019) and more likely to be female (79% vs. 67%, p = 0.062) than non-affected patients. The presence of delirium was associated with increased length of stay (13 vs. 10 days, p = 0.001) and 1-year mortality (25.7% vs. 15% p = 0.03). Independent predictors of delirium included age ≥65 years (Odds Ratio = 5.8), presence of anaemia (OR = 2.9), hypoxia (OR = 2.86), cardiac disease (OR = 2.8), Chronic Obstructive Pulmonary Disease (OR = 2.5), new onset electrolyte imbalance (OR = 2.2) and renal failure (OR = 1.9).

CONCLUSION

Overall analysis demonstrated an increased incidence of delirium in older females with greater comorbid conditions. It was also found to be associated with increased morbidity and mortality. We recommend clinicians put greater effort into recognising risk factors of delirium and diagnosing it in a timely manner to mitigate its effects.

Complications during hospitalization and risk factors in elderly patients with hip fracture following integrated orthogeriatric treatment

INTRODUCTION

This study aimed to evaluate the incidence of complications in elderly patients with a hip fracture following integrated orthogeriatric treatment. To discover factors that might be adjusted, in order to improve outcome in those patients, we examined the association between baseline patient characteristics and a complicated course.

METHODS

We included patients aged 70 years and older with a hip fracture, who were treated at the Centre for Geriatric Traumatology (CvGT) at Ziekenhuisgroep Twente (ZGT) Almelo, the Netherlands between April 2011 and October 2013. Data registration was carried out using the clinical pathways of the CvGT database. Based on the American Society of Anesthesiologists (ASA) score, patients were divided into high-risk (HR, ASA 3 ≥, n = 341) and low-risk (LR, ASA 1-2, n = 111) groups and compared on their recovery. Multivariate logistic regression was used to identify risk factors for a complicated course.

RESULTS

The analysis demonstrated that 49.6% (n = 224) of the patients experienced a complicated course with an in-hospital mortality rate of 3.8% (n = 17). In 57.5% (n = 196) of the HR patients, a complicated course was seen compared to 25.2% (n = 28) of the LR patients. The most common complications in both groups were the occurrence of delirium (HR 25.8% vs. LR 8.1%, p ≤ 0.001), anemia (HR 19.4% vs. LR 6.3%, p = 0.001), catheter-associated urinary tract infections (CAUTIs) (HR 10.6% vs. LR 7.2%, p = 0.301) and pneumonia (HR 10.9% vs. LR 5.4%, p = 0.089). Independent risk factors for a complicated course were increasing age (OR 1.04, 95% CI 1.01-1.07, p = 0.023), delirium risk VMS Frailty score (OR 1.57, 95% CI 1.04-2.37, p = 0.031) and ASA score ≥3 (OR 3.62, 95% CI 2.22-5.91, p ≤ 0.001).

CONCLUSIONS

After integrated orthogeriatric treatment, a complicated course was seen in 49.6% of the patients with a hip fracture. The in-hospital mortality rate was 3.8%. Important risk factors for a complicated course were increasing age, poor medical condition and delirium risk VMS Frailty score. Awareness of risk factors that affect the course during admission can be useful in optimizing care and outcomes. In the search for possible areas for improvement in care, targeted preventive measures to mitigate delirium, and healthcare-associated infections (HAIs), such as CAUTIs and pneumonia are important.

The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients

AIM

To investigate the association of the neutrophil to lymphocyte ratio (NLR) at admission with presence of fracture, comorbid conditions, and its prognostic value for short-term outcomes in orthogeriatric patients.

METHODS

On 415 consecutive patients (mean age 78.8 ±8.7[SD] years, 281 women, 255 with a non-vertebral bone fracture, including 167 with a hip fracture, HF) admitted to the Department of Orthopaedic Surgery at the Canberra hospital (2010 - 2011) data on clinical and laboratory characteristics were collected prospectively. The validation dataset included 294 consecutive patients (mean age 82.1 ± 8.0 years, 72.1% women) with HF.

RESULTS

Multivariate regression revealed four variables, presence of HF, hypoalbuminaemia (<33g/L), anaemia (<120g/L) and hyperparathyroidism (PTH>6.8 pmol/L), as independent determinants of admission NLR≥5.1. There was a dose-graded relationship between presence of fracture, especially HF, postoperative complications and levels of NLR categorized as tertiles. Compared to patients with NLR<5.1(first tertile), patients with NLR 5.1-8.5 (second tertile) had a 1.8-, 3.1-, 2.6-, and 2.5-fold higher risk for presence of any fracture, HF, developing postoperative myocardial injury (troponin I rise) and a high inflammatory response/infection (CRP>100mg/L after the 3rd postoperative day), respectively, while in subjects with NLR>8.5 (third tertile) these risks were 2.6-, 4.9-, 5.9- and 4.5-times higher, respectively; subjects with NLR>8.5 had a 9.7 times higher chance of dying in the hospital compared to patients with NLR 5.1-8.5; the NLR retained its significance on multivariate analyses. The NLR ≥5.1 predicted postoperative myocardial injury with an area under the curve (AUC) of 0.626, CRP>100mg/L with AUC of 0.631 and the NLR >8.5 predicted in-hospital mortality with an AUC of 0.793, showing moderately high sensitivity (86.7%, 80% and 90%, respectively) and negative predictive value (92.9%, 71.2%, 99.6%, respectively), but low specificity. Admission NLR was superior to other, except hypoalbuminaemia, prognostic markers; combined use of both NLR≥5.1 and albumin<33g/L only moderately increased the accuracy of prediction. The validation study confirmed the prognostic value of the admission NLR.

CONCLUSIONS

In orthogeriatric patients, high NLR on admission is an independent indicator of fracture presence, a significant risk factor and moderate predictor of postoperative myocardial injury, high inflammatory response/infection and in-hospital death.