Introducing the "hip call" to facilitate early surgical treatment of hip fractures: A feasibility study

Readmission and mortality before and after introduction of orthogeriatric home visits: A retrospective cohort study in hip fracture patients

INTRODUCTION

Orthogeriatric collaboration in hip fracture patients during admission is well established, however, orthogeriatric involvement after discharge is not common. The aim of this study was to explore the association of orthogeriatric home visits with 30-day and 120-day readmission and mortality in ≥ 65-year-old patients surgically treated for hip fractures.

MATERIALS AND METHODS

A cohort of patients who underwent acute hip fracture surgery in an usual care period from January 2018 to December 2018 was compared with a cohort of patients in an intervention period from June 2020 to June 2021. During the intervention period, patients were offered orthogeriatric home visits at day 2 and 9 after discharge. The home visits were performed by orthogeriatric nurses, in close collaboration with geriatricians and orthopedic surgeons based in the local hospital. Readmission was defined as ≥ 12 h hospital stay, regardless of reason. For the main analysis, we applied Cox-regression models adjusted for age, sex, New Mobility Score, Cumulated Ambulation Score regained, cognitive function, Charlson Comorbidity Index, complications, medication, discharge destination and emergency department visits.

RESULTS

In total, 292 patients were included during the usual care period, and 308 patients during the intervention period. Thirty- and 120-day readmission rates were 27.7 % and 41.4 % in the usual care cohort vs. 21.8 % and 35.1 % in the home visit cohort. Adjusted Hazard Ratios for readmission in the intervention cohort after 30 and 120 days were 0.67 (CI95 %: 0.48-0.93) and 0.71 (CI95 %: 0.54-0.93) respectively. Thirty- and 120-day mortality rates were 7.2 % and 20.9 % in the usual care cohort versus 5.8 % and 13.3 % in the intervention cohort. Adjusted Hazard Ratios for mortality in the intervention cohort after 30 and 120 days were 0.68 (CI95 %: 0.35-1.31) and 0.56 (CI95 %: 0.37-0.84) respectively.

CONCLUSIONS

In a period where hip fracture patients were offered two home visits after discharge, we observed lower 30- and 120- day readmission, and lower 120-day mortality, calling for more studies with a randomized design.

Intensified acute in-hospital physiotherapy for patients after hip fracture surgery: a pragmatic, randomized, controlled feasibility trial

PURPOSE

Intensified acute in-hospital physiotherapy (IP) after hip fracture (HF) may enhance patient's ability to regain basic mobility at discharge. The primary objective was to assess the feasibility of IP. Secondary to estimate the effect of IP on regained basic mobility at discharge.

MATERIALS AND METHODS

In a pragmatic, randomized, unblinded feasibility trial, 60 patients (mean age 79 years, 41 women) with HF and an independent pre-fracture basic mobility level were randomized (2:1) to IP with two daily sessions on weekdays focusing on functional training and weight-bearing activities (n = 40) versus usual care (UC) physiotherapy once daily (n = 20). Feasibility outcomes included physiotherapy completion rates, reasons for non-successful completion, and adverse events. The primary effect outcome was recovery of basic mobility (Cumulated Ambulation Score (CAS)).

RESULTS

Eighty-two percent of the sessions in the IP group were successfully- or partially completed versus 94% of the sessions in the UC group. No adverse events occurred. The main reason for not completing physiotherapy was fatigue. At discharge (median 7 days), 50% in the IP group had regained their pre-fracture basic mobility level (CAS = 6) versus 16% in the UC group; odds ratio = 5.33, 95%CI [1.3;21.5].

CONCLUSIONS

IP seems feasible for patients after HF surgery, and it may enhance recovery. Fatigue was the primary obstacle to completing IP.

What is the impact of a fast-track pathway on length of stay for adult patients with a hip fracture? A systematic review

INTRODUCTION

In orthopaedic surgery, hip fracture patients represent one of the largest cohorts. Hip fracture is a serious injury commonly occurring in frail and elderly patients. Fast-track admission pathways aim to streamline patients through accident and emergency departments, resulting in shorter wait times and less negative patient outcomes.

AIM

To examine the impact of a fast-track pathway on length of stay for adults admitted to an acute hospital with a hip fracture.

METHODS

CINAHL Plus with Full text (via EBSCO host), MEDLINE, Cochrane Library, and Embase database searches were carried out in January 2021, to find all relevant literature for this review, as well as through searching additional sources. Eligible studies were quantitative primary research, focusing on the use of fast-track admission pathway care versus usual care, for adults with a hip fracture. The assessment of study suitability, data extraction, and critical appraisal was carried out by two independent authors. A narrative analysis of the data was conducted, and data were meta-analysed using RevMan where possible. Quality appraisal of the included studies was undertaken using the EBL checklist.

RESULTS

Seven studies reporting data on 5723 patients were included. Length of stay, time to surgery, and mortality did not differ significantly between the fast-track care, and usual care. One study reported on delirium and found statistically significantly fewer encounters of delirium in fast-track care versus usual care. Four of the seven studies satisfied rigorous quality appraisal (> 75%) using the EBL.

CONCLUSION

The fast-track pathway avoided unnecessary delays in emergency departments due to faster X-rays, direct admission to orthopaedic wards, and reduced delirium rates. However, results were unable to show the impact of fast-track on length of stay, time to surgery, and mortality.

Pre-operative epidural analgesia in hip fracture patients - A systematic review and meta-analysis

BACKGROUND

Hip fracture is a common, painful injury with increasing global incidence. Patients require optimal acute pain management. Systematic reviews have investigated the postoperative use of epidural analgesia and found that it may have advantages over systemic analgesia. It is of interest to determine whether pre-operative use of epidural analgesia is also advantageous. We conducted a systematic review and meta-analyses on the effect of epidural analgesia on pre-operative pain management in hip fracture patients.

METHODS

We included randomized controlled trials comparing pre-operatively initiated epidural analgesia with any other method of analgesia, in adults aged ≥55 years scheduled for hip fracture surgery. The main outcome was pre-operative pain at rest. Electronic searches of four medical databases were performed. Two authors independently screened for eligibility, extracted data, and assessed risk of bias. We conducted meta-analyses and assessed the certainty of the evidence by Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Three articles were included, with 179 randomized patients. All studies compared epidural analgesia with systemic analgesia, one additionally with 3-in-1-block. Meta-analyses of pre-operative pain measurements resulted in a mean difference of -5.85 95% CI [-14.90; 3.19] on a 0-100 Visual Analogue Scale with a p-value of 0.17 and a very low certainty of evidence according to the GRADE rating.

CONCLUSIONS

We did not find a difference in pre-operative pain at rest between epidural analgesia and any other method of pre-operatively initiated analgesia. The studies were few, of low quality and the difference between the two interventions remains unknown.

Design and Evaluation of a Hospital-Based Educational Event on Fracture Care for Older Adult

Introduction:

Surgeons, internal medicine physicians, nurses, and other members of the healthcare team managing older adults with a fracture all have barriers to attending educational courses, including time away from practice and cost. Our planning group decided to create and evaluate a hospital-based educational event to address, meet, and improve the care of older adults with a fracture.

Materials and Methods:

A committee of surgeons and geriatricians defined 3 learning objectives to improve knowledge and attitudes in co-managed care. They designed a 1-day educational event consisting of a departmental visit, a review of cases, a planning session to identify gaps and plan changes, and presentations on selected topics. Thirteen hospitals worldwide completed an 8-question online application form, and 7 sites were selected for delivery over 3 years in Denmark, Colombia, Thailand, Paraguay, Switzerland, and the Dominican Republic.

Results:

Each event was conducted by 1 or more visiting surgeons and geriatricians, and the local team leaders. The most common challenges reported in the applications were preoperative assessment or optimization, delayed surgery, lack of protocols, access to a geriatrician, teamwork, and specific aspects of perioperative and postoperative care. In each department, 4 or 5 goals and targets for implementation were agreed. The presentations section was customized and attended by 20 to 50 team members.

Discussion:

Topics selected by a majority of departments were principles of co-managed care (7), preoperative optimization (7), and management of delirium (4). Follow up was conducted after 3 and 12 months to review the degree of achievement of each planned change and to identify any barriers to complete implementation.

Conclusions:

Hospital-based events with visiting and local faculty were effective to engage a broader audience that might not attend external courses. A performance improvement component with goal setting and follow up was acceptable to all host departments.