67 Reducing Delays to Operative Management of Anti-Coagulated Patients With Hip Fractures

Abstract Introduction In the UK, the gold-standard treatment of a hip fracture is surgical fixation within 36 hours. Reduced delay to surgery has been shown to minimise the risk of complications. Locally, frequent delays to surgery were observed in patients taking long-term anticoagulation. There are no national guidelines regarding anticoagulation reversal and surgery timing in patients with hip fractures, and doctors are often unfamiliar with increasingly prevalent Direct Oral Anti-coagulants (DOACs). This quality improvement project aimed to reduce delays to surgery in anti-coagulated patients with hip fractures. Methods A guideline was formulated following literature review and consultation with a Consultant Ortho-geriatrician, Orthopaedic Surgeon and Haematologist. Retrospective casenote audit was conducted including 3-month period before and after implementation. The new guideline was disseminated in poster form. Due to the observation that delays in receiving INR results resulted in reversal delay, patient’s on warfarin were recommended to receive 5 mg IV Vitamin K prior to receiving INR results. The INR was rechecked after 6 hours, and if less than 1.6, surgery could proceed. Those on DOACs could undergo surgery 24 hours after the last dose providing eGFR >30, and after 48 hours if eGFR <30. Exclusions were those anti-coagulated for metallic heart valves or recent venous thromboembolism. Results In the 3 months prior to guideline implementation, 71 patients had a hip fracture; 15 were anti-coagulated. Of these, 8 patients were delayed due to their anticoagulation. Repeat audit after implementation, included 46 patients with a hip fracture over the 3-month period; 7 were anti-coagulated. None were delayed due to anticoagulation (p < 0.05). Conclusions This improvement project describes formulation of a simple protocol with evidence from the literature and local expert opinion in order to reduce unnecessary delays in anti-coagulated patients with hip fractures.

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Hip fracture litigation: A 10-year review of NHS Litigation Authority data and the effect of national guidelines

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0277 ◽

2017 ◽

Vol 99 (1) ◽

pp. 17-21 ◽

Cited By ~ 2

Author(s):

R Fanous ◽

S Sabharwal ◽

A Altaie ◽

CM Gupte ◽

P Reilly

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Best Practice ◽

Clinical Excellence ◽

Freedom Of Information ◽

National Guidelines ◽

Delay In Diagnosis ◽

Significant Difference ◽

Before And After ◽

The Uk

We present a review evaluating all litigation claims relating to hip fractures made in a 10-year period between 2005 and 2015. Data was obtained from the NHS Litigation Authority through a freedom of information request. All claims relating to hip fractures were reviewed. During the period analysed, 216 claims were made, of which 148 were successful (69%). The total cost of settling these claims was in excess of £5 million. The introduction of a best-practice tariff by the Department of Health in 2010 was designed to improve the quality of care for hip fracture patients. This was followed by guidance from the National Institute for Health and Clinical Excellence in 2011 and the British Orthopaedic Association in 2012. We analysed claims submitted before and after these guidelines were introduced and no significant difference in the number of claims was noted. The most common cause for litigation was a delay in diagnosis, which accounted for 86 claims in total (40%). Despite the presence of these guidelines and targets, there has not been a significant reduction in the number of claims or an improvement in diagnostic accuracy. This may be due to an increasing level of litigation in the UK but we must also question whether we are indeed providing best-practice care to our hip fracture patients and whether these guidelines need further review.

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Orthogeriatrics and Hip Fracture Care in the UK: Factors Driving Change to More Integrated Models of Care

Geriatrics ◽

10.3390/geriatrics3030055 ◽

2018 ◽

Vol 3 (3) ◽

pp. 55 ◽

Cited By ~ 2

Author(s):

Mark Middleton

Keyword(s):

Hip Fracture ◽

Financial Incentives ◽

Models Of Care ◽

Social Needs ◽

Medical Rehabilitation ◽

Integrated Models ◽

National Guidelines ◽

Fracture Care ◽

The Uk ◽

The Impact

In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex medical, rehabilitation, and social needs of this patient group. Mounting evidence suggests that more integrated models of orthogeriatric care result in superior quality of care indicators and clinical outcomes. Clinical governance through national guidelines, audit through the National Hip Fracture Database (NHFD), and financial incentives through the Best Practice Tariff (providing a £1335 bonus for each patient) have driven hip fracture care in the UK forward. The demanded improvement in quality indicators has increased the popularity of collaborative care models and particularly integrated orthogeriatric services. A significant fall in 30-day mortality has resulted nationally. Ongoing data collection by the NHFD will lead to greater understanding of the impact of all elements of hip fracture care including models of orthogeriatrics.

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Re-Admissions Following Hip Fracture Surgery

Annals of The Royal College of Surgeons of England ◽

10.1308/003588409x432374 ◽

2009 ◽

Vol 91 (7) ◽

pp. 591-595 ◽

Cited By ~ 46

Author(s):

James Hahnel ◽

Hannah Burdekin ◽

Sanjeev Anand

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

The Elderly ◽

Index Admission ◽

Study Cohort ◽

Rehabilitation Care ◽

Hip Fracture Surgery ◽

Fatal Adverse Events ◽

The Uk ◽

Fracture Surgery

INTRODUCTION Hip fractures in the elderly are a growing problem with a predicted incidence of 117,000 cases per year by 2016. Re-admission following a healthcare episode is an important outcome measure, which reflects non-fatal adverse events and indicates the natural history of disease. The purpose of this observational, multicentre audit was to examine rates and reasons for re-admission following hip fracture, to identify areas in the index admission and rehabilitation care that could be improved to prevent re-admission. PATIENTS AND METHODS A total of 535 patients (> 65 years old) in two district general hospitals in the UK who underwent hip fracture surgery were recruited into the study. RESULTS Of the study cohort, 72 patients (13.5%) died during their index admission and 88 (19.0%) of 463 patients were re-admitted once within 3 months. Causes of re-admission were attributed to medical (54.8%), failure to rehabilitate (23.8%), orthopaedic (19.0%) and surgical (2.4%) reasons. Infection was the most common (31.0%) reason for re-admission and arguably the most treatable. During the 3-month postoperative period, the mortality rate was 21.3%, increasing in those re-admitted to 35.1% representing the frailty of this group of patients. CONCLUSIONS High rates of re-admission are seen following discharge in elderly patients with hip fractures. Re-admitted patients have high mortality rates. Understanding causes of re-admission may help to reduce this burden.

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Failure in the application of fragility fracture prevention guidelines

Annals of The Royal College of Surgeons of England ◽

10.1308/003588414x13946184901164 ◽

2014 ◽

Vol 96 (5) ◽

pp. 381-385 ◽

Cited By ~ 10

Author(s):

MH Elvey ◽

H Pugh ◽

G Schaller ◽

G Dhotar ◽

B Patel ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Fragility Fracture ◽

Fragility Fractures ◽

Fracture Prevention ◽

Consecutive Series ◽

National Guidelines ◽

Fracture Population ◽

The Mean ◽

The Uk

Introduction The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services. Methods Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX® risk calculations were applied to patients prior to their admission with a new hip fracture. Results Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX® ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice. Conclusions In conjunction with NICE and NOGG recommendations, FRAX® was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.

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The impact of direct oral anti-coagulants on hip fracture management : a systematic review and meta-analysis

Acta Orthopaedica Belgica ◽

10.52628/87.2.17 ◽

2021 ◽

Vol 87 (2) ◽

pp. 321-326

Author(s):

Samuel Holmes ◽

Sarmad Bahnam

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Mortality Risk ◽

Meta Analysis ◽

The Elderly ◽

Operative Management ◽

Control Group ◽

Independent Analysis ◽

Fracture Management ◽

The Impact

Hip fractures are a common presentation in the elderly, a group who commonly have co-morbidities requiring the use of anticoagulants. Recently, direct oral anti-coagulants (DOAC) have become a popular method of anticoagulating patients. The primary aim of this review is to determine if the use of DOAC in elderly patients with hip fractures results in delays to theatre and/or an increased mortality risk. Major databases including Pubmed, MEDLINE and Embase were searched for relevant studies and the included studies reference lists were screened for further studies. A total of 6 studies were included in meta-analysis which was undertaken using RevMan software with 95% confidence interval (CI). Compared to control groups, patients who were anticoagulated with DOAC and required operative management of a hip fracture experienced a statistically significant delay to treatment. However independent analysis showed these patients did not experience an increased mortality risk when compared to the control group. While data is limited, treating clinicians should be comforted by these findings as operative manage- ment can be safely delayed to reduce the risk of intraoperative bleeding.

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Hyponatraemia in Hip Fracture Patients

Scottish Medical Journal ◽

10.1177/003693300204700506 ◽

2002 ◽

Vol 47 (5) ◽

pp. 115-116 ◽

Cited By ~ 13

Author(s):

E. McPherson ◽

R. A. Dunsmuir

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Retrospective Review ◽

Surgical Intervention ◽

Close Monitoring ◽

Neck Of Femur ◽

Before And After

We performed a retrospective review of hyponatraemia in patients with hip fractures, before and after surgery. All patients admitted with fractures of the neck of femur who had a surgical intervention to deal with the fracture were included. Results were determined using two definitions for hyponatraemia. The incidence of preoperative and post-operative hyponatraemia were both 2.8% if hyponatraemia was defined as [Na]<130mmol/l. No cases of hyponatraemia were found pre-operatively when hyponatraemia was defined as [Na]<125mmol/l. Using this definition the post operative incidence of hyponatraemia was 0.93%. The incidence of hyponatraemia in this group of patients is small. However the potentially severe affects of hyponatraemia warrant close monitoring of these patients and the establishment of methods to prevent this problem from occurring.

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63 Impact of an Orthogeriatric Service on Osteoporosis Management in HIP Fracture Patients

Age and Ageing ◽

10.1093/ageing/afz164.63 ◽

2019 ◽

Vol 48 (Supplement_4) ◽

pp. iv13-iv17

Author(s):

Homaira Amini ◽

Kevin Ong ◽

Edward Strivens

Keyword(s):

Vitamin D ◽

Hip Fracture ◽

Hip Fractures ◽

Odds Ratio ◽

Diagnosis Of Osteoporosis ◽

Osteoporosis Management ◽

Minimal Trauma ◽

Tertiary Teaching ◽

Before And After ◽

New Diagnosis

Abstract Background Osteoporosis which is now treatable is the major risk factor for hip fractures in the elderly. Having a hip fracture increases morbidity and mortality. Hip fractures are costly. Incidence increases with age. Aims To examine how introduction of an orthogeriatric service (OGS) improves osteoporosis management. Method A dedicated OGS was established in the orthopaedic unit in an Australian tertiary teaching hospital in July 2014. Retrospective analyses were undertaken to compare osteoporosis diagnosis and treatment rates in patients ≥ 65 years old presenting with minimal trauma hip fractures (MTHF) before and after the OGS was established. Results 1. 108 MTHF (mean age 81 years) and 107 MTHF (mean age 82 years) were admitted in 2014 respectively before and after the OGS was established. 2. New osteoporosis diagnoses increased by 27%, new calcium &/or vitamin D prescription increased by 17% and new antiresorptive treatment increased by 30%, after the OGS was established. 3. The odds ratio for receiving a new diagnosis of osteoporosis post MTHF with the OGS compared to pre-OGS was 4.4 (2.1 – 9.0), p<0.0001. 4. The odds ratio for initiating new antiresorptive treatment post fractured NOF with OGS compared to pre-OGS was 6.2 (3.0 – 12.7), p<0.0001. 5. Rates of new diagnoses of osteoporosis and initiation of antiresorptive treatments with the OGS were not affected by age or gender. Conclusion 1. Introduction of a dedicated OGS improved osteoporosis diagnoses and initiation of antiresorptive treatments. 2. Patients who received a new diagnosis of osteoporosis and/or started on antiresorptive treatment were also likely to be prescribed calcium and/or vitamin D supplements as well. 3. There did not appear to be any age or gender bias towards giving more new diagnoses of osteoporosis and/or more new antiresorptive treatments with a dedicated OGS. 4. These results may be useful for benchmarking and comparison purposes.

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COVID-19 pandemic and hip fractures: impact and lessons learned

Bone & Joint Open ◽

10.1302/2633-1462.19.bjo-2020-0116.r1 ◽

2020 ◽

Vol 1 (9) ◽

pp. 530-540

Author(s):

Mohamed Arafa ◽

Samia Nesar ◽

Hamza Abu-Jabeh ◽

Ma Odette Remelou Jayme ◽

Yegappan Kalairajah

Keyword(s):

Hip Fracture ◽

Hospital Stay ◽

Hip Fractures ◽

Care Service ◽

Health Concern ◽

Positive Group ◽

Fracture Care ◽

Significant Difference ◽

The Uk ◽

The Impact

Aims The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks. Methods Data were collected retrospectively on 157 hip fractures admitted from March to May 2019 and 2020. The 2020 group was further subdivided into COVID-positive and COVID-negative. Data including the four-hour target, timing to imaging, hours to operation, anaesthetic and operative details, intraoperative complications, postoperative reviews, COVID status, Key Performance Indicators (KPIs), length of stay, postoperative complications, and the 30-day mortality were compiled from computer records and our local National Hip Fracture Database (NHFD) export data. Results Hip fractures and inpatient falls significantly increased by 61.7% and 7.2% respectively in the 2020 group. A significant difference was found among the three groups regarding anaesthetic preparation time, anaesthetic time, and recovery time. The mortality rate in the 2020 COVID-positive group (36.8%) was significantly higher than both the 2020 COVID-negative and 2019 groups (11.5% and 11.7% respectively). The hospital stay was significantly higher in the COVID-positive group (mean of 24.21 days (SD 19.29)). Conclusion COVID-19 has had notable effects on the hip fracture care service: hip fracture rates increased significantly. There were inefficiencies in theatre processes for which we have recommended the use of alternate theatres. COVID-19 infection increased the 30-day mortality and hospital stay in hip fractures. More research needs to be done to reduce this risk. Cite this article: Bone Joint Open 2020;1-9:530–540.

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Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another

HSS Journal ® ◽

10.1007/s11420-020-09762-8 ◽

2020 ◽

Vol 16 (S2) ◽

pp. 378-382

Author(s):

Eric Swart ◽

Chris Adair ◽

Rachel B. Seymour ◽

Madhav A. Karunakar

Keyword(s):

Clinical Practice ◽

Hip Fracture ◽

Hip Fractures ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

European Society ◽

Operative Management ◽

Fracture Repair ◽

British Society ◽

Fragility Hip Fracture

Abstract Background Osteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients. Questions/Purposes We sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways. Patients and Methods We performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management. Results We identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs’ specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease. Conclusions In patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.

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SO072INCIDENCE OF FRACTURES BEFORE AND AFTER DIALYSIS INITIATION AMONG INCIDENT DIALYSIS PATIENTS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa139.so072 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Ken Iseri ◽

Juan Jesus Carrero ◽

Marie Evans ◽

Li Felländer-Tsai ◽

Hans Berg ◽

...

Keyword(s):

Hip Fracture ◽

Incidence Rate ◽

Hip Fractures ◽

Temporal Pattern ◽

Incidence Rates ◽

Fracture Incidence ◽

Dialysis Initiation ◽

Dialysis Patients ◽

Initiation Of Dialysis ◽

Before And After

Abstract Background and Aims The incidence of fractures is markedly higher in dialysis patients than in pre-dialysis patients, but it is not clear to what extent the initiation of dialysis as such is associated with accelerated fracture incidence or if fracture rates are already increasing prior to dialysis start among incident dialysis patients. Here we investigated the temporal pattern of occurrence of a first major osteoporotic fracture (MOF) among incident dialysis patients in the pre-dialysis period and in the period following dialysis initiation. Method We analyzed data from Swedish Renal Registry (SRR) and identified 9041 incident dialysis patients (2005 -2015; age 67 years, 67% men). We identified all first MOF (MOFfirst) in hip, spine, humerus and forearm during 12 months before and after dialysis initiation. Using flexible parametric hazard models and Fine-Gray analysis accounting for competing risk of death and renal transplantation, we estimated adjusted fracture incidence rates and predictors of MOFfirst. Results During the whole follow-up period, there were 361 fractures including 196 hip fractures. The crude incidence rate of MOFfirst (n=157) before dialysis initiation was 17/1000 patient-years and after initiation of dialysis the incidence rate of MOFfirst increased to 24/1000 patient-years. Overall the adjusted MOFfirst incidence rates increased from 6 months before initiation of dialysis, fluctuated, and stabilized at a higher rate than that of the baseline rate after 12 months. The adjusted hip fracture rate rose steeply 3 months before dialysis initiation, declined 3 months after dialysis initiation, fluctuated, and then became stabilized. On the contrary, the adjusted incidence rates of other fractures, i.e., non-hip fractures, appeared to be stable all the time, before as well as after initiation of dialysis. Female gender, higher age and previous history of MOF had a negative impact on fracture incidence rates before and after dialysis initiation. Conclusion We conclude that the incidence of MOFfirst is increasing already from 6 months prior to dialysis initiation among incident dialysis patients, and that there is a further increase following dialysis initiation. For hip fracture, which was the most common MOF, the temporal pattern of incidence rates was compressed to a high risk period lasting from 3 months before to 3 months after dialysis initiation, underlining the need of increased attention to prevent hip fractures in incident dialysis patients during this critical period.

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