Disparities in length of stay for hip fracture treatment between patients treated in safety-net and non-safety-net hospitals

Introduction: standardised protocols for the care of geriatric hip fractures demonstrate improved patient outcomes with decreased cost. The purpose of this study is to evaluate outcomes of a standardised hip fracture protocol at an urban safety-net hospital. Methods: All trauma patients presenting to our urban safety-net hospital are included in a trauma database and inpatient outcomes recorded. A hip fracture protocol was introduced at our institution in 2015, which depended on admission to a monitored setting due to the absence of a geriatric co-management service. The database was queried to identify patients surgically treated for a geriatric hip fracture in the 3 years prior to protocol implementation (2012–2014) and patients treated in the 3 years following protocol implementation (2016–2018). Demographics, time to surgery, inpatient complications, and length of stay were compared between groups. Results: A total of 633 patients treated operatively for isolated hip fractures were identified, 262 patients in the 2012–2014 pre-protocol cohort, and 371 patients in the 2016–2018 protocol cohort. Following implementation of a hip fracture protocol the number of patients admitted to a surgical service increased from 198 (76%) to 348 (94%, p < 0.005) with the number of patients being admitted to a monitored setting increasing from 40 (15%) to 83 (22%, p = 0.026). The time to surgery was reduced to 2.75 days ( p = 0.054). The complication rate fell from 23% to 4% ( p < 0.0005). Length of stay was significantly reduced from 13.2 days to 12 days ( p = 0.045). Conclusions: A hip fracture protocol including admission to a monitored setting can be effectively implemented at an urban safety-net hospital where geriatric co-management is not available. This resulted in a decrease in complications and length of stay. Additional interventions are required to decrease average time to surgery below 36 hours.

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Admitting Service Affects Cost and Length of Stay of Hip Fracture Patients

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459318808845 ◽

2018 ◽

Vol 9 ◽

pp. 215145931880884 ◽

Cited By ~ 2

Author(s):

Ariana Lott ◽

Jack Haglin ◽

Rebekah Belayneh ◽

Sanjit R. Konda ◽

Kenneth A. Egol

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Safety Net ◽

Cost Of Care ◽

Hospital Length Of Stay ◽

Surgical Service ◽

Lengths Of Stay ◽

Medicine Service ◽

Safety Net Hospital ◽

Hospitalization Costs

Introduction: The purpose of this study was to analyze the effect of the admitting service on cost of care for hip fracture patients by comparing the cost difference between patients admitted to the medicine service versus those admitted to a surgical service. Methods: A 2-year cohort of patients 55 years or older who were admitted to a single level 1 trauma center with an operative hip fracture were included. Patient demographics, comorbidities, admitting service, complications, and hospital length of stay were recorded for each patient. Cost of hospitalization, discharge disposition, and 30-day readmissions were collected. Patients who were admitted to the medicine service (medicine cohort) were compared to those admitted to a surgery service (surgery cohort). Multivariate regression models controlling for age, Charlson comorbidity index (CCI), and American Society of Anesthesiology (ASA) scores were used to evaluate hospitalization costs with a P value of <.05 as significant. Results: Two hundred twenty-five hip fracture patients were included; 143 (63.6%) patients were admitted to a surgical service, while 82 (36.4%) were admitted to the medicine service. Patients admitted to medicine service had greater CCI and ASA scores, longer lengths of stay, and more complications than those patients admitted to surgery service. Linear regression model controlling for age, CCI, ASA score, and time to surgery demonstrates that patients admitted to a surgical service will have 2.0-day (95% confidence interval [CI]: 0.561-3.503; P = .007) shorter admissions with a US$4215 reduction in cost (95% CI: US$314-US$8116; P = .034) compared to patients admitted to the medicine service. Discussions: In our urban safety net hospital, hip fracture patients admitted to medicine service had longer lengths of stay and higher total hospitalization costs than patients who were admitted to surgery service. Conclusions: This study highlights that the admitting service should be an area of focus for hospitals when developing programs to provide effective and cost-conscious care to hip fracture patients.

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Cost comparison in hip fracture treatment

Acta Orthopaedica Scandinavica ◽

10.3109/17453679109155104 ◽

1991 ◽

Vol 62 (sup241) ◽

pp. 38-39 ◽

Cited By ~ 1

Author(s):

Karl-GÖRan Thorngren

Keyword(s):

Hip Fracture ◽

Cost Comparison ◽

Fracture Treatment

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Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients

British Journal of Anaesthesia ◽

10.1016/j.bja.2020.12.026 ◽

2021 ◽

Vol 126 (3) ◽

pp. 730-737

Author(s):

David G.A. Williams ◽

Tetsu Ohnuma ◽

Krista L. Haines ◽

Vijay Krishnamoorthy ◽

Karthik Raghunathan ◽

...

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Nutritional Supplement

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Outcomes of COVID-19 Negative Hip Fracture Patients During the Acute and Subacute Pandemic

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/21514593211006692 ◽

2021 ◽

Vol 12 ◽

pp. 215145932110066

Author(s):

Naoko Onizuka ◽

Lauren N. Topor ◽

Lisa K. Schroder ◽

Julie A. Switzer

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Healthcare System ◽

Perioperative Complications ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Surgical Care ◽

Admission Rate ◽

System Response ◽

Fragility Hip Fracture

Objectives: To better elucidate how the COVID-19 pandemic has affected the operatively treated geriatric hip fracture population and how the health care system adapted to pandemic dictated procedures. Design: Retrospective cohort study. Setting: A community hospital. Participants: Individuals ≥65 years of age presented with a proximal femoral fracture from a low-energy mechanism undergoing operative treatment from January 17, 2020 to July 2, 2020 (N = 125). Measurements: We defined 3 phases of healthcare system response: pre-COVID-19, acute phase, and subacute phase. Thirty-day mortality, time to operating room (OR), length of stay, time to start physical therapy, perioperative complications, delirium rate, hospice admission rate, discharge dispositions, readmission rate, and the reason of surgery delay were assessed. Results: The number of hip fractures has remained constant during the pandemic. The 30-day mortality rate, time to OR, and length of stay were higher in the pandemic compared to the pre-pandemic. Those who had a longer wait time to OR (≥ 24 hours) had more complications and increased 30-day mortality rates. Some of the surgery delays were related to OR unavailability as a consequence of the COVID-19 pandemic. Surgery was delayed in 3 patients who were on direct oral anticoagulants (DOACs) in pandemic but none for pre-pandemic period. Conclusion: This is the first study to compare the effect of the acute and subacute phases of the pandemic on uninfected hip fracture patients. In the age of COVID-19, to provide the best care for the vulnerable geriatric orthopedic populations, the healthcare system must adopt new protocols. We should still aim to promote prompt surgical care when indicated. It is important to ensure adequate resource availability, such as OR time and staff so that hip fracture patients may continue to receive rapid access to surgery. A multidisciplinary approach remains the key to the management of fragility hip fracture patients during the pandemic.

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The independent patient factors that affect length of stay following hip fractures

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2018.0068 ◽

2018 ◽

Vol 100 (7) ◽

pp. 556-562 ◽

Cited By ~ 4

Author(s):

T Richards ◽

A Glendenning ◽

D Benson ◽

S Alexander ◽

S Thati

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hospital Stay ◽

Hip Fractures ◽

Length Of Hospital Stay ◽

Hospital Length ◽

Acute Hospital ◽

Hospital Length Of Stay ◽

Patient Factors ◽

Mobility Status

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

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Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery

JAMA ◽

10.1001/jama.2014.6499 ◽

2014 ◽

Vol 311 (24) ◽

pp. 2508 ◽

Cited By ~ 153

Author(s):

Mark D. Neuman ◽

Paul R. Rosenbaum ◽

Justin M. Ludwig ◽

Jose R. Zubizarreta ◽

Jeffrey H. Silber

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hip Fracture Surgery ◽

Anesthesia Technique ◽

Fracture Surgery

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Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151458517722104 ◽

2017 ◽

Vol 8 (3) ◽

pp. 161-165 ◽

Cited By ~ 6

Author(s):

Alastair G. Dick ◽

Dominic Davenport ◽

Mohit Bansal ◽

Therese S. Burch ◽

Max R. Edwards

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hip Fractures ◽

District General Hospital ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Retrospective Case ◽

Time To Surgery ◽

Surgery Mortality ◽

Hospital Acquired

Introduction: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. Methods: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. Results: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Conclusion: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.

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Achieving best practice tariff may not reflect improved survival after hip fracture treatment

Clinical Interventions in Aging ◽

10.2147/cia.s65736 ◽

2014 ◽

pp. 2097 ◽

Cited By ~ 7

Author(s):

Khan ◽

Mark Shirley ◽

Clare Glennie ◽

Paul Fearon ◽

David Deehan

Keyword(s):

Hip Fracture ◽

Best Practice ◽

Fracture Treatment

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113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Age and Ageing ◽

10.1093/ageing/afab030.74 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

C McCann ◽

A Hall ◽

J Min Leow ◽

A Harris ◽

N Hafiz ◽

...

Keyword(s):

Emergency Department ◽

Acute Kidney Injury ◽

Hip Fracture ◽

Length Of Stay ◽

Kidney Injury ◽

Ward Round ◽

Fluid Administration ◽

Ward Staff ◽

Intravenous Fluid Therapy ◽

Significant Difference

Abstract Background Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of >62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids. Methods Three prospective audits, each including 100 consecutive acute hip fracture patients aged >55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively. Results Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p < 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p < 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p < 0.05). Discussion This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

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