Implementing guidance on hip fracture
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《英国医生杂志》
EDITOR—We agree with Ions that the stabilisation of medical problems is the main reason for delaying surgery on patients with a fractured neck of femur, and that comorbidities, particularly dementia, are important predictors of death. However, we disagree with the view that the timing of the operation is in itself unimportant.
Although a Swedish study of 274 patients found no effect of delaying the operation once the patient had been stabilised, two other studies found that delay increased the risk of death and morbidity and the length of stay even in physiologically stable patients.1-3 Further analyses on our own data for all English NHS hospitals show that, for patients aged 65 and older and admitted from their own homes, even after adjusting for the effects of socioeconomic deprivation, age, sex, and comorbidity, operative delay is associated with a higher risk of death. This was found for all in-hospital deaths and for in-hospital deaths within 30 days of admission.
Nationally, 17% patients waited more than 48 hours for surgery, but trust level figures ranged from 0 to 72% (16% at Newcastle). Such swingeing variations between trusts are unlikely to be entirely due to case mix factors such as differing mental test scores, especially as we excluded patients admitted from residential or nursing homes. This implies that further investigation is required.
Alex Bottle
Dr Foster Unit and Imperial College, Imperial College, London W2 1PG robert.bottle@imperial.ac.uk
Brian Jarman, Paul Aylin, Roger Taylor
Dr Foster Unit and Imperial College, Imperial College, London W2 1PG
Dr Foster is an independent research and publishing organisation created to examine measures of clinical performance.
Competing interests: AB and PA are funded by a grant from Dr Foster.
References
Dolk T. Operation in hip fracture patients—analysis of the time factor. Injury 1990;21: 369-72.
Rogers FB, Shackford SR, Keller MS. Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. Trauma 1995;39: 261-5.
Fox HJ, Pooler J, Prothero D, Bannister GC. Factors affecting the outcome after proximal femoral fractures. Injury 1994;25: 297-300.
Although a Swedish study of 274 patients found no effect of delaying the operation once the patient had been stabilised, two other studies found that delay increased the risk of death and morbidity and the length of stay even in physiologically stable patients.1-3 Further analyses on our own data for all English NHS hospitals show that, for patients aged 65 and older and admitted from their own homes, even after adjusting for the effects of socioeconomic deprivation, age, sex, and comorbidity, operative delay is associated with a higher risk of death. This was found for all in-hospital deaths and for in-hospital deaths within 30 days of admission.
Nationally, 17% patients waited more than 48 hours for surgery, but trust level figures ranged from 0 to 72% (16% at Newcastle). Such swingeing variations between trusts are unlikely to be entirely due to case mix factors such as differing mental test scores, especially as we excluded patients admitted from residential or nursing homes. This implies that further investigation is required.
Alex Bottle
Dr Foster Unit and Imperial College, Imperial College, London W2 1PG robert.bottle@imperial.ac.uk
Brian Jarman, Paul Aylin, Roger Taylor
Dr Foster Unit and Imperial College, Imperial College, London W2 1PG
Dr Foster is an independent research and publishing organisation created to examine measures of clinical performance.
Competing interests: AB and PA are funded by a grant from Dr Foster.
References
Dolk T. Operation in hip fracture patients—analysis of the time factor. Injury 1990;21: 369-72.
Rogers FB, Shackford SR, Keller MS. Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. Trauma 1995;39: 261-5.
Fox HJ, Pooler J, Prothero D, Bannister GC. Factors affecting the outcome after proximal femoral fractures. Injury 1994;25: 297-300.