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Increased wait time linked with greater 30-day mortality risk after hip fracture surgery
Results from this study indicated an increased wait time correlated with a greater chance of mortality within 30 days of surgery for hip fracture.
“What is interesting is that we found a linear relationship between risk and delay, but only after 24 hours,” study author Daniel Pincus, MD, told Healio.com/Orthopedics. “Before 24 hours, there was no increased risk of waiting. Surgery within 24 hours thus appears to be a ‘safe window.’ Some patients will benefit from preoperative medical treatment, so rushing them to the OR before this happens is probably not the right answer. If patients are healthy and ready for the OR, however, there is no reason they need to wait until 24 hours, especially as they are suffering in pain.”
He added, “Unfortunately, only one-third of patients in the study received care within 24 hours. Therefore, though there have been improvements made in the last 5 or 10 years in getting patients to the operating room faster, more work needs to be done.”
Pincus and colleagues performed a population-based, retrospective study of 42,230 patients who underwent hip fracture surgery at 72 hospitals in Ontario, Canada between April 1, 2009 and March 31, 2014. The mean age of patients was 80.1 years. The probability of each complication according to wait time was modeled with risk-adjusted restricted cubic splines. The primary outcome was 30-day mortality. Other outcomes evaluated included a composite of mortality and medical complications, such as myocardial infarction, deep vein thrombosis, pulmonary embolism and pneumonia. Percent absolute risk differences were used to compare outcomes between early and delayed groups.
At 30 days, the overall mortality rate was 7%. Investigators noted that when the wait times were longer than 24 hours, the complication risk increased, regardless of the complication that ensured. The 13,371 patients who underwent surgery after 24 hours had a significantly greater risk of mortality and composite outcome after 30 days compared with the 13,731 propensity score-matched patients who underwent surgery early. – by Monica Jaramillo
Disclosures: The study was supported by the Marvin Tile chair in orthopedic surgery at Sunnybrook Health Sciences Centre in Toronto and by the Institute for Clinical Evaluative Sciences.
Perspective
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Many investigators have affirmed that an increased time to surgery for hip fractures increases the likelihood of complications including urinary tract infections, cardiovascular issues, pneumonia, postoperative dementia, thrombosis, pulmonary embolism and length of stay.
The big question of whether delays to surgery are related to an increased mortality is disparate, with no definitive conclusions. Most of these studies are vastly underpowered and thus, no firm conclusions can be made. However, this study by Pincus and colleagues reviewed a large cohort of more than 42,230 adults. Although the study is retrospective, they found wait times longer than 24 hours were associated with a higher risk-adjusted likelihood of 30-day mortality.
This study should give surgeons additional hard data to demonstrate the value of strategies aimed at preventing time to surgery past 24 to 36 hours. This would include the development of specific preoperative pathways with dedicated personnel to help expedite the preoperative process. As well, in centers with a large volume of these cases, expanded OR availability for these cases can now be justified with the hiring of an additional OR team to be available beyond normal hours.
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In today’s busy hospitals, multiple competing issues often produce conflict and a lack of consensus about what is an acceptable surgical delay following a hip fracture. Pincus and his co-authors used population-level data with a large sample size of more than 42,000 patients to determine at what point the delay to surgery would actually increase the risk of 30-day mortality. Rather than arbitrarily select a cutoff, they looked to the data to find an inflection point and found delay beyond 24 hours led to a linear increase in 30-day mortality and medical complications.
This landmark study provides compelling evidence to support rapid mobilization of resources from multiple different disciplines within the hospital to expedite surgical treatment of a hip fracture. This study provides the ammunition to shift the current status quo at most hospitals in North America as evidenced that only 34% of participants in this study received surgery within 24 hours. Moreover, this work also supports the need for hip fracture surgical care pathways with a specific treatment algorithm, assessment points and outcome goals. As clearly demonstrated and adopted with elective joint arthroplasty, surgical care pathways have been shown to promote interdisciplinary collaboration, reduce variation in treatment, minimize surgical delay, shorten length of stay and improve outcomes. This seminal work encourages us all to consider adopting such pathways for hip fractures to improve patient outcomes by standardizing expeditious surgical care along with demonstrating value-based health care.