Association of anesthesia and analgesia with long-term mortality after hip fracture surgery: an analysis of the Australian and New Zealand hip fracture registry.

INTRODUCTION: Hip fractures are a common frailty injury affecting a vulnerable geriatric population. It is debated if anesthetic and analgesic techniques are associated with altered risk for outcomes in hip fracture patients. This study aimed to determine the association of anesthesia and regional analgesia with all cause 12-month mortality and even longer-term mortality after hip fracture surgery in Australia and New Zealand. METHODS: Data from the Australian and New Zealand Hip Fracture Registry collected from 2016 to 2018, with a minimum follow-up of 12 months, were reviewed. Anesthesia type and use of regional nerve blocks were investigated. The primary outcome was all cause 12-month mortality. RESULTS: 12-month mortality was 30.6% (n=5410) in a total of 17,635 patients. There was no difference in 12-month mortality between patients who received spinal or general anesthesia (p=0.238). The administration of a combination of general and spinal anesthesia for surgery to repair the fracture was an independent predictor of higher 12-month mortality (unadjusted complete case HR=1.17 (95% CI 1.04 to 1.31); p<0.001). Nerve blocks performed in both the emergency department (ED) and the operating theater (OT) were associated with reduced long-term mortality (median follow-up 21 months) with an unimputed unadjusted HR=0.86 (95% CI 0.77 to 0.96; p=0.043). CONCLUSION: There was no difference in the association of 12-month mortality between general and spinal anesthesia in patients undergoing hip fracture surgery. However, there was an association with a higher risk of 12-month mortality in patients who received both general and spinal anesthesia for the same surgery. Patients who received a regional nerve block in both the ED and the OT had a lower association of 12-month and longer-term mortality risk. The reasons for these findings remain unknown and should be the subject of further research investigation.

Does the SORG Orthopaedic Research Group Hip Fracture Delirium Algorithm Perform Well on an Independent Intercontinental Cohort of Patients With Hip Fractures Who Are 60 Years or Older?

BACKGROUND: Postoperative delirium in patients aged 60 years or older with hip fractures adversely affects clinical and functional outcomes. The economic cost of delirium is estimated to be as high as USD 25,000 per patient, with a total budgetary impact between USD 6.6 to USD 82.4 billion annually in the United States alone. Forty percent of delirium episodes are preventable, and accurate risk stratification can decrease the incidence and improve clinical outcomes in patients. A previously developed clinical prediction model (the SORG Orthopaedic Research Group hip fracture delirium machine-learning algorithm) is highly accurate on internal validation (in 28,207 patients with hip fractures aged 60 years or older in a US cohort) in identifying at-risk patients, and it can facilitate the best use of preventive interventions; however, it has not been tested in an independent population. For an algorithm to be useful in real life, it must be valid externally, meaning that it must perform well in a patient cohort different from the cohort used to "train" it. With many promising machine-learning prediction models and many promising delirium models, only few have also been externally validated, and even fewer are international validation studies. QUESTION/PURPOSE: Does the SORG hip fracture delirium algorithm, initially trained on a database from the United States, perform well on external validation in patients aged 60 years or older in Australia and New Zealand? METHODS: We previously developed a model in 2021 for assessing risk of delirium in hip fracture patients using records of 28,207 patients obtained from the American College of Surgeons National Surgical Quality Improvement Program. Variables included in the original model included age, American Society of Anesthesiologists (ASA) class, functional status (independent or partially or totally dependent for any activities of daily living), preoperative dementia, preoperative delirium, and preoperative need for a mobility aid. To assess whether this model could be applied elsewhere, we used records from an international hip fracture registry. Between June 2017 and December 2018, 6672 patients older than 60 years of age in Australia and New Zealand were treated surgically for a femoral neck, intertrochanteric hip, or subtrochanteric hip fracture and entered into the Australian & New Zealand Hip Fracture Registry. Patients were excluded if they had a pathological hip fracture or septic shock. Of all patients, 6% (402 of 6672) did not meet the inclusion criteria, leaving 94% (6270 of 6672) of patients available for inclusion in this retrospective analysis. Seventy-one percent (4249 of 5986) of patients were aged 80 years or older, after accounting for 5% (284 of 6270) of missing values; 68% (4292 of 6266) were female, after accounting for 0.06% (4 of 6270) of missing values, and 83% (4690 of 5661) of patients were classified as ASA III/IV, after accounting for 10% (609 of 6270) of missing values. Missing data were imputed using the missForest methodology. In total, 39% (2467 of 6270) of patients developed postoperative delirium. The performance of the SORG hip fracture delirium algorithm on the validation cohort was assessed by discrimination, calibration, Brier score, and a decision curve analysis. Discrimination, known as the area under the receiver operating characteristic curves (c-statistic), measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities, a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest. RESULTS: The SORG hip fracture algorithm, when applied to an external patient cohort, distinguished between patients at low risk and patients at moderate to high risk of developing postoperative delirium. The SORG hip fracture algorithm performed with a c-statistic of 0.74 (95% confidence interval 0.73 to 0.76). The calibration plot showed high accuracy in the lower predicted probabilities (intercept -0.28, slope 0.52) and a Brier score of 0.22 (the null model Brier score was 0.24). The decision curve analysis showed that the model can be beneficial compared with no model or compared with characterizing all patients as at risk for developing delirium. CONCLUSION: Algorithms developed with machine learning are a potential tool for refining treatment of at-risk patients. If high-risk patients can be reliably identified, resources can be appropriately directed toward their care. Although the current iteration of SORG should not be relied on for patient care, it suggests potential utility in assessing risk. Further assessment in different populations, made easier by international collaborations and standardization of registries, would be useful in the development of universally valid prediction models. The model can be freely accessed at: https://sorg-apps.shinyapps.io/hipfxdelirium/ . LEVEL OF EVIDENCE: Level III, therapeutic study.

Is delirium associated with negative outcomes in older patients with hip fracture: analysis of the 4904 patients 2017-2018 from the Australian and New Zealand hip fracture registry.

AIM: To determine associations between delirium and health outcomes using the Australia and New Zealand population-based hip fracture patient registry (ANZHFR). METHODS: We performed a retrospective cohort study using data from the ANZHFR among hip-fracture surgery patients admitted to and discharged from hospital between 1 January 2017 and 31 December 2018. RESULTS: Of the 4904 patients with complete data and included in the analysis, 1789 (36.5%) experienced delirium during their hospital stay. Patients with delirium also had a higher rate of in-hospital mortality (adjusted HR = 1.76; 95% CI = 1.24, 2.49; P < 0.001), a higher rate of long-term mortality (adjusted HR = 1.30; 95% CI = 1.15, 1.48; P < 0.001) and a higher odds of discharge to an aged care facility (adjusted OR = 1.24; 95% CI = 1.04, 1.48; P = 0.019). CONCLUSION: A high rate of postoperative delirium exists among Australian and New Zealand hip fracture patients. Rates of hospital mortality, length of hospital stay and discharge to residential aged care are considerably worse in these patients.

Prediction of Postoperative Delirium in Geriatric Hip Fracture Patients: A Clinical Prediction Model Using Machine Learning Algorithms.

INTRODUCTION: Postoperative delirium in geriatric hip fracture patients adversely affects clinical and functional outcomes and increases costs. A preoperative prediction tool to identify high-risk patients may facilitate optimal use of preventive interventions. The purpose of this study was to develop a clinical prediction model using machine learning algorithms for preoperative prediction of postoperative delirium in geriatric hip fracture patients. MATERIALS & METHODS: Geriatric patients undergoing operative hip fracture fixation were queried in the American College of Surgeons National Surgical Quality Improvement Program database (ACS NSQIP) from 2016 through 2019. A total of 28 207 patients were included, of which 8030 (28.5%) developed a postoperative delirium. First, the dataset was randomly split 80:20 into a training and testing subset. Then, a random forest (RF) algorithm was used to identify the variables predictive for a postoperative delirium. The machine learning-model was developed on the training set and the performance was assessed in the testing set. Performance was assessed by discrimination (c-statistic), calibration (slope and intercept), overall performance (Brier-score), and decision curve analysis. RESULTS: The included variables identified using RF algorithms were (1) age, (2) ASA class, (3) functional status, (4) preoperative dementia, (5) preoperative delirium, and (6) preoperative need for mobility-aid. The clinical prediction model reached good discrimination (c-statistic = .79), almost perfect calibration (intercept = -.01, slope = 1.02), and excellent overall model performance (Brier score = .15). The clinical prediction model was deployed as an open-access web-application: https://sorg-apps.shinyapps.io/hipfxdelirium/. DISCUSSION & CONCLUSIONS: We developed a clinical prediction model that shows promise in estimating the risk of postoperative delirium in geriatric hip fracture patients. The clinical prediction model can play a beneficial role in decision-making for preventative measures for patients at risk of developing a delirium. If found to be externally valid, clinicians might use the available web-based application to help incorporate the model into clinical practice to aid decision-making and optimize preoperative prevention efforts.

Development of a postoperative delirium risk scoring tool using data from the Australian and New Zealand Hip Fracture Registry: an analysis of 6672 patients 2017-2018.

BACKGROUND AND PURPOSE: This study aimed to determine the incidence, predictors of postoperative delirium and develop a post-surgery delirium risk scoring tool. PATIENTS AND METHODS: A total of 6672 hip fracture patients with documented assessment for delirium were analyzed from the Australia and New Zealand Hip Fracture Registry between June 2017 and December 2018.Thirty-six variables for the prediction of delirium using univariate and multivariate logistic regression were assessed. The models were assessed for diagnostic accuracy using C-statistic and calibration using Hosmer-Lemeshow goodness-of-fit test. A Delirium Risk Score was developed based on the regression coefficients. RESULTS: Delirium developed in 2599/6672 (39.0%) hip fracture patients. Seven independent predictors of delirium were identified; age above 80 years (OR=1.6 CI 1.4-1.9; p=0.001), male (OR=1.3 CI 1.1-1.5; p=0.007), absent pre-operative cognitive assessment (OR=1.5 CI 1.3-1.9; p=0.001), impaired pre-operative cognitive state (OR=1.7 CI 1.3 -2.1; p=0.001), surgery delay (OR=1.7 CI 1.2-2.5; p=0.002) and mobilisation day 1 post-surgery (OR=1.9 CI 1.4-2.6; p=0.001). The C-statistics for the training and validation datasets were 0.74 and 0.75, respectively. Calibration was good (χ2=35.72 (9); p<0.001). The Delirium Risk Score for patients ranged from 0 to 42 in the validation data and when used alone as a risk predictor, had similar levels of diagnostic accuracy (C-statistic=0.742) indicating its potential for use as a stand-alone risk scoring tool. CONCLUSION: We have designed and validated a delirium risk score for predicting delirium following surgery for a hip fracture using seven predicting factors. This could assist clinicians in identifying high risk patients requiring higher levels of observation and post-surgical care.

Does implementation of a tailored intervention increase adherence to a National Safety and Quality Standard? A study to improve delirium care.

BACKGROUND: Delirium is commonly detected in older people after hip fracture. Delirium is considered to be a multifactorial disorder that is often seen post-operatively (incidence ranging from 35% to 65%). Hospitals in Australia are required to meet eight standards including the comprehensive care standard to be able to maintain their accreditation. The standard includes actions related to falls, pressure injuries, nutrition, mental health, cognitive impairment and end-of-life care. Delirium prevention was identified as an area for improvement in our Orthopaedic unit in a Level 1 University Trauma Centre in Australia. This implementation research project aimed to understand the efficacy of a delirium prevention intervention within an existing orthopaedic speciality care system. OBJECTIVE: Implementation of the tailored intervention will increase adherence to National Safety and Quality Health Service Standards, thereby reducing rate of delirium. METHODS: In this study, we used an interrupted time series design to examine changes in practice over time in people admitted to hospital with a hip fracture. Clinical staff caring for patients with hip fracture in an acute care setting in Adelaide, South Australia, participated in the project. In brief, intervention included education, environmental restructuring, change champions, infographics and audit feedback reports. The primary outcome of interest was rate of delirium. The secondary outcome was compliance with the use of delirium 4AT screening tool, duration of delirium and hospital length of stay. RESULTS: The rate of change per month in patients with delirium decreased significantly by 19.2%. There was no significant change observed in trend for duration of delirium and length of hospital stay between pre-intervention and post-intervention phases. A significant increase in the use of screening tool was observed from 4.7% in the pre-intervention phase to 33.6% in the post-intervention phase. CONCLUSION: Translation of evidence-based intervention model incorporating well-considered implementation strategies had a mixed impact on decreasing the rate of delirium. The scheduled hospital accreditation enhanced the use of validated screening tool to recognize delirium. This project highlights the importance of aligning implementation goals with the wider goals of the organization as well as making clinicians accountable by consistent auditing.

Design and establishment of a cancer registry: a literature review.

BACKGROUND: Establishment of a cancer registry is a complex process that requires substantial resources and careful planning. There are numerous resources available to provide guidance for this, which include guidelines and frameworks of varying quality. It is the authors' goal to identify evidence-based recommendations within the literature to help guide the process of designing a new registry with optimal efficiency, workability and data use. The objective of this study is to examine the primary literature for evidence-based recommendations on how to design and establish a cancer registry, with a focus on literature which analyses the performance and usefulness of already established registries or guidelines. METHODS: An electronic search was completed in MEDLINE, CINAHL, EMCARE, SCOPUS and the Cochrane Database of Systematic Reviews. Recommendations were extracted from the identified articles and collated as themes. RESULTS: Nine articles of varying quality were included in the review. Recommendations obtained from the literature included broad themes of the importance of clinician involvement, establishment of clear data definitions, number of variables used, inbuilt strategies to improve quality and completeness of data, considerations of costs, an 'opt-out' strategy for ethics and privacy and flexibility of the system. CONCLUSION: This review concluded that there is a large gap in the primary literature for evidence-based recommendations on the design and establishment of cancer registries. The included articles established a small scope of relevant themes, which were largely non-specific. This area of deficiency provides an opportunity for future research, which would further strengthen the quality of current or new guidelines in cancer registry establishment.

Early Mobilization Post-Hip Fracture Surgery.

INTRODUCTION: Early mobilization after hip fracture surgery is a widely practiced component of postoperative care. However, there is little evidence to suggest that early mobilization post-hip fracture surgery is beneficial in reducing postoperative complications. This study aims to investigate the effect of early mobilization following hip fracture surgery on postoperative complications. MATERIALS AND METHODS: This study retrospectively included 240 patients (female = 165, male = 75, mean age: 82.2 years) admitted to a level 1 trauma center in Adelaide, Australia, for hip fracture surgery. The effect of early mobilization on postoperative complications was assessed along with premorbid status. Subgroup analysis of patients stratified by premorbid health was subsequently analyzed to reduce confounding. RESULTS: The odds of developing a complication were 1.9 times higher if the patient remained bedbound compared to mobilizing. Early mobilization was favorable to delayed mobilization. On average, complication-free patients mobilized earlier (mean [M] = 29 hours) compared to patients who experienced complications (M = 38 hours). In particular, rates of delirium was significantly reduced in patients who mobilized compared to remaining bedbound. However, premorbid status varied greatly. Early mobilizers had significantly better premorbid health than patients who remained bedbound. Overall subgroup analysis of patients with similar premorbid health showed mobilization was not associated with a reduction in complications. With an exception of patients with poor premorbid health, who experienced a reduction in complications following early mobilization. DISCUSSION: In general, early mobilization was associated with the same complication rates as delayed mobilization and remaining bedbound. Patients with poor premorbid health benefited most from early mobilization with reduced complication rates. CONCLUSION: Postoperative delirium and premorbid health were better indicators of postoperative outcomes than time to mobilization.

"Just another piece of paperwork": perceptions of clinicians on delirium screening following hip fracture repair elicited in focus groups.

ABSTRACTBackground:Delirium is a complex clinical syndrome characterized by disturbed consciousness, cognitive function, or perception and associated with serious adverse outcomes such as death, dementia, and the need for long-term care. However, recognition and management of delirium is poorly prioritized even though it is the most frequent complication among patients undergoing surgery following hip fracture. The aim of this study was to understand clinicians' from orthopedic speciality perceptions in relation to recognition, diagnosis, and management of delirium. METHODS: This was a qualitative study using in-depth focus groups discussions with clinical staff of one orthopedic unit within a level 1 trauma center, south of Adelaide, South Australia. RESULTS: A total number of 17 individuals (14 nurses, 1 geriatric registrar, 1 nursing manager, and 1 speech therapist) participated in the focus groups. Four major themes were identified: (1) Delirium is important but can be hard to recognize and validate; (2) ambiguity on the use of delirium screening tool; (3) need of designated delirium care pathway; and (4) vital role of the family. Despite the initial lack of agreement on use of the objective tool to screen delirium, nurses did propose a number of ways that formal delirium screening could be included in routine nursing duties and existing nursing documentation. CONCLUSION: Although orthopedic nurses aim to provide effective care to patients experiencing delirium symptoms following hip fracture, they are doing so in the absence of structured screening, assessment, and multidisciplinary team approach. This study emphasizes the various barriers which need to be considered before attempting to change practice in this important area.

Effectiveness of multicomponent interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic review.

ABSTRACTBackground:Delirium is the most frequent complication among the hospitalized elderly with hip fracture. Although, delirium is associated with longer hospital stay, higher mortality rates, worse functional outcomes, and higher institutionalization rates yet health service planners have hugely ignored its existence. This review aims to identify the effectiveness of multicomponent interventions to prevent delirium in hospitalized elderly patients with hip fracture. METHODS: This review includes experimental, non-experimental, and observational studies. Electronic searches were conducted in MEDLINE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Embase, and Web of science. RESULTS: After inclusion and exclusion criteria were applied, nine full text articles were included in the review. The studies reported the following effect on delirium: We pooled data regarding incidence of delirium from the three RCTs. The effect was in favor of the intervention group (odds ratio 0.64, 95% CI 0.46-0.87). All three RCTs reported that duration of delirium was shorter in the intervention group than in the usual care group (mean 2.9 vs. 3.1 days, median 3 vs. 4 days, median 5.0 vs. 10.2 days). Four other studies reported on the duration of delirium with Milisen and colleagues reported shorter duration of delirium within the intervention group. Four studies reported on severity of delirium with two research groups reporting significant results. CONCLUSION: Early engagement of multidisciplinary staff who addresses the risk factors of delirium as soon as the patient presents to the acute care environment is the key element of a successful delirium prevention program. Once delirium had developed, the multicomponent interventions did not appear to make a difference to the duration or severity of delirium.

Effectiveness of multi-component interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to identify, evaluate and synthesize evidence on the effectiveness of multi-component interventions on the incidence of delirium in hospitalized elderly patients with hip fracture.Specifically, the review question is: In hospitalized older patients with hip fracture, what is the effectiveness of multi-component interventions on the incidence of delirium?