Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study.

INTRODUCTION: Currently, evidence-based guidelines regarding delay to theatre for urgent surgical intervention in patients taking direct oral anticoagulants (DOACs) are lacking. Therefore, this study aims to investigate the effect of DOACs on patient outcomes receiving early (<48 hours) versus delayed (>48 hours) surgery for neck of femur fractures. METHODS: A retrospective cohort study was conducted at a tertiary teaching hospital. Treatment groups were hip fracture patients taking DOACs on admission and receiving surgery in <48 hours (n = 17) and >48 hours (n = 11). A control cohort of hip fracture patients not taking DOACs (n = 56) was matched to the <48 hours treatment group for comparison. Patient demographics were recorded and key outcome measures included perioperative hemoglobin levels, transfusion rates, time to surgery, 90-day mortality, hematoma rates, and length of stay in hospital. RESULTS: There was no significant difference in perioperative hemoglobin levels, transfusion rates, or hematoma between groups. Patients taking DOACs and receiving early surgery had significantly longer time to surgery compared to the non-DOAC control (32.21 ± 7.83 vs 25.98 ± 11.4, P = .01). No deaths were recorded in the early DOAC group at 90 days, compared to 4 (36%) in the late DOAC group (P = .04). DISCUSSION AND CONCLUSIONS: Our study suggests hip fracture patients taking DOACs on admission is not a reason to delay surgery. However, given the lack of literature in this area, further prospective research with larger patient numbers is required to definitively guide clinical practice.

Emergency Department Femoral Nerve Blocks and 1-Year Mortality in Fragility Hip Fractures.

OBJECTIVE: Femoral nerve blocks (FNBs) for fragility hip fractures have benefits in improving pain relief and early mobilization while decreasing opioid use and rates of pneumonia. However, no study has looked at 1-year mortality outcomes for this intervention. This study aims to provide insight into 1-year outcomes. METHODS: A single-site retrospective case-control study from 2007 to 2016 in primary fragility hip fractures compared 665 patients who received an emergency department FNB to 326 patients who did not receive an FNB. The primary outcome was 1-year mortality. Secondary outcomes included mortality, mobility, and residence at discharge, 6 months, and 1-year intervals. RESULTS: There were no significant differences in preoperative characteristics. Although there was no statistically significant difference in 1-year mortality, patients who did not receive an FNB were more likely to be nonambulant at 1 year (odds ratio 1.71, 95% confidence interval, 1.14-2.57, P = .005). There were no other significant differences in mobility, residence, or mortality. CONCLUSION: There was no statistically significant difference in 1-year mortality, although individuals who did not receive an FNB were more likely to be nonambulant at 1 year.

Using Care Bundles to Improve Surgical Outcomes and Reduce Variation in Care for Fragility Hip Fracture Patients.

INTRODUCTION: Fragility hip fractures constitute a large proportion of orthogeriatric admissions to orthopedic wards. This study looked at reducing variation in care in fragility hip fracture patients using a novel approach with care bundles. The care bundle comprises 5 elements targeted at providing adequate analgesia, early mobilization, improving recognition of delirium, and decreasing rates of urinary infections. METHODS: A total of 198 patients who sustained a fragility hip fracture during the intervention period were included in the study. The primary outcome measure was compliance in applying the bundle to the study population, and secondary outcome measures were in-hospital mortality, acute length of stay, delirium and duration of delirium, and urinary tract infections. RESULTS: During the 12-month intervention period, compliance to the bundle of care was 47% (n = 92) based on the "all-or-none" approach. This was 28% higher than the preintervention rate. Overall, there was an increased rate of compliance across all individual elements of the bundle in the intervention group when compared to the preintervention group (P = .01). The most significant clinical result was a 10.5% reduction in "in-hospital mortality" in the intervention group (P < .001). CONCLUSION: This study demonstrated that the implementation of specific care bundle in patients with fragility hip fracture significantly reduces variation in care.

Factors associated with the successful removal of indwelling urinary catheters post-operatively in the fragility hip fracture patient.

INTRODUCTION: Patients presenting to hospital with a fragility hip fracture are routinely catheterized in the emergency department. Studies have found that the duration of catheterization is the greatest and most important risk factor for developing a urinary tract infection. Whilst there is a considerable body of evidence around correct techniques for insertion of urinary catheters, there appears to be little evidence as to the timing of their removal. AIM OF THE STUDY: To describe the current practice of indwelling catheter (IDC) removal post operatively in the fragility hip fracture patient and to identify factors associated with the successful removal of IDCs post operatively in the same cohort of patients. METHODS: This study was a retrospective cohort analysis of patients admitted to a large, tertiary hospital with an established ortho-geriatric model of care. RESULTS: Aperient regime was the only factor that appeared to have a significant impact on the successful IDC removal. The patient commenced on the aperient regime was three times more likely to have an unsuccessful IDC removal than the patient on a limited or no aperient regime. CONCLUSION: This study highlights the need for redesigning care that is patient focused, evidence-based, effective and efficient. The argument that a patient's bowel is required to be emptied prior to the successful removal of an IDC appears to be false, as in this study it was not identified as a predictor of successful IDC removal. A prospective clinical trial may be the next step forward in developing a clinical guideline for the successful removal of IDCs in the fragility hip fracture patient and/or surgical patient. Nurses have a crucial role to play in contributing to evidence-based practice and are continually challenged to do so.

Evaluating the orthogeriatric model of care at an Australian tertiary hospital.

INTRODUCTION: The management of fragility hip fractures requires a collaborative multi-disciplinary approach to care to ensure optimal patient outcomes. It is important to rigorously evaluate the model of care and enable the delivery of evidence based optimal patient care. AIM OF THE STUDY: The aim of this study was to document an orthogeriatric model of care (OGMOC) at a major tertiary hospital: assessing how particular indicators within the patient's admission were influenced by the OGMOC. METHODS: A retrospective case analysis of all patients with fragility hip fracture from two pre-intervention groups and three post-intervention groups was undertaken. Data from (i) length of stay in the emergency department (ii) length of stay in the orthopaedic unit (iii) time from admission to surgery and (iv) time from surgery to admission to rehabilitation were used. RESULTS: Implementation of the OGMOC resulted in: reduced time in the emergency department, quicker access to surgery, reduced length of acute hospital stay and an increase in the number of patients accessing the rehabilitation unit. CONCLUSION: This study contributes to the increasing body of evidence for best practice in the management of fragility hip fracture within an OGMOC.

Identifying outcomes associated with co-managed care models for patients who have sustained a hip fracture: an integrative literature review.

AIMS AND OBJECTIVES: The aim of this integrative literature review is to identify themes associated with improved patient outcomes related to orthogeriatric co-managed inpatient unit models of care for patients who had sustained a hip fracture. APPROACH: An integrative literature review was undertaken from 2002-July 2013 using electronic databases with specific search terms. METHODS: The theoretical framework of Whittemore and Knafl was used to guide the review. This framework was chosen as it allows for the inclusion of varied methodologies and has the capability to increase informed evidence-based nursing practice. RESULTS: Five distinct themes relating to outcomes emerged from the analysis, which were: time from admission to surgery; complications; length of stay; mortality and initiation of osteoporosis treatment. CONCLUSION: The analysis of this integrative literature review clearly indicates the need for national and international sets of agreed outcome measures to be adopted to facilitate the comparison of models of care. This would significantly improve the way in which outcomes and costs are reported, further enhancing international partnerships as the health care team strive to achieve overall improvements in the management of older people presenting to hospital with hip fracture.

Can geriatric hip fractures be managed effectively within a level 1 trauma center?

OBJECTIVES: To determine whether geriatric hip fractures can be managed effectively within a level 1 trauma center. DESIGN: A prospective observational cohort study with a historical control group. SETTING: Level 1 trauma center. PATIENTS: A total of 199 patients admitted under our hip fracture service were prospectively identified from 2011-2012. These were compared with 191 hip fracture patients who were admitted before the service. INTERVENTION: The hip fracture service includes coadmission under an orthopaedic and a geriatric team. A daily, consultant-led operating list was made available for hip fracture surgery. A "neck of femur" nurse was employed to coordinate patient care. MAIN OUTCOME MEASUREMENTS: Time to surgery, length of stay, discharge destination, and mortality. A cost-benefit analysis and a comparison with a lower acuity hospital were also performed. RESULTS: Since the hip fracture service, more patients underwent surgery within 48 hours (67% vs. 52%; P = 0.004), the length of stay significantly decreased from 26 to 22 days (P = 0.004), significantly more patients were admitted to the rehabilitation unit (58.7% vs. 3.5%; P < 0.001) and ultimately discharged to their own residence (51.6% vs. 40.5%; P = 0.034). Inpatient mortality rates did not change significantly (7.5% vs. 6.8%; P = 0.780). The estimated cost saving in 2011 was $981,040. CONCLUSIONS: Only minor changes are required to significantly improve the management of geriatric hip fracture patients. These patients can be managed effectively within a level 1 trauma center when an organized service prioritizing these patients is used. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for authors for a complete description of levels of evidence.