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Delay of more than 24 hours to hip fracture surgery associated with increased mortality
Clinical Question
Is increased time-to-surgery for hip fractures associated with higher mortality?
Bottom line
For patients with hip fractures, the 24-hour mark after arrival to the emergency department (ED) may represent the threshold at which complications increase if no surgery is performed. In this Canadian study, two-thirds of patients underwent surgery after the 24-hour mark, and this delay was associated with increased 30-day mortality and greater number of medical complications. 2b
Reference
Study design: Cohort (retrospective)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
Using data from a Canadian health administrative database, these authors examined the association between wait time for surgery (defined as the elapsed time from arrival at the ED until surgery) and 30-day mortality for adults with hip fractures. The study cohort consisted of approximately 42,000 patients—their mean age was 80 years, 70% were women, and mean time to surgery was 38.8 hours. A risk-adjusted model to visualize the association between surgical delay and mortality showed that complications started to increase at the 24-hour mark. Delayed surgery was thus defined as occurring more than 24 hours after ED arrival. Using this definition, 34% of the cohort received early surgery and 66% received delayed surgery. Patients in the delayed group were more likely to be men, have comorbidities, be transferred from other institutions, and be treated at academic or high-volume centers. Propensity scoring was used to match 13,731 patients in the early group with patients in the delayed group. More patients in the delayed group than in the early group died within 30 days (6.5% vs 5.8%; P = .006). The delayed group was also more likely to have medical complications within 30 days, including pulmonary embolism, pneumonia, and myocardial infarction.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
Patients with more comorbidities and thus longer delays would obviously have poorer outcome related to comorbidities. The results were very modest and could be completely explained by comorbidities. The results are misleadingly reported to suggest that the increased mortality was due to surgical delay and not the higher comorbidities.
There are similar don more than 10-15 yrs ago and orthopedist in our hospital brought that to general surgery meeting and requesting priority to be given to hip surgery.
The difficulty is getting general surgeons to accept this. They all seem to think a gallbladder issue is much more important. This data should be mandatory reading for all surgical department heads and OR supervisors.
I am dismayed but not surprised by this. Obviously our orthopedic surgical colleagues have no vested interest in delaying hip fracture surgery. Hopefully they will be able to use this information to successfully advocate at high levels for the resources required to ensure timely access to care for this group of patients. I would love to see a cost effectiveness study done looking into increased costs of taking care of patients who experience a complication. This should include not just hospital costs but rehab and home care costs as well. I "know" what the answer will be but it may take something like this to "wake up" the bean counters so they realize that having elderly people lying in bed with a hip fracture for too long before surgery is not a good use of health care dollars.
Congruent with own experience as medical consultant for ortho ward. Also to be noted is the burden of pain symptoms with cognitive/orientation spin-offs in those patients for whom the delay is postponed
This is research that underlines the prooblem with inadequate capacity in healthcare. Increasing populations with increasing average age in BC Lower Mainland requires increase in resources for appropriate surgical capacity
Good poem
It is akways been known yhat delay in any treatment results inncomplications.
This should be directed to hospital adminstration and orthopedic surgeons
What an embarrassment to the Canadian healthcare system. Sadly, this kind of information never makes it before the public eye as we in Ontario face of an election.
Common sense. We do not need any reserche to confirm that if we delay a surgery in a patient with a hip fracture, they are going to start with serious complications. The reserche should be doing in how to do the surgery as soon as possible.