Importance Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Objective To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases. Design, Setting, and Participants Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). Exposure Time elapsed from hospital arrival to surgery (in hours). Main Outcomes and Measures Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia). Results Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89). Conclusions and Relevance Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

/pdf/association-between-wait-time-and-30-day-mortality-in-adults-1qblyo7cq0.pdf

Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery.

https://nottingham-repository.worktribe.com/preview/3949546/HIP%20ATTACK%20paper%20submitted%20version.pdf

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

Background: We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture. Our aim was to evaluate the association between surgical delay and early mortality in these patients.

Methods: We performed a retrospective analysis of prospectively collected data from the Danish Fracture Database and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture. Femoral head fracture (classified as OTA/AO 31C per the OTA/AO classification system), high-energy trauma, pathological fractures, multiple fractures, and surgeries performed with implants not commonly used were excluded. End points were adjusted odds ratios for thirty-day and ninety-day mortality.

Results: For the 3517 surgeries included in this study, the median patient age was 82.0 years (range, fifty-one to 107 years), 2458 patients (70%) were female, and 1720 surgeries (49%) were performed because of a trochanteric fracture. Within twelve hours, 722 of the surgeries (21%) had been performed; within twenty-four hours, 2482 surgeries (71%); within thirty-six hours, 3024 surgeries (86%); within forty-eight hours, 3242 surgeries (92%); and within seventy-two hours, 3353 surgeries (95%). Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 (51%) of all cases. The thirty-day mortality was 380 (10.8%) and the ninety-day mortality was 612 (17.4%). The risk of thirty-day mortality increased with a surgical delay of more than twelve hours (odds ratio, 1.45; p = 0.02), more than twenty-four hours (odds ratio, 1.34; p = 0.02), and more than forty-eight hours (odds ratio, 1.56; p = 0.02); the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016). Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality.

Conclusions: In this study, a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality. The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon. The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons.

Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

/pdf/time-to-surgery-is-associated-with-thirty-day-and-ninety-day-3w813k4ffs.pdf

Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators.

Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study. A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register. A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients’ accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h. Safety measures to prevent fall at elderly patient’s accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity.

/pdf/epidemiology-treatment-and-mortality-of-trochanteric-and-21b0ar80pd.pdf

Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register.

Objectives:To empirically define a “delay” for hip fracture surgery based on clinical outcomes, and to identify patient demographics and hospital factors contributing to surgical delay.Design:Retrospective database analysis.Setting:Hospital discharge data.Patients/Participants:A total of 2,121,215 p

Delay in Hip Fracture Surgery: An Analysis of Patient-Specific and Hospital-Specific Risk Factors.

Background Hip fracture is a common injury with associated high mortality. Recent drives by the Department of Health have sought to prioritise these patients’ care. In April 2010, the Best Practice Tariff was introduced in England and Wales. This offers financial incentives to institutions that provide holistic care and surgery within 36 h for hip fracture patients. The England and Wales National Institute for Health and Clinical Excellence (NICE) published its first guidance on hip fracture management in June 2011, and emphasised the need for surgery on the day or day after admission. In spite of the emphasis placed on this injury, the predictors of in-hospital mortality remain ill-defined. In particular the effect of the timing of surgery remains contentious. Objective To address the issues raised by NICE around surgical timing and examine whether surgery before a 36 h watershed improves survival. In addition, to examine survival outcomes for each 12 h watershed following admission. Materials and methods Prospectively collected data on 2056 patients presenting to our unit with hip fractures between February 2008 and May 2011 were retrospectively reviewed. Multivariate regression analysis was used to correct for confounders, and so determine the effect of various parameters on in-patient mortality. Results Age ( p p p p p p p Conclusions Expeditious surgery is associated with improved patient survival. Other predictors of in-hospital mortality include age, gender, in-hospital fracture and ASA-grade. Ultra-early surgery (within 12 h) reduces risk of in-hospital mortality.

Early and ultra-early surgery in hip fracture patients improves survival.

Summary
Background

Shortcomings in non-technical skills have frequently been shown to play a role in adverse events during surgery. Human-factors training has an increasing role to play in enhancing patient safety and reducing medical errors. Programmes in non-technical skills are promoted by the surgical Royal Colleges in the UK and Ireland, and are currently aimed at consultants, senior trainees and theatre teams. Since 2009, the Severn Postgraduate Deanery School of Surgery in the UK has developed a 1-day human-factors training course specifically designed for junior surgical trainees.



Methods

Analysis of post-course feedback on self-assessed confidence in the use of non-technical skills was undertaken for all junior surgical trainees undertaking the course in 2012/13.



Results

Thirty-three junior surgical trainees attended the 1-day human-factors training course. In all, 91 per cent of trainees reported that the course would change their practice. There was a statistically significant difference between the self-assessed confidence of trainees in the use of all four categories of non-technical skills (p ≤ 0.001) before and after the course.



Discussion

The Severn Deanery offers a compulsory human-factors training course for surgeons at the start of their career. Given the importance of reducing human error, maintaining patient safety and the introduction of competency-based training with an emphasis on simulation, human-factors training has a vital place in surgical training, and is highly recommended to others involved in training junior surgical trainees.

Human‐factors training for surgical trainees

Background and PurposeSerum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures.Method and ResultsOver a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02–1.41) increased risk of in-hospital mortality. Patients with a venous lacta...

Serum lactate is a prognostic indicator in patients with hip fracture.

Summary
Background: The advent of simulated surgical skills courses has brought dynamic changes to the traditional approach to acquiring practical skills in surgery.

Context:  Teaching is a core part of the surgical profession, and any trainee can be involved in the organisation of skills training courses. This paper outlines the importance of organising surgical skills courses for trainees, and provides a practical guide on how to do so within busy clinical environments.

Innovation:  The paper examines how to plan a course, how to design the programme, and provides tips on faculty staff requirements, venue, finance and participants, with additional suggestions for assessment and evaluation.

Implications:  We recommend the organisation of skills courses to any trainee. By following key ground rules, the surgical trainee can enable the acquisition of advanced learning opportunities and the ability to demonstrate valuable organisational skills.

Surgical training in your hands: organising a skills course.

Bilateral insufficiency fractures of the proximal femur often have a pathological basis. Diagnosis of rare causes of insufficiency fractures can be challenging. Tumour-induced osteomalacia (TIO) is...

H.G.F. Burnand

Papers

Early and ultra-early surgery in hip fracture patients improves survival.

Human‐factors training for surgical trainees

Serum lactate is a prognostic indicator in patients with hip fracture.

Surgical training in your hands: organising a skills course.

Bilateral subtrochanteric fractures in tumour-induced osteomalacia caused by a nasal haemangiopericytoma.