Improving the quality of care for hip fracture patients : studies on fast-track to surgery and adverse events

Hip fractures in the elderly are common and are associated with high comorbidity and mortality. Their care and treatment present challenges for nurses and other healthcare professionals and impose a substantial burden on healthcare resources. The general aim of this thesis was to examine how a new enhanced fast-track system to operation, waiting time to surgery, and depression influence outcomes in patients after hip fracture, with particular interest in adverse events.

In study I, we examined the effects of the implementation of a new enhanced fast-tracking system for the management of hip-fracture patients compared to an already existing system in 415 patients. Data was collected prospectively and a record review was carried out. Our results showed that the time to surgery was reduced by an average of 3 hours in patients admitted via the new fast-track system compared to the existing system. We found no difference in the 3-month mortality or the length of stay (LOS) between the groups. There was a trend toward a lower incidence of adverse events (AEs) in the invention group at 3 months, but this difference did not reach statistical significance. We were able to show that the introduction of an enhanced fast-track management system to surgery could reduce waiting time to surgery for this patient group.

In study II, we investigated how waiting time to surgery influenced the risk of serious adverse advents (SAEs) in patients with hip fracture and how time affected risk. A retrospective record review was conducted. Outcomes were the occurrence of SAEs, the LOS and one-year mortality rate. A cohort of 576 patients was included (577 hip fractures) in the study. We found that around 20.6% suffered at least one SAE during the hospital stay (range 1-5). Risk of SAE increased by 12% with every 10 hours of waiting time and the length of the hospital stay was prolonged by 0.6 days with every 24 hours of waiting time to operation. No optimal cut-off times for waiting time to surgery were found and no correlation between waiting time to surgery and one-year mortality. Those patients at greatest risk of SAEs were patients with pre-existing health problems, males and those with subtrochanteric fractures.

In study III we explored the incidence, preventability and nature of adverse events occurring in hip-fracture patients up to 90 days after surgery. A structured retrospective record review, using the Swedish version of Global Trigger Tool methodology was carried out on prospectively collected data from 163 patients. Sixty-two of the patients (38%) suffered at least one AE during their hospital stay and up to 90 days post-operatively (range 1-7). The most common types of AEs were infections such as pneumonia and urinary tract infections, but pressure ulcers and AEs associated with surgery were also common. AEs were more common in older patients and those with pre-existing health conditions. About 60% of these AEs were judged to be preventable.

In study IV, we investigated the influence of depression on patient-reported outcome up to one year after hip fracture. A cohort of 162 patients with intact cognitive function were included into either the depression or control group and were followed from baseline, to 3-months and 12-months. Using questionnaires, patients reported on their pain levels, hip function and quality of life. The depression group had significantly poorer hip function at baseline but this had improved at 3-months. The depression group experienced a lower health-related quality of life at baseline compared to the control group. At 12 months, neither group had returned to their pre-fracture level of function. Both groups experienced a decline in their health-related quality of life. The one-year mortality rate was higher in the depression group compared to the control group but the difference was not statistically significant. In this study we did not find that depression had a bearing on patient-reported outcome one year after hip fracture in patients without cognitive impairment.

In conclusion, the results of these studies demonstrate that the introduction of a new fast-track can reduce waiting time to surgery. Long waiting time to surgery is correlated with increased risk for SAEs and prolonged hospital stay. No optimal cut-off times exist, the risk for SAEs increases linearly over time. Patients at greatest risk of suffering SAEs are those with a higher American Society of Anaethesiologist’s (ASA) classification score, males and those with subtrochanteric fractures. We have also shown that many hip-fracture patients suffer AEs and the majority of these are preventable. We found no correlation between the presence of depression pre-fracture and poorer functional outcome one year after hip fracture.

List of scientific papers

I. ‘Straight to bed’ for hip-fracture patients: A prospective observational cohort study of two fast-track systems in 415 hips. Martin Eriksson, Paula Kelly-Pettersson, André Stark, Anna K. Ekman, Olof Sköldenberg. Injury, International Journal of the Care of the Injured. 2012;43:2126-2131.
https://doi.org/10.1016/j.injury.2012.05.017

II. Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study. Paula Kelly-Pettersson, Bodil Samuelsson, Olle Muren, Maria Unbeck, Max Gordon, André Stark, Olof Sköldenberg. International Journal of Nursing Studies. 2017;69:91-97.
https://doi.org/10.1016/j.ijnurstu.2017.02.003

III. The identification of adverse events in hip-fracture patients using the global trigger tool: A prospective observational cohort study. Paula Kelly-Pettersson, Olof Sköldenberg, Bodil Samuelsson, Andreas Stark, Olav Muren, Maria Unbeck. [Manuscript]

IV. The influence of depression on patient-reported outcomes for hip-fracture patients 1 year after surgery: A prospective cohort study. Paula Kelly-Pettersson, Bodil Samuelsson, Maria Unbeck, Olav Muren, Martin Magnéli, Max Gordon, André Stark, Olof Sköldenberg. [Manuscript]