Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

doi:10.4236/ojo.2013.34035

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Open Journal of Orthopedics, 2013, 3, 193-198

http://dx.doi.org/10.4236/ojo.2013.34035 Published Online August 2013 (http://www.scirp.org/journal/ojo)

193

Causes of Surgical Delay and Demographic Characteristics

in Patients with Hip Fracture*

Sjöstrand Desirée1, Hommel Ami1, Johansson Anders2#

1Department of Clinical Sciences, Lund University and Skane University Hospital, Lund, Sweden; 2Sections of Anaesthesiology and

Intensive Care, Department of Clinical Sciences, Lund University and Skane University Hospital, Lund, Sweden.

Email: #[email protected]

Received June 19th, 2013; revised July 15th, 2013; accepted July 25th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Several studies analyze how surgical delay affects patien ts with hip fracture. The aim of this study was to

identify the causes of surgical delay and demographic characteristics in patients with hip fracture who had delays longer

than 24 hours from admission to hospital. Methods: Quantitative retrospective register study of 484 patients was con-

secutively included during the period November 1, 2010 and October 31, 2011 in the University Hospital in Lund (Swe-

den). Results: A frequen cy of 29.4% had a su rgical delay longer than 24 hours. The main reaso ns for delays to surgery

were lack of theatre facilities (54%), medical unstable patient (16%) and anticoagulan t treatment (10%). Of all patients,

69% (n = 332) wer e women and 31% (n = 151) were men. The mean age for women were 83.6 (CI 83 - 85) vs. 79 (CI

77 - 81 ) f or men , re sp ec ti ve ly . T he mos t c o mmo n t yp e o f h ip fr ac tu re wa s di splaced cervical hip fracture (39%, n = 188)

with a majority of fractures in male patients. In total, women suffered hip fractures to a greater extent than men (69% vs.

31%, p = 0.016), but no relationship was found with respect to the fracture type and age (p = 0.358). Conclusion: The

main result demonstrated that d elays longer than 24 hou rs were due to lack of theatre facilities. Further researches have

to be done in order to investigate whether lack of theatre facilities depends on improper operation planning and/or on

lack of medical staff.

Keywords: Orthopedics; Hip Fracture; Surgical Delay; Register Study

1. Introduction

Hip fracture is one of the conditions that have become a

major problem with significant post-fracture disability,

reduced quality of life as well as increasing mortality [1].

The number and the proportion of older persons are

growing in practically all countries [2]. With the in-

creasing proportion of elderly in the worldwide popula-

tion, the number of cases of hip fracture will inevitably

rise [3,4]. It is estimated that the annual number of hip

fractures worldwide will rise from 1.7 million in 1990 to

around 6.3 million by 2050. Each year in Sweden (with

around 9 million inhabitants), approximately 18,000 pa-

tients are hospitalized and operated due to hip fractures

[5,6].

Despite a growing awareness of the impact on quality

of life and on outcome after hip fracture, the surgical

delay is still an abundant problem among hip fracture

patients [7-11]. Several studies have shown that delayed

surgery in patien ts with hip fracture pro longs hospitaliza-

tion and increases morbidity, the number of complica-

tions, physical and psychological suffering and mortality

[10,12,13]. However, some recently published studies

have suggested that there is a correlation between early

surgery and decrease in postoperative complications.

Patients with hip fracture who were operated within 24

hours from admission have fewer complications and

lowered mortality risk than those patients who had to

wait longer for surgery [3,8,9,14,15]. Regardless of this

knowledge, some studies indicate that a significant number

of patients suffer according surgical delay and some

studies point out improper operation planning and/or

staff unavailability at the surgical d epartment [11,16]. To

our knowledge, th ere are no publish ed trials with the aim

of explicitly identifying the causes of surgical delay in

patients with hip fracture.

*Conflict of interest: We declare there isn’t any conflict of interest.

Funding: This research needed no funding.

#Corres

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Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

194

2. Material and Methods

The study was approved by the Ethics Committee of the

Medical Faculty of the Lund University (VEN 128-11)

and has been performed in accordance with the declara-

tion of Helsinki. Study sample includes entirely 484 pa-

tients undergoing surgery for hip fracture during the pe-

riod November 1, 2010 and October 31, 2011 at Skåne’s

University Hospital in Lund (Sweden). Both patients

who underwent surgery within 24 hours and patients with

surgical delays longer than 24 hours were included. The

reason for this was to exactly identify the proportion of

individuals who underwent surgery later than 24 hours

after admission and to precisely descr ibe the wh ole group

of hip fracture patients during the study period. One pa-

tient was excluded from the study and the reason was

that the patient passed away before surgery was possible.

All data for the study were collected from the Swedish

National Hip Register , RIKSHÖFT. The main purpose of

the registry is to ensure co n tinu ou s quality and to create a

high quality of care for hip fracture patients across the

country [13]. The registry consists of several forms which

are used to collect data about the patient, the treatment,

the functional outcome and the rehabilitation outcome.

For this study we created a new document with variables

from these forms which were considered relevant to the

purpose of the study. These variables were: age, gender,

fracture type, date of arrival, time of arrival, start time

for surgery, surgery within 24 hour and reason for delay.

In order to identify if there was any connection between

the number of delays and day of arrival we conv erted the

category date of arrival to day of the week of arrival.

Afterwards and to determine whether the number of de-

lays was affected by the time of arrival, we divided the

day into 4 intervals: 7:00 to 12:00, 12:01 to 17:00, 17:01

to 9:00 p.m. and 9:01 p.m. to 6:59, respectively. The reg-

ister was checked by authorized personnel and a further

regular check of the collected data was carried out in

order to ensure the reliability of the study: the data of

every twentieth patient was compared to the original

from the Swedish National Hip Register.

Statistics

Data were analyzed using the Statistical Package for So-

cial Sciences (SPSS 14.0). Results are presented using

descriptive statistics according to numbers of patients (n),

mean/median, standard deviation (SD) and proportions

where appropriate.

A comparative analysis was performed to identify sta-

tistical differences between fracture type and gender,

fracture type and age, number of delays and day of the

week of arrival, delays and time of arrival, delays and

age, and between delays and gender. Normal distribution

was determined by Kolmogorov-Smirnov test. Compari-

son analyses were carried out with confidence interval

(CI) for age, Chi-Square test was used for nominal data

and for differences of proportions, and Fisher’s exact test

was used when variables were less than 5. Ratio data was

analyzed with Student’s t-test. A statistically significant

differe n ce w a s re garded a s p < 0. 05.

3. Results

3.1. Demographics

The study group enrolled in the study consisted of 483

hip fracture patients, 69% (n = 332) were female and

31% (n = 151) were men. Age ranged between 22 and 98

years in men and between 45 and 102 years in women.

Mean age for men w as 79 (CI 77 - 81) and 83.6 ( CI 83 -

85) for women, respectively. The most common type of

hip fracture was the displaced cervical hip fracture (39%,

n = 188) with a clear majority of fractures in male pa-

tients. Overall, women suffer hip fractures to a greater

extent than men (69% vs. 31%, p = 0.016) (Table 1).

However, no statistically significant relationship was

found with respect to the fracture type and age (p =

0.358).

3.2. Surgical Delay and Effect of Age and

Gender

A number 29.4% (n = 142) patients had to wait over 24

hours before surgery with no significant difference be-

tween the “24-hour target” and gender (p = 0.516). The

patients who were operated in within 24 hours from

admission were significant older (p = 0.022) (Table 2).

3.3. Causes of Surgical Delay

The most common reason for surgical delay was “lack of

theatre facilities” (54%, n = 76) followed by “medically

unstable patient” (16%, n = 22) and “patient on antico-

agulant th erapy” (10%, n = 14) (Table 3).

3.4. Surgical Delay and Effect of Time of Day

and Day of the Week of Admission

When day of the week of admission was surveyed the

largest number of patients arrived at the hospital on

Thursday and a minimum number of patients on Sundays

with no statistical differences between the number of

delays to surgery and the day of the week (p = 0.248,

Table 4). Depict Time of day of admission showed that

the majority of patients arrived at the hospital between

12:01 and 17:00 (Table 5), with no differences between

the time points (p = 0.345). The largest proportion of

patients had to wait between 24 and 48 hours for surgery

(Table 6). The mean waiting time for patients with de-

layed surgery was 40 ± 29 hours with a mean median

value of 30 hours.

Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

195

Table 1. Incidence of fracture types.

Gender Fracture type

Cervical Displaced cervical Basocervical Trochanteric 2

fragment Trochanteric

+ 2 fragment Subtrochanteric Total (n)

Men 9.9% 51% 2% 13.2% 15.9% 7.9% 151

Women 12.9% 33.6% 4.2% 19.8% 18.9% 10.5% 332

Total 12% 39% 3.5% 17.8% 18% 9.7% 483

Analysis be t ween gender and frequency of fractures, p = 0. 0 16, Pearson’s chi-squared test.

Table 2. Compliance with 24-hour goal.

Compliance with 24-hour goal Mean age (±SD)

Yes 83 ± 11

No 80 ± 11

Difference between “24-hour goal” according to age: p = 0.022, T-test.

Table 3. Causes of surgical delay.

Cause of delay Total (n) P ercent (%)

Delayed examinati on 1 <1

Repeated X-ray 1 <1

Diagnosis after CT scan 5 4

Diagnosis after MRI 3 2

Administrative delay 3 2

Lack of theatre facilities 76 54

Surgeon not available 1 <1

Anesthesiologist not available 1 <1

Medically unstable patient 22 16

Gastrointestinal haemorrhage 2 1

To determine the diagnosis 9 6

Recent myocardial infarction 2 1

Anticoagulant therapy 14 10

Other 1 <1

Total 142 <101

4. Discussion

The purpose of th is study was to identify the cause of the

delay to surgery in patients with hip fracture in Skåne,

southern Sweden. The variables analyzed were consi-

dered important for the development and assurance of

care for this patient population. In summary, the results

showed that the main reason for surgical delay was lack

of theatre facilities (54%) and Medical unstable patient

(16%).

According lack of theatre facilities we could not find

Table 4. Number of delays to surgery and day of the week

of admission.

Day of the week Total (n) Percent (%)

Monday 74 15.3

Tuesday 73 15.1

Wednesday 77 15.9

Thursday 81 16.9

Friday 63 13.0

Saturday 65 13.4

Sunday 50 10.3

Total 483 100

p = 0.248, Pe arson’s c h i-squared te st.

Table 5. Time of day of admission.

Time Total (n) Percent (%) Number delays

7:00 to 12:00 101 20.9 30

12:01 to 17:00 172 35.5 59

17:01 to 21:00 99 20.7 28

21:01 to 06:59 111 22.9 25

Total 483 100 142

p = 0.345, Pe arson’s c h i-squared te st.

Table 6. Number of patients within the different time points

that underwent surgery later than 24 hours from admission.

Hours to surgery MonTu Wen Thur FriSatSun

24 - 48 hours 141725 23 14208

48 - 72 hours 3 31 2 2 10

More than 72 h 2 20 1 4 0 0

Total 192226 26 20218

p = 0.248, Fi sh er’s exact test.

information why the absence occurred. A probable rea-

son could be improper operation planning or staff un-

availability in the surgical department, since these are

known issues [11]. Similar results emerged in an Aus-

Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

196

tralian study by Hamish et al. [16] where 58% of the

delays were due to lack of theater facilities and 33% due

to medical unstable patient. Hommel et al. [9] describes

comparable findings in Sweden.

In present study, there was a significant difference in

age between men and women (men 79 vs. women 84).

The fact that women suffer more frequently than men of

hip fractures and that affected women are older than men

agrees well with the nation al register [17] and with other

studies [3,15,18]. Several published studies on this topic

show similar distribution of gender [3,9,15,18]. The

overwhelming proportion of women who are usually

seen in the majority of the studies can be explained by

two reasons: the fact that women have a higher life

expectancy and that women have an increased tendency

to osteoporosis [2]. Most of the studies in which the topic

hip fracture is surveyed exclude patients over 60 - 65

years. In our study, no patients were excluded because of

age.

According to the National Board of Health and Wel-

fare guidelines for the care and treatment of patients with

hip fractures the most common fracture type is the dis-

placed cervical fracture [19]. Our analysis showed simi-

lar results. However, we found that women suffered

more than men of this particular fracture (59.5% vs.

40.5%) as women were more disposed to hip fractures.

This fact is confirmed by RIKSHÖFT annual reports.

When the reports for the past six years were analyzed

[17,20-24], it demonstrated that the fracture types fol-

lowed the same pattern as in our study and that the

distribution for fracture type was similar for both sexes.

This outcome is confirmed by Gjersten et al. [4], in th eir

study 72% of the participants were wo men and 38.1% of

all fractures were classified as displaced cervical frac-

tures. In terms of frequency distributions of gender, age

and fracture type, our study is comparable with other

studies concerning the subject.

Regarding the relationship between late surgery (not

within 24-hour) and gender we found no significant

difference. This is in contrast with Novack et al. [3]

study in which the proportion of males not operated was

higher than that of female patients (21.8% vs. 16.1%,

respectively). Additionally, they found no differences

according to age whether our analysis revealed a sig-

nificant correlation between to “surgery within 24 hours”.

Patients who met the “24-hour target” after arrival to the

hospital were older than the group of patients with de-

layed surgery.

Regarding the fulfillment of the “24-hour target”, our

result showed that surg ery was started within 24 hou rs in

70.6% of the cases. This figure corresponds well with the

figures of the regions Center for Operational Planning

and Analysis [2 5]. However, international surgical delays

are often defined in different ways and make it more

difficult to compare and evalua te our results. In the study

by Novack et al. [3] the authors reported only the number

of patients who underwent surgery within 48 hours from

arrival to the hospital.Of the included 4633 patients,

there were 17.6% who did not undergo surgery and

29.1% who underwent surgery within 48 hours. These

proportions cor responds to a Spanish study by Librero et

al. [15] that demonstrated an amounts of 24.7% of

patients were receiving surgery within the first days after

arrival to the hospital.

The OECD health report analyzed how health care

quality indicators have been between 1999 and 2004 in

OECD countries [26]. When time to surgery in hip frac-

ture patients was surveyed this issue demonstrated sig-

nificant differences between countries. The proportions of

patients who underwent surgery within 48 hours of arri-

val at the hospital were as follows: Sweden 93.5%,

Norway 93%, Finland 86%, Netherlands 80.4%, Canada

79.5%, Iceland 73.1%, Denmark 68.1%, Mexico 65.1%,

UK 61.5%, Italy 32.7% and Portugal 50.1%. It is clear

that there are considerable differences between the va-

rious countries in the wo rld in terms of quality indicators

for patie nts with hi p f rac ture.

When we analyzed Day of the week and Time of arri-

val, no correlation could be confirmed. Correspond-

ingly, Novack et al. [3] demonstrated that there was no

difference in surgical delay depending on which day of

the week the patients arrived at the hospital. According

to our result the largest proportion of patients who had

delayed surgery waited between 24 and 48 hours before

surgery. These findings agree well to the results of other

studies [15,27].

We believe that there is some strength with present

study. Before the start of the study and with regard to the

study purpose, appropriate data collections were discussed

with coordinator of the Swedish National Hip Registry.

We enrolled all patients from one year in an effort to

minimize the risk of bias that could influence of dif-

ferences in staffing, due to decreased production during

summer and national holidays. We also believe that the

study is based on a sufficiently large sample where the

drop out is minimal and therefore we consider the results

reliable.

Even if there have been significant improvements to

streamline the management of hip fracture patients, the

hospital of Lund has not been able to meet Region

Skåne’s goal (surgery within 24 hours from admission

into hospital for at least 80% of all patients with hip

fracture) during the period, though only 70.6% of the

patients had surgery within the first day. If the main

reason for the result was due to improper planning at the

surgical department or due to understaffing had to be

investigated. Altho ugh it h as been difficult to find stud ies

within the subject (e.g. cause of delay to surgery), we

Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

197

believe that our study could contribute to future actions

and measurements, in order to further optimize the health

care program for these patients and a prospective study

might be useful in order to better identify the causes of

the surgical delay.

5. Conclusion

The causes of delay to surgery within 24 hours occurred

in 29.4% of all patients with hip fracture. The main rea-

sons for delays were lack of theatre facilities (54%),

medical unstable patient (16%) and anticoagulant treat-

ment (10%). The most common type of hip fracture was

displaced cervical hip fracture (39%) with a majority of

fractures in male patients.

REFERENCES

[1] A. Hommel, “Improved Safety and Quality of Care for

Patients with a Hip Fracture,” Ph.D. Dissertation, Lunds

Universitet, Institutionen för Hälsa, Vård Och Samhälle,

2007.

[2] WHO, “Sweden: “Nutrition for Older Persons,” 2011.

www.who.int/nutrition/topics/ageing/en/index2.html

[3] V. Novack, A. Jotkowitz, O. Etzion and A. Porath, “Does

Delay in Surgery after Hip Fracture Lead to Worse Out-

comes? A Multicenter Survey,” International Journal for

Quality in Health Care, Vol. 19, No. 3, 2007, pp. 170-176.

doi:10.1093/intqhc/mzm003

[4] J.-E. Gjertsen, L.-B. Engesæter, O. Furnes, L.-I. Havelin,

K. Steindal, T. Vinje and J.-M. Fevang, “The Norwegian

Hip Fracture Register Experiences after the First 2 Years

and 15,576 Reported Operations,” Acta Orthopaedia, Vol.

79, No. 5, 2008, pp. 583-583.

doi:10.1080/17453670810016588

[5] National Board of Health and Welfare, “Sweden: Fall-

skador i Vården,” 2011.

http://www.socialstyrelsen.se/patientsakerhet/riskomrade

n/fallskador

[6] RIKSHÖFT, “Sweden: Höftfrakturer; 2009a,” 2009.

http://www.rikshoft.se/se/index.php?option=com_content

&view=article&id=50&Itemid=37

[7] J. Richmond, G.-B. Aharonoff, J.-D. Zuckerman and K.-J.

Koval, “Mortality Risk after Hip Fracture,” Journal of

Orthopaedic Trauma, Vol. 17, No. 1, 2003, pp. 53-56.

doi:10.1097/00005131-200301000-00008

[8] P. Vestergaard, L. Rejnmark and L. Mosekilde, “Increased

Mortality in Patients with a Hip Fracture-Effect of Pre-

Morbid Conditions and Post-Fracture Complications,”

Osteoporosi International, Vol. 18, No. 12, 2007, pp.

1583-1593. doi:10.1007/s00198-007-0403-3

[9] A. Hommel, K. Ulander, K. B. Björkelund, P.-O. Norman,

H. Wingstrand and K.-G. Thorngren, “Influence of Opti-

mised Treatment of People with Hipfracture on Time to

Operation, Length of Hospital Stay, Reoperations and

Mortality within 1 Year,” International Journal of the

Care of the Injured, Vol. 39, No. 10, 2008, pp. 1164-1174.

doi:10.1016/j.injury.2008.01.048

[10] S.-K. Khan, S. Kalra, M. M. Thiruvengada and M. J.

Parker, “Timing to Surgery for Hip Fractures: A System-

atic Rewiew of 52 Published Studies Involving 291,413

Patients,” International Journal of the Care of the Injured,

Vol. 40, No. 7, 2009, pp. 692-697.

doi:10.1016/j.injury.2009.01.010

[11] N. Simunovic, P. J. Devereaux and M. Bhandari, “Sur-

gery for Hip Fractures: Does Surgical Delay Affect Out-

comes?” Indian Journal Orthopaedia, Vol. 45, No. 1,

2011, pp. 27-32. doi:10.4103/0019-5413.73660

[12] K. B. Björkelund, “Acute Confusional State in Elderly Pa-

tients with Hip Fracture. Identification of Risk factors and

Intervention Using a Prehospital and Perioperative Man-

agement Program,” Ph.D. Dissertation, Lunds Universitet,

Institutionen för Hälsa, Vård Och Samhälle, 2008.

[13] RIKSHÖFT, “Sweden: Om Rikshöft; 2009b,” 2011.

http://www.rikshoft.se/se/index.php?option=com_content

&view=article&id=46&Itemid=27

[14] A. Bottle and P. Aylin, “Mortality Associates with Delay

in Operation after Hip Fracture: Observational Study,”

British Medical Journal, Vol. 332, No. 7547, 2006, pp.

947-951. doi:10.1136/bmj.38790.468519.55

[15] J. Librero, S. Peiró, E. Leutscher, J. Merlo, E. Bernal-

Delgado, M. Ridao, N. Martínez-Lizaga and G. Sanfélix-

Gimeno, “Timing of Surgery for Hip Fracture and In-Hos-

pital Mortality: A Retrospective Population-Based Cohort

Study in the Spanish National Health System,” BMC

Health Services Research, Vol. 12, No. 15, 2012.

doi:10.1186/1472-6963-12-15

[16] C. R. Hamish, I. A. Harris, L. Mcevoy and T. Todovora,

“Delay to Surgery and Mortality after Hip Fracture,” The

Australian and New Zealand Journal of Surgery, Vol. 77,

No. 10, 2007, pp. 889-891.

doi:10.1111/j.1445-2197.2007.04267.x

[17] RIKSHÖFT-SAHFE, “Annual Report 2009,” 2012.

http://rikshoft.se/se/images/stories/arsrapporter/arsrapport

2009.pdf

[18] K. B. Björkelund, A. Hommel, K.-G. Thorgren, L. Gus-

tafson, S. Larsson and D. Lundberg, “Reducing Delirium

in Elderly Patients with Hip Fracture: A Multi-Factorial

Intervention Study,” Acta Anaesthesiologica Scandinavia,

Vol. 54, No. 6, 2010, pp. 678-688.

doi:10.1111/j.1399-6576.2010.02232.x

[19] National Board of Health and Welfare, “Guidelines for

Care and Treatment in Patients with Hip Fracture,” So-

cialstyrelsen, Stockholm, 2003.

[20] RIKSHÖFT-SAHFE, “Annual Report 2005,” 2011.

http://rikshoft.se/se/images/stories/arsrapporter/Arsrappor

t2005.pdf

[21] RIKSHÖFT-SAHFE, “Annual Report 2006,” 2011.

http://rikshoft.se/se/images/stories/arsrapporter/Arsrappor

t2006.pdf

[22] RIKSHÖFT-SAHFE, “Annual Report 2007,” 2011.

http://rikshoft.se/se/images/stories/arsrapporter/Arsrappor

t2007.pdf

[23] RIKSHÖFT-SAHFE, “Annual Report 2008,” 2011.

http://www.rikshoft.se/se/images/stories/arsrapporter/Arsr

apport2008.pdf

Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

198

[24] RIKSHÖFT-SAHFE, “Annual Report 2010,” 2012.

http://rikshoft.se/se/images/stories/arsrapporter/arsrapport

2010.pdf

[25] Center for Operational Planning and Analysis, 2011.

http://www.skane.se/Upload/Webbplatser/vardgaranti/l%

C3%A4gesbilder/Uppf%C3%B6jlning%20T2%202011%

20h%C3%B6ftprocessm%C3%A5l%20internetversion%

20_3_.pdf

[26] HCQI, “Health Care Quality Indicators Project. Initial

Indicators Report,” 2012.

http://www.oecd.org/dataoecd/1/34/36262514.pdf

[27] M. P. Fantini, G. Fabbria, M. Lausb, E. Carrettaa, S. Mi-

mmia, G. Franchino, L. Faveroc and P. Rucci, “Determi-

nants of Surgical Delay for Hip Fracture,” The Surgeon,

Vol. 9, No. 3, 2011, pp. 130-134.

doi:10.1016/j.surge.2010.11.031