STRATIFYING HIP FRACTURE PATIENTS TO GUIDE AND FOCUS APPROPRIATE CARE WHILST OPTIMISING RESOURCES

Abstract

Background: The implications of clinical governance, changing epidemiology, financial restraints alongside the increasing demands of the informed consumer-patient mean we must continually adapt our practice to efficiently meet expectations.

As a busy regional Trauma and Orthopaedics Unit of a District General Hospital we are increasingly affected by economic agendas and have noted an increase in the presenting frailty of our fracture hip patients.

Our practice has already changed by the use of an Orthogeriatrics Team (OGT): optimising patient status pre-operatively and ensuring maximum post-operatively continuity. The OGT has significantly reduced time to theatre. With appropriate investigation and lower complication rates it will offset the cost of the team.

We wanted to see if the care of fractured hip patients could be further focused.

On this basis, a four-part clinical stratification system was devised for patients undergoing fractured hip repair:

• Complex 0 (C0): Hip repair of a non-complex fracture pattern in an otherwise fit, healthy patient.

• Complex I (CI): A fit, healthy patient with a complex hip fracture pattern.

• Complex II (CII): Medically unfit patient with a non-complex hip fracture.

• Complex III (CIII): Medically unfit patient with a complex hip fracture.

Patients and Methods: The first 50 patients operated on across the same three months in both 2004 and 2005 were retrospectively assessed from prospectively collected data.

Patients were grouped accordingly and age, length of stay, time to theatre and reason for delay, mental state examination score (MSE) on admission, and number of co-morbidities were also recorded.

Chi-square was performed on co-morbidity, MSE and theatre times with AVOVA used for age and length of stay data.

Results: No significant difference between groups for age.

Two fold increase in stay (2004 paired classes C0+I vs CII+III; P< 0.003).

Chance of more than 2 co-morbidities (C0+I vs CII+III): 52% vs 96% (2004) and 56% vs 92% (2005).

MSE with a positive dementia score: 26% vs 82% (2004; P0.001) and 39% vs 70% (2005; P< 0.05).

Time delays to theatre greater than 24hrs were seen 24% vs 92% (P< 0.001) in 2005. The correlating values in 2004 were 63% vs 87%.

Active treatment delaying theatre in the C0+I group 24% vs 57% (CII+III) in 2004 and 0% vs 78% 2005 (P< 0.001).

Conclusion: The benefit of the OGT can be seen clearly in most parameters and this classification system correlates and quantifies increasing hip fracture complexity with increasing post-operative burden even under their care.

Stratifying patients for pre- and postoperative planning, risk counselling, and surgeon selection can identify patient groups likely to incur greater cost during their treatment.

The classifications are easily reproducible and can be applied to larger patient groups via institutional or national joint registries.