- Email: [email protected]
Factors affecting the outcome after proximal femoral fractures
297
Factors affecting the outcome after proximal femoral fractures H. J. Fox, J. Pooler, D. Prothero and G. C. Bannister Southmead
Hospital,
Westbury-on-Trym,
Bristol, UK
One hundred and forty-two consecutive patients with proximal femoral fractures were audited prospectively over a l-year period. Mobil@, age and sex were recorded along wifh timing of surgery, complicafions, ‘will to live’, length of admission, mortality, mobility and housing requirements on discharge. Operative procedures were pprformed mostly by intermediate surgical staff on night-time emergency lists shared with other specialities. Pafienfs were treated on a ward with nursing staff levels less than the minimum recommended by professional bodies. Mean hospital stay was 31 days. In-patient mortality was 37 per cent in males and s per cent in females. It was possible to predict protracted hospital stay in 84 per cent, mortality in 84 per cent, mobility on discharge in 92 per cent and need for rehousing in 83 per cent of patients. Of the 10 principal variables that affected outcome, four could be influenced by hospital practice. These variables were associated with 1284 hospital bed days, which constituted 30 per cent of total bed occupancy. Fifty-five per cent of these were associated with non-medical delay to surgery, 25 per cent with wound infection or re-operation and 20 per cent with broken pressure areas. There would appear to be the potential fo improve outcome in proximal femoral fractures by stabilizing fractures within 24 h, adopting measures additional to antibiotic prophylaxis to reduce infection and ensun’ng that patients do not develop pressuresores.
Injury, 1994, Vol. 25, 297-300,
July
Introduction In 1977, 18 per cent of all orthopaedic beds in England and Wales were occupied by patients who had sustained proximal femoral fracture (Lewis, 1981) and an increase of 83 per cent between 1986 and 2012 has been predicted (Lord and Sinnett, 1986). Following proximal femoral fracture, a proportion of patients lose their independence and occupy acute hospital beds for prolonged periods whilst rehousing arrangements are made. Many factors affecting the outcome of proximal femoral fractures are predetermined and can be recognized on admission, but few studies have addressed the influence of hospital practice (Evans et al., 1980; Bannister et al., 1990). Identification of such factors would allow accurate early prognosis, accelerate rehousing arrangements and target areas for improvement in hospital practice. 0
1994 Butterworth-Heinemann
0020-1383/94/050297-04
Ltd
The aim of this audit was to identify the factors affecting the outcome of proximal femoral fractures in an affiliated teaching hospital and to quantify the influence of hospital practice.
Materials and methods During a l-year audit period from May 1990 to April 1991, 142 patients with proximal femoral fractures were admitted to Southmead Hospital, and were prospectively assessed according to the variables shown in TableI. Patients were managed on a ward with nurse staffing levels less than the minimum recommended by nursing and orthopaedic professional bodies (British Orthopaedic Association, 1990). Operative procedures were performed predominantly by peri-Fellowship junior staff, under antibiotic prophylaxis in conventional theatres, usually on night-time emergency lists shared with other specialities, as a result of which cases were subject to frequent cancellation. Statistical analysis Statistical analysis was carried out by the third author using multivariate analysis on an SPSS computer programme employing Pearson chi-squared, two-tailed Fisher exact and Student’s f-tests. Discriminant variables were identified for mortality, length of admission, discharge mobility, need for rehousing and new nursing home placement.
Table I. Variables affecting outcome Status on admission
Age Sex Housing status Mobility Housebound Walking aids Stairs Social function Shopping Home help ‘Meals on wheels’ ‘Will to live’
Hospital factors Time to operation Operative fixation Nursing complications Wound infection Re-operation
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 5
298
Results Mortality
Table II. Mortality (Table II)
Percentage
In-patient mortality was 12 per cent. The policy of the Anaesthetic Department was to proceed with surgery as soon as was practically possible, and only four patients were considered unfit for operation: they died before discharge. The other 13 cases died 5-15 days postoperatively. Male sex, age above 80 years, wound infection and non-medical delay to surgery were the independent variables affecting mortality. When all these variables were applied, they predicted mortality in 84 per cent of cases. Mortality rose sharply when surgery was carried out more than 24 h after admission (P= 0.04). Mortality was neither associated with the grade of surgeon, the operative procedure undertaken nor the type of fracture. The overall re-operation rate was 2.9 per cent. All patients were allowed to walk fully weight-bearing, within limits of pain, within 48 h. Length of hospital stay (Table 111)
The mean length of stay was 31 days. Patients from nursing homes remained for II days because of the simplicity of discharge back. Patients from Elderly Mentally Infirm Institutions stayed a mean of 56 days and all required rehousing in nursing homes. Mean stay after admission from sheltered or warden-controlled accommodation was 31 days, from home 35 days and from residential homes 38 days. Patients receiving home care remained for 36 days (PC 0.001) and receiving ‘meals on wheels’ for 40 days. The 17 patients affected by pressure sores remained in hospital for a mean of 53 days (P
Discharge
24-72 >72h h
36.7 5.4 14.7 6.4 33 10
P
6.8:1
P-C 0.001
2.3:1
NS
3.3:1
P< 0.01
0 ::
8
NS, not significant.
Table III. Length of hospital stay Number of days Age > 80 years Age c 80 years Operation Day 0,l Day 2 Nursing complications Home care
P
43.2 23.9
PC 0.0001
25.3 32.8 52.9 36.0
P< 0.01 P< 0.0001 P-C 0.001
Table IV. Need for rehousing Housebound Not housebound ‘Meals on wheels’ No ‘meals on wheels’ Age > 80 years Age < 80 years Admission > 28 days -C28 days
43% 11% 67% 14% 29.6% 6.8% 41.5%
6.9%
PC 0.001 PC 0.01 PC 0.01
PC 0.001
mobility
Mobility on discharge could be predicted in 92 per cent of cases from data obtainable on admission. Overall, 125 patients were discharged, 82 per cent with walking aids (sticks or Zimmer frames) and 18 per cent in wheelchairs. Ninety per cent of patients admitted walking independently were discharged using walking aids and 10 per cent were not independently mobile. Ten per cent of those who could climb stairs on admission, 20 per cent of those using walking aids and 32 per cent of those unable to climb stairs were unable to walk independently on discharge. A total of 2.4 per cent of patients who shopped independently before proximal femoral fracture and 25 per cent of those unable to do so were unable to walk on discharge. Four per cent of patients who walked outdoors and 46 per cent of housebound patients were discharged unable to walk (P
The factors
Male Female Age > 80 years Age < 80 years Infected cases Non-infected cases Days to operation Within 24 h
Ratio
destination and rehousing (Table
associated
most
significantly
IV)
with need for
rehousing were housebound status (P< O.OOl), receipt of ‘meals on wheels’ (PCO.01) and age over 80 years (P-C 0.001) before fracture and hospitalization exceeding 31 days (P
Fox et al.: Outcomeafterproximalfemoral frachwes from sheltered accommodation and 58 per cent from residential homes were discharged to nursing homes. Four per cent of patients living with a spouse, 10 per cent living alone, 20 per cent of those living with family, friends or relatives, 21 per cent who were unable to shop and 5 per cent of patients able to do so required nursing home placement. Resource implications Discriminant analysis revealed 10 independent variables which were associated with the outcome of proximal femoral fracture. Six of these were predetermined before admission and four could be influenced by hospital practice. Age, sex, being housebound, lack of ‘will to live’, and receipt of home care and ‘meals on wheels’ were the six variables predetermined before admission. Delay to operation, development of pressure sores and wound infection could be influenced by hospital management, and three of the four patients requiring re-operations remained in hospital for more than 28 days. These four complications accounted for 1284 hospital bed days, or 30 per cent of total bed days for all patients in the study. Fifty-five per cent of the excess was associated with non-medical delay to surgery, 20 per cent with pressure sores, 18 per cent infection and 7 per cent re-operation.
Discussion MortaIity The in-patient mortality in this series is comparable to other studies, which record between 6 and 36 per cent (Thomas and Stevens, 1974; Jensen and Tonderold, 1979; Jensen, 1984; Bannister et al., 1990). Although historically mortality rates are declining, there appears to be an inevitable in-patient mortality for patients with proximal femoral fractures of at least 6 per cent. The discriminant variables affecting mortality in this study are similar to the observations of other authors. Jensen (1984) and Dahl (1980) recorded higher mortality in males. Reno and Burlington (1958) and Jensen et al. (1979) all noted the effect of age. Infection has not previously been recognized, but delay to active treatment was identified by Reno and Burlington (1958). Length of hospital stay Likewise, factors affecting the length of hospital stay have not been widely studied. Hospital stay following proximal femoral fractures is highly variable, ranging from means of 16 (Ceder et al., 1987) to 75 days (Evans et al., 1980) depending on geographical location, hospital practice and community rehabilitation facilities. Early mobilization on stable hips helped to reduce bed occupancy in Sweden (Ceder et al., 1987) and whilst nursing complications were associated with increased mortality in Newcastle and Bristol, their effect on length of stay was not recorded (Evans, 1979; Bannister et al., 1990). Discharge mobility Mobility has been less thoroughly researched than mortality after proximal femoral fractures. It appeared that patients required not only the physical ability to walk but also the mental drive to venture forth from the confines of their homes to improve their prognosis. This was reflected in their ‘will to live’ which was a subjective assessment made by nursing staff and physiotherapists, but previously
299
identified by Reno and Burlington ambition’.
(1958) as ‘morale and
Need for rehousing Riska (19701, Ceder et al. (1980) and Wallace et al. (1986) have noted that trochanteric fractures require discharge more frequently to more sheltered accommodation, whilst this study identifies housebound status, receipt of ‘meals on wheels’ and age over 80 years as the markers of age-related infirmity that predicted the need for rehousing. Prolonged admission implied slow rehabilitation and Ceder et al. (1987) identified rapid mobilization as a factor predisposing to higher rates of discharge home. In this study, patients who before fracture walked outside, went shopping and had a surviving spouse remained independent. Those fully dependent in nursing homes remained so. Partially dependent patients, such as those in residential homes, in sheltered housing or at home with high levels of support, are at greatest risk of becoming fully dependent and requiring rehousing in nursing homes. New nursing home admissions Factors predicting the need for long-term nursing home care have not previously been addressed. Housebound patients had compromised independence before fracture but non-medical delay and enforced bed-rest appeared to allow this to deteriorate and it was never recovered postoperatively. Resource implications Of the 10 factors that influenced outcome, age over 80 years, male sex, being housbound, lack of a positive ‘will to live’, and receipt of home care and ‘meals on wheels’ are predetermined before admission. Delay to operation, development of pressure sores and wound infection can be influenced by hospital management. In this audit, proximal femoral fracture surgery was carried out on emergency lists shared with other specialities and was frequently delayed by more urgent cases. The incidence of broken pressure areas was 12 per cent and probably reflected the prevailing nurse staffing levels. Inadequate theatre availability and nurse staffing levels are associated with increased morbidity and mortality and, quite apart from associated human suffering, represent false economy in health care provision, because of prolonged acute hospital bed occupancy.
References Bannister G. C., Gibson A. G. F., Ackroyd C. E. and Newman J. H. (1990) The fixation and prognosis of trochanteric fractures. Clin. Orthop. Rel. Res. 254, 242. British Orthopaedic Association (1990) Adti?on~ Booklet on Consultant Orthopaedic and Trauma Services. London: British
Orthopaedic Association. Ceder L., Stromquist B. and Hansonn
L. I. (1987) Effects of strategy changes in the treatment of femoral neck fractures during a 17 year period. Clin. Orthop. Rel. Res. 218, 53. Ceder L., Thofngren K. G. and Wallden B. (1980)Prognostic indicators and early home rehabilitation in elderly patients with hip fractures. Clin. Orthop. Rel. Res. 152, 173. Dahl E. (1980)Mortality and life expectancy after hip fractures. Acta Orthop. Stand. 51, 163.
300
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 5
Evans J. G. (1979) Fractured proximal femur in Newcastle upon Tyne. Age Ageing 8, 16. Evans J. G., Wandless I. and Prudham D. (1980) A prospective study of fractured proximal femur: hospital differences. Publ. Hlth Lond. 94, 149. Jensen J. S. (1984) Determining factors for the mortality following hip fractures. Injury 15,411. Jensen J. S. and Tonderold E. (1979) Mortality after hip fractures. Actu Orthop. Scund. 50, 161. Lewis A. F. (1981) Fracture of neck of the femur: changing incidence. Br. Med. J 283, 1217. Lord S. R. and Sinnett P. F. (1986) Femoral neck fractures: admissions, bed use, outcome and projections. Med. 1. Aust. 145,493. Reno J. H. and Burlington H. (1958) Fractures of the hip mortality survey. Am. 1. Surg. 95, 581.
Riska E. B. (1970) Factors influencing primary mortality in the treatment of hip fractures. Injury 2, 107. Thomas T. G. and Stevens R. S. (1974) Social effects of fractures of the neck of the femur. Br. Med. J. 3, 456. Wallace R. G. H., Lowry J. H., McLeod N. W. and Mollan R. A. B. (1986) A simple grading system to guide the prognosis after hip fracture in the elderly. Br. Med. 1. 293, 665. Paper accepted
Requests for Consultant Orthopaedic Bristol BSlo
7 March
1994.
reprints should be addressed to: Mr G. C. Bannister, Orthopaedic Surgeon, University Department of Surgery, Southmead Hospital, Westbury-on-Trym, 5NB, UK.
International Conference on Recent Advances in Neurotraumatology and Neurosurgical Society of Australasia Annual Scientific Meeting 25-28 September 1994 Gold Coast, Queensland, Australia The Neurosurgical Society of Australasia is hosting the 1995 International Conference on Recent Advances in Neurotraumatology (ICRAN 94). This biennial event, coordinated by the International Committee of Neurotrauma, is being held in Australia for the first time. In support of this significant international conference the Neurosurgical Society of Australasia (NSA) has decided to hold its annual scientific meeting concurrently with ICRAN 94. The conference will focus on the following issues: 0 0 0 0
management protocols in acute neurotrauma neuronal and vascular injury of the brain and spinal cord neuronal repair, reorganisation and outcome assessment of traumatic brain injury spinal instrumentation
The conference programme will feature keynote plenary sessions, concurrent sessions, breakfast sessions and poster presentations. An extensive trade exhibition will be staged in conjunction with the conference. For further information please contact: Miss Vivienne Mackenzie, ICRAN 94., PO Box 1280, Milton Queensland 4064, Australia. Tel: +(617) 369 0477. Fax: +(617) 369 1512.
Factors affecting the outcome after proximal femoral fractures H. J. Fox, J. Pooler, D. Prothero and G. C. Bannister Southmead
Hospital,
Westbury-on-Trym,
Bristol, UK
One hundred and forty-two consecutive patients with proximal femoral fractures were audited prospectively over a l-year period. Mobil@, age and sex were recorded along wifh timing of surgery, complicafions, ‘will to live’, length of admission, mortality, mobility and housing requirements on discharge. Operative procedures were pprformed mostly by intermediate surgical staff on night-time emergency lists shared with other specialities. Pafienfs were treated on a ward with nursing staff levels less than the minimum recommended by professional bodies. Mean hospital stay was 31 days. In-patient mortality was 37 per cent in males and s per cent in females. It was possible to predict protracted hospital stay in 84 per cent, mortality in 84 per cent, mobility on discharge in 92 per cent and need for rehousing in 83 per cent of patients. Of the 10 principal variables that affected outcome, four could be influenced by hospital practice. These variables were associated with 1284 hospital bed days, which constituted 30 per cent of total bed occupancy. Fifty-five per cent of these were associated with non-medical delay to surgery, 25 per cent with wound infection or re-operation and 20 per cent with broken pressure areas. There would appear to be the potential fo improve outcome in proximal femoral fractures by stabilizing fractures within 24 h, adopting measures additional to antibiotic prophylaxis to reduce infection and ensun’ng that patients do not develop pressuresores.
Injury, 1994, Vol. 25, 297-300,
July
Introduction In 1977, 18 per cent of all orthopaedic beds in England and Wales were occupied by patients who had sustained proximal femoral fracture (Lewis, 1981) and an increase of 83 per cent between 1986 and 2012 has been predicted (Lord and Sinnett, 1986). Following proximal femoral fracture, a proportion of patients lose their independence and occupy acute hospital beds for prolonged periods whilst rehousing arrangements are made. Many factors affecting the outcome of proximal femoral fractures are predetermined and can be recognized on admission, but few studies have addressed the influence of hospital practice (Evans et al., 1980; Bannister et al., 1990). Identification of such factors would allow accurate early prognosis, accelerate rehousing arrangements and target areas for improvement in hospital practice. 0
1994 Butterworth-Heinemann
0020-1383/94/050297-04
Ltd
The aim of this audit was to identify the factors affecting the outcome of proximal femoral fractures in an affiliated teaching hospital and to quantify the influence of hospital practice.
Materials and methods During a l-year audit period from May 1990 to April 1991, 142 patients with proximal femoral fractures were admitted to Southmead Hospital, and were prospectively assessed according to the variables shown in TableI. Patients were managed on a ward with nurse staffing levels less than the minimum recommended by nursing and orthopaedic professional bodies (British Orthopaedic Association, 1990). Operative procedures were performed predominantly by peri-Fellowship junior staff, under antibiotic prophylaxis in conventional theatres, usually on night-time emergency lists shared with other specialities, as a result of which cases were subject to frequent cancellation. Statistical analysis Statistical analysis was carried out by the third author using multivariate analysis on an SPSS computer programme employing Pearson chi-squared, two-tailed Fisher exact and Student’s f-tests. Discriminant variables were identified for mortality, length of admission, discharge mobility, need for rehousing and new nursing home placement.
Table I. Variables affecting outcome Status on admission
Age Sex Housing status Mobility Housebound Walking aids Stairs Social function Shopping Home help ‘Meals on wheels’ ‘Will to live’
Hospital factors Time to operation Operative fixation Nursing complications Wound infection Re-operation
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 5
298
Results Mortality
Table II. Mortality (Table II)
Percentage
In-patient mortality was 12 per cent. The policy of the Anaesthetic Department was to proceed with surgery as soon as was practically possible, and only four patients were considered unfit for operation: they died before discharge. The other 13 cases died 5-15 days postoperatively. Male sex, age above 80 years, wound infection and non-medical delay to surgery were the independent variables affecting mortality. When all these variables were applied, they predicted mortality in 84 per cent of cases. Mortality rose sharply when surgery was carried out more than 24 h after admission (P= 0.04). Mortality was neither associated with the grade of surgeon, the operative procedure undertaken nor the type of fracture. The overall re-operation rate was 2.9 per cent. All patients were allowed to walk fully weight-bearing, within limits of pain, within 48 h. Length of hospital stay (Table 111)
The mean length of stay was 31 days. Patients from nursing homes remained for II days because of the simplicity of discharge back. Patients from Elderly Mentally Infirm Institutions stayed a mean of 56 days and all required rehousing in nursing homes. Mean stay after admission from sheltered or warden-controlled accommodation was 31 days, from home 35 days and from residential homes 38 days. Patients receiving home care remained for 36 days (PC 0.001) and receiving ‘meals on wheels’ for 40 days. The 17 patients affected by pressure sores remained in hospital for a mean of 53 days (P
Discharge
24-72 >72h h
36.7 5.4 14.7 6.4 33 10
P
6.8:1
P-C 0.001
2.3:1
NS
3.3:1
P< 0.01
0 ::
8
NS, not significant.
Table III. Length of hospital stay Number of days Age > 80 years Age c 80 years Operation Day 0,l Day 2 Nursing complications Home care
P
43.2 23.9
PC 0.0001
25.3 32.8 52.9 36.0
P< 0.01 P< 0.0001 P-C 0.001
Table IV. Need for rehousing Housebound Not housebound ‘Meals on wheels’ No ‘meals on wheels’ Age > 80 years Age < 80 years Admission > 28 days -C28 days
43% 11% 67% 14% 29.6% 6.8% 41.5%
6.9%
PC 0.001 PC 0.01 PC 0.01
PC 0.001
mobility
Mobility on discharge could be predicted in 92 per cent of cases from data obtainable on admission. Overall, 125 patients were discharged, 82 per cent with walking aids (sticks or Zimmer frames) and 18 per cent in wheelchairs. Ninety per cent of patients admitted walking independently were discharged using walking aids and 10 per cent were not independently mobile. Ten per cent of those who could climb stairs on admission, 20 per cent of those using walking aids and 32 per cent of those unable to climb stairs were unable to walk independently on discharge. A total of 2.4 per cent of patients who shopped independently before proximal femoral fracture and 25 per cent of those unable to do so were unable to walk on discharge. Four per cent of patients who walked outdoors and 46 per cent of housebound patients were discharged unable to walk (P
The factors
Male Female Age > 80 years Age < 80 years Infected cases Non-infected cases Days to operation Within 24 h
Ratio
destination and rehousing (Table
associated
most
significantly
IV)
with need for
rehousing were housebound status (P< O.OOl), receipt of ‘meals on wheels’ (PCO.01) and age over 80 years (P-C 0.001) before fracture and hospitalization exceeding 31 days (P
Fox et al.: Outcomeafterproximalfemoral frachwes from sheltered accommodation and 58 per cent from residential homes were discharged to nursing homes. Four per cent of patients living with a spouse, 10 per cent living alone, 20 per cent of those living with family, friends or relatives, 21 per cent who were unable to shop and 5 per cent of patients able to do so required nursing home placement. Resource implications Discriminant analysis revealed 10 independent variables which were associated with the outcome of proximal femoral fracture. Six of these were predetermined before admission and four could be influenced by hospital practice. Age, sex, being housebound, lack of ‘will to live’, and receipt of home care and ‘meals on wheels’ were the six variables predetermined before admission. Delay to operation, development of pressure sores and wound infection could be influenced by hospital management, and three of the four patients requiring re-operations remained in hospital for more than 28 days. These four complications accounted for 1284 hospital bed days, or 30 per cent of total bed days for all patients in the study. Fifty-five per cent of the excess was associated with non-medical delay to surgery, 20 per cent with pressure sores, 18 per cent infection and 7 per cent re-operation.
Discussion MortaIity The in-patient mortality in this series is comparable to other studies, which record between 6 and 36 per cent (Thomas and Stevens, 1974; Jensen and Tonderold, 1979; Jensen, 1984; Bannister et al., 1990). Although historically mortality rates are declining, there appears to be an inevitable in-patient mortality for patients with proximal femoral fractures of at least 6 per cent. The discriminant variables affecting mortality in this study are similar to the observations of other authors. Jensen (1984) and Dahl (1980) recorded higher mortality in males. Reno and Burlington (1958) and Jensen et al. (1979) all noted the effect of age. Infection has not previously been recognized, but delay to active treatment was identified by Reno and Burlington (1958). Length of hospital stay Likewise, factors affecting the length of hospital stay have not been widely studied. Hospital stay following proximal femoral fractures is highly variable, ranging from means of 16 (Ceder et al., 1987) to 75 days (Evans et al., 1980) depending on geographical location, hospital practice and community rehabilitation facilities. Early mobilization on stable hips helped to reduce bed occupancy in Sweden (Ceder et al., 1987) and whilst nursing complications were associated with increased mortality in Newcastle and Bristol, their effect on length of stay was not recorded (Evans, 1979; Bannister et al., 1990). Discharge mobility Mobility has been less thoroughly researched than mortality after proximal femoral fractures. It appeared that patients required not only the physical ability to walk but also the mental drive to venture forth from the confines of their homes to improve their prognosis. This was reflected in their ‘will to live’ which was a subjective assessment made by nursing staff and physiotherapists, but previously
299
identified by Reno and Burlington ambition’.
(1958) as ‘morale and
Need for rehousing Riska (19701, Ceder et al. (1980) and Wallace et al. (1986) have noted that trochanteric fractures require discharge more frequently to more sheltered accommodation, whilst this study identifies housebound status, receipt of ‘meals on wheels’ and age over 80 years as the markers of age-related infirmity that predicted the need for rehousing. Prolonged admission implied slow rehabilitation and Ceder et al. (1987) identified rapid mobilization as a factor predisposing to higher rates of discharge home. In this study, patients who before fracture walked outside, went shopping and had a surviving spouse remained independent. Those fully dependent in nursing homes remained so. Partially dependent patients, such as those in residential homes, in sheltered housing or at home with high levels of support, are at greatest risk of becoming fully dependent and requiring rehousing in nursing homes. New nursing home admissions Factors predicting the need for long-term nursing home care have not previously been addressed. Housebound patients had compromised independence before fracture but non-medical delay and enforced bed-rest appeared to allow this to deteriorate and it was never recovered postoperatively. Resource implications Of the 10 factors that influenced outcome, age over 80 years, male sex, being housbound, lack of a positive ‘will to live’, and receipt of home care and ‘meals on wheels’ are predetermined before admission. Delay to operation, development of pressure sores and wound infection can be influenced by hospital management. In this audit, proximal femoral fracture surgery was carried out on emergency lists shared with other specialities and was frequently delayed by more urgent cases. The incidence of broken pressure areas was 12 per cent and probably reflected the prevailing nurse staffing levels. Inadequate theatre availability and nurse staffing levels are associated with increased morbidity and mortality and, quite apart from associated human suffering, represent false economy in health care provision, because of prolonged acute hospital bed occupancy.
References Bannister G. C., Gibson A. G. F., Ackroyd C. E. and Newman J. H. (1990) The fixation and prognosis of trochanteric fractures. Clin. Orthop. Rel. Res. 254, 242. British Orthopaedic Association (1990) Adti?on~ Booklet on Consultant Orthopaedic and Trauma Services. London: British
Orthopaedic Association. Ceder L., Stromquist B. and Hansonn
L. I. (1987) Effects of strategy changes in the treatment of femoral neck fractures during a 17 year period. Clin. Orthop. Rel. Res. 218, 53. Ceder L., Thofngren K. G. and Wallden B. (1980)Prognostic indicators and early home rehabilitation in elderly patients with hip fractures. Clin. Orthop. Rel. Res. 152, 173. Dahl E. (1980)Mortality and life expectancy after hip fractures. Acta Orthop. Stand. 51, 163.
300
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 5
Evans J. G. (1979) Fractured proximal femur in Newcastle upon Tyne. Age Ageing 8, 16. Evans J. G., Wandless I. and Prudham D. (1980) A prospective study of fractured proximal femur: hospital differences. Publ. Hlth Lond. 94, 149. Jensen J. S. (1984) Determining factors for the mortality following hip fractures. Injury 15,411. Jensen J. S. and Tonderold E. (1979) Mortality after hip fractures. Actu Orthop. Scund. 50, 161. Lewis A. F. (1981) Fracture of neck of the femur: changing incidence. Br. Med. J 283, 1217. Lord S. R. and Sinnett P. F. (1986) Femoral neck fractures: admissions, bed use, outcome and projections. Med. 1. Aust. 145,493. Reno J. H. and Burlington H. (1958) Fractures of the hip mortality survey. Am. 1. Surg. 95, 581.
Riska E. B. (1970) Factors influencing primary mortality in the treatment of hip fractures. Injury 2, 107. Thomas T. G. and Stevens R. S. (1974) Social effects of fractures of the neck of the femur. Br. Med. J. 3, 456. Wallace R. G. H., Lowry J. H., McLeod N. W. and Mollan R. A. B. (1986) A simple grading system to guide the prognosis after hip fracture in the elderly. Br. Med. 1. 293, 665. Paper accepted
Requests for Consultant Orthopaedic Bristol BSlo
7 March
1994.
reprints should be addressed to: Mr G. C. Bannister, Orthopaedic Surgeon, University Department of Surgery, Southmead Hospital, Westbury-on-Trym, 5NB, UK.
International Conference on Recent Advances in Neurotraumatology and Neurosurgical Society of Australasia Annual Scientific Meeting 25-28 September 1994 Gold Coast, Queensland, Australia The Neurosurgical Society of Australasia is hosting the 1995 International Conference on Recent Advances in Neurotraumatology (ICRAN 94). This biennial event, coordinated by the International Committee of Neurotrauma, is being held in Australia for the first time. In support of this significant international conference the Neurosurgical Society of Australasia (NSA) has decided to hold its annual scientific meeting concurrently with ICRAN 94. The conference will focus on the following issues: 0 0 0 0
management protocols in acute neurotrauma neuronal and vascular injury of the brain and spinal cord neuronal repair, reorganisation and outcome assessment of traumatic brain injury spinal instrumentation
The conference programme will feature keynote plenary sessions, concurrent sessions, breakfast sessions and poster presentations. An extensive trade exhibition will be staged in conjunction with the conference. For further information please contact: Miss Vivienne Mackenzie, ICRAN 94., PO Box 1280, Milton Queensland 4064, Australia. Tel: +(617) 369 0477. Fax: +(617) 369 1512.