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Length of hospital stay and outcome after femoral neck fracture: a prospective study comparing the performance of two hospitals
464
Injury (1993)24,(7), 464-466 Prinfed inGreat Brifuin
Length of hospital stay and outcome after femoral neck fracture: a prospective study comparing the performance of two hospitals H. J. Fox, S. J. Hughes, J. Pooler, D. Prothero and G. C. Bannister University
Department
of Orthopaedics,
Southmead
Hospital, Bristol, UK
Lengfh of hospital stay and oufcome affer femoral neck fracfure were compared in a prospective sfudy between fwo tijacenf hospitals. In matched pop&ions, mean lengfk of stay was 30.8 dclys at Hospital X and 15.7 days at Hospital Y. Need for rehousing, age over 80 years and new nursing home placemenf prolonged lengfk of stay at Hospital X but not at Hospital Y. Hospital X kad an orfkopaedic rehabilitation ward and returned 88 per cent of patients to their own home, plachg 9 per cenf admiffedfrom home in nursing homes. Hospital Y refumed 76 per cenf of patients fo their own home and 19 per cent to nursing homes. Tke rapid discharge policy of Hospital Y saved significanf resources within fke acute kospifal at tke expense ofrefuming significantlyfewerpatienfs to their own homes.
Introduction Patients with femoral neck fracture occupied 18 per cent of all NHS orthopaedic beds in 1977 (Lewis, 1981). The elderly population is increasing and the age-specific incidence of this fracture is increasing (Wallace, 1983). Lord and Sinnett (1986) predict an 83 per cent increase in bed occupancy due to proximal femoral fracture betwen 1986 and 2011. Rehabilitation of patients, often with low morale, highly dependent, and with co-existing pathologies, is time consuming, labour intensive and the principal resource implication is bed occupancy. A common fracture, with obligatory inpatient management and prolonged lengths of stay, makes large demands on hospital resources. Annual inpatient costs in England and Wales are approximately f ZOOmillion for an incidence of 40 000 cases per year (Wallace, 1987). In some studies, rehabilitation units have shown better outcomes. Early postoperative mobilization and transfer to a dedicated rehabilitation unit may reduce length of stay, improve activities of daily living and placement (Kennie et al., 1988). The aim of this study was to examine length of stay and outcome by a prospective comparison of patients with femoral neck fracture from two hospitals in the region. Hospital X has a rehabilitation unit and serves an area where residential and nursing home availability, community support and rehabilitation resources are severely limited. Hospital Y does not have a rehabilitation ward, operates an 0 1993 Butterworth-Heineman OOZO-1383/93/070464-03
Ltd
early discharge policy, and uses community hospitals for rehabilitation and convalescence, and has better access to nursing home accommodation. The aim of this study was to compare the length of inhospital stay and outcome of patients with femoral neck fracture managed by these two different postoperative regimens.
Materials and methods Allpatients admitted to Hospital X and Y with femoral neck fracture during the I-year audit period were studied. Age, sex, accommodation before admission, time to operation, operative fixation, length of stay, and need for rehousing were recorded. In both hospitals operative procedures were performed largely by middle-grade staff. Antibiotic prophylaxis was used. At Hospital X, operations were performed in conventional theatres, mostly on nighttime emergency lists shared with other specialties, and at Hospital Y mostly on planned daytime trauma lists. Both hospitals operate the same postoperative policy of early mobilization after check radiographs. At Hospital X, patients whose independence is threatened are able to transfer to an orthopaedic rehabilitation unit with intensive physiotherapy and occupational therapy input. At Hospital Y, patients are rehabilitated on the acute ward and discharged rapidly to community hospitals or nursing home accommodation. Statistical analysis Statistical analysis was by multivariate analysis on a mainframe computer using the SPSS programme with x2 Pearson rank and two-tailed Fisher Exact tests. Data were analysed by comparing all variables between the two hospitals. Mortality, length of inhospital stay and need for rehousing were analysed against all other variables for each hospital.
Results There were 142 patients from Hospital X and 193 from Hospital Y. Age, sex, housing before admission, type of fracture, time to operation, rate of infection and re-
Fox et al.: Hospital stay and outcome after femoral neck fracture
operation, and inpatient mortality were similar in the two populations. Broken pressure areas occurred in 12 per cent of patients in Hospital X and 4 per cent in Hospital Y (PC 0.01). Mean length of stay at Hospital X was 30.8 days and at Hospital Y 15.7 days (P
Table I. Placement after admission from home Hospital X (N=92)
Returned home To residential home To nursing home To community hospital To hospital outside district Died Total
69 (75.0%) 2 (2.2%) 7 (7.6%) : (3.3%) 11 (12.0%) 92
8 130
Discussion Inpatient mortality rates of 6 per cent and 12 per cent are similar to other published work (Thomas and Stevens, 1974; Jensen and Tonderold, 1979) as is the high mortality in males (Jensen and Tonderold, 1979; Dahl, 1980). Performance differences between hospitals treating proximal femoral fracture have been shown in previous studies (Evans et al., 1980; Bannister et al., 1990). Lengths of hospital stay and placement after admission from home were the differences seen between Hospitals X and Y and are the result of the different policies operated. Delay to operation led to prolonged length of stay at both hospitals and so does not account for the difference. Advanced age and need for rehousing significantly prolonged length of stay at Hospital X, but not at Hospital Y. Two factors contributed to the difference in lengths of stay between the two hospitals. At Hospital X there was rapid turnover of nursing and social work staff, whereas at Hospital Y all discharges were directed by an experienced ward sister with a permanent support team. Hospital X has no access to community hospitals and limited nursing home availability. Hospital Y benefited from community hospitals, above average nursing home availability (Hepple et al., 1989) and liaison with them through the experienced ward sister. Hospital X returned 88 per cent of patients from home back there by use of the orthopaedic rehabilitation unit. This is in accordance with government policy (Community Care Act, 1990) of returning as many patients to their own home as possible, but is at the expense of prolonged length of inhospital stay and hence increased consumption of resources. Length of stay at Hospital Y did not include time spent at community hospitals. Operating a rapid discharge policy, the mean length of stay at Hospital Y was one-half that of Hospital X, but over twice as many patients admitted from their own homes were placed in nursing home accommodation. Of patients from home, 55 per cent were discharged there directly and 76 per cent eventually, requiring 35 per cent fewer bed days per patient returned home. The main resource implication of patients with femoral neck fracture is hospital bed occupancy. It would appear that there is a choice between expending greater resources on rehabilitation facilities in the postoperative period, or reducing length of hospital stay by discharging patients who have the potential to return to their own homes to nursing home accommodation. Some of Hospital Y’s resource savings will be borne elsewhere in the community and the rest need to be justified against significantly reduced numbers returned home and increased numbers placed to nursing homes.
References
Hospital Y (N= 130) 71 6 16 14 15
465
(54.6%) P
Bannister G. C., Gibson A. G. F., Ackroyd C. E. et al. (1990) The fixation and prognosis of trochanteric fractures. Clin. orthop. 254,242. Community Care Act (1990) National Health Service and Community Care Act, Chapter 19. London: HMSO. Dahl E. (1980) Mortality and life expectancy after hip fractures. Acta Ortkop. Stand. 51, 163. Evans J. G., Wandless I. and Prudham D. (1980) A prospective study of fractured proximal
Health 94, 149.
femur: hospital differences.
P&C
466
Injury: International Journal of the Care of the Injured
Hepple J. Bowler I. and Bowman C. E. (1989) A survey of private nursing home residents in Weston-super-Mare. Age &ting 18, 61. Jensen J. S. and Tonderold E. (1979) Mortality after hip fractures. Acfa Orhop. &and. 50,161. Kennie D. C., Reid J., Richardson I. R. et al. (1988) Effectiveness of geriatric rehabilitative care after fractures of the proximal femur & elderly women: a randomised clinical trial. I%. Med. 1. 297, 1083. 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. J. Ausf. 145,493.
(1993) Vol. 24/No.
7
Thomas T. G. and Stevens R. S. (1974) Social effects of fractures of the neck of the femur. Br. Med. 1. 3,456. Wallace W. A. (1983) The increasing incidence of fractures of the proximal femur: an orthopaedic epidemic. LAnczt 1,1413. Wallace W. A. (1987) The scale and financial implications of osteoporosis. Int. Med. (Suppl). 12,~ Paper accepted
3 February
1993.
Requestsfor reprints shouti be addressed fo: Mr G. C. Bannister, University Department of Orthopaedics, Southmead Hospital, Westbury-on-Trym, Bristol BSlO SNB, UK.
Injury (1993)24,(7), 464-466 Prinfed inGreat Brifuin
Length of hospital stay and outcome after femoral neck fracture: a prospective study comparing the performance of two hospitals H. J. Fox, S. J. Hughes, J. Pooler, D. Prothero and G. C. Bannister University
Department
of Orthopaedics,
Southmead
Hospital, Bristol, UK
Lengfh of hospital stay and oufcome affer femoral neck fracfure were compared in a prospective sfudy between fwo tijacenf hospitals. In matched pop&ions, mean lengfk of stay was 30.8 dclys at Hospital X and 15.7 days at Hospital Y. Need for rehousing, age over 80 years and new nursing home placemenf prolonged lengfk of stay at Hospital X but not at Hospital Y. Hospital X kad an orfkopaedic rehabilitation ward and returned 88 per cent of patients to their own home, plachg 9 per cenf admiffedfrom home in nursing homes. Hospital Y refumed 76 per cenf of patients fo their own home and 19 per cent to nursing homes. Tke rapid discharge policy of Hospital Y saved significanf resources within fke acute kospifal at tke expense ofrefuming significantlyfewerpatienfs to their own homes.
Introduction Patients with femoral neck fracture occupied 18 per cent of all NHS orthopaedic beds in 1977 (Lewis, 1981). The elderly population is increasing and the age-specific incidence of this fracture is increasing (Wallace, 1983). Lord and Sinnett (1986) predict an 83 per cent increase in bed occupancy due to proximal femoral fracture betwen 1986 and 2011. Rehabilitation of patients, often with low morale, highly dependent, and with co-existing pathologies, is time consuming, labour intensive and the principal resource implication is bed occupancy. A common fracture, with obligatory inpatient management and prolonged lengths of stay, makes large demands on hospital resources. Annual inpatient costs in England and Wales are approximately f ZOOmillion for an incidence of 40 000 cases per year (Wallace, 1987). In some studies, rehabilitation units have shown better outcomes. Early postoperative mobilization and transfer to a dedicated rehabilitation unit may reduce length of stay, improve activities of daily living and placement (Kennie et al., 1988). The aim of this study was to examine length of stay and outcome by a prospective comparison of patients with femoral neck fracture from two hospitals in the region. Hospital X has a rehabilitation unit and serves an area where residential and nursing home availability, community support and rehabilitation resources are severely limited. Hospital Y does not have a rehabilitation ward, operates an 0 1993 Butterworth-Heineman OOZO-1383/93/070464-03
Ltd
early discharge policy, and uses community hospitals for rehabilitation and convalescence, and has better access to nursing home accommodation. The aim of this study was to compare the length of inhospital stay and outcome of patients with femoral neck fracture managed by these two different postoperative regimens.
Materials and methods Allpatients admitted to Hospital X and Y with femoral neck fracture during the I-year audit period were studied. Age, sex, accommodation before admission, time to operation, operative fixation, length of stay, and need for rehousing were recorded. In both hospitals operative procedures were performed largely by middle-grade staff. Antibiotic prophylaxis was used. At Hospital X, operations were performed in conventional theatres, mostly on nighttime emergency lists shared with other specialties, and at Hospital Y mostly on planned daytime trauma lists. Both hospitals operate the same postoperative policy of early mobilization after check radiographs. At Hospital X, patients whose independence is threatened are able to transfer to an orthopaedic rehabilitation unit with intensive physiotherapy and occupational therapy input. At Hospital Y, patients are rehabilitated on the acute ward and discharged rapidly to community hospitals or nursing home accommodation. Statistical analysis Statistical analysis was by multivariate analysis on a mainframe computer using the SPSS programme with x2 Pearson rank and two-tailed Fisher Exact tests. Data were analysed by comparing all variables between the two hospitals. Mortality, length of inhospital stay and need for rehousing were analysed against all other variables for each hospital.
Results There were 142 patients from Hospital X and 193 from Hospital Y. Age, sex, housing before admission, type of fracture, time to operation, rate of infection and re-
Fox et al.: Hospital stay and outcome after femoral neck fracture
operation, and inpatient mortality were similar in the two populations. Broken pressure areas occurred in 12 per cent of patients in Hospital X and 4 per cent in Hospital Y (PC 0.01). Mean length of stay at Hospital X was 30.8 days and at Hospital Y 15.7 days (P
Table I. Placement after admission from home Hospital X (N=92)
Returned home To residential home To nursing home To community hospital To hospital outside district Died Total
69 (75.0%) 2 (2.2%) 7 (7.6%) : (3.3%) 11 (12.0%) 92
8 130
Discussion Inpatient mortality rates of 6 per cent and 12 per cent are similar to other published work (Thomas and Stevens, 1974; Jensen and Tonderold, 1979) as is the high mortality in males (Jensen and Tonderold, 1979; Dahl, 1980). Performance differences between hospitals treating proximal femoral fracture have been shown in previous studies (Evans et al., 1980; Bannister et al., 1990). Lengths of hospital stay and placement after admission from home were the differences seen between Hospitals X and Y and are the result of the different policies operated. Delay to operation led to prolonged length of stay at both hospitals and so does not account for the difference. Advanced age and need for rehousing significantly prolonged length of stay at Hospital X, but not at Hospital Y. Two factors contributed to the difference in lengths of stay between the two hospitals. At Hospital X there was rapid turnover of nursing and social work staff, whereas at Hospital Y all discharges were directed by an experienced ward sister with a permanent support team. Hospital X has no access to community hospitals and limited nursing home availability. Hospital Y benefited from community hospitals, above average nursing home availability (Hepple et al., 1989) and liaison with them through the experienced ward sister. Hospital X returned 88 per cent of patients from home back there by use of the orthopaedic rehabilitation unit. This is in accordance with government policy (Community Care Act, 1990) of returning as many patients to their own home as possible, but is at the expense of prolonged length of inhospital stay and hence increased consumption of resources. Length of stay at Hospital Y did not include time spent at community hospitals. Operating a rapid discharge policy, the mean length of stay at Hospital Y was one-half that of Hospital X, but over twice as many patients admitted from their own homes were placed in nursing home accommodation. Of patients from home, 55 per cent were discharged there directly and 76 per cent eventually, requiring 35 per cent fewer bed days per patient returned home. The main resource implication of patients with femoral neck fracture is hospital bed occupancy. It would appear that there is a choice between expending greater resources on rehabilitation facilities in the postoperative period, or reducing length of hospital stay by discharging patients who have the potential to return to their own homes to nursing home accommodation. Some of Hospital Y’s resource savings will be borne elsewhere in the community and the rest need to be justified against significantly reduced numbers returned home and increased numbers placed to nursing homes.
References
Hospital Y (N= 130) 71 6 16 14 15
465
(54.6%) P
Bannister G. C., Gibson A. G. F., Ackroyd C. E. et al. (1990) The fixation and prognosis of trochanteric fractures. Clin. orthop. 254,242. Community Care Act (1990) National Health Service and Community Care Act, Chapter 19. London: HMSO. Dahl E. (1980) Mortality and life expectancy after hip fractures. Acta Ortkop. Stand. 51, 163. Evans J. G., Wandless I. and Prudham D. (1980) A prospective study of fractured proximal
Health 94, 149.
femur: hospital differences.
P&C
466
Injury: International Journal of the Care of the Injured
Hepple J. Bowler I. and Bowman C. E. (1989) A survey of private nursing home residents in Weston-super-Mare. Age &ting 18, 61. Jensen J. S. and Tonderold E. (1979) Mortality after hip fractures. Acfa Orhop. &and. 50,161. Kennie D. C., Reid J., Richardson I. R. et al. (1988) Effectiveness of geriatric rehabilitative care after fractures of the proximal femur & elderly women: a randomised clinical trial. I%. Med. 1. 297, 1083. 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. J. Ausf. 145,493.
(1993) Vol. 24/No.
7
Thomas T. G. and Stevens R. S. (1974) Social effects of fractures of the neck of the femur. Br. Med. 1. 3,456. Wallace W. A. (1983) The increasing incidence of fractures of the proximal femur: an orthopaedic epidemic. LAnczt 1,1413. Wallace W. A. (1987) The scale and financial implications of osteoporosis. Int. Med. (Suppl). 12,~ Paper accepted
3 February
1993.
Requestsfor reprints shouti be addressed fo: Mr G. C. Bannister, University Department of Orthopaedics, Southmead Hospital, Westbury-on-Trym, Bristol BSlO SNB, UK.