- Email: [email protected]
Management of hip fractures pre- and post-Major Trauma Centre activation
G Model
JINJ-6266; No. of Pages 3 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Management of hip fractures pre- and post-Major Trauma Centre activation Ken Wong a,*, James Rich b, Grace Yip a, Constantinos Loizou a, Peter Hull a a b
Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom Cambridge University Medical School, University of Cambridge, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 21 June 2015
Introduction: In April 2012, the activation of the regional trauma networks in England was carried out to improve the organisation of trauma care. NHS Trusts that could meet the highest standard of care to complex trauma were designated Major Trauma Centres (MTCs). MTCs receive patients fulfilling certain triage criteria, as well as secondary transfers from nearby trauma units. While complex trauma care is streamlined with this new organisation, the impact this would have on the rest of the trauma workload within MTCs as well as non-MTC hospitals is uncertain. We investigate whether the management of hip fracture cases had suffered as a result of a trauma unit becoming a MTC. Methods: Summary data was collated from the National Hip Fracture Database website for the periods of April 2011–April 2012 (the ‘pre-MTC’ activation period) and April 2012–April 2013 (the ‘post-MTC’ activation period). As our primary outcome, we compared the time to surgery within 36 h between MTCs and non-MTCs for the periods detailed above. Other outcome measures were: reasons for delay to surgery, length of acute stay, proportion of cases meeting Best Practice Tariff criteria. Results: A total of 54,897 and 55,998 fNOF patients were included for all hospitals in England in the preand post-MTC periods respectively. For MTCs, a weighted mean average of 66.6% patients had surgery within 36 h in the pre-MTC period versus 71.4% of patients in the post MTC period (p < 0.0001). For nonMTCs, a weighted mean average of 70.0% of patients had surgery within 36 h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p < 0.0001). Non-MTCs in both pre- and post-MTC activation periods were therefore better in percentage of patients receiving surgery within 36 h. Discussion: The data presented suggests that the creation of MTCs has not had a deleterious effect on the management of hip fracture patients. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, in conjunction with the development of regional Major Trauma Networks. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Hip fractures Fracture neck of femur Proximal femur fracture NOF Fragility fractures Major Trauma Centre Trauma network Best practice tariff Delay to surgery National Hip Fracture Database
Introduction Fracture neck of femur (fNOF) is a prevalent problem with 70,000 cases recorded annually in the UK and account for up to 87% of the total cost of all fragility fractures [1]. Mortality rates are high in the elderly population who sustain these fractures. There is an overall 10% mortality at 1 month post injury and up to 30% mortality at 1 year post injury [7] with 20% needing long term care.
* Corresponding author at: Box 37, Department of Trauma and Orthopaedics, Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom. Tel.: +44 77 21696063; fax: +44 1223 257221. E-mail addresses: [email protected], [email protected] (K. Wong), [email protected] (J. Rich), [email protected] (G. Yip), [email protected] (C. Loizou), [email protected] (P. Hull).
Amongst other factors [8], time to surgery is a key predictor to mortality rate in those sustaining fNOF [9]. The National Hip Fracture Database (NHFD) [2] is a UK-wide clinical audit project commissioned by the Healthcare Quality Improvement Partnership and managed by the Royal College of Physicians as part of the Falls and Fragility Fracture Audit Programme. It was established in 2007 as a joint venture of the British Geriatrics Society and the British Orthopaedic Association, and is designed to facilitate improvements in the quality and cost effectiveness of hip fracture care. The NHFD’s role is to allow care to be audited against the six evidence-based standards set out in the BOA/BGS Blue Book on the care of patients with fragility fracture; and enables local health economies to benchmark their performance in hip fracture care against national data.
http://dx.doi.org/10.1016/j.injury.2015.06.030 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wong K, et al. Management of hip fractures pre- and post-Major Trauma Centre activation. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.030
G Model
JINJ-6266; No. of Pages 3 K. Wong et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
The management of fNOF has evolved as the understanding of the problem has increased [10,11]. A dramatic change has been brought about since specialised orthogeriatric teams have been established in many hospitals around the country, and there has been a drive from surgeons and orthogeriatricians to minimise time to surgery. The Best Practice Tariff (BPT) was introduced in April 2010 and reflects a commitment for hospitals to provide the highest quality care to those with fNOF. In addition to improving patient outcome, hospitals have a financial incentive to meet the BPT. For the BPT to be met, the time to surgery must be within 36 h from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia. In comparison the fNOF in the elderly population, for those under 40, major trauma is the leading cause of death and results in significant morbidity [3]. Following the National Audit Office’s report on the unacceptable variation in trauma care throughout the UK [12], 22 Major Trauma Centres (MTCs) have now been set up in England [4]. Those who meet criteria relating to vital signs, anatomy of injury or mechanism of injury may be triaged to a MTC. A 15-20% reduction in mortality is seen in patients who are treated in a MTC [5]. National centralisation of major trauma started upon activation of the Major Trauma Network on 1 April 2012, where patients are diverted away from regional hospitals to MTCs [6]. With the designation of MTC and the additional workload of major trauma patients, there may have a negative knock-on effect on management of neck of femur fractures in having their surgery within 36 h. This paper describes the impact of transition to MTC status on the management of neck of femur fractures.
Methods The NHFD website publishes its summary data on its website, and these data were sourced for this paper [2]. We collated the data from NHFD Excel spreadsheets for the period of April 2011–April 2012 (i.e. the ‘pre-MTC’ activation period) and April 2012–April 2013 period (i.e. the ‘post-MTC’ activation period). We hypothesised that in the first year post-activation of the Major Trauma Network, MTCs would suffer in terms of the proportion of patients having surgery within 36 h, compared with the corresponding proportion at non-MTCs. The main reason for this would be due to limited trauma list capacity being occupied by major trauma cases at MTCs in addition to trauma work being diverted from non-MTCs. Our primary outcome measure was: proportion of patients having surgery within 36 h. Our secondary outcome measures were: length of acute stay, proportion of those meeting all BPT criteria, reasons for delay to surgery. Excel spreadsheet data for the periods of April 2011–April 2012 and April 2012–April 2013 was downloaded from the NHFD website. These datasets correspond to the periods immediately
pre-MTC activation and immediately post-MTC activation, therefore 20 MTCs were included in the study, of which 12 were Adult and Children’s MTCs and 8 were Adult MTCs. The 4 dedicated Children’s MTCs and 2 Collaborative MTCs were not classified as adult MTCs in this paper. Statistical analysis: This was undertaken using Graphpad Instat software (Graphpad software, San Diego, CA). Categorical data were analysed using the Chi Squared test. Length of stay was found to be normally distributed, so differences between groups were analysed using the unpaired Student t-test. A p value of <0.05 was considered statistically significant. Results A total of 54,897 fNOF patients were included for all hospitals in England in the April 2011–April 2012 ‘pre-MTC’ period. A total of 55,998 fNOF patients were included for all hospitals in England for the April 2012–April 2013 ‘post-MTC’ period. There were a total of 143 non-MTC trauma units and 20 MTCs included in this analysis. Figures for the proportions of patients between MTCs and nonMTCs can be found in Table 1. For MTCs, a weighted mean average of 66.6% patients had surgery within 36 h in the pre-MTC period versus 71.4% of patients in the post MTC period (p < 0.0001). For non-MTCs, a weighted mean average of 70.0% of patients had surgery within 36 h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p < 0.0001). Non-MTCs in both pre- and post-MTC activation periods were better in percentage of patients receiving surgery within 36 h (see table below, p > 0.0001). There was no difference in the length of acute stay in MTCs between the pre- and post-MTC activation periods (p = 0.858). Similarly, in non-MTCs, there was no difference in length of stay between the pre- and post-MTC activation periods (p = 0.670). For MTCs, the percentage of those meeting BPT was 50.5% and 56.1% pre- and post-MTC period respectively. Similarly, for nonMTCs, the percentage of those meeting BPT was 47.9% and 60.2% in the pre- and post-MTC periods respectively. It is difficult to cross compare the percentage improvements for BPT, as no weighted averages could be calculated from the data available from the NHFD. Common reasons given for a delay in surgery beyond 36 h were ‘awaiting space on a theatre list,’ ‘cancelled due to list being over run,’ ‘problem with theatre/anaesthetic/staff cover.’ There were also ‘other reasons’ and ‘unknown reasons’ why patients did not have surgery within 36 h. These data are summarized in Table 1. Discussion This paper is an observational study into key criteria kept within the NHFD. We expected that in the first year of MTC activation, the increased MTC workload would have impacted
Table 1 Fracture neck of femur patients in Major Trauma Centres and non-Major Trauma Centres pre- and post-activation of the National Major Trauma Network.
Included fNOF patients (MTCs) Included fNOF patients (non-MTCs) Percentage of patients receiving surgery within 36 h (MTCs) Percentage of patients receiving surgery within 36 h (non-MTCs) Mean length of stay (MTCs) Mean length of stay (non-MTCs) Percentage of those meeting BPT (MTCs) Percentage of those meeting BPT (non-MTCs)
April 2011–April 2012 ‘Pre-MTC activation’
April 2012–April 2013 ‘Post-MTC activation’
p value
8535 46,362 66.6 70.0 16.2 15.8 50.5 47.9
8940 47,058 71.4 73.8 15.5 15.7 56.1 60.2
– – <0.0001 <0.0001 =0.858 =0.670 – –
Please cite this article in press as: Wong K, et al. Management of hip fractures pre- and post-Major Trauma Centre activation. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.030
G Model
JINJ-6266; No. of Pages 3 K. Wong et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
negatively on the more ‘routine’ trauma. This result of improved time to theatre for fNOF patients nationally was unexpected but welcome. There was a significant improvement of 4.8% and 3.8% in the percentage of patients operated within 36 h post-MTC activation for MTCs and non-MTCs, respectively. The reasons for the improvement in patients having surgery within 36 h post-MTC activation are likely to be multi-factorial. It is possible that the financial benefit of the BPT has appropriately motivated clinicians to prioritise these frail and vulnerable patients, over the years since it has been introduced. Therefore, an additional capacity may have been created to accommodate all patients. This may have come with an increased understanding into the Best Practice management of fNOF and an increased emphasis on the financial benefits from meeting BPT in the era of efficiency savings within the National Health Service. An increased presence of consultant-level orthogeriatric care is likely to have also contributed. In addition to their medical input, orthogeriatric consultants are often advocates for fNOF patients having their hip fracture surgery emergently. An increase in funding allocated to MTCs, with associated increase in trauma list space, may have also led to the improved performance. We thought that there were several reasons as to why our fNOF management would have suffered from Major Trauma Network activation. Firstly, major trauma cases may be seen as more time-urgent due to the nature of injury (open fractures, need for stabilisation of long bone/pelvic fractures, neurovascular injury, compartment syndrome). They tend to occupy more theatre space because the complex nature of surgery, which requires more time. There is often the thought that the complex polytrauma cases should be operated on early in the day to prevent straying into out-of-hours periods with its associated compromise in theatre support staff. Secondly, in those sustaining complex wounds, surgical management often involves repeated irrigation, debridement and negative pressure dressing applications. These occupy more theatre time. Thirdly, the logistical need for collaborative specialties to be present in theatre may put pressure on cases to be done only when specialist surgeons are available. However, despite these three issues, the result of our primary outcome measure supports the suggestion that fNOF management has improved in both MTCs and non-MTCs. Indeed, the national improvement in percentage of those meeting BPT is also in agreement with our results. The length of stay has not changed pre- and post-MTC activation. There are some limitations to this paper: a small fraction of the summary data collected as part of the NHFD may or may not be complete, and therefore the use of inferential statistics to determine statistical significance here has to be interpreted carefully. However, the strength of the results shown is based on the vast number of patients from data collected nationally, meaning that ‘time to surgery’ are highly statistically significant (n = 54,897 and n = 55,998 for ‘pre-’ and ‘post-MTC’ groups). Another limitation is that we assume that trauma lists are predominantly orthopaedic-led in all MTCs, whereas in some centres, the dedicated Major Trauma theatre list may assume more of a multidisciplinary emergency list (i.e. led by a dedicated trauma surgeon).
3
The improvement in our primary outcome- or may not be due to becoming a MTC, or due to the activation of the Major Trauma Network. It is impossible to say whether a trend in quality of fNOF management exists, however this paper aims to stimulate thinking and discussion in the matter of prioritisation of the ‘new’ polytrauma patients versus the ‘routine’ fNOF patients, as they will often be competing for the same trauma list space. The data in the pre-MTC period has noted delays to surgery due to patients being ‘medically unfit – awaiting medical review and stabilisation’ and ‘medically unfit – awaiting orthopaedic diagnosis or investigation.’ Thus, it will be important to address these issues. Encouragingly, the low numbers of fNOF cases with: ‘problems with anaesthetic/surgical/theatre staff cover’, ‘problems with theatre equipment’ and ‘awaiting inpatient or high dependency bed’ in MTCs during the post-MTC period suggests that the infrastructure has not struggled, or have successfully accommodated the increased workload following MTC activation. In conclusion – the data is presented as above shows that the national activation of MTCs has not had a deleterious effect on the time to theatre for fNOF patients, as initially hypothesised; in fact there has been an improvement. There may have also been an improvement in the proportion of those meeting the BPT, although this is difficult to prove statistically given the summary data. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, including that of fNOF, in conjunction with the development of regional Major Trauma Networks. Conflict of interest The authors confirm that no conflicts of interest exist. References [1] Dolan P, Torgerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporos Int 1998;8:611–7. [2] Goldacre MJ, Roberts SE, Yeates D. Mortality after admission to hospital with fractured neck of femur: database study. BMJ 2002;325(7369):868–9. [3] Sexson SB, Lehner JT. Factors affecting hip fracture mortality. J Orthop Trauma 1987;1(4):298–305. [4] Ions GK, Stevens J. Prediction of survival in patients with femoral neck fractures. J Bone Joint Surg 1987;3(64-B):384–7. [5] National Hip Fracture Database website. http://www.nhfd.co.uk. [6] BOAST 1 guidelines (version 2). http://www.boa.ac.uk/LIB/LIBPUB/ Documents/ BOAST%201%20Version%202%20-%20Hip%20Fracture%20in%20the%20Older %20Person%20-%202012.pdf. [7] National Clinical Guideline Centre. Management of hip fractures in adults. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf. [8] von Ru¨den C, Woltmann A, Ro¨se M, Wurm S, Ru¨ger M, Hierholzer C, et al. Outcome after severe multiple trauma: a retrospective analysis. J Trauma Manag Outcomes 2013;7:4. [9] National Audit Office. Major Trauma Care in England – Report by the Comptroller and Auditor General. National Audit Office; 20109780102963472. [10] Locations of Major Trauma Centres. www.nhs.uk/NHSEngland/. . ./ map-of-major-trauma-centres-2012.pdf. [11] Hipps D, Holmes A, Sugden K, Refaie R, Dowen D, Gray AC. The impact the transition to a level 1 major trauma centre has on the management of patients sustaining a fractured neck of femur using the national boast guidelines. Bone Joint J 2013;12:24. vol. 95-B no. SUPP. [12] Moy R, Han K, Dean Smith G, Henning J. Trauma systems: the potential impact of a trauma divert policy on a regional ambulance service. Emerg Med J 2012. http://dx.doi.org/10.1136/emj.2011.112870.
Please cite this article in press as: Wong K, et al. Management of hip fractures pre- and post-Major Trauma Centre activation. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.030
JINJ-6266; No. of Pages 3 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Management of hip fractures pre- and post-Major Trauma Centre activation Ken Wong a,*, James Rich b, Grace Yip a, Constantinos Loizou a, Peter Hull a a b
Orthopaedic Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom Cambridge University Medical School, University of Cambridge, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 21 June 2015
Introduction: In April 2012, the activation of the regional trauma networks in England was carried out to improve the organisation of trauma care. NHS Trusts that could meet the highest standard of care to complex trauma were designated Major Trauma Centres (MTCs). MTCs receive patients fulfilling certain triage criteria, as well as secondary transfers from nearby trauma units. While complex trauma care is streamlined with this new organisation, the impact this would have on the rest of the trauma workload within MTCs as well as non-MTC hospitals is uncertain. We investigate whether the management of hip fracture cases had suffered as a result of a trauma unit becoming a MTC. Methods: Summary data was collated from the National Hip Fracture Database website for the periods of April 2011–April 2012 (the ‘pre-MTC’ activation period) and April 2012–April 2013 (the ‘post-MTC’ activation period). As our primary outcome, we compared the time to surgery within 36 h between MTCs and non-MTCs for the periods detailed above. Other outcome measures were: reasons for delay to surgery, length of acute stay, proportion of cases meeting Best Practice Tariff criteria. Results: A total of 54,897 and 55,998 fNOF patients were included for all hospitals in England in the preand post-MTC periods respectively. For MTCs, a weighted mean average of 66.6% patients had surgery within 36 h in the pre-MTC period versus 71.4% of patients in the post MTC period (p < 0.0001). For nonMTCs, a weighted mean average of 70.0% of patients had surgery within 36 h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p < 0.0001). Non-MTCs in both pre- and post-MTC activation periods were therefore better in percentage of patients receiving surgery within 36 h. Discussion: The data presented suggests that the creation of MTCs has not had a deleterious effect on the management of hip fracture patients. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, in conjunction with the development of regional Major Trauma Networks. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Hip fractures Fracture neck of femur Proximal femur fracture NOF Fragility fractures Major Trauma Centre Trauma network Best practice tariff Delay to surgery National Hip Fracture Database
Introduction Fracture neck of femur (fNOF) is a prevalent problem with 70,000 cases recorded annually in the UK and account for up to 87% of the total cost of all fragility fractures [1]. Mortality rates are high in the elderly population who sustain these fractures. There is an overall 10% mortality at 1 month post injury and up to 30% mortality at 1 year post injury [7] with 20% needing long term care.
* Corresponding author at: Box 37, Department of Trauma and Orthopaedics, Cambridge University Hospital NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom. Tel.: +44 77 21696063; fax: +44 1223 257221. E-mail addresses: [email protected], [email protected] (K. Wong), [email protected] (J. Rich), [email protected] (G. Yip), [email protected] (C. Loizou), [email protected] (P. Hull).
Amongst other factors [8], time to surgery is a key predictor to mortality rate in those sustaining fNOF [9]. The National Hip Fracture Database (NHFD) [2] is a UK-wide clinical audit project commissioned by the Healthcare Quality Improvement Partnership and managed by the Royal College of Physicians as part of the Falls and Fragility Fracture Audit Programme. It was established in 2007 as a joint venture of the British Geriatrics Society and the British Orthopaedic Association, and is designed to facilitate improvements in the quality and cost effectiveness of hip fracture care. The NHFD’s role is to allow care to be audited against the six evidence-based standards set out in the BOA/BGS Blue Book on the care of patients with fragility fracture; and enables local health economies to benchmark their performance in hip fracture care against national data.
http://dx.doi.org/10.1016/j.injury.2015.06.030 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wong K, et al. Management of hip fractures pre- and post-Major Trauma Centre activation. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.030
G Model
JINJ-6266; No. of Pages 3 K. Wong et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
The management of fNOF has evolved as the understanding of the problem has increased [10,11]. A dramatic change has been brought about since specialised orthogeriatric teams have been established in many hospitals around the country, and there has been a drive from surgeons and orthogeriatricians to minimise time to surgery. The Best Practice Tariff (BPT) was introduced in April 2010 and reflects a commitment for hospitals to provide the highest quality care to those with fNOF. In addition to improving patient outcome, hospitals have a financial incentive to meet the BPT. For the BPT to be met, the time to surgery must be within 36 h from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia. In comparison the fNOF in the elderly population, for those under 40, major trauma is the leading cause of death and results in significant morbidity [3]. Following the National Audit Office’s report on the unacceptable variation in trauma care throughout the UK [12], 22 Major Trauma Centres (MTCs) have now been set up in England [4]. Those who meet criteria relating to vital signs, anatomy of injury or mechanism of injury may be triaged to a MTC. A 15-20% reduction in mortality is seen in patients who are treated in a MTC [5]. National centralisation of major trauma started upon activation of the Major Trauma Network on 1 April 2012, where patients are diverted away from regional hospitals to MTCs [6]. With the designation of MTC and the additional workload of major trauma patients, there may have a negative knock-on effect on management of neck of femur fractures in having their surgery within 36 h. This paper describes the impact of transition to MTC status on the management of neck of femur fractures.
Methods The NHFD website publishes its summary data on its website, and these data were sourced for this paper [2]. We collated the data from NHFD Excel spreadsheets for the period of April 2011–April 2012 (i.e. the ‘pre-MTC’ activation period) and April 2012–April 2013 period (i.e. the ‘post-MTC’ activation period). We hypothesised that in the first year post-activation of the Major Trauma Network, MTCs would suffer in terms of the proportion of patients having surgery within 36 h, compared with the corresponding proportion at non-MTCs. The main reason for this would be due to limited trauma list capacity being occupied by major trauma cases at MTCs in addition to trauma work being diverted from non-MTCs. Our primary outcome measure was: proportion of patients having surgery within 36 h. Our secondary outcome measures were: length of acute stay, proportion of those meeting all BPT criteria, reasons for delay to surgery. Excel spreadsheet data for the periods of April 2011–April 2012 and April 2012–April 2013 was downloaded from the NHFD website. These datasets correspond to the periods immediately
pre-MTC activation and immediately post-MTC activation, therefore 20 MTCs were included in the study, of which 12 were Adult and Children’s MTCs and 8 were Adult MTCs. The 4 dedicated Children’s MTCs and 2 Collaborative MTCs were not classified as adult MTCs in this paper. Statistical analysis: This was undertaken using Graphpad Instat software (Graphpad software, San Diego, CA). Categorical data were analysed using the Chi Squared test. Length of stay was found to be normally distributed, so differences between groups were analysed using the unpaired Student t-test. A p value of <0.05 was considered statistically significant. Results A total of 54,897 fNOF patients were included for all hospitals in England in the April 2011–April 2012 ‘pre-MTC’ period. A total of 55,998 fNOF patients were included for all hospitals in England for the April 2012–April 2013 ‘post-MTC’ period. There were a total of 143 non-MTC trauma units and 20 MTCs included in this analysis. Figures for the proportions of patients between MTCs and nonMTCs can be found in Table 1. For MTCs, a weighted mean average of 66.6% patients had surgery within 36 h in the pre-MTC period versus 71.4% of patients in the post MTC period (p < 0.0001). For non-MTCs, a weighted mean average of 70.0% of patients had surgery within 36 h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p < 0.0001). Non-MTCs in both pre- and post-MTC activation periods were better in percentage of patients receiving surgery within 36 h (see table below, p > 0.0001). There was no difference in the length of acute stay in MTCs between the pre- and post-MTC activation periods (p = 0.858). Similarly, in non-MTCs, there was no difference in length of stay between the pre- and post-MTC activation periods (p = 0.670). For MTCs, the percentage of those meeting BPT was 50.5% and 56.1% pre- and post-MTC period respectively. Similarly, for nonMTCs, the percentage of those meeting BPT was 47.9% and 60.2% in the pre- and post-MTC periods respectively. It is difficult to cross compare the percentage improvements for BPT, as no weighted averages could be calculated from the data available from the NHFD. Common reasons given for a delay in surgery beyond 36 h were ‘awaiting space on a theatre list,’ ‘cancelled due to list being over run,’ ‘problem with theatre/anaesthetic/staff cover.’ There were also ‘other reasons’ and ‘unknown reasons’ why patients did not have surgery within 36 h. These data are summarized in Table 1. Discussion This paper is an observational study into key criteria kept within the NHFD. We expected that in the first year of MTC activation, the increased MTC workload would have impacted
Table 1 Fracture neck of femur patients in Major Trauma Centres and non-Major Trauma Centres pre- and post-activation of the National Major Trauma Network.
Included fNOF patients (MTCs) Included fNOF patients (non-MTCs) Percentage of patients receiving surgery within 36 h (MTCs) Percentage of patients receiving surgery within 36 h (non-MTCs) Mean length of stay (MTCs) Mean length of stay (non-MTCs) Percentage of those meeting BPT (MTCs) Percentage of those meeting BPT (non-MTCs)
April 2011–April 2012 ‘Pre-MTC activation’
April 2012–April 2013 ‘Post-MTC activation’
p value
8535 46,362 66.6 70.0 16.2 15.8 50.5 47.9
8940 47,058 71.4 73.8 15.5 15.7 56.1 60.2
– – <0.0001 <0.0001 =0.858 =0.670 – –
Please cite this article in press as: Wong K, et al. Management of hip fractures pre- and post-Major Trauma Centre activation. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.030
G Model
JINJ-6266; No. of Pages 3 K. Wong et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
negatively on the more ‘routine’ trauma. This result of improved time to theatre for fNOF patients nationally was unexpected but welcome. There was a significant improvement of 4.8% and 3.8% in the percentage of patients operated within 36 h post-MTC activation for MTCs and non-MTCs, respectively. The reasons for the improvement in patients having surgery within 36 h post-MTC activation are likely to be multi-factorial. It is possible that the financial benefit of the BPT has appropriately motivated clinicians to prioritise these frail and vulnerable patients, over the years since it has been introduced. Therefore, an additional capacity may have been created to accommodate all patients. This may have come with an increased understanding into the Best Practice management of fNOF and an increased emphasis on the financial benefits from meeting BPT in the era of efficiency savings within the National Health Service. An increased presence of consultant-level orthogeriatric care is likely to have also contributed. In addition to their medical input, orthogeriatric consultants are often advocates for fNOF patients having their hip fracture surgery emergently. An increase in funding allocated to MTCs, with associated increase in trauma list space, may have also led to the improved performance. We thought that there were several reasons as to why our fNOF management would have suffered from Major Trauma Network activation. Firstly, major trauma cases may be seen as more time-urgent due to the nature of injury (open fractures, need for stabilisation of long bone/pelvic fractures, neurovascular injury, compartment syndrome). They tend to occupy more theatre space because the complex nature of surgery, which requires more time. There is often the thought that the complex polytrauma cases should be operated on early in the day to prevent straying into out-of-hours periods with its associated compromise in theatre support staff. Secondly, in those sustaining complex wounds, surgical management often involves repeated irrigation, debridement and negative pressure dressing applications. These occupy more theatre time. Thirdly, the logistical need for collaborative specialties to be present in theatre may put pressure on cases to be done only when specialist surgeons are available. However, despite these three issues, the result of our primary outcome measure supports the suggestion that fNOF management has improved in both MTCs and non-MTCs. Indeed, the national improvement in percentage of those meeting BPT is also in agreement with our results. The length of stay has not changed pre- and post-MTC activation. There are some limitations to this paper: a small fraction of the summary data collected as part of the NHFD may or may not be complete, and therefore the use of inferential statistics to determine statistical significance here has to be interpreted carefully. However, the strength of the results shown is based on the vast number of patients from data collected nationally, meaning that ‘time to surgery’ are highly statistically significant (n = 54,897 and n = 55,998 for ‘pre-’ and ‘post-MTC’ groups). Another limitation is that we assume that trauma lists are predominantly orthopaedic-led in all MTCs, whereas in some centres, the dedicated Major Trauma theatre list may assume more of a multidisciplinary emergency list (i.e. led by a dedicated trauma surgeon).
3
The improvement in our primary outcome- or may not be due to becoming a MTC, or due to the activation of the Major Trauma Network. It is impossible to say whether a trend in quality of fNOF management exists, however this paper aims to stimulate thinking and discussion in the matter of prioritisation of the ‘new’ polytrauma patients versus the ‘routine’ fNOF patients, as they will often be competing for the same trauma list space. The data in the pre-MTC period has noted delays to surgery due to patients being ‘medically unfit – awaiting medical review and stabilisation’ and ‘medically unfit – awaiting orthopaedic diagnosis or investigation.’ Thus, it will be important to address these issues. Encouragingly, the low numbers of fNOF cases with: ‘problems with anaesthetic/surgical/theatre staff cover’, ‘problems with theatre equipment’ and ‘awaiting inpatient or high dependency bed’ in MTCs during the post-MTC period suggests that the infrastructure has not struggled, or have successfully accommodated the increased workload following MTC activation. In conclusion – the data is presented as above shows that the national activation of MTCs has not had a deleterious effect on the time to theatre for fNOF patients, as initially hypothesised; in fact there has been an improvement. There may have also been an improvement in the proportion of those meeting the BPT, although this is difficult to prove statistically given the summary data. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, including that of fNOF, in conjunction with the development of regional Major Trauma Networks. Conflict of interest The authors confirm that no conflicts of interest exist. References [1] Dolan P, Torgerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporos Int 1998;8:611–7. [2] Goldacre MJ, Roberts SE, Yeates D. Mortality after admission to hospital with fractured neck of femur: database study. BMJ 2002;325(7369):868–9. [3] Sexson SB, Lehner JT. Factors affecting hip fracture mortality. J Orthop Trauma 1987;1(4):298–305. [4] Ions GK, Stevens J. Prediction of survival in patients with femoral neck fractures. J Bone Joint Surg 1987;3(64-B):384–7. [5] National Hip Fracture Database website. http://www.nhfd.co.uk. [6] BOAST 1 guidelines (version 2). http://www.boa.ac.uk/LIB/LIBPUB/ Documents/ BOAST%201%20Version%202%20-%20Hip%20Fracture%20in%20the%20Older %20Person%20-%202012.pdf. [7] National Clinical Guideline Centre. Management of hip fractures in adults. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf. [8] von Ru¨den C, Woltmann A, Ro¨se M, Wurm S, Ru¨ger M, Hierholzer C, et al. Outcome after severe multiple trauma: a retrospective analysis. J Trauma Manag Outcomes 2013;7:4. [9] National Audit Office. Major Trauma Care in England – Report by the Comptroller and Auditor General. National Audit Office; 20109780102963472. [10] Locations of Major Trauma Centres. www.nhs.uk/NHSEngland/. . ./ map-of-major-trauma-centres-2012.pdf. [11] Hipps D, Holmes A, Sugden K, Refaie R, Dowen D, Gray AC. The impact the transition to a level 1 major trauma centre has on the management of patients sustaining a fractured neck of femur using the national boast guidelines. Bone Joint J 2013;12:24. vol. 95-B no. SUPP. [12] Moy R, Han K, Dean Smith G, Henning J. Trauma systems: the potential impact of a trauma divert policy on a regional ambulance service. Emerg Med J 2012. http://dx.doi.org/10.1136/emj.2011.112870.
Please cite this article in press as: Wong K, et al. Management of hip fractures pre- and post-Major Trauma Centre activation. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.06.030