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Predictive factors for in-hospital stay and complications after hip fracture
International Journal of Orthopaedic and Trauma Nursing (2012) 16, 206–213
www.elsevier.com/locate/ijotn
Predictive factors for in-hospital stay and complications after hip fracture Panagiota P. Copanitsanou PhD(c), RN a,*, Joseph Liaskos PhD b, Theodoros C. Tsarouchas MD (Director) a a
Department of Orthopaedics, General Hospital of Piraeus ‘‘Tzaneio’’, Greece Health Informatics Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, Greece b
KEYWORDS
Abstract Background: There are a number of factors, such as preoperative Length Of hospital Stay (LOS), that effect treatment outcomes following proximal hip fracture. Much of this is not completely understood. Objective: To determine whether co-morbidities, complications and patients’ abnormal laboratory findings at admission have an effect on LOS and related complications during hospitalization for hip fracture treatment in a Greek hospital. Design: Prospective observational descriptive study. Setting: A high volume orthopedic ward of a general hospital in Greece, from March to October 2008. Patients: In total, 253 consecutive patients hospitalized for hip fracture treatment in an orthopedic ward of a large Greek hospital were included in the study. All complications, LOS and parameters of clinical history and treatment were recorded. Results: The mean age of the sample was 79.68 years. Only 29.3% of the patients were operated within the first 2 days, as the mean preoperative LOS was 3.71 days, leading to a total LOS of 9.68 days. Preoperative LOS increases somewhat in patients with heart failure and previous cerebrovascular accident. LOS increases when patients present with cardiac complications, respiratory complications, fever and anemia. Complications correlate with the type of patients’ co-morbidities. Abnormal laboratory findings at admission correlate to the type of preoperative complications. Discussion: LOS, mortality and complication rates in the study hospital are comparable to the findings reported in the literature. c 2011 Elsevier Ltd. All rights reserved.
Hip fracture; In-hospital stay; Mortality; Complications; Predictors
* Corresponding author. Address: General Hospital of Piraeus ‘‘Tzaneio’’, Zanni and Afentouli 1 Street, 185 36 Piraeus, Greece. Tel.: +30 210 4592390. E-mail address: [email protected] (P.P. Copanitsanou).
1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.12.005
Predictive factors for in-hospital stay and complications after hip fracture
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Editor’s comments Building upon previous research this article affirms the correlation between co-morbidities and the length of stay in hospital following a hip fracture. Focussing its findings on data obtained from a consecutive sample of hip fracture patients in a Greek hospital this work identifies some of the challenges that face nursing in relation to unplanned admissions. Predicting the length of stay for many trauma patients is at best difficult however, some co-morbidities are recognised to be concomitant with longer hospital episodes. BS
Introduction A hip fracture represents the most common reason for an acute admission to an orthopedic ward and is the most expensive type of osteoporotic fracture (Levy et al., 2002). With an aging population, the incidence of hip fracture may increase still further, despite prevention programs (Alvarez-Nebreda et al., 2008). The number of hospital beds required for such a demand, and the associated costs, are constantly increasing. The main complications during hospitalization following hip fracture involve pressure ulcers formation, urinary tract and respiratory infections, thromboses, cardiac events and perioperative delirium (Gdalevich et al., 2004; Mc Guire et al., 2004; Orosz et al., 2004; Weller et al., 2005; Bottle and Aylin, 2006; Dasgupta and Dumbrell, 2006; Lundstro ¨m et al., 2007; Zanni and Wick, 2007; Browne et al., 2009) that appear in approximately 20% of the patients (Lawrence et al., 2002; Shah et al., 2005; Hirose et al., 2008). Mean Length Of in-hospital Stay (LOS) rests between 6 days (Shah et al., 2005; Browne et al., 2009) extending to over 15 days (Novack et al., 2007; Alvarez-Nebreda et al., 2008; Kondo et al., 2010), though it is generally following a downward trend (Lippuner et al., 2005; Gehlbach et al., 2007). The overall in-hospital mortality rate is reported between 1.6% (Hirose et al., 2008; Browne et al., 2009) and 3.3% (Shah et al., 2005; Browne et al., 2009). The main causes of in-hospital mortality after hip fracture includes cardiac failure and myocardial infarction (Dawson-Bowling et al., 2008; Panula et al., 2011).
Background/literature The treatment outcomes during in-hospital stay after a hip fracture are related to several factors that are not susceptible to change (i.e. demographic factors, number and type of co-morbidities), but also to factors that are modifiable (i.e. timing of operation, preoperative LOS and type of surgical procedure). The effects of delaying the
surgery on the treatment outcomes are not completely understood, as early surgery is reported to have no effects on mortality (Pillay et al., 2007; Rodriguez-Fernandez et al., 2011) and LOS (Harries and Eastwood, 1991) or seen to be associated with a lower mortality rate (Orosz et al., 2004; Novack et al., 2007; Shiga et al., 2008) and LOS (Siegmeth et al., 2005; Rodriguez-Fernandez et al., 2011). Also, some studies have supported early surgery suggesting it leads to decreased complications (Orosz et al., 2004; Pillay et al., 2007; Al-Ani et al., 2008), while others have indicated that it is the stable preoperative condition of the patient that is associated with shorter preoperative LOS (Bottle and Aylin, 2006). Functional status has also been identified as a risk factor for mortality in the elderly (Minicuci et al., 2003), but there are only a few studies examining this correlation (Orosz et al., 2004). The purpose of this study was to determine if comorbidities, complications and the patients’ abnormal laboratory findings at admission, following hip fracture, have an effect on LOS and associated complications during hospitalization in a Greek hospital. We aim to illustrate the situation pertaining to Greek hospitals by studying these factors in one of the region’s biggest hospitals. To the best of our knowledge there has not been such a study conducted in Greece.
Patients and methods A prospective observational descriptive study was conducted during an 8-month period, from March to October 2008, in an orthopedic ward of an urban public general hospital of Attica region, Greece. All consecutive patients who met the inclusion criteria (Caucasian race, primary osteoporotic hip fracture and no other fracture, age of 51 years or older, voluntary involvement) participated in the study. Any hip fracture that occurred after a low trauma event, such as a fall from standing height, was considered as osteoporotic. All patients having pathologic fracture or a fracture that occurred after a high energy impact (i.e. car accident, occupational
208 accident), patients with previous fracture or surgery on the currently fractured site, as well as all pre-menopausal women, were excluded from the study. Patients with a systemic disease, such as myasthenia or other severe neurological disorder, and/or with extensive pressure ulcers, were also excluded. The study was conducted utilizing the orthopedic department within a high-volume hospital which is supported by high-volume surgeons, as defined by the number of surgical procedures conducted per year ( Lavernia, 1998; Browne et al., 2009). The minimum number of hip fracture operations performed by a single surgeon was 16 with the maximum being 35 throughout the 8-month survey period (Browne et al., 2009). During the study period, 253 patients fulfilled the inclusion criteria, while seven patients were excluded (2.8%). At admission, data were collected regarding demographics, Body Mass Index (BMI), type of fracture, vital signs, blood test results, electrocardiogram (ECG) results, followed by a detailed personal history (from the patients and/or their significant others). Laboratory test results were evaluated according to the normal values suggested by the hospital’s laboratory. During patients’ hospitalization mortality and all complications (i.e. cardiac and respiratory complications) were recorded both pre- and post-operatively. Any myocardial infarction, aggravation of congestive heart failure, unstable angina or major arrhythmia was recorded as a single cardiac complication. Respiratory complications included respiratory infection, acute respiratory distress syndrome (ARDS) and respiratory failure. Renal complications involved acute renal failure. Fever was reported as a temperature equal to or greater than 38 °C for one measurement. At discharge the patients’ place of residence was recorded and their LOS. Co-morbidities included heart failure, diabetes, hypertension, previous cerebrovascular accident, coronary heart disease or myocardial infarction, cardiac arrhythmia (such as atrial fibrillation), renal failure, hepatitis, chronic obstructive pulmonary disease, Parkinson’s disease, depression, dementia and malignancy without metastasis. In the present study, we classified hip fractures to intra- and extra-capsular, according to their relationship to the capsular attachment of the hip (Alvarez-Nebreda et al., 2008). The surgical treatment followed for extracapsular fractures involved intramedullary nailing (Schatzker and Tile, 2005; Utrilla et al., 2005; Saarenpaa et al., 2007; Aros et al., 2008; Jiang et al., 2008), which is widely used for the fixation of hip fractures (Saarenpaa et al., 2007) and also enables insertion by a semi-
P.P. Copanitsanou et al. closed procedure (Min et al., 2007; Jiang et al., 2008). Hemiarthroplasty was applied to all patients with intracapsular fracture or with a displaced fracture, as most of the patients were undergoing surgery at more than 2 days, which is associated with necrosis of the femoral head. Hemiarthroplasties were cemented when the patient’s age was over 75 years. Hemiarthroplasty leads to significantly fewer hip complications and re-operations (Schatzker and Tile, 2005; Shah et al., 2005; Rogmark and Johnell, 2006), better functional status (Shah et al., 2005) and represents the most frequent surgical technique used for this type of fracture (Parker and Johansen, 2006). All patients treated surgically underwent spinal anesthesia and necessitated at least one blood transfusion during surgery along with blood drainage apparatus. For all patients treated surgically their first ambulation was non-weight bearing and commonly took place on the second postoperative day, with active flexion and extension of the hip and knee of the affected site. Non-operative treatment was only offered to patients with serious cardiac or respiratory problems and those with extensive pressure ulcers. The patients treated for low impact fractures were observed closely for complications (i.e. neurological symptoms) during their hospitalization. After their discharge from the hospital they were given written medical instructions related to the self-administration of appropriate medications (i.e. bisphosphonates, calcitonin). At follow-up, besides the clinical examination, they underwent bone density measurements and X-rays. The limitations of our study include the subjective evaluation of patients’ BMI. The variables of the study sample were tested for normality (Kolmogorov–Smirnov test) and it was found that the sample follows a normal distribution. Statistical analysis included univariate testing methods (t-test, v2 test, and analysis of variance – ANOVA). The statistical significance level was defined to a = 0.05. For the analysis the statistical data we used SPSS version 15.0.
Results The mean age of the sample was 79.68 years (range 51–97, SD = 8.195). The majority the participants were women (78.7%). Form the sample 53.4% of the patients suffered an extracapsular and 46.2% an intracapsular fracture. Of these, 3.6% of patients were not treated surgically due to serious cardiac or respiratory problems and/or extensive pressure ulcers, while 50.1% of the patients were
Predictive factors for in-hospital stay and complications after hip fracture Table 1
Descriptive statistics.
Age Female Intra-captural fractures Extra-captural fractures LOS pre-operatively LOS post-operatively
79.68 (SD = 0.518) 78.7% 46.2% 53.4% 3.71 (SD = 0.151) 5.97 (SD = 0.174)
Residence before fracture With relatives Alone Nursing home for the elderly Private clinic
93.3% 1.2% 3.6% 0.4%
Residence after fracture With relatives Alone Nursing home for the elderly Private clinic Rehabilitation clinic ICU
86.2% 0.8% 3.6% 4.0% 0.4% 0.8%
Mortality
1.6%
Table 2
Percentage of co-morbidities.
Comorbidities
Percentage
Hypertension Depression Diabetes Heart failure Coronary heart disease Arrhythmia Chronic obstructive pulmonary disease Dementia Malignancy without metastasis Cerebrovascular accident Parkinson’s disease Myocardial infraction Hepatitis Renal failure
57.7 34.4 26.9 20.2 17.8 15.8 10.3 8.7 6.7 6.3 5.9 4.7 4.0 4.0
Table 3
209
treated with intramedullary nailing and 41.5% with hemiarthroplasty. After their treatment, only 8.8% of the patients were transferred to a rehabilitation clinic, a private clinic, a nursing home for the elderly or an Intensive Care Unit. The in-hospital mortality was 1.6%, due to cardiac arrest and respiratory complications (Table 1). The mean preoperative LOS was 3.71 days (range 0–21, SD = 2.36) and the mean postoperative LOS was 5.97 days (range 0–21, SD = 2.63), leading to a total LOS of 9.68 days. Gender and BMI did not have any effect on LOS. Preoperative LOS increases particularly in patients with heart failure (p = 0.005) and in those experiencing a previous cerebrovascular accident (p = 0.025). Only the patients with chronic renal failure have longer preoperative (p = 0.031) and postoperative (p = 0.003) LOS. The most prevalent co-morbidities included hypertension (57.7%), depression (34.4%), diabetes (26.9%) and heart failure (20.2%) (Table 2). Preoperative LOS also increases in patients’ with cardiac complications (p < 0.001), respiratory complications (p < 0.001), fever (p = 0.014) and anemia (p < 0.001). Complications that increase postoperative LOS are the postoperative cardiac (p = 0.043), respiratory (p = 0.029) and renal (p = 0.034) complications, fever (p = 0.007) and anemia (p = 0.021). Complications were developed in 28% of the patients preoperatively and in 51.8% of the patients postoperatively, which means that complication rates increase postoperatively. The most frequent complication is postoperative fever, which appears in 29.6% of the patients (Table 3). Age was correlated to the number of complications both preoperatively (p = 0.035) and postoperatively (p = 0.025). Complications correlate also with the type of patients’ co-morbidities, i.e. preoperative cardiac (p = 0.025) and renal complications (p = 0.013) which appear more frequently among patients with heart failure (Table 4). Extracapsular fractures are correlated to anemia (p = 0.008 preoperatively, p < 0.001 postoperatively).
Percentage of pre- and post-operative complications.
Complications
Preoperatively (%)
Postoperatively (%)
Urinary tract infection Pressure ulcer Respiratory complication Cardiac complication Renal complication Gastrointestinal complication Fever Embolism Blood transfusion Erythropoietin
2.0 2.4 6.3 4.7 2.4 6.3 11.1 0 9.1 2.0
2.0 4.7 10.7 12.3 3.6 11.1 29.6 0.8 14.2 3.2
*
0.032#
0.011
# * *
*
* *
*
0.093
*
0.802
0.019 0.009# 0.061 0.045# 0.376 0.413 0.288
#
0.591 0.097 0.084 0.005# 0.534
Discussion
*
0.26
0.698 0.238
* *
0.013 0.089 0.539 0.579 0.052 0.13
Post
Pre
#
Post
Post
Post
Pre
#
0.01 0.544 0.654 0.804 0.105 0.811
0.007# 0.246 0.156 0.023# 0.089 0.829
The most frequent abnormal findings included a decreased hematocrit (52.2%), indicators of poor renal function (45.1%), abnormal white blood cells count (40.3%), electrolytic disorders (29.2%) and decreased number of platelets (20.2%) (Table 5). Abnormal laboratory findings at admission correlate to the type of preoperative complications (p = 0.01), i.e. decreased hematocrit was correlated with anemia and the need for transfusion or administration of erythropoietin (p < 0.001), abnormal ECG and indicators of poor renal function were correlated with cardiac (p < 0.001) and renal complications respectively (p < 0.001).
*
#
Not convenient. Statistically significant (p < a).
0.631
0.207
0.692 0.669 * *
*
Heart failure Coronary heart disease Diabetes Malignancy without metastasis Renal failure Myocardial Infraction
* * *
*
*
0.028#
* *
0.031# 0.011# 0.464
*
0.243 0.421 * *
0.126 0.146
0.025 0.273 0.509
#
Pre Post Pre Post Pre
*
Renal Cardiac Respiratory Urinary tract infection
Complications (pre- and post-operatively)
Statistical significance (p) between co-morbidities and complications.
Co-morbidity
Table 4
*
Pulmonary embolism
Pre
Trauma infection
Post
P.P. Copanitsanou et al.
Total number of complications
210
The purpose of this study was to determine if comorbidities, complications and abnormal laboratory findings at admission have an effect on LOS and any complications during the in-hospital treatment of patients suffering from an osteoporotic hip fracture. The limitations of our study, as described above, include the subjective evaluation of patients’ BMI. During the 8-month period of the study, 253 patients with hip fracture were included and treated in the study ward, apart from all the other patients treated in the same ward (i.e. patients undergoing total arthroplasties and patients with other types of fractures). Only 29.3% of the patients were operated within the first 2 days. This percentage is far less than in other hospitals (Clague et al., 2002; Orosz et al., 2004; Siegmeth et al., 2005; Bottle and Aylin, 2006; Novack et al., 2007). In the present study LOS was 9.68 days, which is comparable to the mean LOS commonly reported (Koeck et al., 2001; Shah et al., 2005; Bottle and Aylin, 2006; Olsson et al., 2006; Gehlbach et al., 2007; Novack et al., 2007; Alvarez-Nebreda et al., 2008; Browne et al., 2009). Preoperative LOS increases especially in patients with heart failure and previous cerebrovascular accident. Thus, co-morbidities affect the timing of operation, which is in congruence with previous results (Bottle and Aylin, 2006). The overall in-hospital mortality was 1.6%, therefore comparable to some recent studies (Hirose et al., 2008; Browne et al., 2009; Kadono et al., 2010) however, less so in others (Koeck et al., 2001; Clague et al., 2002; Su et al., 2003; Shah et al., 2005; Bottle and Aylin, 2006; Alvarez-Nebreda et al., 2008; Dawson-Bowling et al., 2008; Browne et al., 2009). The main causes were cardiac failure and myocardial infarction, as expected (DawsonBowling et al., 2008; Panula et al., 2011).
Predictive factors for in-hospital stay and complications after hip fracture
211
Table 5 Percentage of abnormal laboratory findings at admission.
Conclusions
Abnormal findings at admission
Percentage
Hematocrit Indicators of renal function White blood cells Electrolytes Platelets Abnormal blood pressure Transaminases Electrocardiogram
52.2 45.1 40.3 29.2 20.2 14.2 13.4 11.1
In this study we aimed to determine whether comorbidities, complications and patients’ abnormal laboratory findings at admission have an effect on LOS and related complications during hospitalization for hip fracture treatment in a Greek hospital. We found that preoperative LOS increases in patients with heart failure and previous cerebrovascular accident, whilst only patients with chronic renal failure have both a longer preoperative and postoperative LOS. Also, LOS increases with cardiac and respiratory complications, fever and anemia. Complications correlate to the type of patients’ co-morbidities, while abnormal laboratory findings at admission are correlated to the type of preoperative complications. The results of the present study indicate that LOS, mortality and complication rates in the study hospital are comparable to the findings reported in the literature. More research is needed in order to examine the effects of predictors such as laboratory findings on treatment outcomes.
Complications developed in 28% of the patients preoperatively and in 51.8% of the patients postoperatively, which means that complication rates increase postoperatively. This percentage has been found to be higher in comparison to the findings reported in some studies (Shah et al., 2005; Olsson et al., 2006), whilst lower than in other studies (Vida ´n et al., 2005), and can be attributed to a more detailed recording of the complications in the present study. Indeed, the individual rates for each complication are comparable to the international findings, i.e. the percentage of thromboembolism is only 0.8%, which is very low (Gerkens et al., 2010). Complications correlate with the type of patients’ co-morbidities, as expected. From all demographic factors only age was correlated to the number of complications. In some studies females had a higher complication rate compared to males (Suckel et al., 2007), while in other studies men had an increased risk of mortality (Gdalevich et al., 2004; Orosz et al., 2004; Shah et al., 2005). Abnormal laboratory findings at admission were correlated to preoperative complications. However, due to their correlation with the complications they could have an indirect effect on LOS. In the literature there is a lack of studies that refer to the correlation between abnormal laboratory findings at admission and outcomes, which may represent a subject for further investigation. In the only relevant study found, patients having abnormal laboratory findings had a longer LOS (Orosz et al., 2004). Laboratory findings that have been correlated to outcomes after a hip fracture are serum albumin level, total lymphocyte count (Koval et al., 1999; Symeonidis and Clark, 2006) and C-reactive protein (Beloosesky et al., 2004). More research is needed in order to examine the effects of laboratory findings on outcomes.
Conflict of interest statement Neither personal nor institutional financial support was provided for the needs of the present survey.
Funding source No funding was obtained for this study.
Ethical approval The present study was approved by the ethical board of the National and Kapodistrian University of Athens.
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extra-articular femur fractures: differences in complications, age, sex and surviving rates. International Orthopaedics 31 (5), 689–695. Symeonidis, P.D., Clark, D., 2006. Assessment of malnutrition in hip fracture patients: effects on surgical delay, hospital stay and mortality. Acta Orthopaedica Belgica 72 (4), 420–427. Utrilla, A.L., Reig, J.S., Munoz, F.M., Tufanisco, C.B., 2005. Trochanteric gamma nail and compression hip screw for trochanreric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. Journal of Orthopaedic Trauma 19 (4), 229–233. Vida ´n, M., Serra, J.A., Moreno, C., Riquelme, G., Ortiz, J., 2005. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. Journal of the American Geriatrics Society 53 (9), 1476–1482. Weller, I., Wai, E.K., Jaglal, S., Kreder, H.J., 2005. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. The Journal of Bone and Joint Surgery 87 (3), 361–366. Zanni, G.R., Wick, J.Y., 2007. Hip fracture: improving the outcome. The Consultant Pharmacist 22 (9), 712–724.
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Predictive factors for in-hospital stay and complications after hip fracture Panagiota P. Copanitsanou PhD(c), RN a,*, Joseph Liaskos PhD b, Theodoros C. Tsarouchas MD (Director) a a
Department of Orthopaedics, General Hospital of Piraeus ‘‘Tzaneio’’, Greece Health Informatics Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, Greece b
KEYWORDS
Abstract Background: There are a number of factors, such as preoperative Length Of hospital Stay (LOS), that effect treatment outcomes following proximal hip fracture. Much of this is not completely understood. Objective: To determine whether co-morbidities, complications and patients’ abnormal laboratory findings at admission have an effect on LOS and related complications during hospitalization for hip fracture treatment in a Greek hospital. Design: Prospective observational descriptive study. Setting: A high volume orthopedic ward of a general hospital in Greece, from March to October 2008. Patients: In total, 253 consecutive patients hospitalized for hip fracture treatment in an orthopedic ward of a large Greek hospital were included in the study. All complications, LOS and parameters of clinical history and treatment were recorded. Results: The mean age of the sample was 79.68 years. Only 29.3% of the patients were operated within the first 2 days, as the mean preoperative LOS was 3.71 days, leading to a total LOS of 9.68 days. Preoperative LOS increases somewhat in patients with heart failure and previous cerebrovascular accident. LOS increases when patients present with cardiac complications, respiratory complications, fever and anemia. Complications correlate with the type of patients’ co-morbidities. Abnormal laboratory findings at admission correlate to the type of preoperative complications. Discussion: LOS, mortality and complication rates in the study hospital are comparable to the findings reported in the literature. c 2011 Elsevier Ltd. All rights reserved.
Hip fracture; In-hospital stay; Mortality; Complications; Predictors
* Corresponding author. Address: General Hospital of Piraeus ‘‘Tzaneio’’, Zanni and Afentouli 1 Street, 185 36 Piraeus, Greece. Tel.: +30 210 4592390. E-mail address: [email protected] (P.P. Copanitsanou).
1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.12.005
Predictive factors for in-hospital stay and complications after hip fracture
207
Editor’s comments Building upon previous research this article affirms the correlation between co-morbidities and the length of stay in hospital following a hip fracture. Focussing its findings on data obtained from a consecutive sample of hip fracture patients in a Greek hospital this work identifies some of the challenges that face nursing in relation to unplanned admissions. Predicting the length of stay for many trauma patients is at best difficult however, some co-morbidities are recognised to be concomitant with longer hospital episodes. BS
Introduction A hip fracture represents the most common reason for an acute admission to an orthopedic ward and is the most expensive type of osteoporotic fracture (Levy et al., 2002). With an aging population, the incidence of hip fracture may increase still further, despite prevention programs (Alvarez-Nebreda et al., 2008). The number of hospital beds required for such a demand, and the associated costs, are constantly increasing. The main complications during hospitalization following hip fracture involve pressure ulcers formation, urinary tract and respiratory infections, thromboses, cardiac events and perioperative delirium (Gdalevich et al., 2004; Mc Guire et al., 2004; Orosz et al., 2004; Weller et al., 2005; Bottle and Aylin, 2006; Dasgupta and Dumbrell, 2006; Lundstro ¨m et al., 2007; Zanni and Wick, 2007; Browne et al., 2009) that appear in approximately 20% of the patients (Lawrence et al., 2002; Shah et al., 2005; Hirose et al., 2008). Mean Length Of in-hospital Stay (LOS) rests between 6 days (Shah et al., 2005; Browne et al., 2009) extending to over 15 days (Novack et al., 2007; Alvarez-Nebreda et al., 2008; Kondo et al., 2010), though it is generally following a downward trend (Lippuner et al., 2005; Gehlbach et al., 2007). The overall in-hospital mortality rate is reported between 1.6% (Hirose et al., 2008; Browne et al., 2009) and 3.3% (Shah et al., 2005; Browne et al., 2009). The main causes of in-hospital mortality after hip fracture includes cardiac failure and myocardial infarction (Dawson-Bowling et al., 2008; Panula et al., 2011).
Background/literature The treatment outcomes during in-hospital stay after a hip fracture are related to several factors that are not susceptible to change (i.e. demographic factors, number and type of co-morbidities), but also to factors that are modifiable (i.e. timing of operation, preoperative LOS and type of surgical procedure). The effects of delaying the
surgery on the treatment outcomes are not completely understood, as early surgery is reported to have no effects on mortality (Pillay et al., 2007; Rodriguez-Fernandez et al., 2011) and LOS (Harries and Eastwood, 1991) or seen to be associated with a lower mortality rate (Orosz et al., 2004; Novack et al., 2007; Shiga et al., 2008) and LOS (Siegmeth et al., 2005; Rodriguez-Fernandez et al., 2011). Also, some studies have supported early surgery suggesting it leads to decreased complications (Orosz et al., 2004; Pillay et al., 2007; Al-Ani et al., 2008), while others have indicated that it is the stable preoperative condition of the patient that is associated with shorter preoperative LOS (Bottle and Aylin, 2006). Functional status has also been identified as a risk factor for mortality in the elderly (Minicuci et al., 2003), but there are only a few studies examining this correlation (Orosz et al., 2004). The purpose of this study was to determine if comorbidities, complications and the patients’ abnormal laboratory findings at admission, following hip fracture, have an effect on LOS and associated complications during hospitalization in a Greek hospital. We aim to illustrate the situation pertaining to Greek hospitals by studying these factors in one of the region’s biggest hospitals. To the best of our knowledge there has not been such a study conducted in Greece.
Patients and methods A prospective observational descriptive study was conducted during an 8-month period, from March to October 2008, in an orthopedic ward of an urban public general hospital of Attica region, Greece. All consecutive patients who met the inclusion criteria (Caucasian race, primary osteoporotic hip fracture and no other fracture, age of 51 years or older, voluntary involvement) participated in the study. Any hip fracture that occurred after a low trauma event, such as a fall from standing height, was considered as osteoporotic. All patients having pathologic fracture or a fracture that occurred after a high energy impact (i.e. car accident, occupational
208 accident), patients with previous fracture or surgery on the currently fractured site, as well as all pre-menopausal women, were excluded from the study. Patients with a systemic disease, such as myasthenia or other severe neurological disorder, and/or with extensive pressure ulcers, were also excluded. The study was conducted utilizing the orthopedic department within a high-volume hospital which is supported by high-volume surgeons, as defined by the number of surgical procedures conducted per year ( Lavernia, 1998; Browne et al., 2009). The minimum number of hip fracture operations performed by a single surgeon was 16 with the maximum being 35 throughout the 8-month survey period (Browne et al., 2009). During the study period, 253 patients fulfilled the inclusion criteria, while seven patients were excluded (2.8%). At admission, data were collected regarding demographics, Body Mass Index (BMI), type of fracture, vital signs, blood test results, electrocardiogram (ECG) results, followed by a detailed personal history (from the patients and/or their significant others). Laboratory test results were evaluated according to the normal values suggested by the hospital’s laboratory. During patients’ hospitalization mortality and all complications (i.e. cardiac and respiratory complications) were recorded both pre- and post-operatively. Any myocardial infarction, aggravation of congestive heart failure, unstable angina or major arrhythmia was recorded as a single cardiac complication. Respiratory complications included respiratory infection, acute respiratory distress syndrome (ARDS) and respiratory failure. Renal complications involved acute renal failure. Fever was reported as a temperature equal to or greater than 38 °C for one measurement. At discharge the patients’ place of residence was recorded and their LOS. Co-morbidities included heart failure, diabetes, hypertension, previous cerebrovascular accident, coronary heart disease or myocardial infarction, cardiac arrhythmia (such as atrial fibrillation), renal failure, hepatitis, chronic obstructive pulmonary disease, Parkinson’s disease, depression, dementia and malignancy without metastasis. In the present study, we classified hip fractures to intra- and extra-capsular, according to their relationship to the capsular attachment of the hip (Alvarez-Nebreda et al., 2008). The surgical treatment followed for extracapsular fractures involved intramedullary nailing (Schatzker and Tile, 2005; Utrilla et al., 2005; Saarenpaa et al., 2007; Aros et al., 2008; Jiang et al., 2008), which is widely used for the fixation of hip fractures (Saarenpaa et al., 2007) and also enables insertion by a semi-
P.P. Copanitsanou et al. closed procedure (Min et al., 2007; Jiang et al., 2008). Hemiarthroplasty was applied to all patients with intracapsular fracture or with a displaced fracture, as most of the patients were undergoing surgery at more than 2 days, which is associated with necrosis of the femoral head. Hemiarthroplasties were cemented when the patient’s age was over 75 years. Hemiarthroplasty leads to significantly fewer hip complications and re-operations (Schatzker and Tile, 2005; Shah et al., 2005; Rogmark and Johnell, 2006), better functional status (Shah et al., 2005) and represents the most frequent surgical technique used for this type of fracture (Parker and Johansen, 2006). All patients treated surgically underwent spinal anesthesia and necessitated at least one blood transfusion during surgery along with blood drainage apparatus. For all patients treated surgically their first ambulation was non-weight bearing and commonly took place on the second postoperative day, with active flexion and extension of the hip and knee of the affected site. Non-operative treatment was only offered to patients with serious cardiac or respiratory problems and those with extensive pressure ulcers. The patients treated for low impact fractures were observed closely for complications (i.e. neurological symptoms) during their hospitalization. After their discharge from the hospital they were given written medical instructions related to the self-administration of appropriate medications (i.e. bisphosphonates, calcitonin). At follow-up, besides the clinical examination, they underwent bone density measurements and X-rays. The limitations of our study include the subjective evaluation of patients’ BMI. The variables of the study sample were tested for normality (Kolmogorov–Smirnov test) and it was found that the sample follows a normal distribution. Statistical analysis included univariate testing methods (t-test, v2 test, and analysis of variance – ANOVA). The statistical significance level was defined to a = 0.05. For the analysis the statistical data we used SPSS version 15.0.
Results The mean age of the sample was 79.68 years (range 51–97, SD = 8.195). The majority the participants were women (78.7%). Form the sample 53.4% of the patients suffered an extracapsular and 46.2% an intracapsular fracture. Of these, 3.6% of patients were not treated surgically due to serious cardiac or respiratory problems and/or extensive pressure ulcers, while 50.1% of the patients were
Predictive factors for in-hospital stay and complications after hip fracture Table 1
Descriptive statistics.
Age Female Intra-captural fractures Extra-captural fractures LOS pre-operatively LOS post-operatively
79.68 (SD = 0.518) 78.7% 46.2% 53.4% 3.71 (SD = 0.151) 5.97 (SD = 0.174)
Residence before fracture With relatives Alone Nursing home for the elderly Private clinic
93.3% 1.2% 3.6% 0.4%
Residence after fracture With relatives Alone Nursing home for the elderly Private clinic Rehabilitation clinic ICU
86.2% 0.8% 3.6% 4.0% 0.4% 0.8%
Mortality
1.6%
Table 2
Percentage of co-morbidities.
Comorbidities
Percentage
Hypertension Depression Diabetes Heart failure Coronary heart disease Arrhythmia Chronic obstructive pulmonary disease Dementia Malignancy without metastasis Cerebrovascular accident Parkinson’s disease Myocardial infraction Hepatitis Renal failure
57.7 34.4 26.9 20.2 17.8 15.8 10.3 8.7 6.7 6.3 5.9 4.7 4.0 4.0
Table 3
209
treated with intramedullary nailing and 41.5% with hemiarthroplasty. After their treatment, only 8.8% of the patients were transferred to a rehabilitation clinic, a private clinic, a nursing home for the elderly or an Intensive Care Unit. The in-hospital mortality was 1.6%, due to cardiac arrest and respiratory complications (Table 1). The mean preoperative LOS was 3.71 days (range 0–21, SD = 2.36) and the mean postoperative LOS was 5.97 days (range 0–21, SD = 2.63), leading to a total LOS of 9.68 days. Gender and BMI did not have any effect on LOS. Preoperative LOS increases particularly in patients with heart failure (p = 0.005) and in those experiencing a previous cerebrovascular accident (p = 0.025). Only the patients with chronic renal failure have longer preoperative (p = 0.031) and postoperative (p = 0.003) LOS. The most prevalent co-morbidities included hypertension (57.7%), depression (34.4%), diabetes (26.9%) and heart failure (20.2%) (Table 2). Preoperative LOS also increases in patients’ with cardiac complications (p < 0.001), respiratory complications (p < 0.001), fever (p = 0.014) and anemia (p < 0.001). Complications that increase postoperative LOS are the postoperative cardiac (p = 0.043), respiratory (p = 0.029) and renal (p = 0.034) complications, fever (p = 0.007) and anemia (p = 0.021). Complications were developed in 28% of the patients preoperatively and in 51.8% of the patients postoperatively, which means that complication rates increase postoperatively. The most frequent complication is postoperative fever, which appears in 29.6% of the patients (Table 3). Age was correlated to the number of complications both preoperatively (p = 0.035) and postoperatively (p = 0.025). Complications correlate also with the type of patients’ co-morbidities, i.e. preoperative cardiac (p = 0.025) and renal complications (p = 0.013) which appear more frequently among patients with heart failure (Table 4). Extracapsular fractures are correlated to anemia (p = 0.008 preoperatively, p < 0.001 postoperatively).
Percentage of pre- and post-operative complications.
Complications
Preoperatively (%)
Postoperatively (%)
Urinary tract infection Pressure ulcer Respiratory complication Cardiac complication Renal complication Gastrointestinal complication Fever Embolism Blood transfusion Erythropoietin
2.0 2.4 6.3 4.7 2.4 6.3 11.1 0 9.1 2.0
2.0 4.7 10.7 12.3 3.6 11.1 29.6 0.8 14.2 3.2
*
0.032#
0.011
# * *
*
* *
*
0.093
*
0.802
0.019 0.009# 0.061 0.045# 0.376 0.413 0.288
#
0.591 0.097 0.084 0.005# 0.534
Discussion
*
0.26
0.698 0.238
* *
0.013 0.089 0.539 0.579 0.052 0.13
Post
Pre
#
Post
Post
Post
Pre
#
0.01 0.544 0.654 0.804 0.105 0.811
0.007# 0.246 0.156 0.023# 0.089 0.829
The most frequent abnormal findings included a decreased hematocrit (52.2%), indicators of poor renal function (45.1%), abnormal white blood cells count (40.3%), electrolytic disorders (29.2%) and decreased number of platelets (20.2%) (Table 5). Abnormal laboratory findings at admission correlate to the type of preoperative complications (p = 0.01), i.e. decreased hematocrit was correlated with anemia and the need for transfusion or administration of erythropoietin (p < 0.001), abnormal ECG and indicators of poor renal function were correlated with cardiac (p < 0.001) and renal complications respectively (p < 0.001).
*
#
Not convenient. Statistically significant (p < a).
0.631
0.207
0.692 0.669 * *
*
Heart failure Coronary heart disease Diabetes Malignancy without metastasis Renal failure Myocardial Infraction
* * *
*
*
0.028#
* *
0.031# 0.011# 0.464
*
0.243 0.421 * *
0.126 0.146
0.025 0.273 0.509
#
Pre Post Pre Post Pre
*
Renal Cardiac Respiratory Urinary tract infection
Complications (pre- and post-operatively)
Statistical significance (p) between co-morbidities and complications.
Co-morbidity
Table 4
*
Pulmonary embolism
Pre
Trauma infection
Post
P.P. Copanitsanou et al.
Total number of complications
210
The purpose of this study was to determine if comorbidities, complications and abnormal laboratory findings at admission have an effect on LOS and any complications during the in-hospital treatment of patients suffering from an osteoporotic hip fracture. The limitations of our study, as described above, include the subjective evaluation of patients’ BMI. During the 8-month period of the study, 253 patients with hip fracture were included and treated in the study ward, apart from all the other patients treated in the same ward (i.e. patients undergoing total arthroplasties and patients with other types of fractures). Only 29.3% of the patients were operated within the first 2 days. This percentage is far less than in other hospitals (Clague et al., 2002; Orosz et al., 2004; Siegmeth et al., 2005; Bottle and Aylin, 2006; Novack et al., 2007). In the present study LOS was 9.68 days, which is comparable to the mean LOS commonly reported (Koeck et al., 2001; Shah et al., 2005; Bottle and Aylin, 2006; Olsson et al., 2006; Gehlbach et al., 2007; Novack et al., 2007; Alvarez-Nebreda et al., 2008; Browne et al., 2009). Preoperative LOS increases especially in patients with heart failure and previous cerebrovascular accident. Thus, co-morbidities affect the timing of operation, which is in congruence with previous results (Bottle and Aylin, 2006). The overall in-hospital mortality was 1.6%, therefore comparable to some recent studies (Hirose et al., 2008; Browne et al., 2009; Kadono et al., 2010) however, less so in others (Koeck et al., 2001; Clague et al., 2002; Su et al., 2003; Shah et al., 2005; Bottle and Aylin, 2006; Alvarez-Nebreda et al., 2008; Dawson-Bowling et al., 2008; Browne et al., 2009). The main causes were cardiac failure and myocardial infarction, as expected (DawsonBowling et al., 2008; Panula et al., 2011).
Predictive factors for in-hospital stay and complications after hip fracture
211
Table 5 Percentage of abnormal laboratory findings at admission.
Conclusions
Abnormal findings at admission
Percentage
Hematocrit Indicators of renal function White blood cells Electrolytes Platelets Abnormal blood pressure Transaminases Electrocardiogram
52.2 45.1 40.3 29.2 20.2 14.2 13.4 11.1
In this study we aimed to determine whether comorbidities, complications and patients’ abnormal laboratory findings at admission have an effect on LOS and related complications during hospitalization for hip fracture treatment in a Greek hospital. We found that preoperative LOS increases in patients with heart failure and previous cerebrovascular accident, whilst only patients with chronic renal failure have both a longer preoperative and postoperative LOS. Also, LOS increases with cardiac and respiratory complications, fever and anemia. Complications correlate to the type of patients’ co-morbidities, while abnormal laboratory findings at admission are correlated to the type of preoperative complications. The results of the present study indicate that LOS, mortality and complication rates in the study hospital are comparable to the findings reported in the literature. More research is needed in order to examine the effects of predictors such as laboratory findings on treatment outcomes.
Complications developed in 28% of the patients preoperatively and in 51.8% of the patients postoperatively, which means that complication rates increase postoperatively. This percentage has been found to be higher in comparison to the findings reported in some studies (Shah et al., 2005; Olsson et al., 2006), whilst lower than in other studies (Vida ´n et al., 2005), and can be attributed to a more detailed recording of the complications in the present study. Indeed, the individual rates for each complication are comparable to the international findings, i.e. the percentage of thromboembolism is only 0.8%, which is very low (Gerkens et al., 2010). Complications correlate with the type of patients’ co-morbidities, as expected. From all demographic factors only age was correlated to the number of complications. In some studies females had a higher complication rate compared to males (Suckel et al., 2007), while in other studies men had an increased risk of mortality (Gdalevich et al., 2004; Orosz et al., 2004; Shah et al., 2005). Abnormal laboratory findings at admission were correlated to preoperative complications. However, due to their correlation with the complications they could have an indirect effect on LOS. In the literature there is a lack of studies that refer to the correlation between abnormal laboratory findings at admission and outcomes, which may represent a subject for further investigation. In the only relevant study found, patients having abnormal laboratory findings had a longer LOS (Orosz et al., 2004). Laboratory findings that have been correlated to outcomes after a hip fracture are serum albumin level, total lymphocyte count (Koval et al., 1999; Symeonidis and Clark, 2006) and C-reactive protein (Beloosesky et al., 2004). More research is needed in order to examine the effects of laboratory findings on outcomes.
Conflict of interest statement Neither personal nor institutional financial support was provided for the needs of the present survey.
Funding source No funding was obtained for this study.
Ethical approval The present study was approved by the ethical board of the National and Kapodistrian University of Athens.
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