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Hip fractures in the Royal Victoria Hospital, Belfast: A 15-year experience for hip fractures from a regional trauma centre
Mrs Julie Craig (Orthopaedic Specialty Doctor), Mrs Sinead McDonald (Fracture Outcomes Research Database), Dr Gary Heyburn (Consultant Ortho-physician), Mr R John Barr (Consultant Orthopaedic Surgeon)
Royal Victoria Hospital, Belfast
Background• The Royal Victoria Hospital (RVH) in Belfast received 865 –
1066 hip fracture admission per year in from 2000-2015 • The Fracture Outcomes Research Database (FORD) was
created 16 years ago for collection of inpatient fracture data.
Low 30-Day mortality rate • The UK National Hip Fracture Database (NHFD) identified
RVH as the sole ”‘outlier’ – with mortality below the lower 99.8% limit” [1] for hip fracture admissions in 2014 (Figure 1).
• ‘In 2014 the crude mortality rate (4.4%) & adjusted rate (3.9%) for this unit lay well below the 7.5% average for the NHFD.’ [1]
• Mortality rates have been independently verified by Business Services Organisation.
Aim• The aim was to review demographic and clinical factors which may have
contributed to these low mortality rates and their gradual improvement over several years.
Results Improvements not attributable to lower ASA or ASA grades: • Increasing mean patient age (now 60% aged 80 or over – Figure 2). • Increasing mean ASA (now 54% ASA Grade 3 and 26% ASA 4 – Figure 3). Improvements not attributable to ‘easier operations’: • Increasing numbers of more complex procedures such as IM nails and THR
(Figure 4). Improved compliance with evidence-based guidance has occurred (e.g. NICE guidelines [2] and AAGBI guidelines [3]) • Cemented hemiarthoplasty is used in almost 75% of displaced intracapsular
fractures (Figure 5). • The rate of THR for eligible patients (25%) has been close to the NHFD average. • All arthroplasty is cemented, with routine use of the AAGBI guidelines on
reducing the risk from cemented hemiarthroplasty [3]. • Over 75% of ‘simple’ extracapsular fractures are treated with a DHS, & the rest
with IM nails (Figure 6). • IM nails are now used for 94% of subtrochanteric fractures (Figure 7) .
• Good adherence to other points of NICE guidance has been routinely implemented (Figure 8).
• Time to theatre remains an issue, with most patients waiting around two days for surgery, of which over 80% is RVH inpatient waiting time (Figure 9).
• RVH is subject to UK Department of Health 48-hour targets. • The Best Practice Tariff funding criteria (not available in Northern Ireland)
require surgery to occur on the day of admission or the following day. • Considering 36 hours as more comparable this, only 26% of RVH patients
were operated on within 36 hours in 2014 (Figure 10). • Mortality rates for the first 30 days, and for 1 year, are low and have been
gradually improving (Figure 11).
• The highest mortality rate occurs in the very small number of patients (<2%) who cannot be medically optimised to allow surgery (shown in orange in Figure 12 ).
• However, mortality rates have been low for operated patients of all ASA grades. • 30-day mortality rates rise with ASA, but recent results have been improved in
comparison with the average since 2000 (stated as ‘overall’ in Figure 13).
• While we are striving to improve waiting times and don’t for a moment condone delays, we have observed that patients who had to wait over 36 hours had a better 30-day survival rate than those operated on within 36 hours (Figure 14).
• This is difficult to explain but it is probably due to our high level of ortho-physician care (Figure 15).
• It is our view that our key strength is our multidiscliplinary team work in the best interests of each patient.
Conclusion RVH displays low 30-day mortality rates despite delays to theatre, seemingly due to: • Rationalisation of treatment according to evidence and guidelines • High level of ortho-physician input and, • Multi-disciplinary co-operation.
With special thanks to the staff of the Fracture Outcomes Research Database (FORD), Mr J Elliott & Dr T Beringer
[1] Royal College of Physicians. National Hip Fracture Database mortality supplement 2016. London: RCP, 2016.
[2] National Clinical Guideline Centre. The Management of Hip Fracture in Adults. London: National Clinical Guideline Centre, 2011. www.nice.org.uk/guidance/cg124
[3] Association of Anaesthetists of Great Britain and Ireland. Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015. Anaesthesia 2015, 70, 623–626.
Method • The Fracture Outcomes Research
Database supplied data for 15,345 hip fracture patients admitted to RVH between 2000 & 2015, including inpatient data and telephone follow-up data (for 30 days, 120 days, and 1 year excluding patients in 2015).
• No age-groups were excluded.
0%
20%
40%
60%
80%
100%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
90 & over80s70s60sUnder 60
Age Profile Figure 2
0%10%20%30%40%50%60%70%80%90%
100%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Non-operative
ASA 5
ASA 4
ASA 3
ASA 2
ASA 1
ASA Profile Figure 3
Funnell plot of crude and adjusted mortality rates within 30 days (2014) Figure 1
0%20%40%60%80%
100%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
THROtherInt. fix.IM nailHemi.DHS
Types of operations Figure 4
0%20%40%60%80%
100%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
THROtherInt. fix.IM nailHemi.DHS
Treatment of displaced I/C fractures Figure 5
0%10%20%30%40%50%60%70%80%90%
100%
2000
2001
2002
2003
2004
2005
2006
2007
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2009
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2015
Cons.Other operationsIM nailDHS
Treatment of ‘simple’ E/C fractures Figure 6
Other NICE compliance
Other NICE recommendations RVHSurgery on day of/day after admission
45% within 36 hr in 2015
Planned trauma list Standard
Aim to FWB immediately Standard
Stem of proven design Standard
Cement in arthroplasty Standard
Anterolat. approach Standard
Figure 8
0%
20%
40%
60%
80%
100%
2000
2002
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2014
Over 36 hrWithin 36 hr
Operations within 36 hours Figure 10
0.010.020.030.040.050.060.070.080.090.0
100.0
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Perc
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ASA 2
ASA 3
ASA 4
Non-operative
30 Day mortality rate & ASA Figure 12
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20.0
ASA 1ASA 2ASA 3ASA 4ASA 5
Perc
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Overall2014
Recent & overall 30-day mortality risk of operated patients
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ASA 1ASA 2ASA 3ASA 4ASA 5
Perc
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Overall2014
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Perc
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Overall2014
Figure 13
0.0
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4.0
6.0
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2011 2012 2013 2014 2015
Within 36 hrOver 36 hr
30-day mortality & 36-hour delay (2011-2015) Figure 14 Hours of ortho-physician input Figure 15
Mean cumulative time to operation
0.0
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Admission to operationPresentation to admission
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Admission to operationPresentation to admission
Figure 9
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15Ti
me
inte
rval
(day
s)
Admission to operationPresentation to admission
0.05.0
10.015.020.025.030.0
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Perc
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121-365 days31-120 days</= 30 days
Combined mortality rates Figure 11
0.05.0
10.015.020.025.030.0
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Perc
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121-365 days31-120 days</= 30 days
Treatment of subtrochanteric fractures
0%
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80%
100%
2000
2001
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2015
Cons.Other operationsIM nailDHS
Figure 7
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2000
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Cons.Other operationsIM nailDHS