key: cord-0846174-ih7zl0gd
authors: Sheikh Saleem, Jawaad; Ali Fazal, Muhammad
title: Fragility hip fractures in the COVID-19 pandemic – a local experience in the United Kingdom
date: 2020-08-25
journal: Int J Orthop Trauma Nurs
DOI: 10.1016/j.ijotn.2020.100817
sha: b6795bd0c62eb3d38afad7120a0ef9cbd5fe2cb9
doc_id: 846174
cord_uid: ih7zl0gd

BACKGROUND: Fragility hip fractures are a major cause of morbidity and mortality in the UK. The 2019 novel coronavirus disease (COVID-19) pandemic led to restrictions on trauma services in several hospitals with potential operating delays and unintended negative outcomes. This local study describes the impact of operative pathway changes on clinical outcomes of patients undergoing fragility hip fracture fixation during the COVID-19 pandemic. METHODS: A single centre, retrospective analysis was performed for all patients who presented with fragility hip fractures for operative management between the 23(rd) March and 29(th) April 2020. RESULTS: 34 patients met the inclusion criteria for analysis. The median patient age was 88 years old, with a median inpatient stay of 8 days. Three patients died prior to being operated on. 48% of patients were operated on within 36 hours. The 30 day all-cause mortality from the date of presentation of injury was 20%. DISCUSSION: Our study demonstrates that the pandemic and changes to operating pathways has had a sizeable impact on the hip fracture service with delays in surgery and an increase in the 30 day mortality. These disruptions to surgical operating systems are likely to continue, with potential ongoing unintended negative consequences as demonstrated in this study. We believe that a focus on solving logistical issues including availability of sufficient operating theatre capacity, redeployment of staff, early multidisciplinary input and counselling patients on the increased outcome risks will help to mitigate risks posed to this vulnerable patient population during these periods.

with potential operating delays and unintended negative outcomes. This local study describes the 7 impact of operative pathway changes on clinical outcomes of patients undergoing fragility hip 8 fracture fixation during the COVID-19 pandemic. 9

Methods 10 A single centre, retrospective analysis was performed for all patients who presented with fragility hip 11 fractures for operative management between the 23 rd March and 29 th April 2020. 12

Results 13 34 patients met the inclusion criteria for analysis. The median patient age was 88 years old, with a 14 median inpatient stay of 8 days. Three patients died prior to being operated on. 48% of patients 15 were operated on within 36 hours. The 30 day all-cause mortality from the date of presentation of 16 injury was 20%. 17

Our study demonstrates that the pandemic and changes to operating pathways has had a sizeable 19 impact on the hip fracture service with delays in surgery and an increase in the 30 day mortality. 20

These disruptions to surgical operating systems are likely to continue, with potential ongoing 21 unintended negative consequences as demonstrated in this study. We believe that a focus on solving 22 logistical issues including availability of sufficient operating theatre capacity, redeployment of staff, 23 early multidisciplinary input and counselling patients on the increased outcome risks will help to 24 Patients would be initially admitted at the presenting hospital and either transferred directly from 67 the emergency department or admitted briefly for pain control and stabilisation before transfer. This 68 would occur during daytime working hours. Post-operatively, patients would be discharged to their 69 J o u r n a l P r e -p r o o f residence or back to the initial admitting hospital for ongoing management on a COVID-free ward. 70

The arrangement would enable the operative hospital to stay COVID-19 free without inhibiting its 71 operating capacity. This operative pathway change was challenging as patient transfers are complex 72 undertakings, with a referral needing to take place between orthopaedic teams conditional on 73 acceptable imaging and investigations as well as bed manager liaison and the ensuring of adequate 74 transport being available. This could potentially increase times to surgery as well as increase the 75 overall admission time period for these patients. Fragility fractures are a significant injury and 76 therefore delays to surgery could adversely affect morbidity and mortality outcomes. analysis. The median patient age was 88 years old, with 10 (29%) of patients being male. All patients 120 included had at least one comorbidity, with the most common being hypertension (53%), long term 121 cognitive impairment (32%) and cardiovascular disease (29%). Right sided fractures comprised 50% 122 of fractures and 65% of fractures were intracapsular. Table 1 (Stahel 2020) .With the ongoing disturbance to the pathways, we 146 would advise on being aware of the logistical issues delaying the management of these patients and 147 determine appropriate measures to rectify this . The need for cross-site management, re-patriation 148 and delays to surgery present difficulties for multi-disciplinary teams to assess patients; we would 149 advise allocating specific discharge planning teams to focus on streamlining the admission pathways 150 for hip fragility fractures. Also noted is the redeployment of trauma and orthopaedic nurses to other 151 specialities; hip fragility fracture patients require intensive nursing and the increased risks 152 highlighted by this study emphasise the need for management by dedicated nursing staff. 153

Additionally robust early ortho geriatrician input in the perioperative period is vital in improving the 154 management of a multi comorbid population; this has proved to be of significant benefit in 155 improving patient outcomes. (Middleton et al. 2016 ) Moreover, our data shows that in this 156 particularly 'high risk' period it may be wise to counsel and consent patients and families with 157 emphasis on the increased risks of morbidity and mortality related to both the pandemic and these 158 operative delays. 159

Our study does have limitations. These include our small sample size which may have contributed to 160 our outcome data not achieving statistical significance; we envision more data from other hospital 161 trusts would help to expand on our findings. Another limitation included the lack of documentation 162 found in the repatriated data, we were only able to ascertain discharge summaries and operation 163 notes. Therefore, accurately identifying the events leading up to and the cause of death was difficult. 164 prevent management delays, a focus on solving the logistical issues relating to multi centre 179 management pathways is crucial. Furthermore, staff deployment must be an absolute priority for 180 the hip fracture service along with provision of hip fracture operating lists in accordance with 181 relative hip fracture workload. In addition, we believe that senior anaesthetic and surgeon led 182 operating lists, rapid COVID swab testing for patients, appropriate trauma theatre staffing, ward care 183 led by specialist hip fracture nurses, early ortho-geriatrician input in the perioperative setting, and a 184 dedicated rehabilitation team to enable early discharge from hospital would be essential in 185 improving outcomes and deliver a safe service. We also advise to counsel patients and relatives on 186 the increased mortality risks during the COVID-19 pandemic as a part of informed consent to help 187 increase awareness of the hazards of operating in this period. We believe that the multidisciplinary 188 input as outlined above will ensure safe and effective care for this vulnerable group of patients. 

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