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 0.0001). 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
– –
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 0.0001). 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
– –
