G Model
JINJ-6602; No. of Pages 6 Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial Glenn Larsson a,b,*, Rn Ulf Stro¨mberg c,d, Cecilia Rogmark b,e, Anna Nilsdotter b,f a
Department of Ambulance and Prehospital Care, Region Halland, Sweden Department of Orthopaedics, Lund University, Sweden Department of R&D, Region Halland, Sweden d Department of Cancer Epidemiology, Lund University, Sweden e Skane University Hospital, Malmo¨, Sweden f Department of R&D, Sahlgrenska University Hospital,Go¨teborg, Sweden b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 31 January 2016
Introduction: Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality. Methods: The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group). Results: Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p < 0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p = 0.07); proportion operated within 24 h (79% PFTC, 75% A&E; p = 0.34); length of stay (p = 0.34); post-operative complications (p = 0.75); and 4 month mortality (18% PFTC, 15% A&E p = 0.58). Conclusion: PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded. ß 2016 Elsevier Ltd. All rights reserved.
Keywords: Hip fracture Prehospital fast track care A&E Time to surgery Randomised, Controlled trial
Introduction Elderly patients with hip fractures due to a low-energy trauma are common in ambulance and emergency care. In Sweden the yearly incidence is around 18,000 patients (mean age over 80 years) and the number is increasing [1]. This group of patients
* Corresponding author at: Department of Ambulance and Prehospital Care, Region Halland, Nyhems vc, 302 49 Halmstad, Sweden. Tel.: +46 708436467. E-mail address: [email protected] (G. Larsson).
is one of the most challenging for the healthcare system, considering total care. Patients with hip fractures require surgery and subsequent care in orthopaedic wards [1]. Pre- and postoperative complications associated with hip fractures are common and cause longer hospital stay, increased mortality and suffering for the patients [2,3]. Several studies describe the importance of a short waiting time from hospital admission to surgery [4–8]. Some studies support the conclusion that a waiting time under 24 h reduces postoperative complications, length of stay and mortality [9,10]. Guidelines for start of surgery vary in different countries, between 24 and
http://dx.doi.org/10.1016/j.injury.2016.01.043 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 2
G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
48 h. The Swedish national guidelines recommend surgery within 24 h and quality indicators for good and safe care should focus on fast assessment to surgery [11,12]. Acute assessment starts as soon as the ambulance reaches the patient and continues during transport to hospital. The ambulance nurse takes care of the patient according to existing guidelines [13]. The standard process for ambulance commission is immediate transport to the emergency and accident ward, A&E. A patient often stays for several hours in A&E for care and assessment before transport to an orthopaedic ward for surgery [11,14]. Several studies show various advantages in introducing fast track systems in A&E [14–18]. During the last decade, registered nurses have participated in ambulance care and a majority of Swedish ambulance and hospital organisations have implemented prehospital fast track care pathways, in order to improve hip fracture care [19–22]. This means that the ambulance nurse starts the pre-operative procedure actually in the ambulance and leaves the patient at the radiology department instead of the A&E. When the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. The aim of this study was to compare prehospital fast track care and transport with the A&E pathway, using a randomised, controlled design and focusing on the following patient outcomes: time to radiographic investigation, time to surgery, post-operative complications, length of stay at the hospital and mortality. The assumed advantages of fast track pathways for patients with hip fractures have not been sufficiently studied. This seems actually to be the first randomised, controlled study on this subject, since to date no other studies have been published. Patients and methods This prehospital randomised, controlled study was carried out between July 2012 and May 2014 at the ambulance and hospital organisation in the Region of Halland, Southwestern Sweden (total population 300,000 at the end of 2013; 22% aged 65 years). The Region of Halland has two emergency hospitals. Eligible patients were cared for in the ambulance after a low-energy trauma with a suspected hip fracture (for specific inclusion criteria, see below). The patients in the study were consecutively included by an ambulance nurse and randomised by using a closed, opaque envelope either to care in the fast track programme or to the traditional care pathway with transport to A&E. Patients in the study All the patients in the study were treated following the ambulance organisation’s guidelines, using pain treatment, oxygen therapy and intravenous liquid substitution. The rapid emergency triage and treatment system (RETTS) was used. The RETTS is a triage and priority model, consisting of two parts that in combination result in a priority assessment of the patients. It is based on vital signs and the emergency symptoms and signs (ESS) code depending on the reason the patient called for help. Objective vital signs including blood pressure, oxygen saturation, breathing frequency, heart rate, body temperature and degree of consciousness result in a triage colour: red, orange, yellow or green. Red means life-threatening condition, orange means possible life-threatening condition, yellow means not a lifethreatening condition but requiring emergency hospital care and green means no requirement for any limitation on waiting time [23]. Only healthier patients who were triaged by RETTS as yellow or green were considered for inclusion. Specific parameters for yellow or green are: Saturation > 90% without oxygen, respiratory rate 8–25, pulse 40, alert or sudden signs
of des orientations, body temp >35 or 24 h, post-operative complications, in-hospital and 4 month mortality). We also compared the patient outcomes between PFTC and A&E for subgroups of patients according to age (85, >85 years), ASA [1,2], [3,4], dementia, type of fracture (femoral neck, trochanteric, subtrochanteric) and warfarin use. P-values less than 5% were regarded as significant. IBM SPSS 20.0.2 was used for the statistical analyses. Results During the study period, 1,198 patients with suspected hip fracture were treated in the ambulance organisation. In these, 627 of those were excluded, 215 for not meeting inclusion criteria, 156 for not giving consent and 256 for not being asked about participation.
3
A total of 571 were included and randomised, 292 to PFTC and 279 to A&E. After the exclusion of 97 and 74 non-fracture patients respectively, 400 patients were analysed, 195 from PFTC and 205 from AE&E (Fig. 1). The PFTC and A&E groups did not differ significantly in gender, age, ASA, dementia or fracture type (Table 1). Regarding the lead times, we verified significant difference in mean time from arrival at hospital to start of X-ray, quantified as a mean difference of 118 (95% confidence interval, CI: 103 to 132) minutes in favour of PTFC compared to the A&E (P < 0.001, Table 2, Fig. 2). There was a non-significant (P = 0.07) difference in times from arrival at hospital to start of surgery with a mean difference of 1.85 (95% CI: –0.12 to 3.82) hours in favour of PTFC (Table 2, Fig. 3). However, there was no difference in times between start of X-ray to start of surgery (Table 2, Fig. 4). No significant differences between PTFC and A&E were observed for the following outcomes: surgery within 24 h; length of stay at the hospital; post-operative complications; in-hospital and 4 month mortality. This was true for all the patients in the study (Table 2) and also for the subgroups of patients considered (data not shown). Discussion The main finding of this study is that hip fracture patients with prehospital fast track care pathway, as compared to transport to A&E, did not have more favourable outcomes regarding time to surgery, hospital stay, post-operative complications and mortality, despite their receiving faster radiographic examination. To avoid unnecessary delay and inappropriate care for these patients at A&E, many ambulance and hospital organisations have introduced prehospital fast track care [19–22]. The national recommendation is surgery within 24 h from arriving at the hospital. Our findings showed that a majority of patients in both groups were operated according to the national guidelines [11], regardless of the PFTC or the standard process via A&E. Additional data confirms that the
1,198 suspected hip fractures in ambulance care
Excluded n=627 Not meeting inclusion criteria n=215 Declined to participate n=156 Other reasons n=256
Randomized n=571
Allocation Prehospital Fast Track Care Allocated to fast track n=292 No fracture n=97 Received allocated intervention n=195 Fracture and surgery
A&E Allocated to accident and emergency department n=279 No fracture n=74 Received allocated intervention n=205 Fracture and surgery
Analysis Analyzed n=195
Analyzed n=205 Fig. 1. Flow of patients in the study.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
4
Table 1 Characteristics of the patients for prehospital fast track care (PFTC) and accident & emergency (A&E). PFTC (n = 195) Men (n) Women (n) Age Mean (year) Median Min–max ASA (n) 1–2 3–4 Dementia (n) Fracture (n) Femoral neck Trochanteric Sub trochanteric
A&E (n = 205)
P value
63 132
70 135
0.39
83 85 53–103
82 83 50–99
0.12
110 85 37
118 87 36
0.12
110 72 13
97 85 23
0.11
0.80
time from radiographic examination to start of surgery was equal between the groups. Accordingly, start of surgery depends mainly on how the pre-operative process is handled in the hospital after the patients arrive at the ward and not on measures implemented by the ambulance organisations. Long waiting times for elderly patients in A&E constitute a big problem with subsequent inappropriate care [24]. A fast decision for admission to a ward may prevent complications which otherwise lead to reduced quality of life and increased healthcare costs [24,25]. The main advantages for the patients with hip fractures and PFTC are probably a/avoiding waiting times at A&E, b/almost 2 hours reduced waiting time to X-ray, and c/direct admission to an orthopaedic ward for further preparation before surgery. Previous studies show different results, but the most common outcomes are reduced time to X-ray and admission to a ward [20–22]. Less or no waiting times at A&E frees more time for other patient groups, giving rise to greater numbers of satisfied patients. Direct admission to a ward without any waiting time at A&E means less frustration and mental and physical suffering from a patient and relative perspective.
Another benefit is that PFTC creates the option of an early start for surgery. One study reports that patients experience efficiency and rational care with this pathway [19]. There are prehospital pathways for other patient groups who need hospital care. Advantages for these patients are similar to our findings, with reduced waiting time at A&E and direct admission to a ward for further treatment [26,27]. To avoid the process stopping when the patients arrive at the ward, hospitals need to be better organised and give these patients higher priority in the surgery programme. Higher priority might improve the routine for start of surgery. Surgery should start at least within 24 h, and not only on humanitarian grounds. But as evolving evidence supports urgent surgery, this attitude may shift in the near future [10,28]. Some authors suggest early and ultra early surgery, within 12 h. With an even earlier start of surgery it might be possible to reduce length of stay, post-operative complications and mortality compared with current levels. In a context where demands on efficient healthcare are increasing and development of new prehospital fast tracks will probably be introduced for other patient groups, ambulance care must be integrated with the healthcare system in a more efficient way. Otherwise there is an obvious risk that healthcare resources will continue to be suboptimally used. Strengths and limitations In addition to other prehospital observational studies for patients with hip fracture [20–22], this is the first randomised, controlled study to investigate PFTC compared with a standard process via A&E. The number of patients is relatively large and evenly distributed, controlled and prospectively followed. Our results are generalisable to healthcare systems with the same organisation as ours, i.e. direct transfer from home to both primary and definitive treatment in the same emergency hospital. One limitation of the study is a possible selection bias caused by some participants not having given their informed consent and by other patients who did fulfil the inclusion criteria nevertheless not
Table 2 Comparisons of patient outcomes between Prehospital fast track care (PFTC) and Accident & Emergency (A&E). PFTC (n = 195)
A&E (n = 205)
Mean difference
CI (95%)
P value
Mean (minutes) Median Min–max Time from arrival to start of surgery
27.57 21 4–203
145.36 118 15–781
–117.78
–132.19, –103.38
0.00
Mean (hours) Median Min–max Time from start of X-ray to start of surgery
18.90 18 3–53
20.76 20 1–65
–1.85
–3.83, 0.12
0.07
Mean (hours) Surgery within 24 h (n) Length of stay in hospital
18.40 154 (79%)
18.40 153 (75%)
0.00
–1.98, 1.98
1.00 0.34
Mean (days) Min–max Post-operative complications(n) Pneumonia Pressure ulcers UVI Infection Mortality (n) In hospital After 4 months
9.71 1–28 64 9 20 14 6
9.29 2–40 71 9 24 19 5
0.42
–0.45, 1.29
0.34
9 (5%) 35 (18%)
6 (3%) 30 (15%)
Time from arrival to start of X-ray,
0.75
0.35 0.58
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
5
The sample size was 200 patients in each group but only 195 patients were included in PFTC, and the additional 5 patients might have resulted in a significant finding on lead time from arrival in hospital to start of surgery. The potential selection bias hampers the generalisability of the results, but thanks to the randomised design it does not affect the validity of the group comparisons for the patients included. Conclusion
Fig. 2. Time from arrival to start of X-ray.
In this first randomised, controlled study with prehospital fast track care, patients with a hip fracture avoided unnecessary delays at the emergency department and were given fast radiographic examination and direct admission to a ward. However, in our study this pathway does not have any impact on time to start of surgery, length of stay, post-operative complications or mortality. These outcomes seem to be affected by other factors at hospitals. The result should be seen in the light of the fact that most of the patients in the control group also underwent surgery within 24 h. The occurrence of any other favourable outcomes of PFTC, such as patient satisfaction, will be studied in future projects. 1. Flow chart of patients in the study 2. Bar chart, from arrival at hospital to start of X-ray (minutes). The dotted line indicates mean time and the solid line indicates median time. 3. Bar chart, from arrival at hospital to start of surgery (hours). The dotted line indicates mean time and the solid line indicates median time. 4. Bar chart, from arrival at X-ray to start of surgery (hours). The mean time and median time were equal between the groups as indicated by the solid line. Conflict of interest There are no conflict of interest. Acknowledgements
Fig. 3. Time from arrival to start of surgery.
This study has been funded by the Department of Prehospital Care and the Scientific Council of Region Halland. References
Fig. 4. Time from start of X-ray to start of surgery.
being included. This may partly be explained by the fact that initially there was considerable scepticism amongst ambulance nurses towards assigning patients to the older A&E pathway, since PFTC was considered the gold standard of the moment.
[1] Thorngren K. Riksho¨ft. A˚rsrapport 2013. www.rikshoft.se. 2014(ISBN 978-91980722-9-7). [2] Vestergaard P, Rejnmark L, Moskilde L. Increased mortality in patients with a hip fracture-effect of pre-mobid conditions and post-fracture complications; 2007;18. [3] Lindgren U, Svensson O. Ortopedi. Falko¨ping: Liber AB; 2004. [4] Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes?. A multicenter survey. Int J Qual Health Care 2007;19(June (3)):170–6. [5] Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ 2006;332(April (7547)):947–51. [6] Westberg M, Snorrason F, Frihagen F. Preoperative waiting time increased the risk of periprosthetic infection in patients with femoral neck fracture. Acta Orthop 2013;84(April (2)):124–9. [7] Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury 2009;40(7):692–7. [8] Hamish C, Harris IA, Mcevoy L, Todorva T. Delay to surgery and mortality after hip fracture. ANZ J Surg 2007;77:889–91. [9] Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H, Thorngren KG. Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury 2008;39(October (10)):1164–74. [10] Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury 2013;44(June (6)):726–9. [11] Sverige, Socialstyrelsen. Socialstyrelsens riktlinjer fo¨r va˚rd och behandling av ho¨ftfraktur. Stockholm: socialstyr; 2003.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 6
G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
¨ ppna ja¨mfo¨relser [12] Sverige, Socialstyrelsen. Sveriges kommuner och landsting O 2013. Ha¨lso- och sjukva˚rd: ja¨mfo¨relser mellan landsting. Stockholm: sveriges kommuner och landsting: socialstyrelsen; 2012. [13] Suserud B, Svensson L. Prehospital akutsjukva˚rd 1 uppl ed.. Stockholm: Liber; 2009. [14] Taylor R, Nairn S. Audit of standards of practice in suspected hip fracture. Int Emerg Nurs 2012;20(4):236–42. [15] Pedersen SJ, Borgbjerg FM, Schousboe B, Pedersen BD, Jorgensen HL, Duus BR, et al. A comprehensive hip fracture program reduces complication rates and mortality. J146?Am Geriatr Soc 2008;56(October (10)):1831–8. [16] Egerod I, Rud K, Specht K, Jensen PS, Trangbaek A, Ronfelt I, et al. Room for improvement in the treatment of hip fractures in Denmark. Dan Med Bull 2010;57(December (1)):A4199. [17] Hommel A, Ulander K, Thorngren KG. Improvements in pain relief, handling time and pressure ulcers through internal audits of hip fracture patients. Scand J Caring Sci 2003;17(March (1)):78–83. [18] Ryan J, Ghani M, Staniforth P, Bryant G, Edwards S. Fast tracking’’ patients with a proximal femoral fracture. J Accid Emerg Med 1996;13(2):108–10. [19] Aronsson K, Bjorkdahl I, Wireklint Sundstrom B. Prehospital emergency care for patients with suspected hip fractures after falling - older patients’ experiences. J Clin Nurs 2014;23(November (21–22)):3115–23. [20] Eriksson M, Kelly-Pettersson P, Stark A, Ekman AK, Skoldenberg O. ‘Straight to bed’ for hip-fracture patients: a prospective observational cohort study of two fast-track systems in 415 hips. Injury 2012;43(December (12)): 2126–31.
[21] Larsson G, Holgers KM. Fast-track care for patients with suspected hip fracture. Injury 2011;42(November (11)):1257–61. [22] Turesson E, Ivarsson K, Ekelund K, Hommel A. The implementation of a fast track care pathway for hip fracture patients. Eur Orthop Traumatol 2012;3: 195–203. [23] Widgren BR, Jourak M. Medical Emergency Triage and Treatment System (METTS): a new protocol in primary triage and secondary priority decision in emergency medicine. J Emerg Med 2011;40(June (6)):623–8. [24] Socialstyrelsen. Hur tas a¨ldre om hand pa˚ akutmottagning. En nationell verksamhetstillsyn 2006. 2006-109-20. [25] Bjorkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study. Acta Anaesthesiol Scand 2010;54(July (6)):678–88. [26] Vicente V, Svensson L, Wireklint Sundstrom B, Sjostrand F, Castren M. Randomized controlled trial of a prehospital decision system by emergency medical services to ensure optimal treatment for older adults in Sweden. J Am Geriatr Soc 2014;62(July (7)):1281–7. [27] Wennman I, Klittermark P, Herlitz J, Lernfelt B, Kihlgren M, Gustafsson C, et al. The clinical consequences of a pre-hospital diagnosis of stroke by the emergency medical service system. A pilot study. Scand J Trauma Resusc Emerg Med 2012;20(July):48–7241. [28] Smektala R, Endres HG, Dasch B, Maier C, Trampisch HJ, Bonnaire F, et al. The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures. BMC Musculoskelet Disord 2008;9(December). 1712474-9-171.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
JINJ-6602; No. of Pages 6 Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial Glenn Larsson a,b,*, Rn Ulf Stro¨mberg c,d, Cecilia Rogmark b,e, Anna Nilsdotter b,f a
Department of Ambulance and Prehospital Care, Region Halland, Sweden Department of Orthopaedics, Lund University, Sweden Department of R&D, Region Halland, Sweden d Department of Cancer Epidemiology, Lund University, Sweden e Skane University Hospital, Malmo¨, Sweden f Department of R&D, Sahlgrenska University Hospital,Go¨teborg, Sweden b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 31 January 2016
Introduction: Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality. Methods: The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group). Results: Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p < 0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p = 0.07); proportion operated within 24 h (79% PFTC, 75% A&E; p = 0.34); length of stay (p = 0.34); post-operative complications (p = 0.75); and 4 month mortality (18% PFTC, 15% A&E p = 0.58). Conclusion: PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded. ß 2016 Elsevier Ltd. All rights reserved.
Keywords: Hip fracture Prehospital fast track care A&E Time to surgery Randomised, Controlled trial
Introduction Elderly patients with hip fractures due to a low-energy trauma are common in ambulance and emergency care. In Sweden the yearly incidence is around 18,000 patients (mean age over 80 years) and the number is increasing [1]. This group of patients
* Corresponding author at: Department of Ambulance and Prehospital Care, Region Halland, Nyhems vc, 302 49 Halmstad, Sweden. Tel.: +46 708436467. E-mail address: [email protected] (G. Larsson).
is one of the most challenging for the healthcare system, considering total care. Patients with hip fractures require surgery and subsequent care in orthopaedic wards [1]. Pre- and postoperative complications associated with hip fractures are common and cause longer hospital stay, increased mortality and suffering for the patients [2,3]. Several studies describe the importance of a short waiting time from hospital admission to surgery [4–8]. Some studies support the conclusion that a waiting time under 24 h reduces postoperative complications, length of stay and mortality [9,10]. Guidelines for start of surgery vary in different countries, between 24 and
http://dx.doi.org/10.1016/j.injury.2016.01.043 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 2
G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
48 h. The Swedish national guidelines recommend surgery within 24 h and quality indicators for good and safe care should focus on fast assessment to surgery [11,12]. Acute assessment starts as soon as the ambulance reaches the patient and continues during transport to hospital. The ambulance nurse takes care of the patient according to existing guidelines [13]. The standard process for ambulance commission is immediate transport to the emergency and accident ward, A&E. A patient often stays for several hours in A&E for care and assessment before transport to an orthopaedic ward for surgery [11,14]. Several studies show various advantages in introducing fast track systems in A&E [14–18]. During the last decade, registered nurses have participated in ambulance care and a majority of Swedish ambulance and hospital organisations have implemented prehospital fast track care pathways, in order to improve hip fracture care [19–22]. This means that the ambulance nurse starts the pre-operative procedure actually in the ambulance and leaves the patient at the radiology department instead of the A&E. When the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. The aim of this study was to compare prehospital fast track care and transport with the A&E pathway, using a randomised, controlled design and focusing on the following patient outcomes: time to radiographic investigation, time to surgery, post-operative complications, length of stay at the hospital and mortality. The assumed advantages of fast track pathways for patients with hip fractures have not been sufficiently studied. This seems actually to be the first randomised, controlled study on this subject, since to date no other studies have been published. Patients and methods This prehospital randomised, controlled study was carried out between July 2012 and May 2014 at the ambulance and hospital organisation in the Region of Halland, Southwestern Sweden (total population 300,000 at the end of 2013; 22% aged 65 years). The Region of Halland has two emergency hospitals. Eligible patients were cared for in the ambulance after a low-energy trauma with a suspected hip fracture (for specific inclusion criteria, see below). The patients in the study were consecutively included by an ambulance nurse and randomised by using a closed, opaque envelope either to care in the fast track programme or to the traditional care pathway with transport to A&E. Patients in the study All the patients in the study were treated following the ambulance organisation’s guidelines, using pain treatment, oxygen therapy and intravenous liquid substitution. The rapid emergency triage and treatment system (RETTS) was used. The RETTS is a triage and priority model, consisting of two parts that in combination result in a priority assessment of the patients. It is based on vital signs and the emergency symptoms and signs (ESS) code depending on the reason the patient called for help. Objective vital signs including blood pressure, oxygen saturation, breathing frequency, heart rate, body temperature and degree of consciousness result in a triage colour: red, orange, yellow or green. Red means life-threatening condition, orange means possible life-threatening condition, yellow means not a lifethreatening condition but requiring emergency hospital care and green means no requirement for any limitation on waiting time [23]. Only healthier patients who were triaged by RETTS as yellow or green were considered for inclusion. Specific parameters for yellow or green are: Saturation > 90% without oxygen, respiratory rate 8–25, pulse 40, alert or sudden signs
of des orientations, body temp >35 or 24 h, post-operative complications, in-hospital and 4 month mortality). We also compared the patient outcomes between PFTC and A&E for subgroups of patients according to age (85, >85 years), ASA [1,2], [3,4], dementia, type of fracture (femoral neck, trochanteric, subtrochanteric) and warfarin use. P-values less than 5% were regarded as significant. IBM SPSS 20.0.2 was used for the statistical analyses. Results During the study period, 1,198 patients with suspected hip fracture were treated in the ambulance organisation. In these, 627 of those were excluded, 215 for not meeting inclusion criteria, 156 for not giving consent and 256 for not being asked about participation.
3
A total of 571 were included and randomised, 292 to PFTC and 279 to A&E. After the exclusion of 97 and 74 non-fracture patients respectively, 400 patients were analysed, 195 from PFTC and 205 from AE&E (Fig. 1). The PFTC and A&E groups did not differ significantly in gender, age, ASA, dementia or fracture type (Table 1). Regarding the lead times, we verified significant difference in mean time from arrival at hospital to start of X-ray, quantified as a mean difference of 118 (95% confidence interval, CI: 103 to 132) minutes in favour of PTFC compared to the A&E (P < 0.001, Table 2, Fig. 2). There was a non-significant (P = 0.07) difference in times from arrival at hospital to start of surgery with a mean difference of 1.85 (95% CI: –0.12 to 3.82) hours in favour of PTFC (Table 2, Fig. 3). However, there was no difference in times between start of X-ray to start of surgery (Table 2, Fig. 4). No significant differences between PTFC and A&E were observed for the following outcomes: surgery within 24 h; length of stay at the hospital; post-operative complications; in-hospital and 4 month mortality. This was true for all the patients in the study (Table 2) and also for the subgroups of patients considered (data not shown). Discussion The main finding of this study is that hip fracture patients with prehospital fast track care pathway, as compared to transport to A&E, did not have more favourable outcomes regarding time to surgery, hospital stay, post-operative complications and mortality, despite their receiving faster radiographic examination. To avoid unnecessary delay and inappropriate care for these patients at A&E, many ambulance and hospital organisations have introduced prehospital fast track care [19–22]. The national recommendation is surgery within 24 h from arriving at the hospital. Our findings showed that a majority of patients in both groups were operated according to the national guidelines [11], regardless of the PFTC or the standard process via A&E. Additional data confirms that the
1,198 suspected hip fractures in ambulance care
Excluded n=627 Not meeting inclusion criteria n=215 Declined to participate n=156 Other reasons n=256
Randomized n=571
Allocation Prehospital Fast Track Care Allocated to fast track n=292 No fracture n=97 Received allocated intervention n=195 Fracture and surgery
A&E Allocated to accident and emergency department n=279 No fracture n=74 Received allocated intervention n=205 Fracture and surgery
Analysis Analyzed n=195
Analyzed n=205 Fig. 1. Flow of patients in the study.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
4
Table 1 Characteristics of the patients for prehospital fast track care (PFTC) and accident & emergency (A&E). PFTC (n = 195) Men (n) Women (n) Age Mean (year) Median Min–max ASA (n) 1–2 3–4 Dementia (n) Fracture (n) Femoral neck Trochanteric Sub trochanteric
A&E (n = 205)
P value
63 132
70 135
0.39
83 85 53–103
82 83 50–99
0.12
110 85 37
118 87 36
0.12
110 72 13
97 85 23
0.11
0.80
time from radiographic examination to start of surgery was equal between the groups. Accordingly, start of surgery depends mainly on how the pre-operative process is handled in the hospital after the patients arrive at the ward and not on measures implemented by the ambulance organisations. Long waiting times for elderly patients in A&E constitute a big problem with subsequent inappropriate care [24]. A fast decision for admission to a ward may prevent complications which otherwise lead to reduced quality of life and increased healthcare costs [24,25]. The main advantages for the patients with hip fractures and PFTC are probably a/avoiding waiting times at A&E, b/almost 2 hours reduced waiting time to X-ray, and c/direct admission to an orthopaedic ward for further preparation before surgery. Previous studies show different results, but the most common outcomes are reduced time to X-ray and admission to a ward [20–22]. Less or no waiting times at A&E frees more time for other patient groups, giving rise to greater numbers of satisfied patients. Direct admission to a ward without any waiting time at A&E means less frustration and mental and physical suffering from a patient and relative perspective.
Another benefit is that PFTC creates the option of an early start for surgery. One study reports that patients experience efficiency and rational care with this pathway [19]. There are prehospital pathways for other patient groups who need hospital care. Advantages for these patients are similar to our findings, with reduced waiting time at A&E and direct admission to a ward for further treatment [26,27]. To avoid the process stopping when the patients arrive at the ward, hospitals need to be better organised and give these patients higher priority in the surgery programme. Higher priority might improve the routine for start of surgery. Surgery should start at least within 24 h, and not only on humanitarian grounds. But as evolving evidence supports urgent surgery, this attitude may shift in the near future [10,28]. Some authors suggest early and ultra early surgery, within 12 h. With an even earlier start of surgery it might be possible to reduce length of stay, post-operative complications and mortality compared with current levels. In a context where demands on efficient healthcare are increasing and development of new prehospital fast tracks will probably be introduced for other patient groups, ambulance care must be integrated with the healthcare system in a more efficient way. Otherwise there is an obvious risk that healthcare resources will continue to be suboptimally used. Strengths and limitations In addition to other prehospital observational studies for patients with hip fracture [20–22], this is the first randomised, controlled study to investigate PFTC compared with a standard process via A&E. The number of patients is relatively large and evenly distributed, controlled and prospectively followed. Our results are generalisable to healthcare systems with the same organisation as ours, i.e. direct transfer from home to both primary and definitive treatment in the same emergency hospital. One limitation of the study is a possible selection bias caused by some participants not having given their informed consent and by other patients who did fulfil the inclusion criteria nevertheless not
Table 2 Comparisons of patient outcomes between Prehospital fast track care (PFTC) and Accident & Emergency (A&E). PFTC (n = 195)
A&E (n = 205)
Mean difference
CI (95%)
P value
Mean (minutes) Median Min–max Time from arrival to start of surgery
27.57 21 4–203
145.36 118 15–781
–117.78
–132.19, –103.38
0.00
Mean (hours) Median Min–max Time from start of X-ray to start of surgery
18.90 18 3–53
20.76 20 1–65
–1.85
–3.83, 0.12
0.07
Mean (hours) Surgery within 24 h (n) Length of stay in hospital
18.40 154 (79%)
18.40 153 (75%)
0.00
–1.98, 1.98
1.00 0.34
Mean (days) Min–max Post-operative complications(n) Pneumonia Pressure ulcers UVI Infection Mortality (n) In hospital After 4 months
9.71 1–28 64 9 20 14 6
9.29 2–40 71 9 24 19 5
0.42
–0.45, 1.29
0.34
9 (5%) 35 (18%)
6 (3%) 30 (15%)
Time from arrival to start of X-ray,
0.75
0.35 0.58
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
5
The sample size was 200 patients in each group but only 195 patients were included in PFTC, and the additional 5 patients might have resulted in a significant finding on lead time from arrival in hospital to start of surgery. The potential selection bias hampers the generalisability of the results, but thanks to the randomised design it does not affect the validity of the group comparisons for the patients included. Conclusion
Fig. 2. Time from arrival to start of X-ray.
In this first randomised, controlled study with prehospital fast track care, patients with a hip fracture avoided unnecessary delays at the emergency department and were given fast radiographic examination and direct admission to a ward. However, in our study this pathway does not have any impact on time to start of surgery, length of stay, post-operative complications or mortality. These outcomes seem to be affected by other factors at hospitals. The result should be seen in the light of the fact that most of the patients in the control group also underwent surgery within 24 h. The occurrence of any other favourable outcomes of PFTC, such as patient satisfaction, will be studied in future projects. 1. Flow chart of patients in the study 2. Bar chart, from arrival at hospital to start of X-ray (minutes). The dotted line indicates mean time and the solid line indicates median time. 3. Bar chart, from arrival at hospital to start of surgery (hours). The dotted line indicates mean time and the solid line indicates median time. 4. Bar chart, from arrival at X-ray to start of surgery (hours). The mean time and median time were equal between the groups as indicated by the solid line. Conflict of interest There are no conflict of interest. Acknowledgements
Fig. 3. Time from arrival to start of surgery.
This study has been funded by the Department of Prehospital Care and the Scientific Council of Region Halland. References
Fig. 4. Time from start of X-ray to start of surgery.
being included. This may partly be explained by the fact that initially there was considerable scepticism amongst ambulance nurses towards assigning patients to the older A&E pathway, since PFTC was considered the gold standard of the moment.
[1] Thorngren K. Riksho¨ft. A˚rsrapport 2013. www.rikshoft.se. 2014(ISBN 978-91980722-9-7). [2] Vestergaard P, Rejnmark L, Moskilde L. Increased mortality in patients with a hip fracture-effect of pre-mobid conditions and post-fracture complications; 2007;18. [3] Lindgren U, Svensson O. Ortopedi. Falko¨ping: Liber AB; 2004. [4] Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes?. A multicenter survey. Int J Qual Health Care 2007;19(June (3)):170–6. [5] Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ 2006;332(April (7547)):947–51. [6] Westberg M, Snorrason F, Frihagen F. Preoperative waiting time increased the risk of periprosthetic infection in patients with femoral neck fracture. Acta Orthop 2013;84(April (2)):124–9. [7] Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury 2009;40(7):692–7. [8] Hamish C, Harris IA, Mcevoy L, Todorva T. Delay to surgery and mortality after hip fracture. ANZ J Surg 2007;77:889–91. [9] Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H, Thorngren KG. Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury 2008;39(October (10)):1164–74. [10] Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury 2013;44(June (6)):726–9. [11] Sverige, Socialstyrelsen. Socialstyrelsens riktlinjer fo¨r va˚rd och behandling av ho¨ftfraktur. Stockholm: socialstyr; 2003.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
G Model
JINJ-6602; No. of Pages 6 6
G. Larsson et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
¨ ppna ja¨mfo¨relser [12] Sverige, Socialstyrelsen. Sveriges kommuner och landsting O 2013. Ha¨lso- och sjukva˚rd: ja¨mfo¨relser mellan landsting. Stockholm: sveriges kommuner och landsting: socialstyrelsen; 2012. [13] Suserud B, Svensson L. Prehospital akutsjukva˚rd 1 uppl ed.. Stockholm: Liber; 2009. [14] Taylor R, Nairn S. Audit of standards of practice in suspected hip fracture. Int Emerg Nurs 2012;20(4):236–42. [15] Pedersen SJ, Borgbjerg FM, Schousboe B, Pedersen BD, Jorgensen HL, Duus BR, et al. A comprehensive hip fracture program reduces complication rates and mortality. J146?Am Geriatr Soc 2008;56(October (10)):1831–8. [16] Egerod I, Rud K, Specht K, Jensen PS, Trangbaek A, Ronfelt I, et al. Room for improvement in the treatment of hip fractures in Denmark. Dan Med Bull 2010;57(December (1)):A4199. [17] Hommel A, Ulander K, Thorngren KG. Improvements in pain relief, handling time and pressure ulcers through internal audits of hip fracture patients. Scand J Caring Sci 2003;17(March (1)):78–83. [18] Ryan J, Ghani M, Staniforth P, Bryant G, Edwards S. Fast tracking’’ patients with a proximal femoral fracture. J Accid Emerg Med 1996;13(2):108–10. [19] Aronsson K, Bjorkdahl I, Wireklint Sundstrom B. Prehospital emergency care for patients with suspected hip fractures after falling - older patients’ experiences. J Clin Nurs 2014;23(November (21–22)):3115–23. [20] Eriksson M, Kelly-Pettersson P, Stark A, Ekman AK, Skoldenberg O. ‘Straight to bed’ for hip-fracture patients: a prospective observational cohort study of two fast-track systems in 415 hips. Injury 2012;43(December (12)): 2126–31.
[21] Larsson G, Holgers KM. Fast-track care for patients with suspected hip fracture. Injury 2011;42(November (11)):1257–61. [22] Turesson E, Ivarsson K, Ekelund K, Hommel A. The implementation of a fast track care pathway for hip fracture patients. Eur Orthop Traumatol 2012;3: 195–203. [23] Widgren BR, Jourak M. Medical Emergency Triage and Treatment System (METTS): a new protocol in primary triage and secondary priority decision in emergency medicine. J Emerg Med 2011;40(June (6)):623–8. [24] Socialstyrelsen. Hur tas a¨ldre om hand pa˚ akutmottagning. En nationell verksamhetstillsyn 2006. 2006-109-20. [25] Bjorkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study. Acta Anaesthesiol Scand 2010;54(July (6)):678–88. [26] Vicente V, Svensson L, Wireklint Sundstrom B, Sjostrand F, Castren M. Randomized controlled trial of a prehospital decision system by emergency medical services to ensure optimal treatment for older adults in Sweden. J Am Geriatr Soc 2014;62(July (7)):1281–7. [27] Wennman I, Klittermark P, Herlitz J, Lernfelt B, Kihlgren M, Gustafsson C, et al. The clinical consequences of a pre-hospital diagnosis of stroke by the emergency medical service system. A pilot study. Scand J Trauma Resusc Emerg Med 2012;20(July):48–7241. [28] Smektala R, Endres HG, Dasch B, Maier C, Trampisch HJ, Bonnaire F, et al. The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures. BMC Musculoskelet Disord 2008;9(December). 1712474-9-171.
Please cite this article in press as: Larsson G, et al. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury (2016), http://dx.doi.org/10.1016/ j.injury.2016.01.043
