Patients with hip fractures should receive surgery on the day they are admitted into hospital or the following day to reduce the risk of death, according to a new study published Tuesday in the Canadian Medical Association Journal (CMAJ).
The study found the mortality rate is significantly higher among older patients who receive surgery on day three or more of a hospital stay.
In 2005, Canada’s ministers of health adopted a benchmark of providing surgery within 48 hours of admission for 90 per cent of hip fracture patients. But Dr. Pierre Guy, co-lead investigator of the study, says this benchmark is still not being met; according to 2017 data from the Canadian Institute for Health Information, 87 per cent of hip fracture patients received surgery within 48 hours – and even that may be too long of a wait.
Dr. Guy says his team’s recommendation – that patients who are medically stable should receive surgery on the day of admission or the following day – is stricter than the 48-hour timeline. For instance, patients who are admitted late at night should still receive surgery by the next day.
Hip fractures are a major public health issue in Canada, resulting in hospitals admitting about 30,000 older adults per year, according to the researchers.
For older adults, breaking a hip can mean losing their mobility, their independence and a greater risk of death, says Boris Sobolev, co-principal investigator of the study and professor of population and public health at the University of British Columbia. He notes that even after treatment, 30 per cent die within a year, 25 per cent never walk again, and 22 per cent never live independently.
“These numbers are actually quite dramatic in themselves, but we have to take into [account] that hip fracture is a disease of older adults,” he says. And as a growing segment of the population ages and people live longer, “eventually it will put a lot of strain on the health system in Canada.”
The study, funded by the Canadian Institutes of Health Research, examined data for 139,119 patients, ages 65 and older, who were treated for hip fractures across Canada between 2004 and 2012. This did not include patients in Quebec, nor did it include patients whose surgeries were delayed for medical reasons. Within 30 days of having surgery, 6,371 patients, or 4.6 per cent, died.
The risk of death was lower for patients who had surgery sooner. The research team found that within 30 days of surgery, the rate of mortality was 48.9 deaths per 1,000 surgeries done on the day of admission, and 48 deaths per 1,000 surgeries done on day two of hospitalization. This rate increased to 57 deaths per 1,000 surgeries done on day three of a hospital stay, and to 69.1 deaths per 1,000 surgeries done after day three.
Dr. Guy, an associate professor at the University of British Columbia and an orthopedic surgeon, explains that hip fracture surgery is stressful for older individuals, and patients may be fitter to undergo surgery earlier, than if they are made to wait.
Dr. Daniel Pincus, a PhD candidate in the University of Toronto’s faculty of medicine who was not involved in the latest study, says death can occur because of factors such as fasting before surgery, inflammation in the body and being bed-bound, which can lead to blood clots and bleeding. When operations are cancelled and rescheduled, patients are asked to fast each time, which can make them weaker, he says.
“The more time elapses, the more dangerous it can become,” he says.
In a study published in the CMAJ in June, Dr. Pincus and his team found that only one-third of patients in Ontario receive hip fracture surgery within 24 hours. He says delays tend to be highly dependent on hospital culture. For instance, some hospitals order multiple tests, such as echocardiograms, which he says have not been shown to improve outcomes.
Moreover, he says, “some hospitals make it a priority to get these patients to the operating room earlier, and others do not as much.”