Admission delay is associated with worse surgical outcomes for elderly hip fracture patients: A retrospective observational study

doi:10.5847/wjem.j.1920-8642.2020.01.004

Abstract

Abstract:

BACKGROUND: The influence of surgical delay on mortality and morbidity has been studied extensively among elderly hip fracture patients. However, most studies only focus on the timing of surgery when patients have already been hospitalized, without considering pre-admission waiting time. Therefore, the present study aims to explore the influence of admission delay on surgical outcomes.

METHODS: In this retrospective study, we recorded admission timing and interval from admission to surgery for included patient. Other covariates were also collected to control confounding. The primary outcome was 1-year mortality. The secondary outcomes were 1-month mortality, 3-month mortality, ICU admission and postoperative pneumonia. We mainly used multivariate logistic regression to determine the effect of admission timing on postoperative outcomes. An additional survival analysis was also performed to assess the impact of admission delay on survival status in the first year after operation.

RESULTS: The proportion of patients hospitalized on day 0, day 1, day 2 after injury was 25.4%, 54.7% and 66.3%, respectively. And 12.6% patients visited hospital one week later after injury. Mean time from admission to surgery was 5.2 days (standard deviation 2.8 days). Hospitalization at one week after injury was a risk factor for 1-year mortality (OR 1.762, 95% CI 1.026-3.379, P=0.041).

CONCLUSION: Admission delay of more than one week is significantly associated with higher 1-year mortality. As a supplement to the current guidelines which emphasizes early surgery after admission, we also advocate early admission once patients get injured.

Key words: Geriatric, Hip fracture, Admission delay, Mortality, Complications

Wei He, Yue-yang You, Kai Sun, Chen Xie, Yue Ming, Li-na Yu, Feng-jiang Zhang, Min Yan. Admission delay is associated with worse surgical outcomes for elderly hip fracture patients: A retrospective observational study[J]. World Journal of Emergency Medicine, 2020, 11(1): 27-32.

Figures/Tables 7

Figure 1.

Figure 2.

Table 1

Table 2

Table 3

Characteristics of patients by admission timing

Variables	Total (n=867)	≤7 days (n=758)	>7 days (n=109)	P value
Age, mean (SD), years	81.2 (8.0)	81.2 (8.0)	81.0 (7.6)	0.869
Female, n (%)	648 (74.7)	572 (75.7)	76 (69.7)	0.197
ASA classification, n (%)				0.098
1	4 (0.5)	3 (0.4)	1 (0.9)
2	375 (43.3)	338 (44.6)	37 (33.9)
3	470 (54.2)	402 (53.0)	68 (62.4)
4	18 (2.1)	15 (2.0)	3 (2.8)
Fracture type, n (%)				0.000
Femoral neck fracture	582 (67.1)	489 (64.5)	93 (85.3)
Trochanteric fracture	285 (32.9)	269 (35.5)	16 (14.7)
Operative method, n (%)				0.000
Replacement	486 (56.1)	405 (53.4)	81 (74.3)
Fixation	381 (44.0)	353 (46.6)	28 (25.7)
Anesthetic method, n (%)				0.936
General anesthesia	653 (75.3)	571 (75.3)	82 (75.2)
Neuraxial anesthesia	104 (12.0)	90 (11.9)	14 (12.8)
General anesthesia + Neuraxial anesthesia	110 (12.7)	97 (12.8)	13 (11.9)
Intraoperative blood loss, mean (SD), mL	136.3 (127.4)	136.9(131.4)	132.4 (96.0)	0.668
Preoperative comorbidity, n (%)
Pneumonia	208 (24.0)	174 (23.0)	34 (31.2)	0.060
Hypertension	466 (53.7)	402 (53.0)	64 (58.7)	0.266
Coronary heart disease	75 (8.7)	60 (7.9)	15 (13.8)	0.042
Heart failure	13 (1.5)	10 (1.3)	3 (2.8)	0.250
Stroke	120 (13.8)	103 (13.6)	17 (15.6)	0.570
Diabetes mellitus	163 (18.8)	133 (17.5)	30 (27.5)	0.013
Renal insufficiency	35 (4.0)	31 (4.1)	4 (3.7)	0.367
Preoperative laboratory examinations
Hemoglobin, mean (SD), g/L	109.0 (20.4)	108.8 (20.8)	110.2 (17.6)	0.612
White blood cell, mean (SD), 10⁹/L	7.8 (3.7)	8.0 (3.8)	6.8 (2.7)	0.001
Platelet, mean (SD), 10⁹/L	183.9 (74.8)	176.2 (67.7)	237.0 (97.4)	0.000
Albumin, mean (SD), g/L	34.4 (4.0)	34.5 (4.0)	33.4 (4.2)	0.008
Creatinine, median (IQR), μmol/L	58.0 (26.0)	58.0 (26.3)	57.0 (22.0)	0.299
C-reactive protein, median (IQR), mg/L	48.4 (50.3)	50.0 (47.9)	14.8(32.1)	0.000
Admission-to-surgery time, mean (SD), days	5.2 (2.8)	5.2 (2.9)	5.5 (2.5)	0.225
Duration of surgery, mean (SD), hours	2.1(0.6)	2.1 (0.6)	1.8 (0.6)	0.001
Surgery-to-discharge time, mean (SD), days	6.2 (6.2)	6.0 (3.9)	6.2 (3.2)	0.559
Surgery within two days after admission, n (%)	68 (7.8)	66 (8.7)	2 (1.8)	0.013
Year, n (%)				0.177
2014	89 (10.3)	73 (6.9)	16 (14.7)
2015	166 (19.1)	147 (19.4)	19 (17.4)
2016	295 (34.0)	252 (33.2)	43 (39.4)
2017	317 (36.6)	286 (37.7)	31 (28.4)

Table 3

Table 4

Figure 3.

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Admission timing	OR (95% CI)	P value
Day 0 later vs. within day 0	1.006 (0.610-1.658)	0.981
Day 1 later vs. within day 1	1.090 (0.706-1.685)	0.697
Day 2 later vs. within day 2	1.400 (0.898-2.183)	0.138
Day 3 later vs. within day 3	1.222 (0.761-1.960)	0.406
Day 4 later vs. within day 4	1.258 (0.766-2.066)	0.365
Day 5 later vs. within day 5	1.387 (0.824-2.336)	0.219
Day 6 later vs. within day 6	1.453 (0.854-2.473)	0.168
Day 7 later vs. within day 7	1.897 (1.073-3.292)	0.027
Day 8 later vs. within day 8	1.893 (1.066-3.359)	0.029
Day 9 later vs. within day 9	1.741 (0.955-3.175)	0.070

Variables	β value	Standard error	Wald Chi-square	OR (95% CI)	P value
Age	0.069	0.017	17.191	1.072 (1.037-1.107)	0.000
Sex (female vs. male)	-0.509	0.247	4.236	0.601 (0.370-0.976)	0.040
Pneumonia	0.562	0.243	5.353	1.754 (1.090-2.822)	0.021
Admission timing (>7 days vs. ≤7 days)	0.621	0.304	4.175	1.762 (1.026-3.379)	0.041
Admission-to-surgery time (>2 days vs. ≤2 days)	1.315	0.736	3.189	3.724 (0.880-15.769)	0.074
Renal insufficiency	0.839	0.456	3.379	2.314 (0.946-5.662)	0.066
Fracture type (trochanteric vs. femoral neck)	0.338	0.242	1.946	1.402 (0.872-2.254)	0.163

Variables	≤7 days (n=758)	>7 days (n=109)	P value
Primary outcome
1-year mortality	73 (9.6)	18 (16.5)	0.028
Secondary outcomes
1-month mortality	22 (2.9)	7 (6.4)	0.056
3-month mortality	39 (5.1)	8 (7.3)	0.344
Postoperative ICU admission	51 (6.7)	13 (11.9)	0.052
Postoperative pneumonia	39 (5.1)	7 (6.4)	0.578

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