Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study

Objectives: To determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual. Setting: A single university-affiliated teaching hospital. Participants: 2,541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not. Primary and Secondary Outcome Measures: Primary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality. Results: The introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p = 0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9-21) pre-BPT vs 14 days (IQR 11-22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44hours pre-BPT (IQR 24-44) vs 23hours post-BPT (IQR 17-30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p < 0.005). There was a survival benefit at one year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival. Conclusion: The introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes

Guidance in an uncertain world

In the face of the coronavirus pandemic, clinicians are looking to multiple sources for guidance. Good guidance provides a helpful tool to support decision making by experienced and highly-trained healthcare professionals. However, in the context of a readily changing landscape there are risks of guidance that hinders rather than helps, duplicates effort and fails to consider the front-line implications. Conversely, an overly conservative approach may result in good guidance never seeing the light of day, or being published too late. We suggest that there are key principles that may help guideline producers to improve the process. These include: addressing directly and transparently the competing risks and benefits to individual patients, staff and the wider community; making greater efforts to find reliable data to inform recommendations; ensuring duplication of effort and conflict with extant guidance is minimised; involving front-line staff in development and consideration of real-world implications of delivery; and ensuring that feedback and revisions are integral to the process. The MORAL Balance framework has previously been advocated for making complex individual patient level decision in critical care. We believe the same process can be appliedas a framework for guideline development groups

Anaesthesia workload measurement devices: qualitative systematic review

Background: Management of mental workload is a key aspect of safety in anaesthesia but there is no gold standard tool to assess mental workload, risking confusion in clinical and research use of such tools. Objective: This review assessed currently used mental workload assessment tools. Methods: A systematic literature search was performed on the following electronic databases; Cochrane, EMBASE, MEDLINE, SCOPUS and Web of Science. Screening and data extraction were performed individually by two authors. We included primary published papers focusing on mental workload assessment tools in anaesthesia. Results: A total of 2331 studies were screened by title, 32 at full text and twenty - four studies met the inclusion criteria. Six mental workload measurement tools were observed across included studies. Reliability for the Borg rating scales and Vibrotactile device were reported in two individual studies. The rest of the studies did not record reliability of the tool measurements used. Borg rating scales, NASA-TLX and task oriented mental work load measurements are subjective, easily available, readily accessible and takes a few minutes to complete. However, the Vibrotactile and Eye-tracking methods are objective, require more technical involvement, considerable time for the investigator, and moderately expensive, impacting their potential use. Conclusion: We found that, the measurement of mental workload in anaesthesia is an emerging field supporting patient and anaesthetist safety. The self - reported measures have the best evidence bas

Tight intra-operative blood pressure control versus standard care for patients undergoing hip fracture repair - Hip Fracture Intervention Study for Prevention of Hypotension (HIP-HOP) trial: study protocol for a randomised controlled trial

Background: Hypotension during anaesthesia for hip fracture surgery is common. Recent data suggest that there is an association between the lowest intra-operative blood pressure and mortality, even when adjusted for co-morbidities. This is consistent with data derived from the wider surgical population, where magnitude and duration of hypotension are associated with mortality and peri-operative complications. However, there are no trial to data to support more aggressive blood pressure control.Methods/design: We are conducting a three-centre, randomised, double-blinded pilot study in three hospitals in the United Kingdom. The sample size will be 75 patients (25 from each centre). Randomisation will be done using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be aged >70 years, cognitively intact (Abbreviated Mental Test Score 7 or greater), able to give informed consent and admitted directly through the emergency department with a fractured neck of the femur requiring operative repair. Patients randomised to tight blood pressure control or avoidance of intra-operative hypotension will receive active treatment as required to maintain both of the following: systolic arterial blood pressure >80% of baseline pre-operative value and mean arterial pressure >75 mmHg throughout. All participants will receive standard hospital care, including spinal or general anaesthesia, at the discretion of the clinical team. The primary outcome is a composite of the presence or absence of defined cardiovascular, renal and delirium morbidity within 7 days of surgery (myocardial injury, stroke, acute kidney injury, delirium). Secondary endpoints will include the defined individual morbidities, mortality, early mobility and discharge to usual residence.Discussion: This is a small-scale pilot study investigating the feasibility of a trial of tight intra-operative blood pressure control in a frail elderly patient group with known high morbidity and mortality. Positive findings will provide the basis for a larger-scale study

Predicting 30-day mortality in patients with sepsis: an exploratory analysis of process of care and patient characteristics

Background Sepsis represents a significant public health burden, costing the NHS £2.5 billion annually, with 35% mortality in 2006. The aim of this exploratory study was to investigate risk factors predictive of 30-day mortality amongst patients with sepsis in Nottingham. Methods Data were collected prospectively from adult patients with sepsis in Nottingham University Hospitals NHS Trust as part of an on-going quality improvement project between November 2011 and March 2014. Patients admitted to critical care with the diagnosis of sepsis were included in the study. In all, 97 separate variables were investigated for their association with 30-day mortality. Variables included patient demographics, symptoms of systemic inflammatory response syndrome, organ dysfunction or tissue hypoperfusion, locations of early care, source of sepsis and time to interventions. Results A total of 455 patients were included in the study. Increased age (adjOR = 1.05 95%CI = 1.03–1.07 p < 0.001), thrombocytopenia (adjOR = 3.10 95%CI = 1.23–7.82 p = 0.016), hospital-acquired sepsis (adjOR = 3.34 95%CI = 1.78–6.27 p < 0.001), increased lactate concentration (adjOR = 1.16 95%CI = 1.06–1.27 p = 0.001), remaining hypotensive after vasopressors (adjOR = 3.89 95%CI = 1.26–11.95 p = 0.02) and mottling (adjOR = 3.80 95%CI = 1.06–13.55 p = 0.04) increased 30-day mortality odds. Conversely, fever (adjOR = 0.46 95%CI = 0.28-0.75 p = 0.002), fluid refractory hypotension (adjOR = 0.29 95%CI = 0.10–0.87 p = 0.027) and being diagnosed in surgical wards (adjOR = 0.35 95%CI = 0.15–0.81 p = 0.015) were protective. Treatment timeliness were not significant factors. Conclusion Several important predictors of 30-day mortality were found by this research. Retrospective analysis of our sepsis data has revealed mortality predictors that appear to be more patient-related than intervention-specific. With this information, care can be improved for those identified most at risk of death

Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomized controlled trial

Objective Fractured neck of femur is a severely painful condition with significant mortality and morbidity. We investigated whether early and continuous use of femoral nerve block can improve pain on movement and mobility after surgery in older participants with fragility neck of femur fracture. Design Prospective single centre, randomised controlled pragmatic trial. Setting Secondary care, acute NHS Trust, UK. Participants Participants admitted with a history and examination suggesting fractured neck of femur. Intervention Immediate continuous femoral nerve block via catheter or standard analgesia. Results One hundred and forty one participants were recruited, with 23 excluded. No significant difference was detected between cumulative dynamic pain scores (standard care (n = 56) vs 4 intervention (n = 55) 20 (IQR 15-24) vs 20 (15-23) p=0.51) or cumulated ambulation scores (standard care vs intervention 6 (5-9) vs 7 (5-10) p=0.76). There were no statistically different differences in secondary outcomes except cumulative pain at rest: 5 (0.5-6.5) in the standard care group and 2 (0-5) in the intervention group (p=0.043). Conclusions Early application of continuous femoral nerve block compared with standard systemic analgesia did not result in improved dynamic pain scores or superior post-operative ambulation. This technique may provide superior pain relief at rest. Continuous femoral nerve block did not delay initial control of pain, or mobilisation after surgery

Risk scoring models for predicting peri-operative morbidity and mortality in people with fragility hip fractures: qualitative systematic review

Rationale: Accurate peri-operative risk prediction is an essential element of clinical practice. Various risk stratification tools for assessing patients’ risk of mortality or morbidity have been developed and applied in clinical practice over the years. This review aims to outline essential characteristics (predictive accuracy, objectivity, clinical utility) of currently available risk scoring tools for hip fracture patients. Methods: We searched eight databases; AMED, CINHAL, Clinical Trials.gov, Cochrane, DARE, EMBASE, MEDLINE and Web of Science for all relevant studies published until April 2015. We included published English language observational studies that considered the predictive accuracy of risk stratification tools for patients with fragility hip fracture. Results: After removal of duplicates, 15,620 studies were screened. Twenty-nine papers met the inclusion criteria, evaluating 25 risk stratification tools. Risk stratification tools considered in more than two studies were; ASA, CCI, E-PASS, NHFS and O-POSSUM. All tools were moderately accurate and validated in multiple studies; however there are some limitations to consider. The E-PASS and O-POSSUM are comprehensive but complex, and require intraoperative data making them a challenge for use on patient bedside. The ASA, CCI and NHFS are simple, easy and inexpensive using routinely available preoperative data. Contrary to the ASA and CCI which has subjective variables in addition to other limitations, the NHFS variables are all objective. Conclusion: In the search for a simple and inexpensive, easy to calculate, objective and accurate tool, the NHFS may be the most appropriate of the currently available scores for hip fracture patients. However more studies need to be undertaken before it becomes a national hip fracture risk stratification or audit tool of choice

Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury

Background Hip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture. Methods An observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures – development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay. Results Data were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67). Conclusions Acute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p\u3c0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (−1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (−2 to 4; p=0·71). Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. Funding: Canadian Institutes of Health Research