Improving the quality of care for hip fracture patients : studies on fast-track to surgery and adverse events

Hip fractures in the elderly are common and are associated with high comorbidity and mortality. Their care and treatment present challenges for nurses and other healthcare professionals and impose a substantial burden on healthcare resources. The general aim of this thesis was to examine how a new enhanced fast-track system to operation, waiting time to surgery, and depression influence outcomes in patients after hip fracture, with particular interest in adverse events. In study I, we examined the effects of the implementation of a new enhanced fast-tracking system for the management of hip-fracture patients compared to an already existing system in 415 patients. Data was collected prospectively and a record review was carried out. Our results showed that the time to surgery was reduced by an average of 3 hours in patients admitted via the new fast-track system compared to the existing system. We found no difference in the 3-month mortality or the length of stay (LOS) between the groups. There was a trend toward a lower incidence of adverse events (AEs) in the invention group at 3 months, but this difference did not reach statistical significance. We were able to show that the introduction of an enhanced fast-track management system to surgery could reduce waiting time to surgery for this patient group. In study II, we investigated how waiting time to surgery influenced the risk of serious adverse advents (SAEs) in patients with hip fracture and how time affected risk. A retrospective record review was conducted. Outcomes were the occurrence of SAEs, the LOS and one-year mortality rate. A cohort of 576 patients was included (577 hip fractures) in the study. We found that around 20.6% suffered at least one SAE during the hospital stay (range 1-5). Risk of SAE increased by 12% with every 10 hours of waiting time and the length of the hospital stay was prolonged by 0.6 days with every 24 hours of waiting time to operation. No optimal cut-off times for waiting time to surgery were found and no correlation between waiting time to surgery and one-year mortality. Those patients at greatest risk of SAEs were patients with pre-existing health problems, males and those with subtrochanteric fractures. In study III we explored the incidence, preventability and nature of adverse events occurring in hip-fracture patients up to 90 days after surgery. A structured retrospective record review, using the Swedish version of Global Trigger Tool methodology was carried out on prospectively collected data from 163 patients. Sixty-two of the patients (38%) suffered at least one AE during their hospital stay and up to 90 days post-operatively (range 1-7). The most common types of AEs were infections such as pneumonia and urinary tract infections, but pressure ulcers and AEs associated with surgery were also common. AEs were more common in older patients and those with pre-existing health conditions. About 60% of these AEs were judged to be preventable. In study IV, we investigated the influence of depression on patient-reported outcome up to one year after hip fracture. A cohort of 162 patients with intact cognitive function were included into either the depression or control group and were followed from baseline, to 3- months and 12-months. Using questionnaires, patients reported on their pain levels, hip function and quality of life. The depression group had significantly poorer hip function at baseline but this had improved at 3-months. The depression group experienced a lower health-related quality of life at baseline compared to the control group. At 12 months, neither group had returned to their pre-fracture level of function. Both groups experienced a decline in their health-related quality of life. The one-year mortality rate was higher in the depression group compared to the control group but the difference was not statistically significant. In this study we did not find that depression had a bearing on patient-reported outcome one year after hip fracture in patients without cognitive impairment. In conclusion, the results of these studies demonstrate that the introduction of a new fast-track can reduce waiting time to surgery. Long waiting time to surgery is correlated with increased risk for SAEs and prolonged hospital stay. No optimal cut-off times exist, the risk for SAEs increases linearly over time. Patients at greatest risk of suffering SAEs are those with a higher American Society of Anaethesiologist’s (ASA) classification score, males and those with subtrochanteric fractures. We have also shown that many hip-fracture patients suffer AEs and the majority of these are preventable. We found no correlation between the presence of depression pre-fracture and poorer functional outcome one year after hip fracture

Single cell RNA-seq reveals profound transcriptional similarity between Barrett's oesophagus and oesophageal submucosal glands

Barrett’s oesophagus is a precursor of oesophageal adenocarcinoma. In this common condition, squamous epithelium in the oesophagus is replaced by columnar epithelium in response to acid reflux. Barrett’s oesophagus is highly heterogeneous and its relationships to normal tissues are unclear. Here we investigate the cellular complexity of Barrett’s oesophagus and the upper gastrointestinal tract using RNA-sequencing of single cells from multiple biopsies from six patients with Barrett’s oesophagus and two patients without oesophageal pathology. We find that cell populations in Barrett’s oesophagus, marked by LEFTY1 and OLFM4, exhibit a profound transcriptional overlap with oesophageal submucosal gland cells, but not with gastric or duodenal cells. Additionally, SPINK4 and ITLN1 mark cells that precede morphologically identifiable goblet cells in colon and Barrett’s oesophagus, potentially aiding the identification of metaplasia. Our findings reveal striking transcriptional relationships between normal tissue populations and cells in a premalignant condition, with implications for clinical practice

Timing of adverse events in patients undergoing acute and elective hip arthroplasty surgery: a multicentre cohort study using the Global Trigger Tool

Objective To explore timing in relation to all types of adverse events (AEs), severity and preventability for patients undergoing acute and elective hip arthroplasty.Design A multicentre cohort study using retrospective record review with Global Trigger Tool methodology in combination with data from several registers.Setting 24 hospitals in 4 major regions of Sweden.Participants Patients ≥18 years, undergoing acute or elective total or hemiarthroplasty of the hip, were eligible for inclusion. Reviews of weighted samples of 1998 randomly selected patient records were carried out using Global Trigger Tool methodology. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country.Results The cohort consisted of 667 acute and 1331 elective patients. Most AEs occurred perioperatively and postoperatively (n=2093, 99.1%) and after discharge (n=1142, 54.1%). The median time from the day of surgery to the occurrence of AE was 8 days. The median days for different AE types ranged from 0 to 24.5 for acute and 0 to 71 for elective patients and peaked during different time periods. 40.2% of the AEs, both major and minor, occurred within postoperative days 0–5 and 86.9% of the AEs occurred within 30 days. Most of the AEs were deemed to be of major severity (n=1370, 65.5%) or preventable (n=1591, 76%).Conclusions A wide variability was found regarding the timing of different AEs with the majority occurring within 30 days. The timing and preventability varied regarding the severity. Most of the AEs were deemed to be preventable and/or of major severity. To increase patient safety for patients undergoing hip arthroplasty surgery, a better understanding of the multifaceted nature of the timing of AEs in relation to the occurrence of differing AEs is needed

Patient-reported outcomes after surgical and non-surgical treatment of proximal hamstring avulsions in middle-aged patients

ObjectivesIn the literature on proximal hamstring avulsions, only two studies report the outcomes of non-surgically treated patients. Our objective was to compare subjective recovery after surgical and non-surgical treatment of proximal hamstring avulsions in a middle-aged cohort.MethodsWe included 47 patients (33 surgically and 14 non-surgically treated) with a mean (SD) age of 51 (±9) years in a retrospective cohort study. Follow-up time mean (SD) of 3.9 (±1.4) years. The outcome variables were the Lower Extremity Functional Scale (LEFS) and questions from the Proximal Hamstring Injury Questionnaire. Outcome variables were adjusted in regression models for gender, age, American Society of Anestesiologits (ASA) classification and MRI findings at diagnosis.ResultsThe baseline characteristics showed no differences except for the MRI result, in which the surgically treated group had a larger proportion of tendons retracted ≥ 2 cm. The mean LEFS score was 74 (SD±12) in the surgically treated cohort and 72 (SD±16) in the non-surgically treated cohort. This was also true after adjusting for confounders. The only difference in outcome at follow-up was the total hours performing physical activity per week, p=0.02; surgically treated patients reported 2.5 hours or more (5.2 vs 2.7).ConclusionThis study on middle-aged patients with proximal hamstring avulsions was unable to identify any difference in patient-reported outcome measures between surgically and non-surgically treated patients. The vast majority of patients treated surgically had complete proximal hamstring avulsions with ≥ 2 cm of retraction. We conclude that to obtain an evidence-based treatment algorithm for proximal hamstring avulsions studies of higher scientific level are needed

HOPE-Trial: Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians : A Randomized Controlled Trial

Background: The choice of primary hemiarthroplasty or total hip arthroplasty in patients ≥80 years of age with a displaced femoral neck fracture has not been adequately studied. As the number of healthy, elderly patients ≥80 years of ageis continually increasing, optimizing treatments for improving outcomes and reducing the need for secondary surgery is an important consideration. The aim of the present study was to compare the results of hemiarthroplasty with those of totalhip arthroplasty in patients ≥80 years of age. Methods: This prospective, randomized, single-blinded trial included 120 patients with a mean age of 86 years (range, 80 to 94 years) who had sustained an acute displaced femoral neck fracture <36 hours previously. The patients were randomized to treatment with hemiarthroplasty (n = 60) or total hip arthroplasty (n = 60). The primary end points were hip function and health-related quality of life at 2 years. Secondary end points included hip-related complications and reoperations, mortality, pain in the involved hip, activities of daily living, surgical time, blood loss, and general complications.The patients were reviewed at 3 months and 1 and 2 years. Results: We found no differences between the groups in terms of hip function, health-related quality of life, hip-related complications and reoperations, activities of daily living, or pain in the involved hip. Hip function, activities of daily living,and pain in the involved hip deteriorated in both groups compared with pre-fracture values. The ability to regain previous walking function was similar in both groups. Conclusions: We found no difference in outcomes after treatment with either hemiarthroplasty or total hip arthroplasty inactive octogenarians and nonagenarians with a displaced femoral neck fracture up to 2 years after surgery. Hemiarthroplastyis a suitable procedure in the short term for this group of patients. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

External Validity of the HOPE-Trial Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians

Background: Randomized controlled trials (RCTs) are the most reliable way of evaluating the effect of new treatments by comparing them with previously accepted treatment regimens. The results obtained from an RCT are extrapolated from the study environment to the general health care system. The ability to do so is called external validity. We sought to evaluate the external validity of an RCT comparing the results of total hip arthroplasty with those of hemiarthroplasty for the treatment of displaced femoral neck fractures in patients ≥80 years of age. Methods: This prospective, single-center cohort study included 183 patients ≥80 years of age who had a displaced femoral neck fracture. All patients were screened according to the inclusion and exclusion criteria for an RCT comparing total hip arthroplasty and hemiarthroplasty. The population for this study consisted of patients who gave their informed consent and were randomized into the RCT (consenting group, 120 patients) as well as those who declined to give their consent to participate (non-consenting group, 63 patients). The outcome measurements were mortality, complications, and patient-reported outcome measures. Follow-up was carried out postoperatively with use of a mailed survey that included patient-reported outcome questionnaires. Results: We found a statistically significant and clinically relevant difference between the groups, with the non-consenting group having a higher risk of death compared with the consenting group. (hazard ratio, 4.6; 95% confidence interval, 1.9 to 11.1). No differences were found between the groups in terms of patient-reported outcome measures or surgical complications. Conclusions: This cohort study indicates a higher mortality rate but comparable hip function and quality of life among eligible non-consenters as compared with eligible consenters when evaluating the external validity of an RCT in patients ≥80 years of age with femoral neck fracture. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence

Primary hemiarthroplasty for the elderly patient with cognitive dysfunction and a displaced femoral neck fracture : a prospective, observational cohort study

Background: At least one-third of hip fracture patients have some degree of impaired cognitive status, which may complicate their postoperative rehabilitation. Aim: We aimed to describe the outcome for elderly patients with cognitive dysfunction operated with hemiarthroplasty (HA) for a femoral neck fracture and to study the impact postoperative geriatric rehabilitation has on functional outcome up to 1 year after surgery. Methods: 98 patients with a displaced femoral neck fracture with a mean age of 86 years were included and followed up to 1 year. The outcomes were hip-related complications and reoperations, the capacity to return to previous walking ability, health-related quality of life, hip function and mortality. Results: The prevalence of hip complications leading to a major reoperation was 6% and the 1-year mortality rate was 31%. The lack of geriatric rehabilitation was correlated with poorer outcomes overall and those who receive geriatric rehabilitation were less likely to be confined to a wheelchair or bedridden at the 1-year follow-up. Conclusions: Hemiarthroplasty is an acceptable option for elderly patients with a displaced femoral neck fracture and cognitive dysfunction. A lack of structured rehabilitation is associated with a significant deterioration in walking ability despite a well-functioning hip. However, the causality of this could be due to selection bias of healthier patients being sent to geriatric rehabilitation

Operational strategies to manage non-elective orthopaedic surgical flows : A simulation modelling study

Objectives To explore the value of simulation modelling in evaluating the effects of strategies to plan and schedule operating room (OR) resources aimed at reducing time to surgery for non-elective orthopaedic inpatients at a Swedish hospital. Methods We applied discrete-event simulation modelling. The model was populated with real world data from a university hospital with a strong focus on reducing waiting time to surgery for patients with hip fracture. The system modelled concerned two patient groups that share the same OR resources: hip-fracture and other non-elective orthopaedic patients in need of surgical treatment. We simulated three scenarios based on the literature and interaction with staff and managers: (1) baseline; (2) reduced turnover time between surgeries by 20â €..min and (3) one extra OR during the day, Monday to Friday. The outcome variables were waiting time to surgery and the percentage of patients who waited longer than 24â €..hours for surgery. Results The mean waiting time in hours was significantly reduced from 16.2â €..hours in scenario 1 (baseline) to 13.3â €..hours in scenario 2 and 13.6â €..hours in scenario 3 for hip-fracture surgery and from 26.0â €..hours in baseline to 18.9â €..hours in scenario 2 and 18.5â €..hours in scenario 3 for other non-elective patients. The percentage of patients who were treated within 24â €..hours significantly increased from 86.4% (baseline) to 96.1% (scenario 2) and 95.1% (scenario 3) for hip-fracture patients and from 60.2% (baseline) to 79.8% (scenario 2) and 79.8% (scenario 3) for patients with other non-elective patients. Conclusions Healthcare managers who strive to improve the timelines of non-elective orthopaedic surgeries may benefit from using simulation modelling to analyse different strategies to support their decisions. In this specific case, the simulation results showed that the reduction of surgery turnover times could yield the same results as an extra OR. © 2017 Published by the BMJ Publishing Group Limited.open access</p

The pleasure of the eighteenth-century texts: The conflation of literary and critical discourse in the early novelistic tradition

One of the prominent characteristics of contemporary literature is its assimilation to critical discourse. The self-reflexivity in literature, which transforms literary texts into acts of criticism, is paralleled by theory’s tendency to encroach on the literary domain. One of the findings of the poststructuralist literary theory is that descriptions of reading experience elude scientific language and are more aptly conveyed by metaphors. (A good example is Roland Barthes’ The pleasure of the text.) The conflation of literary and critical discourse is not, however, peculiar to postmodernity only. The same phenomenon is observable in the eighteenth-century writings. It turns out that the self-reflexivity evident at the times of the proclaimed “death of the novel” is manifest also in the times of its birth. The aim of my paper is to analyse the metafictional reflection on readerly pleasure incorporated in early novelistic texts