Enhanced recovery after surgery: An opportunity to improve fractured neck of femur management

ABSTRACT INTRODUCTION Approximately 67,000 hip fractures occurred in England, Wales and Northern Ireland in 2014, and annual hospital costs for fracture are around £1.1 billion. We review the potential scope for improving length of stay (LOS). METHODS Hospital Episode Statistics data on non-elective admissions to 137 hospital trusts between November 2013 and October 2014 with a primary diagnosis of fractured neck of femur were analysed. The primary outcome was superspell LOS, which is the total LOS for all related spells for a single patient during an episode of care. Secondary outcomes were discharge to home, readmission at 28 days and in-hospital mortality. RESULTS The mean observed LOS was 22.1±3.8 days (range 12.3–33.7 days). The range for case mix-adjusted expected LOS was 21.5–24.4 days. On average, 6.7±1.5% (range 3.6%–10.9%) of patients died while in hospital, at a relative risk of in-hospital mortality of 28.2–182.9. A mean of 12.3±3.2% (range 3.9% to 23.0%) of patients were readmitted at 28 days, at a relative relative risk of 34.8–203.2. CONCLUSIONS The wide range of observed LOS in our study is unlikely to be due to the case mix, as the case mix-adjusted range of LOS is less than 3 days, but rather due to local processes and pathways. There is therefore considerable scope for quality and efficiency of care improvements in our hospitals. We propose this could be best achieved if clinicians experienced in enhanced recovery focused on FNOF pathways

Dental and microbiological risk factors for hospital-acquired pneumonia in non-ventilated older patients

We obtained a time series of tongue/throat swabs from 90 patients with lower limb fracture, aged 65-101 in a general hospital in the North East of England between April 2009-July 2010. We used novel real-time multiplex PCR assays to detect S. aureus, MRSA, E. coli, P. aeruginosa, S. pneumoniae, H. influenza and Acinetobacter spp. We collected data on dental/denture plaque (modified Quigley-Hein index) and outcomes of clinician-diagnosed HAP.The crude incidence of HAP was 10% (n = 90), with mortality of 80% at 90 days post discharge. 50% of cases occurred within the first 25 days. HAP was not associated with being dentate, tooth number, or heavy dental/denture plaque. HAP was associated with prior oral carriage with E. coli/S. aureus/P.aeruginosa/MRSA (p = 0.002, OR 9.48 95% CI 2.28-38.78). The incidence of HAP in those with carriage was 35% (4% without), with relative risk 6.44 (95% CI 2.04-20.34, p = 0.002). HAP was associated with increased length of stay (Fishers exact test, p=0.01), with mean 30 excess days (range -11.5-115). Target organisms were first detected within 72 hours of admission in 90% participants, but HAP was significantly associated with S. aureus/MRSA/P. aeruginosa/E. coli being detected at days 5 (OR 4.39, 95%CI1.73-11.16) or 14 (OR 6.69, 95%CI 2.40-18.60).Patients with lower limb fracture who were colonised orally with E. coli/ S. aureus/MRSA/P. aeruginosa after 5 days in hospital were at significantly greater risk of HAP (p = 0.002)