Study conducted within Orthopaedic Department at Chesterfield Royal Hospital

Introduction

Fractured neck of femur (NOF) carries a significant mortality. 60000 people are treated for fractured NOF in England and Wales per year ₁ , and as life expectancy increases in the population, fractured neck of femur admissions and mortality will continue to rise.

This is predominantly a problem of the elderly, and occasionally younger people with pathological fractures.

Mortality has been associated with delay in operation to fix fractured NOF, only in patients from their own homes, and a delay of more than 24 hours between admission and operative fixation had been shown to be associated with increased mortality.

Aim

Aim is to look at the mortality in 286 patients at 30 days post fractured neck of femur. Looking at the mortality for patients operated on within 24 hours of admission, and compare this to the mortality of the patients operated on after 24 hours of admission. I will then take into consideration the morbidity of each group of patients by scoring them on a health score of 1-7 depending on their co-morbidities.

Criteria

1. What percentage of patients admitted with fractured NOF are receiving operative treatment where indicated within 24 hours of admission?

2. What percentage of patients operated on within 24 hours of admission have died within 30 days of admission?

3. What percentage of patients operated on 24 hours after admission or more, died within 30 days of admission?

4. What percentage of the morbidity score 0+1 patients (see method), who were operated on within 24 hours of admission died within 30 days of admission?

5. What percentage of morbidity score 0+1 patients, who were operated on 24 hours or more after admission, died within 30 days of admission?

Method

Aim is to look at the mortality at 30 days post fractured neck of femur. Look at the mortality for patients operated on within 24 hours of admission, and compare this to the mortality of the patients operated on after 24 hours of admission. I will then take into consideration the morbidity of each group of patients by scoring them on a score of 1-7 depending on their co-morbidities. This data is collected by the coding department at discharge so these co-morbidities may have developed post fracture fixation. I have scored each patient on the following system;

1. Dementia (ICD codes F00-F03, G30)

2. Diabetes (E10-E14)

3. Ischaemic Heart Disease (I20, I23-25)

4. Respiratory Disease (J40-J47)

5. Heart Failure (I50)

6. Renal Failure (N17-N19)

7. Hypertension (I10-I15)

8. Malignancy (any C code)

I will then reassess the results using the healthiest patients (who scored the lowest) to see if there is any difference in mortality depending on whether they received operative treatment within 24 hours of admission. This will be more accurate, as the more unwell patients are more likely to be delayed in receiving treatment as they were medically unfit for theatre, and so this may have skewed the results.

The exclusion criteria were patients who were managed conservatively, and patients who died before operation.

I have looked at 286 patients who were admitted to Chesterfield Royal Hospital, UK between April and December 2007.

The flaws in this study are;

Only looking at hospital held data for 30 days mortality. There may be a small percentage of patients who died within 30 days of operation after discharge who are not included in the figures.

The coding data that is sent to the audit department does not have any patient ID with the information. Therefore I could not check all the data was correct by cross-referencing case notes.

I can only take into account certain serious co-morbidities which I will score according to the 1-8 system above. To take into account all co-morbidities would be too time consuming, and may not affect results dramatically.

Results

I can draw the following results from my data collection.

Criteria 1

Criteria 2

Criteria 3

Criteria 4

Criteria 5

What percentage of morbidity score 0+1 patients, who were operated on 24 hours or more after admission, died within 30 days of admission?

15 out of 119 patients operated on after 24 hours post-admission were dead at 30 days. 12.6%.

Figure 1

Figure 2

Conclusion

The data and charts conclude that there is an increase in mortality when patients are operated on after 24 hours post-admission. There is a 4% increase overall. When the data for the healthier patients who have less co-morbidities is looked at, there is still an increase in mortality although it is only about 1% and may not be significant.

At Chesterfield Royal Hospital 36% of patients are receiving operative treatment within 24 hours of admission.

The overall conclusion is that the sooner patients are taken to theatre for treatment of fractured neck of femur, the lower the 30 day mortality, and this is more so for the more unwell patients who have more co-morbidities.