Earlier repairs for broken hips aim to save lives and cut complications
Wait for surgery means patients lie flat, which can increase risk of complications
Broken hips are the most common reason for urgent surgery in Canada, but only one-third of patients in Ontario receive surgery within what researchers call the safe 24-hour guideline.
A hip fracture affects the femur, the largest bone in the body, and it needs to be repaired quickly. Studies suggest waiting more than a day after the patient arrives in hospital, as well as being uncomfortable, is associated with a higher risk of complications such as pneumonia, blood clots, heart attacks and death.
Dr. Daniel Pincus, a resident orthopedic doctor at Sunnybrook Health Sciences Centre in Toronto, and his colleagues analyzed data on 42,000 patients with an average age of nearly 81 who had hip fractures repaired across Ontario from 2009 to 2014.
In Monday's issue of the Canadian Medical Association Journal, Pincus found the average wait for the surgery was nearly 39 hours. Only 34 per cent of patients were operated on within a day.
"Twenty-four hours is the cutoff we identified when the risk of complications started to increase," Pincus said in an interview.
The complications occur not necessarily as a result of the fracture, Pincus said, but as a result of waiting for surgery. The wait means patients lie in bed, not able to eat.
Factors that led to delayed surgery included:
- Transferring patients to another hospital.
- Consultations before surgery, such as for anesthesia.
- Waits for echocardiograms.
The study's authors have some suggestions to treat people sooner. In many cases, hospitals book elective hip procedures in the morning, before operating on urgent surgical patients. Pincus and his team say hospitals could flip the order to improve waits for the urgent procedures.
They said another solution works in Manitoba, where rural hospitals are matched to surgical hospitals that agree to prioritize rural patients.
In Hamilton, Dr. P.J. Devereaux, a cardiologist, wondered if hip fracture patients could benefit from advances in treating heart attacks and strokes. In those cases, doctors focus on reversing what's driving the cardiovascular damage.
When a hip is broken, Devereaux said, it starts a strong inflammatory response, which makes patients prone to bleeding and can lead to more serious complications.
Devereaux and his team at McMaster University designed a study called Hip Attack (Hip Fracture Accelerated Surgical Treatment And Care), an international randomized control trial of 3,000 patients with a hip fracture who need surgery. The goal is to get patients into the operating room within six hours of diagnosis.
"We believe if we reverse this quickly there is a great potential … to dramatically improve the outcome for these patients," Devereux said.
The challenge was to bring together those who work in the emergency room, anesthesia, X-ray and other departments to make available an extra operating room slot at the end of the day. That way, no one scheduled for elective surgery needs to have their procedure cancelled and the hip fractures are repaired earlier.
Geri Clark, 90, from Ancaster, Ont., broke her hip last Wednesday and agreed to participate in the rapid surgery group.
"I made a terrible, terrible noise. I knew something had broken, that's for sure," Clark recalled. She is legally blind and was juggling a coffee in one hand and a walker in the other when she fell.
Clark received her surgery within the six-hour window.
Clark said she's OK but her right hip really hurts when she moves it.
Clark started moving on Monday, grimacing through her first few steps with a physiotherapist.
Devereaux expects to finish recruiting patients early in 2019.
With files from Melanie Glanz and Christine Birak