Canadian hospitals take too long to fix broken hips
As our population ages, more Canadians need surgery to fix broken hips. A new study published earlier today in the Canadian Medical Association Journal has uncovered a problem that could endanger their health.
When you break your hip, most guidelines say the hip should be repaired within the first 24 hours.
Researchers from the Institute for Clinical Evaluative Sciences in Toronto looked at more than 42,000 patients age 45 and up who had broken hips repaired at 72 hospitals in Ontario between 2009 and 2014.
The average wait time for surgery was just under 39 hours. A third of the patients got their hip fractures repaired within the recommended 24-hour window; two-thirds did not.
There are several reasons why doctors and hospitals aren't fixing broken hips as fast as recommended.
Several factors were uncovered by the researchers. People who break their hips tend to be older and tend to have lots of other medical problems that could be made worse by the surgery and by the anesthesia.
In general, such patients are seen by an internist and by an anesthesiologist who make recommendations regarding their perioperative care. The study found that it took close to seven hours for an internist and close to six hours for an anesthesiologist to see the patient.
If either doctor recommended an echocardiogram to take a look at the patient's heart, organizing that test added considerable time to the wait for surgery.
Patients who arrived at night waited longer for surgery. In some cases, patients were brought to a hospital that didn't fix broken hips. Some of the biggest delays were caused by the need to transfer the patient elsewhere.
We hear a lot in the news about a lack of hospital beds, but this was not a factor in the study. Three quarters of the patients were admitted within six hours of arriving in the ER.
From what I've seen as an ER physician, the time to fix broken hips is highly variable. Overall, I have seldom seen an urgency on the part of orthopedic surgeons to fix broken hips as soon as possible.
Waiting for hip surgery
Nobody gets excited if a hip that is broken on a Monday gets fixed on a Wednesday. Doctors who work in hospitals expect there to be delays in obtaining tests and consultations with colleagues.
The general view they hold is that it's better to be safe than sorry. To them, that means asking an internist or a cardiologist to do a thorough going over to make sure the patient doesn't have some underlying heart condition that major surgery is likely to make worse.
Still, the delay in getting hip surgery has consequences. The later the hip repair, the more likely the patient is to die.
In the study published in CMAJ, more than five per cent of the patients who had their hip fixed less than 24 hours following the break died within one month. When the hip was fixed more than 24 hours later, more than six per cent died within a month.
A review article found that patients who had hip surgery more than 24 hours following the fracture also had higher rates of life-threatening complications such as heart attacks, pulmonary embolism, and pneumonia.
A British study published in 2017 found that eight per cent more patients died after 30 days if they were operated on between 24 and 36 hours after admission to hospital. That particular delay was thought to have caused 670 excess deaths in four years.
The authors of the study say that hospitals should develop specific policies and timelines for consultations with internists and tests such as echocardiograms.
They say it's possible to speed up transfers from rural hospitals to larger ones that fix hips. They pointed to Manitoba, where rural hospitals have been matched to surgical hospitals that agree to accept patients from the rural hospital regardless of the availability of beds.
There is a tendency at some hospitals for orthopedic surgeons to allow people with fractured hips to wait until they complete their list of non-urgent scheduled operations.
It's not good to postpone those operations anymore than it's good to delay fixing hip fractures. Having a system that guarantees that non-urgent patients who get bumped can get their surgery later the same day would help.
Anyway you look at it, speeding things up requires some new thinking.