Two admission pathways for elderly patients with hip fracture

Godin, Jonathan A.; Brown, Christopher; Mardam-Bey, Sami W.; Deshpande, Chetan; Manson, Maria; Boling, John; Olson, Steven A.; Zura, Robert B.

doi:10.1097/bco.0000000000000255

Cited by 5 publications

(8 citation statements)

References 21 publications

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“… 37 Two studies reported no association between clinical pathway and time to surgery after hip fracture. 42 43 We identified nine factors with proposed mechanisms underlying the association between system factors and timing of surgery after hip fracture ( table 3 , figure 2 ). Resource availability was the proposed mechanism for the association between out-of-hours admission, 28 32 medical test, 22 prioritisation, 22 surgery type, 34 insurance status 30 and hospital type and region 30 with time to surgery after hip fracture.…”

Section: Resultsmentioning

confidence: 99%

Patient and system factors of time to surgery after hip fracture: a scoping review

2017

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ObjectivesIt is disputed whether the time a patient waits for surgery after hip fracture increases the risk of in-hospital death. This uncertainty matters as access to surgery following hip fracture may be underprioritised due to a lack of definitive evidence. Uncertainty in the available evidence may be due to differences in characteristics of patients, their injury and their care. We summarised the literature on patients and system factors associated with time to surgery, and collated proposed mechanisms for the associations.MethodsWe used the framework developed by Arksey and O’Malley and Levac et al for synthesis of factors and mechanisms of time to surgery after hip fracture in adults aged >50 years, published in English, between 1 January 2000 and 28 February 2017, and indexed in MEDLINE, EMBASE, CINAHL or Ageline. Proposed mechanisms for reported associations were extracted from discussion sections.ResultsWe summarised evidence from 26 articles that reported on 24 patient and system factors of time to surgery post hip fracture. In total, 16 factors were reported by only one article. For 16 factors we found proposed mechanisms for their association with time to surgery which included surgical readiness, available resources, prioritisation and out-of-hours admission.ConclusionsWe identified patient and system factors associated with time to surgery after hip fracture. This new knowledge will inform evaluation of the putative timing–death association. Future interventions should be designed to influence factors with modifiable mechanisms for delay.

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Section: Resultsmentioning

confidence: 99%

Patient and system factors of time to surgery after hip fracture: a scoping review

2017

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“…190 studies underwent full-text review, and 69 studies were selected for final analysis (Figure and eAppendix 3 in the Supplement). Among the final 69 improvement programs, 49 programs significantly decreased TTS and 20 programs did not. Delayed TTS cutoffs were most often defined dichotomously as more than 24 hours, more than 36 hours, more than 48 hours, or more than 72 hours, although some studies collected continuous data.…”

Section: Resultsmentioning

confidence: 90%

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures

et al. 2022

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IMPORTANCE Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient-and systemlevel factors. OBJECTIVETo catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. EVIDENCE REVIEW A systematic review was conducted per the Preferred Reporting Items forSystematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.FINDINGS Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. CONCLUSIONS AND RELEVANCEIn this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

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“…[10][11][12] To address delays in TTS, diverse strategies, including targeted resource management, [13][14][15] comanagement programs between orthopedics and medicine or geriatrics, [16][17][18][19] documented protocols, 20,21 and financial incentives, [22][23][24] have been implemented with varying levels of success. 17,19,[25][26][27][28] Challenges in implementing evidence-based improvement interventions include organizational knowledge, medical socialization (ie, medical decision-making based on knowledge from trusted peers or mentors rather than directly from peer-reviewed evidence), and patient and surgeon factors, among others. 29,30 To be successful, evidence-based improvement interventions should be tailored to the context in which they will be implemented; however, there is currently no nationallevel guidance for how hospitals can improve TTS based on their own context.…”

Section: Introductionmentioning

confidence: 99%

“…Facility-level factors, including larger hospital size, annual surgical volume, and a medical optimization protocol, have also been associated with delays . To address delays in TTS, diverse strategies, including targeted resource management, comanagement programs between orthopedics and medicine or geriatrics, documented protocols, and financial incentives, have been implemented with varying levels of success …”

Section: Introductionmentioning

confidence: 99%

Contextual Determinants of Time to Surgery for Patients With Hip Fracture

Welch,

Gomez,

Chatterjee

et al. 2023

JAMA Netw Open

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ImportanceSurgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.ObjectiveTo identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.Design, Setting, and ParticipantsThis qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.Main Outcomes and MeasuresThematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).ResultsA total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.Conclusions and RelevanceIn this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

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Two admission pathways for elderly patients with hip fracture

Cited by 5 publications

References 21 publications

Patient and system factors of time to surgery after hip fracture: a scoping review

Patient and system factors of time to surgery after hip fracture: a scoping review

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures

Contextual Determinants of Time to Surgery for Patients With Hip Fracture

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