By John T Williams and Ajeet Kumar
Queen Elizabeth Hospital, London
Corresponding author e-mail: [email protected]
Published 30 April 2020
The COVID-19 pandemic has led to unprecedented emergency measures introduced in NHS hospitals in the United Kingdom1-3, disrupting many usual treatment pathways and protocols. Measures include staff redeployment, cancellation of elective services and repurposing of theatre and recovery areas into intensive care facilities. The purpose of this study is to assess the impact of the measures placed on our hospital trust on our ability to deliver hip fracture care.
There are approximately 80,000 hip fractures in the UK each year which make up a significant proportion of the trauma workload of an average orthopaedic unit4. Hip fractures are the subject to NICE guidance and a Best Practice Tariff is applied for performance, with individual hospital and national outcomes recorded on the National Hip Fracture Database4,5. It is widely recognised that expedited surgical management is associated with a reduction in morbidity and mortality6,7, which is reflected in the NICE guidance that surgery should be performed on the day of, or after, admission (or within 36 hours for the BPT).
In our district general hospital, 308 hip fractures were treated in 2019 with an average time to surgery of 29.7 hours4. There is usually provision of a daily two-session trauma list, including at weekends. In response to the COVID-19 pandemic our hospital has ceased provision of dedicated trauma lists due to redeployment of anaesthetic and theatre staff. Instead, a daily emergency operating list is shared between surgical specialties including general surgery, urology and orthopaedics. This study aims to assess the potential detrimental impact of these measures on hip fracture care in our hospital.
We have collected data on two separate cohorts of hip fracture patients to compare performance before and after introduction of COVID-19 contingency measures. Data was collected retrospectively for 15 consecutive patients in January 2020 (“pre-COV”) and also for 15 consecutive patients from mid-March 2020, after introduction of COVID-19 contingency plans (“post-COV”). Pre-COV and post-COV groups were admitted over a 16 and 19-day period, respectively. Data on demographics, admission and surgery time, length of stay and morbidity and mortality were compiled from computer records. This was a pragmatic study and all hip fractures were included with no exclusion criteria.
Cohorts were well age and sex matched (pre-COV: F:M 13:2, 86.6 years; post-COV F:M 12:3, 81.5 years). All patients underwent surgical treatment of their hip fracture except one patient from the post-COV group who died prior to theatre. Time to theatre for the pre-COV cohort was a mean of 21.8 hours (range 8 - 48 hours), compared to a mean time of 35.8 hours (8.5 – 79 hours) for the post-COV cohort. One patient in the pre-COV group waited longer than 36 hours compared to 5 in the post-COV group. Length of stay was 11.7 days for pre-COV (all data available) and 6.2 days for post-COV (data complete for six patients).
There was one incidence of post-operative mortality in the pre-COV group at day 3 (6.6%), with 2 further re-admissions for pneumonia. In the post-COV group to date, there have been two mortalities (13.3%) and one dislocation treated with closed reduction. No patients in the pre-COV group were tested for COVID-19; four patients were tested from the post-COV group of which none were positive.
The results of this small study suggest that COVID-19 contingency measures are having a detrimental effect on our ability to provide timely hip fracture care. There is a concerning 64% increase in time taken from admission to perform surgery on hip fracture patients. At this stage there is insufficient follow up data to comment on the clinical sequelae of this delay. As aforementioned, delays to surgical care are widely known to be associated with poorer outcomes and we suspect longer follow up will unfortunately bear this out in our cohort. In any case, an increase in time spent in bed with a painful fractured hip is distressing for patients and challenging for nursing staff.
Length of stay interestingly is shorter in the post-COV group, which may suggest a greater emphasis on expediting discharge to avoid contracting COVID-19 in hospital. Of course, the incomplete nature of the post-COV data will bias toward earlier discharge as those results become available first. Neither group had a positive COVID-19 case which reduces the possibility of concomitant infection skewing outcome data.
The length of follow up in the post-COV group is a significant limitation in observing potential clinical effects of the COVID-19 contingency plans, however the rapidly evolving nature of the situation warrants early reporting of the concerning effect seen on delay to surgery.
Reducing the delay to hip fracture surgery is highly desirable but will prove challenging within the current capacity constraints and new clinical priorities that COVID-19 has presented. Close communication with other clinical specialities that share emergency operating capacity is needed to ensure appropriate prioritisation is appointed to hip fracture patients. It is likely similar delays to hip fracture treatment are being experienced by colleagues across the UK and internationally. This group of vulnerable patients will undoubtedly make up some of the indirect victims of the COVID-19 pandemic.
- British Orthopaedic Association (2020). Emergency BOAST: Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. Available at: https://www.boa.ac.uk/resources/covid-19-boasts-combined.html.
- NHS England, (2020). Clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic. Available at: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0274-Specialty-guide-Orthopaedic-trauma-v2-14-April.pdf.
- NHS England, (2020). Clinical guide for the perioperative care of people with fragility fractures during the coronavirus pandemic. Available at: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0086_Specialty-guide-_Fragility-Fractures-and-Coronavirus-v1-26-March.pdf.
- Royal College of Physicians (2019). National Hip Fracture Database annual report 2019. London: RCP, 2019.
- National Institute for Clinical Excellence (2017). Hip Fracture: Management CG124. London: NICE, June 2017.
- Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep. 2018;8(1):13933.
- Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, Bhandari M. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182(15):1609-16.