Reports From the Field

A Preoperative Transthoracic Echocardiography Protocol to Reduce Time to Hip Fracture Surgery

Journal of Clinical Outcomes Management. 2021 January;28(1):27-34 | 10.12788/jcom.0034

Author(s):

Benjamin R. Oldach, DO, MPH

Kelly Irwin, DO

Michelle Pershing, PhD

Victoria A. Zigmont, PhD, MPH

Gregg M. Gascon, PhD, CHDA

Robert Skully, MD

PDF Download

References

1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573-1579.

2. Lewiecki EM, Wright NC, Curtis JR, et al. Hip fracture trends in the United States 2002 to 2015. Osteoporos Int. 2018;29:717-722.

3. Colais P, Di Martino M, Fusco D, et al. The effect of early surgery after hip fracture on 1-year mortality. BMC Geriatr. 2015;15:141.

4. Nyholm AM, Gromov K, Palm H, et al. Time to surgery is associated with thirty-day and ninety-day mortality after proximal femoral fracture: a retrospective observational study on prospectively collected data from the Danish Fracture Database Collaborators. J Bone Joint Surg Am. 2015;97:1333-1339.

5. Judd KT, Christianson E. Expedited operative care of hip fractures results in significantly lower cost of treatment. Iowa Orthop J. 2015;35:62-64.

6. Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182:1609-1616.

7. Ryan DJ, Yoshihara H, Yoneoka D, et al. Delay in hip fracture surgery: an analysis of patient-specific and hospital-specific risk factors. J Orthop Trauma. 2015;29:343-348.

8. Ricci WM, Brandt A, McAndrew C, Gardner MJ. Factors affecting delay to surgery and length of stay for patients with hip fracture. J Orthop Trauma. 2015;29:e109-e114.

9. Hagino T, Ochiai S, Senga S, et al. Efficacy of early surgery and causes of surgical delay in patients with hip fracture. J Orthop. 2015;12:142-146.

10. Rafiq A, Sklyar E, Bella JN. Cardiac evaluation and monitoring of patients undergoing noncardiac surgery. Health Serv Insights. 2017;9:1178632916686074.

11. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e77-e137.

12. Basu N, Natour M, Mounasamy V, Kates SL. Geriatric hip fracture management: keys to providing a successful program. Eur J Trauma Emerg Surg. 2016;42:565-569.

13. Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014;28:e49-e55.

14. Tai YJ, Yan B. Minimising time to treatment: targeted strategies to minimise time to thrombolysis for acute ischaemic stroke. Intern Med J. 2013;43:1176-1182.

15. Larsson G, Stromberg RU, Rogmark C, Nilsdotter A. Prehospital fast track care for patients with hip fracture: Impact on time to surgery, hospital stay, post-operative complications and mortality a randomised, controlled trial. Injury. 2016;47:881-886.

16. Bohm E, Loucks L, Wittmeier K, et al. Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority. Can J Surg. 2015;58:257-263.

17. Ventura C, Trombetti S, Pioli G, et al. Impact of multidisciplinary hip fracture program on timing of surgery in elderly patients. Osteoporos Int J. 2014;25:2591-2597.

18. Luttrell K, Nana A. Effect of preoperative transthoracic echocardiogram on mortality and surgical timing in elderly adults with hip fracture. J Am Geriatr Soc. 2015;63:2505-2509.

From Dignity Health Methodist Hospital of Sacramento Family Medicine Residency Program, Sacramento, CA (Dr. Oldach); Nationwide Children’s Hospital, Columbus, OH (Dr. Irwin); OhioHealth Research Institute, Columbus, OH (Dr. Pershing); Department of Clinical Transformation, OhioHealth, Columbus, OH (Dr. Zigmont and Dr. Gascon); and Department of Geriatrics, OhioHealth, Columbus, OH (Dr. Skully).

Abstract

Objective: An interdisciplinary committee was formed to identify factors contributing to surgical delays in urgent hip fracture repair at an urban, level 1 trauma center, with the goal of reducing preoperative time to less than 24 hours. Surgical optimization was identified as a primary, modifiable factor, as surgeons were reluctant to clear patients for surgery without cardiac consultation. Preoperative transthoracic echocardiogram (TTE) was recommended as a safe alternative to cardiac consultation in most patients.

Methods: A retrospective review was conducted for patients who underwent urgent hip fracture repair between January 2010 and April 2014 (n = 316). Time to medical optimization, time to surgery, hospital length of stay, and anesthesia induction were compared for 3 patient groups of interest: those who received (1) neither TTE nor cardiology consultation (ie, direct to surgery); (2) a preoperative TTE; or (3) preoperative cardiac consultation.

Results: There were significant between-group differences in medical optimization time (P = 0.001) and mean time to surgery (P < 0.001) when comparing the 3 groups of interest. Patients in the preoperative cardiac consult group had the longest times, followed by the TTE and direct-to-surgery groups. There were no differences in the type of induction agent used across treatment groups when stratifying by ejection fraction.

Conclusion: Preoperative TTE allows for decreased preoperative time compared to a cardiology consultation. It provides an easily implemented inter-departmental, intra-institutional intervention to decrease preoperative time in patients presenting with hip fractures.

Keywords: surgical delay; preoperative risk stratification; process improvement.

Hip fractures are common, expensive, and associated with poor outcomes.^1,2 Ample literature suggests that morbidity, mortality, and cost of care may be reduced by minimizing surgical delays.^3-5 While individual reports indicate mixed evidence, in a 2010 meta-analysis, surgery within 72 hours was associated with significant reductions in pneumonia and pressure sores, as well as a 19% reduction in all-cause mortality through 1 year.⁶ Additional reviews suggest evidence of improved patient outcomes (pain, length of stay, non-union, and/or mortality) when surgery occurs early, within 12 to 72 hours after injury.^4,6,7 Regardless of the definition of “early surgery” used, surgical delay remains a challenge, often due to organizational factors, including admission day of the week and hospital staffing, and patient characteristics, such as comorbidities, echocardiographic findings, age, and insurance status.^7-9

Among factors that contribute to surgical delays, the need for preoperative cardiovascular risk stratification is significantly modifiable.¹⁰ The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force risk stratification framework for preoperative cardiac testing assists clinicians in determining surgical urgency, active cardiac conditions, cardiovascular risk factors, and functional capacity of each patient, and is well established for low- or intermediate-risk patients.¹¹ Specifically, metabolic equivalents (METs) measurements are used to identify medically stable patients with good or excellent functional capacity versus poor or unknown functional status. Patients with ≥ 4 METs may proceed to surgery without further testing; patients with < 4 METs may either proceed with planned surgery or undergo additional testing. Patients with a perceived increased risk profile who require urgent or semi-urgent hip fracture repair may be confounded by disagreement about required preoperative cardiac testing.

At OhioHealth Grant Medical Center (GMC), an urban, level 1 trauma center, the consideration of further preoperative noninvasive testing frequently contributed to surgical delays. In 2009, hip fracture patients arriving to the emergency department (ED) waited an average of 51 hours before being transferred to the operating room (OR) for surgery. Presuming prompt surgery is both desirable and feasible, the Grant Hip Fracture Management Committee (GHFMC) was developed in order to expedite surgeries in hip fracture patients. The GHFMC recommended a preoperative hip fracture protocol, and the outcomes from protocol implementation are described in this article.