Background (Importance): Hip fractures in the elderly are the result of low energy trauma. These events are often associated with osteoporosis/low bone mass and other associated medical conditions that may increase the predisposition to falls. There are around 340,000 hip fracture patients per year in the United States. Most of these fractures occur in women older than 65 years. This is a significant problem with an annual worldwide incidence of approximately 1.7 million. The current increase in life expectancy suggests that the number of elderly individuals with chronic health conditions will increase. The number of people older than age 65 years is expected to increase from 37.1 million to 77.2 million by the year 2040. This suggests that the incidence of hip fractures is expected to increase, with an estimated 6.3 million hip fractures predicted worldwide by 2050. The surgical management of elderly patients with hip fractures is not standard. Even though there is significant evidence of the benefits of surgical repair within 24 hours related to a reduction of morbidity and mortality this is not universally performed among the hospitals in the United States.
Clinical Intervention: Hip repair within 24 hours
Background (Critical timing): Many experts advocate repairing hip fractures expeditiously—within 8 to 24 hours from admission to the hospital. In published series, patients who underwent surgery earlier had lower rates of nonunion, avascular necrosis of the femoral head, urinary tract infections, decubitus ulcers, pneumonia, venous thromboembolism, and death, and better long-term functional status than did those who underwent surgery later. In addition, delaying surgery prolongs the patient's pain and suffering. In a recent prospective cohort study of 1,206 patients, those who underwent surgery within 24 hours had significantly fewer days of severe and very severe pain and shorter lengths of hospital stay. Higher pain ratings in patients with hip fracture are associated with longer postoperative lengths of stay, delayed postoperative rehabilitation, and increased risk of delirium, which increases mortality and complications in elderly hospitalized patients.
Do professional bodies, guidelines or other normative bodies support the use of this intervention? Many hospitals already use 24h as the cutoff.
To what extent is this evidence-based practice underutilized? Is this intervention being used in some settings but not generally? Is it available only to some patients defined by socio-economic status, geography, or insurance type?
Despite the current evidence that supports that hip fracture surgery time is associated with better outcomes, the practice is not universal. Also, there are limitations associated with hospital resources and practices.
What are the health status consequences of this failure to use this intervention? In terms of morbidity and mortality? In terms of economic productivity? Educational attainment? Costs?
Higher pain ratings in patients with hip fracture are associated with longer postoperative lengths of stay, delayed postoperative rehabilitation, and increased risk of delirium, which increases mortality and complications in elderly hospitalized patients.