Page last updated: 27-MAY-2008

‘Clinical Decision-Making: Is the Patient Fit for Theatre?’ is a report from the Scottish Hip Fracture Audit’ presenting data on the outcome of the preoperative assessment process of hip fracture patients in Scotland over 11 months in 2007.  It has identified variations in practice, common reasons for delays, and potential areas for improvement.  Hospitals will be able to review their practice against others and the Scottish average.

 

Surgical teams aim to operate promptly on hip fracture patients to reduce pain and distress. Delay may also be associated with deterioration in physical condition. However, it may also be appropriate to postpone patients who have reversible medical conditions to allow further investigation or treatment, and safer surgery.

 

The Scottish Government Health Delivery Directorate introduced a target of surgery within 24 safe operating hours by December 2007, subject to medical fitness. 96% of all hip fractures audited by the Scottish Hip Fracture Audit (SHFA) in 2006 were treated surgically, but 11% of these were excluded from Time to Theatre targets because they were documented as medically unfit for immediate surgery. This proportion varied between hospitals.

 

This time-limited audit looked at whether the variation in postponement rates for medical reasons between hospitals occurred as a result of differences in patient casemix between hospitals, or whether the differences reflect variation in anaesthetic and surgical management. 

 

From February to December 2007 medical staff (predominantly anaesthetists) from all 21 mainland orthopaedic units which carry out hip fracture surgery in Scotland were asked to complete an assessment sheet describing hip fracture patients’ fitness for theatre, or documenting their reasons for postponement and subsequent plans of action.

 

There may be complex or unaudited reasons for the differences in the results from this audit but it allows us to compare similarities and differences in current clinical practice. We welcome the opportunity to work with all those who care for this vulnerable group of patients to identify further the underlying problems and help them develop solutions and to change practice where necessary.

5447 hip fractures (92% of Scottish total) were audited between February and December 2007 – 1254 (23%) patients were determined to be “medically unfit” and surgery postponed at first theatre assessment. 

 

Patients with major medical abnormalities were more likely to be postponed than those with minor or no abnormalities.

 

Although 53% of patients postponed with a major abnormality had this problem resolved before going to theatre, 9% of postponed patients developed or were diagnosed with new abnormalities following postponement.

 

Rates of postponement at first assessment varied between 13 and 37% between hospitals after casemix adjustment, reflecting preferences in anaesthetic and surgical management.

 

Whilst delay may not unequivocally impact on mortality, surgical teams should aim for early surgery on compassionate grounds (less pain and distress for patients/carers). Hip fracture patients frequently have co-existing medical illnesses and the level of investigation and treatment required to enable safe operation will always require clinical judgement. Delay to allow this may be entirely appropriate.  Although it may be safer to treat these conditions preoperatively to reduce operative risks, delay may also be associated with deterioration in physical condition.

 

There may be complex or unaudited reasons for the differences in the results from this audit but it allows us to compare similarities and differences in current clinical practice. We welcome the opportunity to work with all those who care for this vulnerable group of patients to identify further the underlying problems and help them develop solutions and to change practice where necessary.

 

 

We report on data from 5447 patients, representing 92% of all hip fractures admitted in Scotland during this eleven-month period.  Perth had variable participation in the audit, but submitted data from 66% of patients from September to December. Resource issues prevented collection of up to two months data from seven other hospitals. A small number of other patients were excluded who were managed conservatively by surgeon’s choice or refused surgery (88), notes were unavailable (7) or the patient died soon after admission (7).

 

Medical staff completed assessment forms documenting patients’ fitness for theatre for 56% of all hip fracture patients. Trained SHFA Local Audit Co-ordinators (LACs) completed the remainder from casenotes. LACs also collected further routine data  (observations, blood tests, etc. available at the time of assessment) from all patients. Although LACs were more likely to have to complete assessment forms for patients who were postponed or who had major medical abnormalities, this was associated with casemix differences between Medical- and LAC-completed assessment forms and is not thought to influence other results presented in this report. 

 

 

Documented medical abnormalities recorded by routine investigations (e.g. heart rhythm, ECG and CXR) and observations (blood results, vital signs), were used to confirm whether postponement rates increased with medical co-morbidity. These data were defined as major or minor abnormalities.  This classification originates from McLaughlin et al (2006) who defined eleven classes of preoperative clinical abnormalities (major and minor) that were associated with poor postoperative outcomes in a group of hip fracture patients. They concluded that major clinical abnormalities should be corrected (if possible) prior to surgery, although 15% of patients still proceeded to surgery with major abnormalities. To allow comparison, SHFA used McLaughlin definitions as far as possible to identify patients with preoperative abnormalities, their associated rates of postponement and correction prior to surgery.

 

5447 hip fractures (92% of Scottish total) were audited. 1254 (23%) hip fracture patients were determined to be “medically unfit” for theatre and surgery postponed at first theatre assessment.

 

Coagulation/haematology (5% of all patients), cardiac (5%), respiratory/infection (4%) and combined medical problems (4%) were the commonest specific reasons listed for postponement, but unavailability of information (past medical history, casenotes, routine results, etc) accounted for another 3% of patients being postponed.

 

Postponements due to lack of information were resolved most quickly, whilst patients with coagulation disturbance, respiratory infection and combined problems resulted in the longest postponements to surgery.

Preoperative Medical Abnormalities - Frequency and Associated Postponement

 

58% of 941 patients with one or more major abnormalities were postponed at first assessment, compared to 25% of 1384 patients with minor abnormalities.

 

361 (12%) patients with no documented abnormality were postponed at first theatre assessment. Many of these postponements were associated with lack of information, observations close to abnormal limits, or other problems not specifically audited by SHFA.

 

53% Of the 548 patients with a major abnormality who were postponed at first theatre assessment had this problem resolved before they went to theatre. Rates of resolution depended on the nature of the abnormality (Table 3) – for example, 95% of patients with coagulation disturbance were improved significantly when re-assessed, but only 36% of patients with renal impairment as measured by creatinine levels exceeding 225 umol/L had these levels reduced.

 

126 patients (9% of all postponed patients) had additional major abnormalities identified whilst being postponed prior to surgery. At least 74% of these developed during postponement. Delay may have contributed to these deteriorations.

Delays by Hospital

Rates of postponement at first assessment varied between 12 and 40% between hospitals. Hospitals with high rates of postponement for patients with major abnormalities were also more likely to postpone more patients with minor abnormalities. This range of hospital postponement rates was only slightly lowered following casemix adjustment.

 

There was no indication that hospitals that postponed more patients reduced overall delay by taking postponed patients to theatre more quickly.

 

Use of specialised investigations differed between hospitals. 4.3% of all patients were planned to have echocardiography following first assessment, but this varied between 0 and 15% between hospitals.

Bigger Picture

 

Despite a concurrent target for reducing hip fracture patient times to theatre if medically fit, there was no indication nationally that the proportion of patients delayed as medically unfit increased from 2006, or during 2007 as pressure to meet the target increased towards the end of the year.

 

Nationally, time to theatre was reduced for target (medically fit) patients, with no consequential adverse increase in waiting times of patients who were medically unfit.

 

Medically fit patients who missed the target for surgery were not further postponed more than necessary: less than 2% were delayed beyond 3-days post-admission, and only 15% of these were associated with theatre unavailability.

 

Mortality rates remained at pre-target levels.

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CMO
Jill Vickerman in the SG's Scottish Health Advisory Service
Alex Bowerman of the SG’s Health Delivery Directorate
Chief Execs of contributing hospitals/boards
Anaesthetic leads in contributing hospitals

 

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