Length of hospital stay after hip fracture
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h823 (Published 24 February 2015) Cite this as: BMJ 2015;350:h823
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As an Orthopaedic trainee I read Professor Cram's editorial and Nordström et als paper with interest. However I was struck by an assumption made in the editorial that intramedullary nailing is performed for patients with hip fractures who have significant comorbidities, whereas healthier patients receive arthroplasty. This would suggest that all hip fractures are the same. The morphology of a neck of femur fracture largely dictates the operative management which can be performed, and we commonly describe these fractures as either intra or extra capsular fractures. Broadly speaking operative management can be either fixation or replacement, with either a hemi or total hip arthroplasty. Due to the risk of avascular necrosis and re-operation for failure of fixation it would be inappropriate to suggest that intramedullary nailing was only performed due to the patients poor functional status. Although there was an association with a higher mortality for hip fractures managed with intramedullary nailing the answer is not to perform more arthroplasty as again this would not be appropriate for many of the fractures morphology. Perhaps the more interesting question is why do patients with poorer functional status more commonly suffer extra rather than intra-capsular fractures.
Competing interests: No competing interests
Re: Length of hospital stay after hip fracture
Having formerly nursed patients with hip fractures I was surprised in reading that earlier admission is associated with increased risk of death, as the patients that stayed longer tended to be more elderly. The discussion seems to focus on the medical side of things, but what is the interaction with the social side? My ideas are narrowed by lack of medical knowledge and being limited in experience to predominantly elderly patients, but perhaps relative degrees monitoring of patients once they are discharged into the community could have an effect.
Following a hip fracture the patient needs to undergo physiotherapy to rebuild their strength, and undergo occupational therapy assessments to see if they will be able to cope at home. A hip fracture can often mark the transition for someone from living independently to relying on care. The result of the prior two sentences is that, in my analogous experience, the patients discharged less than ten days were younger and more independent, so would presumably go on to living normal life without medical surveillance.
Admittedly, patients that stayed longer had complications such as infections, poorly healing wounds, blood loss and dementia exacerbated from anaesthetic, so perhaps it was beneficial that these complications where picked up during their longer stay, such that they did not occur post discharge.
The other patients that stayed longer where the ones that needed more physiotherapy to rebuild their strength and the administrative side of these patients discharge took longer due to care services needing to be put in place. Perhaps these later patients, who have a longer hospital stay, could have reduced mortality from being under ‘medical surveillance’ in the community as they then go on to receiving care rather than living independently. It would be interesting to see the impact of post discharge levels of surveillance on mortality.
Competing interests: No competing interests