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Abstract

Introduction

The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.

Materials and Methods

Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.

Results

Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.

Conclusion

A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Keywords

hip fracture echocardiogram time to surgery arthroplasty fixation

Introduction

Hip fractures remain a major public health concern as a result of the aging population and recent growth in elderly populations.¹ From 2010 to 2020, there was a 4.7% increase (18.2% to 22.9%) in people over the age of 60 in the United States.^2,3 Similarly, the proportion of the US population expected to be older than 60 in 2050 is projected to double from the population seen in 2010 (40.2 million to 88.5 million Americans).⁴ Among elderly patients, hip fractures are more common and especially more likely to result in morbidity, mortality, and loss of independence.^5,6 Additionally, older patients often also have associated medical comorbidities that can lead to a worse prognosis.^7,8 As such, hip fracture incidence has increased in recent years, highlighting the importance of proper care and management of patients in this particular population.⁹ Operative treatment via fixation or arthroplasty remains the standard of care for the majority of patients who sustain hip fractures.¹⁰

Cardiovascular disease is highly correlative to age, and therefore very prevalent in older patient populations.^11,12 It is estimated roughly 70–75% of individuals 65 and older have some form of cardiovascular disease, with 82% of all deaths in people aged 65 or older being attributable to cardiovascular disease.^13,14 In addition to the high prevalence and associated risk of morbidity and mortality for patients with cardiovascular disease at baseline, cardiac events are currently one of the most common complications after hip fracture surgery.¹⁵

Transthoracic echocardiogram (TTE) is a noninvasive imaging modality used to assess the structure and function of the heart. Given the operator dependent nature of obtaining the imaging and routine need for cardiologist evaluation, utilization of a preoperative TTE has been demonstrated to prolong time to surgery and subsequently increase perioperative mortality risk and associated healthcare costs in hip fracture patients.^16,17 Despite this, many physicians routinely utilize a preoperative TTE for perioperative assessment of moderate to higher risk cardiovascular patients in hopes of improved medical optimization. This may include patients with moderate or severe clinical valvular pathology (stenosis, regurgitation) and recent clinical symptoms or no recent TTE, and other high-risk patients with poor functional capacity deemed to benefit from cardiac stress testing in particular. Both are recommended to undergo preoperative TTE in accordance with guidelines constructed by the American College of Cardiology/American Heart Association (ACC/AHA).^18,19 These have shown to be effective, especially in orthopedic patients, although there remain challenges in the proper adherence and execution across different specialties.^20,21 Therefore, the implementation of standardized protocol to appropriately abide by these guidelines and assess preoperative cardiovascular risks remains of interest.

The purpose of this study was to assess the hospital quality measures and clinical outcomes of patients undergoing hip fracture repair or arthroplasty surgery before and after implementation of an anesthesiology department protocol assigning the Hospitalist co-management service to determine need for a preoperative transthoracic echocardiogram, compared to the prior arrangement where the need for preoperative TTE evaluation was at the discretion of the patient’s medical doctor or attending anesthesiologist providing anesthesia during the case.

Materials and Methods

A consecutive series of 1002 patients presenting with a hip fracture [AO/OTA 31A, 31B, and 32A-C] between September 2015 and June 2021 were evaluated at one orthopedic specialty hospital. Treatment options for each patient included arthroplasty or operative fixation. Demographics, injury details, hospital quality measures, and outcomes were collected for each patient. Patients were excluded if they underwent non-operative management.

Prior to the new policy, individual anesthesiologists, medical doctors and or private cardiologists would make recommendations regarding the need for a pre-operative TTE as part of the medical clearance prior to hip fracture surgery. On May 22, 2019, the Department of Anesthesiology developed and instituted a new policy that mandated the responsible co-managing hospitalist, with or without cardiology input, to provide the final decision for which patients would require a preoperative TTE as part of the medical optimization for each patient. Based on this new protocol, two cohorts, those who presented before the mandate (pre-protocol), those who presented after (post-protocol) were created.

The following baseline demographic data were collected: Age, sex, race, AO/OTA fracture classification, Glasgow Coma Score (GCS), Abbreviated Injury Score (AIS), ambulatory status before presentation, and medical comorbidities measured by the Charlson Comorbidity Index (CCI). Hospital quality measures collected included what type of fixation they received, time to surgery, length of stay, need for a higher level of care, and whether they were discharged home or not (home discharge including home independently and home with home health aide/assistance). Outcomes collected included inpatient and 30-day mortality, as well as inpatient complications. Complications collected include the development of sepsis, pneumonia, DVT/PE, myocardial infarction, acute renal failure, stroke, surgical site infection, decubitus ulcer, urinary tract infection (UTI), acute respiratory failure, anemia, or cardiac arrest. Finally, patients that underwent a preoperative transthoracic echocardiogram were collected.

Baseline demographics, injury details, hospital quality measures, and clinical outcomes were compared between the pre-protocol and post-protocol cohorts using chi-square tests, independent samples t-tests, and Mann–Whitney U tests with a Bonferroni adjusted alpha as appropriate. Multivariable analysis was completed using time to surgery as the dependent variable. Independent variables included age, female gender, high energy mechanism of injury (MOI), GCS, CCI, and whether the patient presented after the mandate was instituted (part of the post-protocol cohort).

Results

Between September 2015 and June 2021, 1002 patients aged 55 and older who sustained a hip fracture [AO/OTA fracture classifications: 31A, 31B, 32(A-C)] were seen within our urban tertiary care and orthopedic specialty hospital and enrolled in an IRB approved geriatric trauma database. Exclusion of patients managed non-operatively left a population of 968. Overall demographics demonstrated 68% female sex, a mean age of 79.9 (years) ± 10.21, mean GCS of 14.94 ± .34, mean CCI of 1.53 ± 1.86, mean AIS Head/Neck of .02 ± .22, mean AIS Chest of .01 ± .18, and mean AIS extremity/pelvis of 2.99 ± .10. Most common injury presentations included the following AO/OTA fracture classifications: 502 (52%) 31B and 449 (46%) 31A. Most common intervention chosen included: 355 (37%) were repaired with a short intramedullary nail (IMN) and 235 (24%) underwent a hemiarthroplasty (Table 1).

Table 1.

Demographics.

Demographic	Pre-Protocol	Post-Protocol	Overall	P Value
All Patients, n (%)	557	411	968
Age (y), mean ± std	80.52 ± 9.96	79.07 ± 10.49	79.90 ± 10.21	.029
Sex, n (%)				.234
Male	167 (30%)	138 (34%)	305 (32%)
Female	390 (70%)	273 (66%)	663 (68%)
Race, n (%)				.127
White	477 (86%)	338 (82%)	815 (84%)
Black	14 (3%)	12 (3%)	26 (3%)
Hispanic	13 (2%)	17 (4%)	30 (3%)
Asian	34 (6%)	18 (4%)	52 (5%)
Unknown	5 (1%)	7 (2%)	12 (1%)
Other	14 (3%)	19 (5%)	33 (3%)
Glasgow coma score, mean ± std	14.95 ± .34	14.93 ± .35	14.94 ± .34	.409
Charlson Comorbidity Index, mean ± std	1.53 ± 1.90	1.53 ± 1.82	1.53 ± 1.86	.979
AIS H/N, mean ± std	.02 ± .19	.02 ± .26	.02 ± .22	.575
AIS C, mean ± std	.01 ± .12	.02 ± .23	.01 ± .18	.230
AIS E/P, mean ± std	3.00 ± .08	2.99 ± .12	2.99 ± .10	.352
Ambulatory status, n (%)
Community ambulator	426 (76%)	288 (70%)	714 (74%)	.028
Household ambulator	112 (20%)	111 (27%)	223 (23%)	.012
Nonambulatory	19 (3%)	12 (3%)	31 (3%)	1.00
Fracture classification, n (%)				.552
31A	255 (46%)	194 (47%)	449 (46%)
31B	290 (52%)	213 (52%)	503 (52%)
32A	9 (2%)	3 (1%)	12 (1%)
32B	0 (0%)	0 (0%)	0 (0%)
32C	3 (1%)	1 (0%)	4 (0%)
Treatment, n (%)				.013
CRPP	62 (11%)	58 (14%)	120 (12%)
Hemiarthroplasty	134 (24%)	101 (25%)	235 (24%)
Total hip arthroplasty	66 (12%)	41 (10%)	107 (11%)
Long IMN	49 (9%)	44 (11%)	93 (10%)
Short IMN	200 (36%)	155 (38%)	355 (37%)
Sliding hip screw	46 (8%)	12 (3%)	58 (6%)	<.01

Note. AIS = Abbreviated Injury Score; IMN = intramedullary nail

Across both cohorts, the demographics were similar in regards to sex, race, GCS, CCI, AIS H/N, AIS C, AIS E/P, and AO/OTA fracture classification. Patients in the post-protocol cohort were younger (79.07 vs 80.52, P = .029), less likely to be a community ambulator (70% vs 76%, P = .028), and more likely to be a household ambulator (27% vs 20%, P = .012).

Hip fracture patients in the post-protocol cohort were 3.5x less likely to undergo a preoperative echocardiogram (10% vs 35%, P < .01), experienced a shorter time (days) to surgery (1.05 vs 1.47, P < .01), shorter average length (days) of stay (5.74 vs 6.70, P < .01), and were more likely to be discharged home (39% vs 28%, P < .01). Finally, patients in the post-protocol cohort experienced a lower inpatient risk of urinary tract infection (6% vs 11%, P < .01), and acute blood loss anemia (21% vs 36%, P < .01) (Table 2). The average number of cases each month with patients experiencing a time from admission to surgery >24 hours decreased from 5.6 to 3.4 in the post-protocol cohort (Figure 1).

Table 2.

Outcomes.

Outcome	Pre-Protocol	Post-Protocol	P Value
All patients, n (%)	557	411
Hospital quality measures, n (%)
Time to surgery (d), mean (SD)	1.47 ± 1.67	1.05 ± .96	<.01
LOS (d, *mean ± std)	6.70 ± 4.23	5.74 ± 3.60	<.01
Need for advanced level of care, n (%)	110 (20%)	74 (18%)	.494
Discharge home, n (%)	154 (28%)	159 (39%)	<.01
Preoperative echo, n (%)
Transthoracic echocardiogram	196 (35%)	41 (10%)	<.01
Mortality
Inpatient, n (%)	10 (2%)	3 (1%)	.155
Within 30 days, n (%)	22 (4%)	12 (3%)	.393
Complications, n (%)
Sepsis/septic shock	9 (2%)	6 (1%)	.850
Pneumonia	25 (4%)	14 (3%)	.397
Deep vein thrombosis/pulmonary embolism	18 (3%)	9 (2%)	.334
Myocardial infarction	6 (1%)	4 (1%)	.877
Acute renal failure/acute kidney injury	34 (6%)	32 (8%)	.295
Stroke	3 (1%)	1 (0%)	.479
Surgical site infection	0 (0%)	0 (0%)	-
Decubitus ulcer	10 (2%)	4 (1%)	.290
Urinary tract infection	61 (11%)	23 (6%)	<.01
Acute respiratory failure	37 (7%)	16 (4%)	.064
Anemia	201 (36%)	87 (21%)	<.01
Cardiac arrest	9 (2%)	2 (0%)	.101

Figure 1.

Control chart (c-chart) showing number of cases with time from admission to surgery >24 hours before and after the protocol demonstrating the decrease in mean number of cases >24 hours.

Multivariable analysis demonstrated age, female gender, high energy MOI, and GCS were not significant predictors for time to surgery. CCI (Beta: .082, 95% CI: .034 to .131, P < .01) and post-protocol presentation (Beta: −.410, 95% CI: −.591 to −.229, P < .01) were found to be significant predictors for time to surgery (Table 3).

Table 3.

Multivariable Regression for Time to Surgery.

Multivariable Analysis	Time to Surgery	P Value
Independent variables	Beta (95% CI)
Age	.006 (−.003, .015)	.170
Female gender	−.087 (−.280, .107)	.381
High energy mechanism of injury	−.124 (−.700, .452)	.673
Glasgow coma score	−.107 (−.368, .154)	.421
Charlson Comorbidity Index	.082 (.034, .131)	<.01
Post-protocol presentation	−.410 (−.591, −.229)	<.01

Discussion

In this study, we compared the hospital quality measures and outcomes, most notably time to surgery, length of stay, need for an advanced level of care, and discharge home, among hip fracture patients who presented before or after an anesthesiology department mandate co-managing hospitalists would provide the final decision for which patients should undergo a preoperative transthoracic echocardiogram (TTE). For those in the post-protocol cohort, there were significant decreases in the number of patients undergoing a preoperative TTE, a shorter time to surgery and length of stay with significant increases in the amount of people discharged home despite a greater proportion of home vs community ambulators. Similarly, the post-protocol cohort also had a lower complication risk for urinary tract infections, and acute blood loss anemia during their hospitalization. The latter is likely related to the quicker turn around to surgery, faster rehabilitation, and greater home discharge.

Preoperative echocardiograms in patients undergoing non-cardiac surgery are associated with increased time to surgery.^16,17 Preoperative TTEs are obtained as they can induce changes in medication, anesthetic choice, or illuminate need for additional workup.^22-24 Therefore, it is hard to determine whether the surgical delay is due to the TTE itself or these associated alterations to the patient’s management. It is likely a combination. However, the lower rate of TTE with no evidence of increased postoperative cardiac and non-cardiac complications likely represents a previous standard of “overtesting.” The common use of preoperative echocardiograms in population studies further demonstrates their widespread usage and the need to optimize their inclusion in a patient’s management.^25,26 Preoperative TTE may be necessary in certain patients; however, obtaining them in patients unnecessarily can increase time to surgery, length of stay, hospital costs, and potentially result in harm to the patient. Despite the ACC/AHA guidelines for perioperative assessment, studies have demonstrated that adherence to these guidelines can be a challenge when physicians from multiple specialties are involved in the care of the patient.^21,27,28 Our study demonstrated the institutional implementation of a set protocol for co-managing hospitalist faculty to determine which patients should undergo preoperative echocardiograms rather than leave it up to various stakeholders, helped minimize this negative impact.

Our study demonstrated a shorter average length of stay in the post-protocol cohort. It is important to note the backdrop of the COVID-19 pandemic in spring 2020 (many of the post-protocol cohort patients) placed a large burden on the healthcare system, resulting in worse outcomes and hospital quality measures, notably, increased mortality rates and longer hospitalizations.^29,30 The cause of this shortened length of stay is likely 3-fold. First, the protocol reduced the time to surgery which has been previously demonstrated to reduce overall length of stay and allow for more rapid rehabilitation and improvement in functional outcomes.^31-35 Second, patients who presented following the protocol experienced lower complication rates of UTIs and acute blood loss anemia. Studies demonstrate both hospital-acquired urinary tract infections and perioperative anemia prolong length of stay.^36,37 Therefore, our lower complication rate profile aligns with a shorter length of stay. Third, the protocol has caused a reduction in the amount of preoperative TTEs that are ordered, highlighting a more selective process that targets more at risk patients. This reduces the total burden of preoperative TTEs to allow for high-risk patients to get theirs much faster, and for lower-risk patients to proceed to surgery without the hassle of extra preoperative imaging. Our institution also has a standardized hip protocol that provides for a proactive assessment when needed as opposed to a reactive assessment based on what an anesthesiologist says preoperatively.

The proportion of patients undergoing a preoperative TTE dropped extensively in the post-protocol cohort with patients being 3.5x less likely to undergo a preoperative TTE. Similarly, the post-protocol cohort experienced a 1.5x higher rate of discharge home than pre-protocol cohort. While it is well documented that the COVID-19 pandemic played a role in the reduction of patients discharged to skilled nursing facilities instead of home, this is likely only part of the cause. The shortened time to surgery, length of stay, and lower complication rate both likely allowed for a larger proportion of patients to be discharged home.

The association between time to surgery and postoperative complications is well studied in the literature.³⁸ Our study demonstrated a significant reduction in the complication rates for urinary tract infections and acute blood loss anemia in all patients that presented after the protocol. Davis et al. also observed a trend towards lower UTI rates with shorter times to surgery, although this was not found to be significant.³⁹ Acute blood loss resulting in perioperative anemia without appropriate and timely management has been shown to worsen outcomes in hip fracture patients.⁴⁰ Our study demonstrates streamlined preoperative management allows for a shorter time to surgery and reduced risk of anemia, highlighting a proactive measure that can be taken to mitigate the effects of perioperative anemia on patient outcomes. As discussed previously, a faster time to surgery allows for more rapid rehabilitation prior to earlier discharge, lowering the risk of these common postoperative complications.

This study has several limitations. First, it is retrospective in nature. However, prospective study assessing the mandate’s impact is challenging as the mandate has already been instituted with downstream effects clearly apparent. Second, the onset and persistence of the COVID-19 pandemic during the post-protocol time period may have altered the hospital quality measures and outcomes seen within patients. The improved hospital quality measures and better outcomes seen in the post-protocol cohort demonstrate the pandemic’s impact may be minimal. Third, management changes prompted by each preoperative TTE are not characterized. This prevents an idea of what further inpatient management decisions can be expected in patients who undergo preoperative TTE. Fourth, there is no explicit recognition of which actions hospitalist faculty were more or less likely to pursue as compared to anesthesiologists or other providers, making it hard to generalize and compare to other protocols designed for streamlining the determination of which patients should undergo preoperative TTE. Fourth, there is no explicit recognition of cases where hospitalist faculty opted for a cardiology consultation to assist in the preoperative work up for the patient. The viewpoint of each specialty on certain patient presentations could help further illicit the improvements and changes in management that occurred as a result of the mandate.

In conclusion, our Department of Anesthesiology’s decision to implement the mandate authorizing co-managing hospitalist faculty to decide which patients required a preoperative TTE improved many aspects of our hip fracture patient’s care. We saw significant decreases in surgical wait times and length of stay, with a higher proportion of patient’s discharged home. While hard to directly attribute to the shorter admissions and faster time to surgery, patients presenting after the protocol also experienced a lower risk for common inpatient complications such as UTIs and anemia. The improvement seen by our institution may be an example for others to implement a similar protocol in hopes of offsetting the expected delays in surgery due to obtaining preoperative echocardiograms which can be unnecessary at times and potentially result in worsened perioperative outcomes.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sanjit Konda

David Furgiuel

Kenneth Egol

References

Veronese

Maggi

. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458-1460. doi:10.1016/j.injury.2018.04.015

US Census Bureau . Population 60 Years and over in the United State. Suitland-Silver Hill, MD: United States Census Bureau; 2011.

US Census Bureau . Population 60 Years and over in the United States. Suitland-Silver Hill, MD: United States Census Bureau; 2020.

Vincent

Velkoff

. The Next Four Decades: The Older Population in the United States: 2010 to 2050. Suitland-Silver Hill, MD: United States Census Bureau; 2010.

Lönnroos

Kautiainen

Karppi

, et al. Increased incidence of hip fractures. A population based-study in Finland. Bone. 2006;39(3):623-627. doi:10.1016/j.bone.2006.03.001

Silverman

Madison

. Decreased incidence of hip fracture in Hispanics, Asians, and blacks: California hospital discharge data. Am J Publ Health. 1988;78(11):1482-1483. doi:10.2105/ajph.78.11.1482

Braithwaite

Col

Wong

. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc. 2003;51(3):364-370. doi:10.1046/j.1532-5415.2003.51110.x

Holt

Smith

Duncan

Hutchison

Gregori

. Outcome after surgery for the treatment of hip fracture in the extremely elderly. J Bone Joint Surg Am. 2008;90(9):1899-1905. doi:10.2106/JBJS.G.00883

Parker

Johansen

. Hip fracture. BMJ. 2006;333(7557):27-30. doi:10.1136/bmj.333.7557.27

10.

Michael Lewiecki

Wright

Curtis

, et al. Hip fracture trends in the United States, 2002 to 2015. Osteoporos Int. 2018;29(3):717-722. doi:10.1007/s00198-017-4345-0

11.

North

Sinclair

. The intersection between aging and cardiovascular disease. Circ Res. 2012;110(8):1097-1108. doi:10.1161/CIRCRESAHA.111.246876

12.

Rodgers

Jones

Bolleddu

, et al. Cardiovascular risks associated with gender and aging. J Cardiovasc Dev Dis. 2019;6(2):E19. doi:10.3390/jcdd6020019

13.

Lloyd-Jones

Adams

, et al. Heart disease and stroke statistics--2009 update: a report from the american heart association statistics committee and stroke statistics subcommittee. Circulation. 2009;119(3):e21-181. doi:10.1161/CIRCULATIONAHA.108.191261

14.

Yazdanyar

Newman

. The burden of cardiovascular disease in the elderly: morbidity, mortality, and costs. Clin Geriatr Med. 2009;25(4):563-577. doi:10.1016/j.cger.2009.07.007

15.

Lawrence

Hilsenbeck

Noveck

Poses

Carson

. Medical complications and outcomes after hip fracture repair. Arch Intern Med. 2002;162(18):2053-2057. doi:10.1001/archinte.162.18.2053

16.

Chang

Ravi

Jenkinson

Paterson

Huang

Pincus

. Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture. Bone Jt J. 2021;103-B(2):271-278. doi:10.1302/0301-620X.103B2.BJJ-2020-1011.R1

17.

Hoehmann

Thompson

Long

, et al. Unnecessary preoperative cardiology evaluation and transthoracic echocardiogram delays time to surgery for geriatric hip fractures. J Orthop Trauma. 2021;35(4):205-210. doi:10.1097/BOT.0000000000001941

18.

Fleisher

Fleischmann

Auerbach

, et al. ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245. doi:10.1161/CIR.0000000000000105

19.

Chatterjee

Hage

. Guidelines in review: 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 Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2015;22(1):158-161. doi:10.1007/s12350-014-9992-3

20.

Salerno

Carlson

Soh

Lettieri

. Impact of perioperative cardiac assessment guidelines on management of orthopedic surgery patients. Am J Med. 2007;120(2):e1-185. doi:10.1016/j.amjmed.2005.11.009

21.

Vigoda

Sweitzer

Miljkovic

, et al. American college of cardiology/American heart association (ACC/AHA) Guidelines on perioperative cardiac evaluation are usually incorrectly applied by anesthesiology residents evaluating simulated patients. Anesth Analg. 2011;112(4):940-949. doi:10.1213/ANE.0b013e31820a1457

22.

Canty

Royse

Kilpatrick

Williams

Royse

. The impact of pre-operative focused transthoracic echocardiography in emergency non-cardiac surgery patients with known or risk of cardiac disease. Anaesthesia. 2012;67(7):714-720. doi:10.1111/j.1365-2044.2012.07118.x

23.

O'hEire

Beyer

Ahmed

Mulhall

. The role of preoperative cardiac investigation in emergency hip surgery. J Trauma. 2011;71(5):1345-1347. doi:10.1097/TA.0b013e318224cfa3

24.

Bajwa

Sawhney

Trikha

Janani

Sharma

Khanna

. Impact of preoperative echocardiography on perioperative management in geriatric hip trauma: A retrospective observational study. Int J Appl Basic Med Res. 2017;7(2):104-107. doi:10.4103/2229-516X.205816

25.

Wijeysundera

Austin

Beattie

Hux

Laupacis

. A population-based study of anesthesia consultation before major noncardiac surgery. Arch Intern Med. 2009;169(6):595-602. doi:10.1001/archinternmed.2009.3

26.

Wijeysundera

Beattie

Austin

Hux

Laupacis

. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study. BMJ. 2010;340:b5526. doi:10.1136/bmj.b5526

27.

Amhaz

Kuo

Chidiac

, et al.

Resident implementation of the 2007 ACC/AHA guidelines on preoperative cardiac evaluation in non-cardiac surgery patients: Is clinical experience enough?

Middle East J Anaesthesiol. 2015;23(2):147-155.

28.

AbuSharar

Bess

Hennrikus

. Pre-operative echocardiograms in acute fragility hip fractures: How effective are the guidelines? Medicine (Baltim). 2021;100(12):e25151. doi:10.1097/MD.0000000000025151

29.

Olanipekun

. The impact of COVID-19 testing on length of hospital stay and patient flow in hospitals. J Community Hosp Intern Med Perspect. 2021;11(2):180-183. doi:10.1080/20009666.2020.1866249

30.

Conway

Byrne

O’Riordan

DMR

, et al. Emergency medical admissions and COVID-19: Impact on 30-day mortality and hospital length of stay. Ir J Med Sci . 2021. Published online. doi:10.1007/s11845-021-02752-7

31.

Moja

Piatti

Pecoraro

, et al. Timing matters in hip fracture surgery: Patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One. 2012;7(10):e46175. doi:10.1371/journal.pone.0046175

32.

Siegmeth

Gurusamy

Parker

. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87(8):1123-1126. doi:10.1302/0301-620X.87B8.16357

33.

Chilov

Cameron

March

Australian National Health and Medical Research Council . Evidence-based guidelines for fixing broken hips: An update. Med J Aust. 2003;179(9):489-493. doi:10.5694/j.1326-5377.2003.tb05653.x

34.

Zuckerman

Skovron

Koval

Aharonoff

Frankel

. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551-1556. doi:10.2106/00004623-199510000-00010

35.

McGuire

Bernstein

Polsky

Silber

. The 2004 Marshall Urist award: delays until surgery after hip fracture increases mortality. Clin Orthop 2004;(428):294-301. doi:10.1097/01.blo.0000146743.28925.1c.

36.

Mitchell

Ferguson

Anderson

Sear

Barnett

. Length of stay and mortality associated with healthcare-associated urinary tract infections: a multi-state model. J Hosp Infect. 2016;93(1):92-99. doi:10.1016/j.jhin.2016.01.012

37.

Halm

Wang

Boockvar

, et al. The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture. J Orthop Trauma. 2004;18(6):369-374. doi:10.1097/00005131-200407000-00007

38.

Simunovic

Devereaux

Sprague

, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ Can Med Assoc J J Assoc Medicale Can. 2010;182(15):1609-1616. doi:10.1503/cmaj.092220

39.

Davis

Sher

Porter

Checketts

. The timing of surgery for intertrochanteric femoral fractures. Injury. 1988;19(4):244-246. doi:10.1016/0020-1383(88)90036-8

40.

Clemmesen

Palm

Foss

. Delay in detection and treatment of perioperative anemia in hip fracture surgery and its impact on postoperative outcomes. Injury. 2019;50(11):2034-2039. doi:10.1016/j.injury.2019.09.001

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality

Abstract

Introduction

Materials and Methods

Results

Conclusion

Keywords

Introduction

Materials and Methods

Results

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References