International Journal of Orthopaedic and Trauma Nursing (2010) 14, 169–175

www.elsevier.com/locate/ijotn

An epidemiological study of the relationshipbetween time to surgery and health status forelderly patients with a hip fracture

Carol Reid RN, Master Applied Science (Research), Graduate CertificateHealth Studies (Sexual Health), Bachelor of Health Science (Nursing)(Nurse Researcher) a,*, Glenn Gardner RN, Ph.D. FRCNA (Professor andDirector) a,b,1, Carol Rooney RN, Bachelor Nursing (Clinical Nurse) c,2,Kylie-Ann Mallitt Bachelor of Science (Hons) (Biostatistician) d,3

a Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Butterfield St., Herston, 4059Queensland, Australiab Queensland University of Technology, Victoria Park Rd., Kelvin Grove, 4059 Queensland, Australiac Department of Orthopaedics, Royal Brisbane and Women’s Hospital, Butterfield St., Herston, 4059Queensland, Australiad Queensland Institute Medical Research, Royal Brisbane and Women’s Hospital, Herston Rd., Herston,4029 Queensland, Australia

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KEYWORDSHip;Fracture;Health;Time;Surgery;Preoperative

78-1241/$ - see front mattei:10.1016/j.ijotn.2010.03.0

* Corresponding author. Te365832.E-mail addresses: Carol_L_.gardner@qut.edu.au (G. G. Gardner), CarolRooney@lieAnn.Mallitt@qimr.edu.auTel.: +61 7 36365395; fax:Tel.: +61 7 36362140; fax:Tel.: +61 7 38453562.

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Reid@heardner)health.q(K.-A. M+61 7 36+61 7 36

Summary A hip fracture causes permanent changes to life style for older people,including premature death. Two important mortality indicators found post-opera-tively for this group include, the time until surgery after fracture, and pre-operativehealth status prior to surgery. Yet no research is available investigating relationshipsbetween time to surgery and health status. The researchers aimed to establish astudy of the health status risks for patients aged over 65 years with a non-patholog-ical hip fracture to guide nursing care interventions and to test the feasibility of themethods and procedures for later use in a larger study. A prospective cohort designwas used to investigate relationships between time to surgery and measures of

Copyright �c 2010 Published by Elsevier Ltd. All rights reserved.

7 36362653; fax: +61 7

alth.qld.gov.au (C. Reid),, ge.gardner@qut.edu.auld.gov.au (C. Rooney),allitt).365832.365832.

Editors’s comments

It is nothing new that this paper show

status is in the longer term may be. In

surgery, the more intense the negativ

purported that surgery should take pla

elderly, frail patients with a significant

that this is an isolated example and tha

need to be renewed multidisciplinary

vulnerable older people who sustain a h

170 C. Reid et al.

pre-operative health status including, skin integrity risk, vigour, mental state,bowel function and continence. Twenty-nine patients with a mean age in years of81.93 (SD, 9.49), were recruited. The mean number of hours from diagnosis to sur-gery was 52.72 (SD, 58.35) and the range was 1 h to 219 h. At two hours before sur-gery, the mean scores of vigour and skin integrity risk were significantly higher thanat diagnosis, indicating poorer health status. A change in health status occurred,but, possibly due to the small sample size, it was difficult to relate this result totime. However the results informed pre-operative care prior to surgery, for thisgroup.Crown Copyright �c 2010 Published by Elsevier Ltd. All rights reserved.

s concern that the longer patients with a hip fracture wait for surgery the worse their health

deed, it was shown very clearly in the 1980s that the longer the gap between admission and

e impact on patient recovery and other outcomes. Guidance on this matter has long since

ce within 48 h of admission. What is worrying is that the authors of this paper demonstrate that

orthopaedic injury are still waiting too long for their surgery more than 25 years later. I doubt

t there are many examples of such delays across the globe. As has always been the case, there

efforts to find solutions to the common failure to provide optimum care for the frail and

ip fracture. JS

Background

A hip fracture is a common and serious injury thatcan have devastating consequences for older peo-ple, resulting in permanent changes to life style,independence and mobility.

There has been an increased incidence of hipfractures in Australia, particularly in the olderpopulation, which has resulted in a large eco-nomic expense to the health system (Kreisfeldand Newson, 2006). The associated cost of hipfractures has been reported to be in excess of420 million dollars (McLeod et al., 2005). Furthermore, hip fractures are expected to more thandouble from 15,000 in 1996 to 34,000 in 2026,then almost double again by 2051 (Sanderset al., 1999). The economic and human cost tothe community associated with hip fractures isincreasing and this increase is attributed toAustralia’s aging population (Sanders et al.,1999; McLeod et al., 2005). The projectedincrease of hip fractures in this population alsopresents challenges for the public hospital systemas competing demands for surgery can result indelayed treatment, extending the pre-operativeperiod for up to several days (Moran et al., 2005).

To date, several studies discuss the outcomesfor elderly patients with a hip fracture post-opera-tively. International figures indicate that traumatichip fractures have a 20–30% mortality rate at12 months post surgery (Novack et al., 2007; Moranet al., 2005). What has emerged is that the twomost important mortality indicators for these pa-tients are; the time until surgery following a frac-ture, and pre-operative health status prior to

surgery (Scottish Intercollegiate Guidelines net-work, 2009; Hamlet et al., 1997).

Delays in operative treatment of hip fracturesmay result in increased postoperative mortality inboth the short term and long term (Charalambouset al., 2003; McGuire et al., 2004; Novack et al.,2007) as well as poor functional recovery for survi-vors in the long term (Charalambous et al., 2003;McGuire et al., 2004; Al-Ani et al., 2008). Recentstudies found early surgery <48 h following hipfractures improved the patients’ capability to re-turn to an independent living state (Al-Ani et al.,2008), reduced the risk of pressure area develop-ment and also reduced length of hospital stay(Al-Ani et al., 2008; Lefaivre et al., 2009). CurrentAustralian guidelines recommend that patientsshould undergo surgery for hip fractures eitherwithin 24 or 36 h once a patient has been assessedand is stabilised (Chilov et al., 2003).

An audit conducted in an Australian hospital(McLeod et al., 2005) identified important indica-tors of health status for patients with a hip frac-ture. These included, pressure injury, hydrationand nutrition, fluid balance, pain, core body tem-perature, continence, comorbidities, mental state,previous mobility, previous functional ability andsocial circumstances.

In relation to many of these health indicators,the elderly orthopaedic patient is especially vul-nerable to rapid decline (Lizi, 2000) and yet, todate, no research is available which investigatesthe relationship between the time to surgery andhealth status. This pilot study, which was com-pleted in 2007, informed pre-operative care forthese patients in order to improve their condition

An epidemiological study of the relationship between time to surgery and health status 171

before surgery and provided information for surgi-cal priority planning for this vulnerable group.

This information was required due to increasingpressure at the time on the hospital system, whichled to alternative models of care being explored byhealth service providers. Some patients who werewaiting for surgical fixation of a fractured hip wererelocated to non acute care environments. There-fore, there was an urgent need for research toestablish the health status risks for these patientsin order to develop focused, evidence based careinterventions that could guide nursing practice inthe non acute care environment.

Methods

Research question

We investigated the relationship between thehealth status of elderly patients and the lengthof time between traumatic hip fracture andsurgical fixation for patients over 65 who had anon-pathological hip fracture. We hypothesisedthat as time to surgery increased, scores on theWaterlow Pressure Ulcer Risk Assessment ScoringSystem would increase, scores on the Vigour scaleand the Folstein Mini Mental State Examinationwould decrease, and disruption to normal bowelfunction and urinary incontinence would increase.This pilot study also tested the feasibility of themethods and procedures for use later in a largerstudy.

Research design

A prospective cohort design was used to investigatethe relationship between time to surgery for pa-tients with non-pathological hip fracture and mea-sures of specific pre-operative health statusindicators. The study was conducted in the ortho-paedic ward at a major tertiary hospital in Queens-land, Australia. The time increment studied wasnumber of hours from diagnosis of a fractured hipfollowing admission to the emergency department,to the time of surgical intervention. The indicatorsof health status for the study were risk to skinintegrity, vigour, mental state, bowel functionand continence.

Population

The population consisted of men and women over65 years of age who were admitted to the ortho-paedic ward or other outlying wards at the hospital

and who were diagnosed with a non-pathologicalfractured neck of femur.

Sampling and recruitment

Prior to recruitment the participants were fully in-formed verbally about the research study, given aplain language summary and asked to provide writ-ten consent.

Patients who consented and met the selectioncriteria (>65 years of age, non-pathological hipfracture, no other traumatic injury and not takingPlavix medication) were included in the study.Posters were placed on walls in the staff areas ofthe participating orthopaedic wards and the emer-gency department to alert staff to the project.Recruitment of participants was facilitated by reg-ular visits by research staff to the orthopaedicwards and the emergency department. A timeframe of six (6) months was set for the study andtwenty-nine (29) participants were recruited tothe study in this time. This approach to recruit-ment was dictated by available funding.

Ethical considerations

Ethical approval for the study was obtained fromthe Human Research Ethics Committee of thehealth care facility.

Data collection

After consent was obtained data were collectedfrom each participant at two time points. The firstfollowing diagnosis of a fractured hip. The secondtime point for data collection was within 2 h priorto surgery for each participant. Time to surgerywas defined as the number of hours between thesetwo data collection points.

Instruments

Patient demographics were collected and re-corded. These included age, sex, occupation, andliving arrangements. The ‘time’ that data collec-tion took place after admission and again prior tosurgery was also collected. Permission was soughtto use the instruments for this study.

The Weighted Index of Comorbidity (CharlsonComorbidity Index) is a measure of the prognosticimpact of co morbid disease and was used in thisstudy to further describe the sample. This instru-ment assigns a weighted score according to patientspecific factors that influence prognosis. Each

172 C. Reid et al.

condition a patient has is assigned with a score ofeither 1, 2, 3 or 6 (highest risk), depending onthe risk of dying associated with this condition(Charlson et al., 1987). The Charlson ComorbidityIndex is a reliable instrument with an intraclasscorrelation coefficient (ICC) ranging between 0.67and 0.93 in different studies (Hall et al., 2006).

The Waterlow Pressure Ulcer Risk AssessmentScoring System (Waterlow, 1985) was used to pro-vide a score of risk or deterioration of pressureinjury. This was used to measure changes in apatient’s risk of pressure injury from Time 1assessment to Time 2 assessment. Scores and theirmeanings include 10+ (at risk), 15+ (high risk) and20+(very high risk). Interrater reliability of thisinstrument has not been measured (Kottneret al., 2009).

Vigour was measured using appropriate compo-nents of the pre-operative Vigour Assessmentinstrument (Keating et al., 1999). This instrumentconsists of self-report questions and objectivemeasures (muscle strength, using a hand held dyna-mometer). The instrument is useful in assessingvigour in the short term post-operatively to enableoptimal rehabilitation and discharge planning.Chronbach’s Alpha for the pre-operative subjectivescale components of the Vigour Assessment instru-ment ranged from 0.83 to 0.90 (Keating et al.,1999). For the purposes of this study three relevantquestions about energy, appetite and strengthwere chosen from the questionnaire. The threeself-report questions were asked using a Likertscale ranging from 1 to 6 with a score of 6 for eachquestion indicating poorer energy, appetite andstrength.

Muscle strength was measured using the handheld dynamometer. Hand grip dynamometry is anobjective measure of muscle strength (Wanget al., 2002) and a predictor of functional decline(Bohannon, 2001). The test–retest reliabilityfor hand held dynamometry ranged from 0.95 to0.99 with one measure and 0.97–1.0 with twomeasures (Wang et al., 2002). Hand grasp hasthe ability to illustrate overall muscle strengthparticularly of the upper extremity of the body(Bohannon, 2009). Muscle strength was measuredin kilograms.

The Mini Mental State Examination (MMSE) isuseful for the systematic assessment of mental sta-tus such as cognitive change and the severity ofcognitive impairment. This test was used to quan-tify changes in the participants’ mental state.The test–retest reliability for the instrument hasbeen shown to be stable following 24 h retest bya single tester (0.887) or by two examiners(0.827). It was also found reliable at retest 28 days

apart (0.988) (Folstein et al., 1975). The maximumMMSE score is 30.

Data relating to constipation, urinary catheteri-sation, and urinary and faecal continence were col-lected from ward records as a measure of healthstatus at Time 1 and Time 2. Constipation andurinary catheterisation was measured as (1) yes or(2) no, with lower scores indicating poorer out-comes. Urinary and faecal continence were mea-sured as (1) full, (2) partial, and (3) not at all (i.e.,incontinent). Higher scores indicated poorer healthoutcomes.

Of these instruments, Vigour, Weighted Index ofComorbidity and the Mini Mental State Examinationhave been previously validated (Keating et al.,1999; Charlson et al., 1987; Folstein et al., 1975).The other instruments such as the WaterlowPressure Ulcer Risk Assessment Scoring System,constipation and urinary continence are measuresregularly used in clinical practice.

Data analysis

Descriptive analyses were used to examine demo-graphic variables. The mean and standard devia-tion for continuous variables were calculated.Time to surgery is a continuous variable createdby subtracting the date of hospital admission fromthe date of surgery. This variable was natural logtransformed for all analyses to obtain a normal dis-tribution. Differences between Time 1 and Time 2for each of Waterlow score, vigour, mental state(MMSE), bowel function and urinary continencewere tested using a paired t-test (continuous vari-ables) or McNemar’s test (categorical variables).Statistical significance was reported at the conven-tional p-value of equal to or less than 0.05 level.

Data were analysed with SPSS (Version 16.0,SPSS, INC, Chicago, IL). (SPSS Inc., 2005). One-way analysis of variance (ANOVA) was used todetermine the relationship between time to sur-gery and the demographic variables age, gendercomorbidities and living arrangements. Variablesof the difference between Time 1 and Time 2 werecreated for each of Waterlow score, vigour, mentalstate (MMSE), bowel function and urinary conti-nence. The relationship between these differentvariables and time to surgery was explored by AN-OVA for categorical variables and linear regressionfor continuous variables.

Results

A total of 29 patients over 65 years of age, diag-nosed on admission to hospital with a fractured

An epidemiological study of the relationship between time to surgery and health status 173

neck of femur were recruited for this study. Thesample consisted of 7 males and 22 females witha mean age in years of 81.93 (SD, 9.49) and a rangefrom 65 to 99 years. Comorbidities for this groupshowed a mean weighted score of 1.21 (SD, 1.29)from an index of 1, 2, 3 and 6 out of a possible totalscore of 12. Eleven (11) people (37.9%) had nocomorbidities and two people (6.9%) had the high-est comorbidity score for this study of 4. Most ofthe participants lived independently in their ownhome (44.8%) and all participants were retiredfrom work. No significant relationship was foundbetween any of these demographic variables andtime to surgery (data not shown).

The mean number of hours from Time 1 assess-ment to surgery was 52.72 (58.35) with the mode20 h and median 26 h. The range from Time 1assessment to surgery was from 1 to 219 h. Table 1shows that relative to Time 1, at Time 2 the meanscores of the self-report Vigour and Waterlow RiskAssessment were significantly higher, indicatingpoorer health status in relation to vigour (energy,appetite and strength) (p = 0.002) and an increasedskin integrity risk (p = 0.001). Interestingly all theparticipants with lowered mean vigour scores werefemales. Constipation scores in the current studywere significantly lower at Time 2 (p = 0.039), indi-cating that patients were more likely to be consti-pated by this time point. It was also observed thatfor patients in the youngest age category (65–74yrs), there was a reduction in 55.6% of patients’MMSE scores between Time 1 and Time 2. Althoughnot significant, the results show there was deterio-ration in the mental state of this younger group.Older patients however, did not have an increasedscore (0%). There was no significant difference inurinary continence between Time 1 and Time 2.

Table 1 Descriptive statistics (mean and standard error)fracture (Time 1) and 2 h prior to hip surgery (Time 2); wit

Score Time 1 mean (S.E.)

Waterlow 15.45 (0.78)Average vigour 2.80 (0.19)Mental state (MMSE) 23.96 (0.99)Constipation 1.79 (0.08)Urinary incontinence 1.50 (0.13)

Table 2 Relationship (p-values) between time to surgery astatus expressed as the change over time between Time 1 (hip surgery) in elderly patients.

Waterlow Vigour

Time to surgery (p-value) 0.955 0.720

Therefore our initial hypotheses of increased riskof pressure ulcer development, decreased vigourand increased constipation with increased time tosurgery have been accepted; while the hypothesesof decreased MMSE scores and increased urinaryincontinence with increased time to surgery havebeen rejected.

Table 2 shows that there is no significant rela-tionship found between time to surgery and the dif-ference between Time 1 and Time 2 for Waterlowscore, vigour, mental state (MMSE), bowel functionand urinary continence. The relationship did notbecome significant when the time variable was cat-egorised (data not shown).

Limitations

This pilot study tested the feasibility of the meth-ods and procedures for use later in a larger study.This was a single site study and included a specificpopulation of elderly people over 65 years of agewith non-pathological hip fractures. A larger mul-ti-site study is recommended for future studiesof this kind. Also problems of data collectionoccurred during the pilot study due to fundingrestraints such as; some participants were admit-ted overnight but due to the lack of availabilityof research staff. These participants were notrecruited prior to surgery. This limited the abilityof the researchers to obtain the required samplesize (124) over a 24 h, 7 days a week period andas a result data collection continued over a longerperiod of time.

A change in health status did occur for thisgroup, but was not significantly associated withtime to surgery. This is possibly due to the small

for five measures of health status after diagnosis of hiph p-values of the difference between times.

Time 2 mean (S.E.) p-Value

18.79 (0.74) <0.0013.80 (0.22) 0.00223.38 (1.07) 0.2731.55 (0.10) 0.0391.79 (0.17) 0.261

nd between five measures of health status, with healthafter diagnosis of hip fracture) and Time 2 (2 h prior to

MMSE Constipation Urinary Continence

0.772 0.550 0.804

174 C. Reid et al.

sample size and resultant lack of power in thissmall pilot study. Recruitment to obtain the re-quired sample size over a 24 h, 7 days per weekperiod for a study such as this is important.

Discussion

The aim of this pilot study was to investigate therelationship between the health status of elderlypatients and the length of time between traumatichip fracture and surgical fixation.

Previous studies have shown that an associationexists between delayed surgery and increased mor-tality in the short term (Charalambous et al., 2003)(McGuire et al., 2004) and poor functional recoveryin the long term (Al-Ani et al., 2008; Charalambouset al., 2003; McGuire et al., 2004), for elderly peo-ple admitted to hospital with a hip fracture requir-ing repair. This association occurred even aftercontrolling for other patient characteristics suchas comorbidities. Some studies have also shownthat early surgery results in lower rates of compli-cations and reduced length of hospitalisation(Al-Ani et al., 2009; Lefaivre et al., 2009). Howeverno other studies to date have determined if arelationship exists between time to surgery andhealth status in patients over 65 years of age, witha non-pathological hip fracture.

The results of this current study indicated thatthere was a decline in health status on some indica-tors between the patient’s Time 1 assessment‘on admission’ and Time 2, ‘time of surgery’. Sig-nificant differences indicating poorer health statusfor patients with a hip fracture were found for thevariables vigour (energy, appetite and strength),skin integrity risk and constipation. While earlyprevention of pressure injury, constipation and adecline in nutritional status have been identifiedas essential for the post operative managementof patients with a hip fracture (Scottish Intercolle-giate Guidelines Network, 2009), the significantresults of poorer subjective vigour, constipationand risk to skin integrity that occurred pre-opera-tively in this group, provides nurses with evidencefor the development of specific interventions forthe pre-operative management of the elderlypatient with a hip fracture. There were no signifi-cant differences found in urinary incontinence norin mental state with increased time to surgery.However there was a reduction for MMSE scoresbetween Time 1 and Time 2 for the younger group(65–74 years). Although not significant, the resultsshowed that there was a deterioration in the men-tal state of the younger group.

Despite the existing guidelines in Australia whichrecommend patients should undergo surgery for hip

fractures within 24 to 36 h once a patient is as-sessed and stabilised (Chilov et al., 2003), the timefrom admission to surgery varied in the currentstudy from 1 to 219 h (9.125 days). The reason forthe large range in the pre-operative waiting timesduring of this study is unclear.

Conclusion

Although no direct relationships were foundbetween time to surgery and the dependent vari-ables in this study, a significant difference inhealth status occurred over time as patientswaited for surgery. Due to the small sample size,it is not clear whether this difference in healthstatus is related to time. A larger study needs tobe conducted to investigate further the resultsof this study. There is an urgent need to establishthe health status risks for the period of time fromadmission to time to surgery for elderly patientswith a hip fracture in order to develop focused,evidence based care interventions to guide nursingpractice.

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