COVID-19 pandemic and hip fractures: impact and lessons learned

Study design and participants

This was an observational, descriptive, retrospective study conducted at a single NHS hospital trust. This study was approved by our Trust Audit Committee as a service improvement activity. Included participants were all patients ≥ 60 years of age diagnosed with a proximal femoral fracture. These include intracapsular, extracapsular, peri-trochanteric, and sub-trochanteric fractures. Two groups were studied. The first group represented the period from 1 March, 2020 until 31 May, 2020. The second group corresponded to the same dates in the previous year. The 2020 group was further subdivided according to COVID status: COVID-negative and COVID-positive. Patients with polytrauma; femoral shaft, open, pathological, periprosthetic, or peri-implant fractures were excluded.

Data collection

Demographic, treatment, and outcome data were compiled from electronic medical records and most of 2019 data were obtained from our NHFD export data. Incomplete, inconsistent, or implausible data were queried and checked against electronic medical records for accuracy. The primary outcome of this study was the assessment of the 30-day mortality rate.

Patient pathway

Our local orthopaedic pathway consists of structured steps and checklists to ensure that neck of femur (NOF) cases are optimized preoperatively to facilitate safe surgery within 36 hours from registration.

Once a patient with a NOF fracture is identified via radiography in the ED, a NOF bleep is put out. This alerts the orthopaedic on-call team, patient flow manager, and the ward nurse in charge that a NOF bed is required on the designated orthopaedic ward. The ED then performs rapid targeted assessment, investigations, and pain management to ensure that the patient is safe for early transfer to the orthopaedic ward. The patient is then clerked, and a nursing and orthopaedic checklist is completed, checked, and signed by the orthopaedic registrar on-call. If a patient has a Nottingham Hip Fracture Score (NHFS) score of ≥ 6 the on-call anaesthetist is contacted to review the patient as soon as feasibly possible, otherwise they are reviewed on the morning of surgery.⁵

In the following trauma meeting, the patient is discussed with the orthogeriatric team present. Once called for theatres, the patient is taken into the holding bay, and then the anaesthetic room where anaesthesia is induced before they proceed to have surgery. Postoperatively, they are recovered in the recovery area until they are deemed safe to return to the ward.

One of the changes during the COVID-19 pandemic include the orthopaedic registrar independently clerking the patient and completing the checklist. As well as this, due to the shortage of regular nurses, there was difficulty in achieving the nursing checklist compliance. Moreover, the anaesthetists would only assess in theatres regardless of the NHFS score. We assumed all patients were COVID-19 positive and had a single theatre pathway. Hence, all patients were recovered in the same operating theatre.

Availability of dedicated orthopaedic trauma lists varied. Provision of dedicated trauma lists ceased for four days during the peak period of COVID-19 (23 March, 28 March, 30 March, and 4 April, 2020), and therefore, Trauma and Orthopaedics had to share the emergency operating list with other surgical specialities. This arrangement rapidly became incompatible with the volume of daily trauma cases, resulting in a high number of trauma patients awaiting surgery.

Due to doctors being redeployed, the orthogeriatric team took care of patients operated with only one registrar and junior doctor.

Variables

A total of 32 variables were studied:

1. Demographic data: age, sex, and type of fracture.

2. COVID status: this was applied to the 2020 group. We also assessed its relation against the NHFS.⁵

3. Preoperative assessment - this included:

   1. Time to imaging: time from ED registration or from inpatient fall until the imaging was performed.

   2. Four-hour target: time from ED registration until arrival on the orthopaedic ward.

   3. Checklist compliance: our pathway involves completion of a 15-point checklist of preoperative measures to ensure patients are fit for surgery to achieve the 36 hour best practice tariff target (Figure 1).

   4. Hours to operation: time from ED registration until arrival in theatre.

4. Theatre management:

   1. Sending time: time from calling the ward to send the patient until the patient arrives in theatres.

   2. Holding bay time: time from the arrival of the patient in theatres holding bay until arrival in the anaesthetic room.

   3. Anaesthetic preparation time: time from the arrival of the patient in the anaesthetic room until induction of anaesthesia. This time included donning of the personal protective equipment (PPE) by the anaesthetic team in all 2020 group either COVID-positive or -negative.

   4. Anaesthesia time: time from induction of anaesthesia until knife to skin.

   5. Operation time: time taken from knife to skin until completion of skin closure.

   6. Recovery time: time of the patient in the recovery room until patient arrival back on the ward. Due to COVID regulations, recovery was done in theatres in the 2020 group.

   7. Type of anaesthesia.

   8. Intraoperative complications.

5. Postoperative review:

   1. Day zero review: medical and surgical review of the patient within 12 hours after operation.

   2. Day one postoperative review by Orthopaedic Consultant.

   3. Nutrition assessment: malnutrition universal screening tool calculation to assess if a patient is malnourished.

   4. Bone health assessment: osteoporosis screen.

6. KPIs³: The KPIs set by NHFD measure performance against guidance and clinical standards for hip fracture care from NICE. These include:

   1. KPI 1 – Prompt orthogeriatric assessment: percentage of hip fracture patients assessed by a Senior Orthogeriatrician within 72 hours.

   2. KPI 2 – Prompt surgery: percentage of patients receiving hip fracture surgery by the day following admission.

   3. KPI 3 – NICE compliant surgery: percentage of patients who received a NICE compliant surgical approach to their hip fracture surgery.

   4. KPI 4 – Prompt mobilization after surgery: percentage of patients mobilized by the day following hip fracture surgery.

   5. KPI 5 – Not delirious when tested after surgery: percentage of patients who were assessed and found not to be delirious after their surgery.

   6. KPI 6 – Return to original residence by 120 days: percentage of patients known to have returned to their original residence by 120 days after their hip fracture.

7. Postoperative complications:

   1. Wound infection.

   2. Reoperation rate.

   3. Inpatient falls: any fall the patient experienced postoperatively during their hospital stay.

8. 30-day mortality.

9. Length of the hospital stay.

Fig. 1

Checklist for fracture neck of femur fast-track admission protocol, courtesy of Dr S. Nesar. CXR, chest x-ray; ED, emergency department; IPM, in-patient management; INR, international normalized ratio; IV, intravenous; MUST, malnutrition universal screening tool; VTE, venous thromboembolism.

Statistical analysis

Data were entered into the computer and analyzed using International Business Machines Statistical Package for the Social Sciences (IBM SPSS) software package version 20.0 (IBM; Armonk, New York, USA). Qualitative data were described using the number and percentage. The Kolmogorov-Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, median, and interquartile range (IQR). A p-value ≤ 0.05 was considered statistically significant.

The following statistical tests were:

1. Chi-squared test: for categorical variables, to compare between different groups.

2. Fisher’s exact test or Monte Carlo correction: correction for chi-squared when more than 20% of the cells have expected count less than five.

3. Independent-samples t-test: For normally distributed quantitative variables, to compare between two studied groups.

4. Mann-Whitney U test: for abnormally distributed quantitative variables, to compare between two studied groups.

5. F-test (analysis of variance (ANOVA)): for normally distributed quantitative variables, to compare between more than two groups, and post hoc Tukey test for pairwise comparisons.

6. Kruskal Wallis test: for abnormally distributed quantitative variables, to compare between more than two studied groups and post hoc (Dunn's multiple comparisons test) for pairwise comparisons.

Demographic data

A total of 157 records were identified. During the COVID-19 pandemic, there was a significant increase in the number of hip fractures. We had 37 more hip fractures in 2020 compared to 2019, equivalent to an increase of 61.7%. In all, 67 patients (69%) in 2020 group were tested for COVID-19, 17 (17.5%) of whom had a confirmed positive test; we believed two patients (2%) had a false negative test, as although their swab tests were negative, their clinical and radiological findings indicated the presence of COVID-19: these were therefore also considered COVID-positive (Figure 2). There were no statistically significant differences in mean age, sex, or fracture types among the three groups (Table I). Six patients (two in COVID-positive, one in COVID-negative, and three in the 2019 group) were medically unfit for surgery and died preoperatively. Two patients in the 2020 group underwent conservative management, though they failed and needed surgery.

Fig. 2

COVID-19 test status of hip fractures in 2020 group.

Preoperative assessment

The checklist compliance was statistically significant, however the time to imaging, four-hour target, and the mean hour to operation variables were not (Table II) (Figure 3).

Fig. 3

Comparison between the three studied groups according to hours to operation.

Theatre management

The COVID-positive group showed a significant delay in the mean anaesthetic preparation and anaesthetic times (14.06 and 68.88 minutes, respectively). The mean recovery time, however, was significantly shorter (76.71 minutes, p = 0.010, Kruskal-Wallis test). This was being performed in theatres during the pandemic. Nevertheless, all other timings showed no statistical difference (Figure 4). There was no difference regarding the type of anaesthesia and intraoperative complications (Table III).

Fig. 4

Comparison between the three studied groups according to theatre timings. Asterisks indicate outliers.

Postoperative review

The three groups showed no statistical difference across all parameters except for the day one postoperative review by the orthopaedic consultant, which showed significant improvement in the 2020 group (Table IV).

KPIs

The differences in KPIs were statistically insignificant, but they showed a decrease in the number of patients who returned to original residence among the COVID-positive which was as low as 58.8% (Table V). The reasons for the delay in surgery are outlined in Figure 5.

Fig. 5

Reasons for delay in surgery. PPM, permanent pacemaker; Pt, patient.

Postoperative complications

There were no statistically significant differences except for inpatient falls which were significantly higher in the 2020 group (7.2%) compared to 2019 group (0%) (Table VI). One patient was reoperated due to hemiarthroplasty dislocation in 2019, while two patients in the 2020 group were reoperated due to hemiarthroplasty dislocation and wound dehiscence.

30-day mortality

The 30-day mortality was significantly higher in the 2020 COVID-positive group (7/19 patients, 36.8%) than the 2020 COVID-negative and 2019 groups ((7/78 patients (11.5%) and 7/60 patients (11.7%), respectively); p = 0.014, chi-squared test). The causes of death are outlined in Figure 6. There were two patients of the COVID-negative group who were discharged and re-admitted within 30 days under the care of the Department of Medicine for the Elderly (DME) and subsequently died with COVID pneumonia.

Fig. 6

Comparison between the three studied groups according to causes of death. MI, myocardial infarction.

The length of hospital stay

The mean length of hospital stay was significantly longer in the COVID-positive group compared to the other two groups (Figure 7). Though not statistically significant (p = 0.068, independent-samples t-test), the mean NHFS was higher in the COVID-positive group of 19 patients (5.79 (SD 1.08)) compared to the COVID-negative group of 78 patients (5.10 (SD 1.53)) .

Fig. 7

Comparison between the three studied groups according to length of hospital stay.