The implementation of a clinical pathway enhancing early surgery for geriatric hip fractures: how to maintain a success story?

BACKGROUND: Timing of surgery in geriatric hip fracture treatment remains controversial. Early surgery is acknowledged as a quality indicator and NICE guidelines recommend surgery within 0-48 h from admission. In 2014 we implemented the indicator of early surgery in our institution, enhancing operative treatment within the next calendar day. We aimed to evaluate the implementation, define the room for improvement and provide strategies to maintain the quality indicator.

METHODS: Clinical outcome of 744 patients (January 2011-December 2013) before early surgery was implemented, compared to 817 patients (June 2014-May 2017) after implementation of early surgery with a follow-up of 6 months. Data-analysis was done by Pearson's Chi-square test and Mann-Whitney U test.

RESULTS: Early surgery was achieved in 47.6% and 85.7% in the preimplementation and postimplementation group, respectively (P < 0.001). Both 30 days and 6 months mortality were similar (6.0% vs. 5.4%, P = 0.573 and 18.7% vs. 16.9%, P = 0.355, preimplementation vs. postimplementation, respectively). Early surgery resulted in a significantly shorter total length-of-stay (14 vs. 12 days, P < 0.001, preimplementation vs. postimplementation, respectively). Early surgery did not reduce the readmission rate.

CONCLUSIONS: The indicator of early surgery has been successfully implemented. Early surgery resulted in a significantly shorter LOS. No significant reduction in 30 days and 6 months mortality, and 90 days readmission was observed. To maintain early surgery, continuous engagement and monitoring is required by all shareholders involved and if necessary, adjustment of the clinical route is appropriate.