SpR T&O Leicester Royal Infirmary, Infirmary Square, Leicester, United Kingdom.
Injury. 2013 Jun;44(6):726-9. doi: 10.1016/j.injury.2012.08.025. Epub 2012 Sep 23.
Hip fracture is a common injury with associated high mortality. Recent drives by the Department of Health have sought to prioritise these patients' care. In April 2010, the Best Practice Tariff was introduced in England and Wales. This offers financial incentives to institutions that provide holistic care and surgery within 36h for hip fracture patients. The England and Wales National Institute for Health and Clinical Excellence (NICE) published its first guidance on hip fracture management in June 2011, and emphasised the need for surgery on the day or day after admission. In spite of the emphasis placed on this injury, the predictors of in-hospital mortality remain ill-defined. In particular the effect of the timing of surgery remains contentious.
To address the issues raised by NICE around surgical timing and examine whether surgery before a 36h watershed improves survival. In addition, to examine survival outcomes for each 12h watershed following admission.
Prospectively collected data on 2056 patients presenting to our unit with hip fractures between February 2008 and May 2011 were retrospectively reviewed. Multivariate regression analysis was used to correct for confounders, and so determine the effect of various parameters on in-patient mortality.
Age (p<0.0001), male-gender (p<0.0001), source of admission (p<0.05), ASA-grade (p<0.0001) and delay of surgery (p<0.01) were associated with an increased risk of in-hospital mortality. The adjusted odds of in-hospital mortality were 1.58 (p<0.05) times higher in those undergoing surgery after 36h compared to surgery before this time. Early surgery (within 24h) resulted in reduced in-hospital mortality when compared to the 36h watershed. Similarly ultra-early surgery (within 12h) was even better still (adjusted odds ratio 3.9 p<0.05).
Expeditious surgery is associated with improved patient survival. Other predictors of in-hospital mortality include age, gender, in-hospital fracture and ASA-grade. Ultra-early surgery (within 12h) reduces risk of in-hospital mortality.
髋部骨折是一种常见的损伤，死亡率较高。最近，卫生部采取了一些措施来优先考虑这些患者的护理。2010 年 4 月，英格兰和威尔士引入了最佳实践关税。这为在 36 小时内为髋部骨折患者提供整体护理和手术的机构提供了经济激励。英格兰和威尔士国家卫生与临床优化研究所（NICE）于 2011 年 6 月发布了其关于髋部骨折管理的第一份指南，并强调需要在入院当天或次日进行手术。尽管对这种损伤的重视程度很高，但住院死亡率的预测因素仍未得到明确界定。特别是手术时间的影响仍存在争议。
解决 NICE 提出的关于手术时机的问题，并研究是否在 36 小时的时间点之前进行手术可以提高生存率。此外，还研究了入院后每 12 小时的时间点对生存率的影响。
对 2008 年 2 月至 2011 年 5 月期间我院收治的 2056 例髋部骨折患者的前瞻性收集数据进行回顾性分析。采用多变量回归分析校正混杂因素，以确定各种参数对住院死亡率的影响。
年龄（p<0.0001）、男性性别（p<0.0001）、入院来源（p<0.05）、ASA 分级（p<0.0001）和手术延迟（p<0.01）与住院死亡率增加相关。与手术前相比，术后 36 小时内进行手术的患者住院死亡率的调整后优势比（OR）为 1.58（p<0.05）。与 36 小时的时间点相比，早期手术（24 小时内）降低了住院死亡率。同样，超早期手术（12 小时内）效果更好（调整后的 OR 为 3.9，p<0.05）。
快速手术与患者生存率的提高有关。住院死亡率的其他预测因素包括年龄、性别、住院骨折和 ASA 分级。超早期手术（12 小时内）可降低住院死亡率的风险。
