Morrison R S, Chassin M R, Siu A L
Mount Sinai School of Medicine, New York, New York 10029, USA.
Ann Intern Med. 1998 Jun 15;128(12 Pt 1):1010-20. doi: 10.7326/0003-4819-128-12_part_1-199806150-00010.
Hip fractures are an important cause of death and functional dependence in the United States.
To review the evidence for clinical decisions that medical consultants make for patients with hip fracture and to develop recommendations for care.
Published reports of clinical studies were found by searching MEDLINE and selected bibliographies.
Studies were included if data were presented on clinical interventions to improve care of conditions typically encountered by medical consultants in the care of patients with hip fracture. Such conditions include timing of surgery, infection prophylaxis, thromboembolic prophylaxis, postoperative nutritional management, urinary tract management, prevention and management of delirium, application and timing of rehabilitation services, and prevention of subsequent falls. Meta-analyses; randomized, controlled trials; or other controlled studies were included if possible. If no such trials were identified, the best evidence from studies with other designs was included.
Interventions were selected on the basis of their efficacy or potential efficacy in improving functional outcome. Trials with positive and negative results were compared for differences in intervention and strength of study methods.
Strong evidence supports medical recommendations for decisions about timing and duration of prophylactic antibiotics, selection of thromboembolic prophylaxis, urinary tract and nutritional management, and rehabilitative services. Many case series support early surgical repair, although patients who would benefit from delay and further medical work-up have not been well identified. Evidence for decisions about assessment of subsequent risk for fall and risk for and management of delirium is based largely on data from patients without hip fracture but is probably applicable. Future research should target optimal duration of thromboembolic prophylaxis, cost-effectiveness of low-molecular-weight heparin compared with that of other thromboembolic prophylactic regimens, management of delirium, rehabilitative services, and efficacy of assessment of risk for later falls.
The data suggest that evidence-based medical care can improve hip fracture outcomes. The medical consultant has a key role in providing this care and managing the preoperative conditions and postoperative complications that may affect optimal functional recovery.
在美国，髋部骨折是导致死亡和功能依赖的重要原因。
回顾医学顾问为髋部骨折患者做出临床决策的证据，并制定护理建议。
通过检索MEDLINE和选定的参考文献找到临床研究的已发表报告。
如果研究呈现了关于改善医学顾问在髋部骨折患者护理中通常遇到的状况的临床干预数据，则纳入该研究。此类状况包括手术时机、感染预防、血栓栓塞预防、术后营养管理、尿路管理、谵妄的预防和管理、康复服务的应用和时机，以及后续跌倒的预防。如有可能，纳入荟萃分析、随机对照试验或其他对照研究。如果未找到此类试验，则纳入其他设计研究的最佳证据。
根据干预措施在改善功能结局方面的疗效或潜在疗效进行选择。比较有阳性和阴性结果的试验，分析干预措施和研究方法强度的差异。
有力证据支持关于预防性抗生素使用时机和持续时间、血栓栓塞预防措施选择、尿路和营养管理以及康复服务的医学建议。许多病例系列支持早期手术修复，尽管尚未明确哪些患者会从延迟手术和进一步的医学检查中获益。关于评估后续跌倒风险以及谵妄风险和管理的决策证据主要基于非髋部骨折患者的数据，但可能适用。未来的研究应针对血栓栓塞预防的最佳持续时间、低分子量肝素与其他血栓栓塞预防方案相比的成本效益、谵妄的管理、康复服务以及后期跌倒风险评估的疗效。
数据表明，基于证据的医疗护理可改善髋部骨折的结局。医学顾问在提供此类护理以及管理可能影响最佳功能恢复的术前状况和术后并发症方面发挥关键作用。
