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Delays In Discharge Following Hemiarthroplasty: Is There A Solution? 

Elahi MM,  Kwong FC, Spaine LA

Department of Orthopaedic Surgery, Glenfield Hospital, Leicester, LE3 9QP, United Kingdom.

Address for Correspondence
Mr Maqsood M Elahi,
Room 22, Leicester General Hospital,
Gwendolen Road, LE5 4PW, United Kingdom
Tel/ Fax:  +44 (0) 792-901-0164 

The increasing number of hip fractures as a result of ageing population, has markedly increased the need for hip fracture beds. 1,2 The care of patients with hip fracture is a good indicator of the quality of hospital services for elderly people in general because their recovery requires a wide range of services.  There is a large variation in the mean length of stay of patients between different hospitals.3   The length of hospital stay is partly dependent on patient characteristics such as age, the presence of cognitive impairment, implant complications and type of operations. 4 The implementation of hospital strategies, such as joint orthopaedic-geriatric rehabilitation 5 and ‘hospital at home’ teams 6 can also significantly reduce the length of hospital stay.  Those patients with poor mobility before the hip fractures are the ones that utilize most of the cost in rehabilitation. Although experienced clinicians are often able to make an accurate prediction, little information is available about the factors that allow early determination of whether a patient may return to the community.  We prospectively studied 95 consecutive patients > 70 years admitted with fractures of the neck of femur and treated with a hemiarthroplasty between January 2001 to March 2001 in a busy tertiary centre.  61.1% of them had their operation within 48 hrs of admission compared to the rest (36.8%) who had their operation > 48 hrs.  The overall mortality was 7.4%.  At the time of their injury, 38.9% were resident in a nursing home, a residential home or a warden controlled flat. The rest were living independently either on their own or with their spouse.  Prior to sustaining their injury, 3% of patients were immobile, 63% were mobile with use of aids and 34% were independently mobile without aids.  When functional ability was considered, 42% were independent while the majority (53%) were either house bound and/or depended on meals on wheels delivered to their residence.  88% of the patients had established, significant medical problems on admission.  38% of patients developed a post-operative complication such as deep vein thrombosis and chest infection. 47% of patients were discharged within 10 days following surgery.  The main causes of delays in discharge were delay in provision of social services (5%), delay in obtaining placement in a suitable place after discharge (11%), waiting for occupational therapist assessment (9%), arranging a care package (17%) and medical problems (10%) (Figure 1).

It is now recognised that the rising incidence of hip fractures in the elderly is a disturbing trend with significant health and socio-economic consequences, including increased morbidity, loss of function, long term institutionalisation and mortality. 7 Moreover, delay in the treatment of these patients leads to increased morbidity, mortality; length of hospital stay and overall cost as well 8 but there are no published guidelines on how to possibly avoid a reasonable delay between admission and discharge by the accurate assessment of the patients admitted with fracture of the proximal femur. With the view of fast tract referral system and the avoidance of possible delays a new initiative at our centre was developed called Post Acute Care Team (PACT). The service is available to patients from Leicestershire, who are able to satisfy specific pre-determined criteria such as cognitive function, pre-injury mobility and functional abilities.  During their inpatient stay and following surgery, the patients receive intensive physiotherapy in order to achieve independent mobility with a mobility aid and a full activity of daily living assessment is taken by the occupational therapist. Continued care and rehabilitation is provided in the community by the team on a daily basis, aiming to discharge the patient within ten days following their admission. 

We conclude that monitoring at the time of admission by the provision of designated staff and appropriate treatment package by early recognition of potential factors may result in a significant reduction in both morbidity and mortality together with significant savings in patient bed days. Para-medical services involved in rehabilitation should be improved.  This would enable more patients to be treated with the same number of hospital beds and lower direct costs of rehabilitative care.  With the increasing number of hip fractures over time, this study highlights the need to expand rehabilitation services perhaps more than was previously thought.


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. Clague JE, Craddock E, Andrew G, Horan MA, Pendleton N. Predictors of outcome following hip fracture. Admission time predicts length of stay and in-hospital mortality. Injury. 2002; 33: 1-6.
. Lau EM, Cooper C, Fung H< Lam D, Tsang KK.  Hip fracture in Hong Kong over the last decade- a comparison with the UK.  J Public Health Med 1999; 21(3): 249-50.
. Melton LJ 3rd.  Epidemiology of hip fractures; implications of the exponential increase with age.  Bone (Suppl 3) 1996; 18:121-5.
. Murphy PJ, Rai GS, Lowy M, Bielawaska C.  The beneficial effects of joint orthopaedic-geriatric rehabilitation.  Age Ageing 1987; 16: 273-8.
. Pryor GA, Myles JW, Williams DRR, Anand JK.  Team management of the elderly patient with hip fracture.  Lancet 1988; 1 (8582): 401-3.
. Ethens, KD., MacKnight, C. (1998) Hip fracture in the elderly. An interdisciplinary team approach towards rehabilitation. Postgrad Med; 103: 157-8, 163-4, 167-70.
. Lancaster, BJ., Paterson, Medical Practice., Capon, G., Belcher, J. (2000) Delays in orthopaedic trauma treatment: setting standards in time interval between admission and operation. Ann R Coll Surg Engl; 82: 322-6

 This is a peer reviewed paper 

Please cite as :Maqsood M Elahi, Letter to the editor: Delays In Discharge Following Hemiarthroplasty: Is There A Solution?

J.Orthopaedics 2005;2(6)e10






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