Authors: Aejin Sung, Dong Hoon Kim, Dong-Hee Kim, Jin Hee Jeong
Categories: Article, Hip fractures, Preoperative period, Length of stay, Albumins, Risk factors, Geriatrics, Therapeutics
Source: Scientific Reports
Authors: Aejin Sung, Dong Hoon Kim, Dong-Hee Kim, Jin Hee Jeong
Hip fractures are a significant health concern, increasingly common among the elderly. Surgical intervention is crucial and recommended within 48 h of presentation. Many patients with hip fractures present to the emergency department (ED), but the impact of ED-related factors remains unclear. This study investigated ED-related factors affecting surgical delay in hip fracture patients. This retrospective observational study evaluated patients aged ≥ 60 years with hip fractures who presented to a tertiary care university hospital ED between January 2017 and December 2022. Demographic and clinical variables, including ED-related factors such as length of stay and occupancy, were recorded. Outcomes were delayed surgery (i.e., performed after 48 h). Among 434 patients, 209 underwent early surgery and 225 delayed surgery. Univariate analyses revealed significant associations between time to surgery and comorbidities, presentation on the day before holidays, prolonged ED stay, surgery type, international normalized ratio, and albumin levels. In multivariable analysis, ischemic heart disease, presentation on the day before holidays, prolonged ED stay, surgery type, and albumin level ≤ 3.8 g/dL were significantly associated with delayed surgery. In conclusion, delayed surgery is associated with ischemic heart disease, pre-holiday presentation, prolonged ED stay, surgery type, and albumin ≤ 3.8 g/dL.
The online version contains supplementary material available at 10.1038/s41598-025-08913-3.
Hip fractures include fractures of the femoral head, femoral neck, greater trochanter, intertrochanteric, or subtrochanteric regions. These fractures are broadly categorized into intracapsular fractures, which mainly involve the femoral neck, and extracapsular fractures, which include intertrochanteric and subtrochanteric fractures, and are treated accordingly^1,2^. Hip fractures are a common injury, particularly among the older population. The worldwide incidence of hip fractures is high and is expected to increase further with the growing elderly population in the future^3–5^. Older individuals have a high prevalence of hip fractures, with the frequency increasing from the age of 60 onwards, and annual incidence rising with age^6^. One study of hospitalized trauma patients over the age of 85 demonstrated that hip fractures account for 72% of all fractures^7^. Considering the substantial population residing in Asian countries, they play a significant role in the increasing number of hip fractures^4^. Notably, South Korea transitioned into an elderly society in 2018 and is expected to progress to an ultra-elderly society in the coming years. Consequently, the incidence of hip fractures is rising rapidly in tandem with the aging population^8^.
Hip fractures represent a serious injury with persistently high mortality and morbidity rates^9^. Surgery plays a pivotal role in mitigating these risks, as the prognosis is often poor for patients without surgical intervention. Early surgery is preferred, and guidelines recommend surgery within 48 h of presentation in stable patients and those with correctable medical condition^4,10,11^.
A considerable number of hip fracture patients arrive at the emergency department (ED) and await surgical intervention. Consequently, ED often serves as a temporary haven, delivering essential pain management and preparing patients for the impending surgery. While many studies have explored various aspects of hip fracture management in the ED, most have concentrated on patient characteristics, conditions, and pain control^12–15^, without establishing their correlation with the time to surgery, which significantly impacts outcomes. Previous studies on time to surgery have revealed several influencing factors; however, the impacts of ED-related factors, such as ED length of stay (LOS), ED occupancy (EDO), and patient characteristics at the time of ED arrival, remain unclear.
The primary aim of this study was to identify ED-related factors that impact the time to surgery in patients with hip fractures. The secondary aim was to assess the subsequent clinical outcomes associated with these ED-related factors.
We performed a retrospective observational study of patients with hip fractures who presented to the ED of a 900-bed tertiary care university hospital, Gyeongsang National University Hospital, between January 1, 2017, and December 31, 2022. Our ED is a regional emergency center, serving as the final referral center for the region. In our ED, we examine the patient, take x-rays, and contact an orthopedic surgeon over the phone within 30 min of their arrival. Consultations are available 24 h, but the time it takes for an actual consultation with an orthopedic surgeon can vary depending on the conditions of the operating room and outpatient clinic. Patients confirmed to have a hip fracture undergo basic tests, including blood tests necessary for surgery. If, during these tests, an acute issue requiring care from another department is discovered, the patient is referred to that department for further evaluation and treatment. Should it be determined that treatment from another department takes precedence over surgery, the patient is admitted to that department rather than orthopedics. The ED does not have a femur fracture care pathway or dedicated teams and does not administer nerve blocks for pain control. It is staffed by board-certified emergency physicians and orthopedic surgeons. Surgeries, X-ray, and Computed Tomography are performed 24 h a day. But certain exams, such as echocardiograms, are only available during regular hours. This research protocol is a retrospective study and has been approved by the GNUH Institutional Review Board for an exemption from the informed consent form (GNUH 2023-11-003-003). We had access to the medical records from December 11, 2023 to January 30, 2024. All methods were performed in accordance with the relevant guidelines and regulations.
The inclusion criteria encompassed patients aged 60 years and older with proximal femur fractures, including femur neck fractures, intertrochanteric fractures, and other types such as greater trochanteric fractures, femur head fractures, and subtrochanteric fractures, who presented to the ED.
Patients who met the following conditions were excluded from the individuals who were discharged from the ED, those with non-trivial injuries such as traffic accident or fall from a high places, individuals with pathologic fractures or peri-prosthetic fractures, those with incidentally discovered fractures who didn’t know when the fractures occurred, patients transferred from other hospitals with complications that occurred during other hospital stays, and those who did not undergo surgical intervention. We also excluded patients admitted to other departments who needed immediate treatment, such as pulmonary embolism, myocardial infarction, and severe pneumonia, as these patients were not considered suitable for evaluating the timing of surgery.
The collected demographic information included age, sex, smoking status, alcohol consumption, comorbidities (diabetes mellitus, hypertension, neurological diseases, chronic kidney disease, ischemic heart disease, arrhythmia, heart failure, chronic lung disease, active cancer, or liver cirrhosis), anticoagulant or antiplatelet drug use, and pre-injury Koval grade^16^. The Koval grade is a classification system used to assess the ambulatory ability of patients. This grade ranges from 1 to 7, with grade 1 indicating independent community ambulators, and grade 7 indicating nonfunctional ambulators. Patients requiring priority medical treatment or presenting with complications were excluded, and the presence of underlying conditions was examined to indirectly assess their impact on surgery. At this hospital, relevant departments are consulted to assess surgical risk prior to proceeding with surgery. If additional exams are recommended based on the patient’s condition, these are conducted before consulting again.
The collected clinical information included time to surgery, fracture type, presentation by ambulance, transfer from other hospitals, concomitant injury, Korean Triage and Acuity Scale^17^, off-hours presentation, presentation on the day before holidays, presentation during the coronavirus disease 2019 pandemic, EDO ratio, ED LOS, prolonged ED stay, oxygen saturation, American Society of Anesthesiology class, anesthesia type, surgery type, white blood cell and platelet counts, hemoglobin, international normalized ratio, creatinine, albumin, sodium levels, and arterial blood partial pressure of oxygen. The Korean Triage and Acuity Scale is a system used in Korean emergency departments to categorize the acuity of patients. It divides patients into levels 1 to 5 based on severity, with levels 1 to 3 classified as emergency and levels 4 to 5 as non-emergency.
Clinical outcomes included in-hospital mortality, in-hospital complications (delirium, pressure sore, acute kidney injury, infections, cardiac complications [e.g., myocardial infarction, arrhythmia, and pulmonary edema], thromboembolic events [e.g., deep vein thrombosis, pulmonary thromboembolism, arteriosclerosis obliterans, and cerebral infarction], others [e.g., drug-induced liver injury, gastrointestinal bleeding, ileus and asthma attack]), and hospital LOS. Complications were determined by reviewing medical records made by healthcare providers.
Time to surgery, defined as the interval from ED arrival to surgery commencement, was used to categorize patients into an early surgery group (≤ 48 h) and a delayed surgery group (> 48 h). The pre-injury Koval grades were categorized as ≥ 4 or < 4 based on the presence or absence of spontaneous activity. Off-hours presentation was defined as ED presentation between 00 and 00 or on Saturdays, Sundays, or Korean holidays. Typically, surgery is scheduled for the second day after the presentation or later. Consequently, if the day after the presentation is a holiday, including Saturdays and Sundays, when routine surgeries are not performed, the surgery might be postponed. Therefore, we categorized patients into two groups based on whether or not the day after the presentation was a holiday. Our hospital performed mandatory Coronavirus disease 2019 (COVID-19) testing for all patients after November 23, 2020. Consequently, patients were admitted for hospitalization or surgery after obtaining their COVID-19 test results. Presentation by patients on or after November 23, 2020 were categorized as presentation during the COVID-19 pandemic. We evaluated ED crowding based on the EDO ratio when the patient was received, calculated as the total number of ED patients divided by the total number of ED beds when a patient was admitted to the ED. Although there is variability in EDO, the number of medical staff in our ED remains fixed regardless of the occupancy rate. ED LOS was defined as the duration from a patient’s arrival to their departure from the ED. Previous studies that have evaluated LOS have used various definitions of extended boarding, with most considering a duration of 6–8 h as prolonged^18–20^. Considering that standards recommended in the evaluation of emergency medical institutions in Korea are aimed at within ≤ 6 h, prolonged ED stay was defined as > 6 h. Surgery type was categorized as internal fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Hospital LOS was calculated as the number of days from the time of ED arrival to discharge.
The primary outcomes were delayed surgery (i.e., those performed > 48 h after presentation). The secondary outcomes were clinical outcomes according to delayed surgery.
Data analysis was performed using SPSS software (version 21.0; IBM Corp., Armonk, NY, USA). Categorical variables are expressed as numbers with percentages, whereas continuous variables are presented as medians with interquartile range (IQR). We employed the Shapiro-Wilk test to assess the normal distribution of continuous variables. Univariate logistic regression analyses were used to compare patients’ baseline and clinical variables. Multivariable logistic regression analysis was used to identify predictors of delayed surgery that showed significant results in the univariate analyses. For convenience, continuous variables were converted to categorical variables using the median value of the delayed surgery group. P < 0.05 was considered indicative of statistical significance.
During the study period, the hospital received 780 patients aged ≥ 60 years with hip fractures. After excluding 101 patients who were not hospitalized, 75 with non-trivial injury, 28 with pathological or periprosthetic fractures, 23 with incidental fractures, 89 transferred from other hospitals due to complications, 18 admitted to other departments for immediate treatment, and 12 who did not undergo surgery, 434 patients were included in the study (Fig. 1).
Fig. 1The study patients.
The median age of participants was 81 (IQR: 75.8–85.0) years, and 311 (71.7%) were female. A significant proportion of patients had preexisting medical conditions (394, 90.8%), including diabetes mellitus (146, 33.6%), hypertension (286, 65.9%), neurological diseases (179, 41.2%), chronic kidney disease (81, 18.7%), ischemic heart disease (70, 16.1%), arrhythmia (56, 12.9%), heart failure (28, 6.5%), chronic lung disease (61, 14.1%), active cancer (27, 6.2%), and liver cirrhosis (18, 4.1%).
The median time to surgery was 49.0 (IQR: 22.4–92.6) h for all patients, 21.6 (IQR: 8.3–28.6) h in the early surgery group, and 92.0 (IQR: 67.7–119.3) h in the delayed surgery group. The early and delayed groups included 209 and 225 patients, respectively.
No group differences were observed in age, sex, smoking status, alcohol consumption, diabetes mellitus, hypertension, neurological diseases, chronic kidney disease, arrhythmia, active cancer, liver cirrhosis, anticoagulant or antiplatelet drug use, or the pre-injury Koval grade. However, significant differences were observed between the groups in terms of the prevalence rates of ischemic heart disease, heart failure, and chronic lung disease (Table 1). Significant differences between the groups were observed in terms of presentation on the day before holidays, prolonged ED stay, surgery type, international normalized ratio, and albumin level (Table 2, Supplementary Table S1). Based on the factors that showed significant results in the univariate analyses, a multivariable analysis was performed. It was found that ischemic heart disease (Odds Ratio [OR]: 2.547, 95% CI: 1.377–4.710, P = 0.003), presentation on the day before holidays (OR: 5.804, 95% CI: 3.482–9.673, P < 0.001), prolonged ED stay (OR: 1.792, 95% CI: 1.102–2.914, P = 0.019), surgery type (with bipolar hemiarthroplasty OR: 2.193, 95% CI: 1.406–3.420, P = 0.001 and total hip arthroplasty OR: 5.884, 95% CI: 1.785–19.393, P = 0.004), and albumin level ≤ 3.8 g/dL (OR: 1.753, 95% CI: 1.130–2.721, P = 0.012) were significantly associated with delayed surgery. (Table 3). Table 4 presents the clinical outcomes according to the time to surgery. Delirium was more frequent in the delayed group, whose hospital LOS was also longer. Most complications were also more common in that group, although the differences were not statistically significant.
Table 1Univariate analysis of baseline characteristics and time to surgery.Total patients(n = 434)Early surgery(n = 209)Delayed surgery(n = 225)P valueAge (yr), median (IQR)81.0 (75.8–85.0)81.0 (75.0–86.0)81.0 (76.0–85.0)0.663Female, n (%)311 (71.7)157 (75.1)154 (68.4)0.124Smoking, n (%)40 (9.2)20 (9.6)20 (8.9)0.807Alcohol consumption, n (%)41 (9.4)22 (10.5)19 (8.4)0.460Comorbidities Diabetes mellitus, n (%)146 (33.6)61 (29.2)85 (37.8)0.059 Hypertension, n (%)286 (65.9)133 (63.6)153 (68.0)0.338 Neurological disease, n (%)179 (41.2)86 (41.1)93 (41.3)0.969 Chronic kidney disease, n (%)81 (18.7)37 (17.7)44 (19.6)0.621 Ischemic heart disease, n (%)70 (16.1)23 (11.0)47 (20.9)0.006 Arrhythmia, n (%)56 (12.9)21 (10.0)35 (15.6)0.089 Heart failure, n (%)28 (6.5)8 (3.8)20 (8.9)0.037 Chronic lung disease, n (%)61 (14.1)19 (9.1)42 (18.7)0.005 Active cancer, n (%)27 (6.2)10 (4.8)17 (7.6)0.236 Liver cirrhosis, n (%)18 (4.1)7 (3.3)11 (4.9)0.424 anticoagulant or antiplatelet drug use, n (%)203 (46.8)88 (42.1)115 (51.1)0.061 Pre-injury Koval grade ≥ 4165 (38.0)75 (35.9)90 (40.0)0.378IQR; interquartile range.
Table 2Univariate analysis of clinical data.Total patients(n = 434)Early surgery(n = 209)Delayed surgery(n = 225)P valueExtracapsular fracture, n (%)269 (62.0)135 (64.6)134 (59.6)0.280Transfer from other hospitals, n (%)305 (70.3)149 (71.3)156 (69.3)0.656Off-hour presentation, n (%)191 (44.0)83 (39.7)108 (48.0)0.083Presentation on the day before holidays, n (%)129 (29.7)29 (13.9)100 (44.4)< 0.001Presentation during COVID-19 pandemic, n (%)145 (33.4)71 (34.0)74 (32.9)0.811ED occupancy ratio, median (IQR)0.76 (0.63–0.870.76 (0.66–0.87)0.74 (0.63–0.91)0.774ED LOS (min), median, (IQR)10.4 (5.5–20.3)9.3 (5.1–19.8)10.8 (6.2–20.9)0.039Prolonged ED stay, n (%)307 (70.7)138 (66.0)169 (75.1)0.038Spinal anesthesia, n (%)335 (77.2)157 (75.1)178 (79.1)0.323Surgery type, n (%) Internal fixation231 (53.2)133 (63.6)98 (43.6)< 0.001 Bipolar hemiarthroplasty180 (41.5)72 (34.4)108 (48.0)< 0.001 Total hip arthroplasty23 (5.3)4 (1.9)19 (8.4)0.001 International normalized ratio, median (IQR)1.05 (1.00-1.12)1.04 (0.99–1.10)1.07 (1.01–1.15)0.030 Albumin, (g/dl), median (IQR)3.9 (3.6–4.2)3.9 (3.6–4.2)3.8 (3.5–4.1)0.049IQR; interquartile range, COVID-19; coronavirus disease 2019,ED; emergency department, LOS; length of stay, ASA; American Society of Anesthesiology, PaO2; arterial blood partial pressure of oxygen.
Table 3Multivariable analysis of delayed surgery.βP valueodds ratio95% Confidence intervalIschemic heart disease0.3140.0032.5471.377–4.710Heart failure0.4780.1062.1660.848–5.532Chronic lung disease0.3280.1471.6100.846–3.065Presentation on the day before holidays0.261< 0.0015.8043.482–9.673Prolonged ED stay0.2480.0191.7921.102–2.914Surgery type Internal fixation< 0.0011 Bipolar hemiarthroplasty0.2270.0012.1931.406–3.420 Total hip arthroplasty0.6090.0045.8841.785–19.393 International normalized ratio ≥ 1.070.2230.3531.2300.794–1.904 Albumin ≤ 3.80.2240.0121.7531.130–2.721ED; emergency department.
Table 4Clinical outcome according to time to surgery.Total patients(n = 434)Early surgery(n = 209)Delayed surgery(n = 225)P valueDeath, n (%)11 (2.5)5 (2.4)6 (2.7)0.856Delirium, n (%)179 (41.2)74 (35.4)105 (46.7)0.018Sore, n (%)76 (17.5)35 (16.7)41 (18.2)0.686Acute kidney injury, n (%)36 (8.3)18 (8.6)18 (8.0)0.817Infection, n (%)78 (18.0)32 (15.3)46 (20.4)0.165Cardiac events, n (%)29 (6.7)14 (6.7)15 (6.7)0.989Thromboembolic events, n (%)15 (3.5)8 (3.8)7 (3.1)0.684Others^^, n (%)29 (6.7)11 (5.3)18 (8.0)0.257Hosptial length of stay, median (IQR)18.0 (16.0–27.0)16.0 (15.0-26.5)19.0 (17.0–27.0)0.026^^ e.g., drug-induced liver injury, gastrointestinal bleeding, ileus and asthma attack.IQR; interquartile range,.
Ischemic heart disease, presentation on the day before holidays, prolonged ED stay, surgery type, and albumin levels ≤ 3.8 were significant factors contributing to delayed surgery. Delirium and prolonged hospital stay were more common in the delayed surgery group.
In line with previous studies^2,21–24^, the present study demonstrated that ischemic heart disease, presentation day, and surgery type influenced the time to surgery. These factors affect the time required to perform necessary tests before anesthesia or the time needed to prepare for the surgical procedure. In cases of ischemic heart disease, if there is no urgent medical condition requiring immediate treatment of the ischemic heart disease upon admission, surgical delays can be caused by the need for additional tests such as echocardiography, consultation with other specialists, or because of anticoagulant or antiplatelet drug use. Recent studies have shown that surgery does not need to be delayed in cases of anticoagulant or antiplatelet drug use^25^. Furthermore, in the present study, anticoagulant or antiplatelet drug use was not significantly associated with the time to surgery, suggesting that the delay was caused by the remaining two causes. Presentation on the day before holidays may result in delayed surgery due to the prolonged time needed to conduct tests and the lack of routine surgeries. Surgery type can be influenced by various factors, including equipment and manpower issues, which in turn can affect the time to surgery. Considering these factors, for hip fracture patients who arrive at the ED, diagnosis and treatment begin immediately, but the factors causing surgical delays can ultimately be summarized as issues related to access to medical resources. Delays occur when there is limited access to medical resources due to holidays or when resources that are difficult to access are required. In our hospital, some tests, such as echocardiography, are only performed during regular working hours in the wards and ED, which can affect surgical delays. Due to staffing and cost issues, hospitals may not be able to conduct tests or perform routine surgeries on holidays. In such cases, it may be beneficial to establish a time-based criterion and prioritize tests, surgeries, and resources for delayed patients to reduce the time to surgery.
In this study, prolonged ED stay and albumin levels are newly identified factors associated with the time to surgery. Prolonged ED LOS is associated with increased hospital LOS, ventilation duration, incidence of delirium, and risk for perioperative complications^26–28^. Additionally, ED stay is widely recognized to be associated with increased mortality in various conditions, such as intracerebral hemorrhage, sepsis, and critical illness^19,26,29^. A recent study has shown that hip fracture patients with prolonged ED LOS are at an increased risk of mortality^30^. However, Hip fracture patients have factors that are risk factors to be associated with prolonged ED LOS, including female gender, advanced age, and a low triage score^31,32^. Elderly patients admitted to the ED tend to have longer ED LOS due to multiple comorbidities, cognitive impairment, and the increased need for various exams and consultations^33,34^. Additionally, since the ED prioritizes the treatment of patients with higher severity, patients with hip fractures, who generally have a lower severity, may be deprioritized in terms of receiving immediate care. Given the lower severity and inability to provide definitive treatment (i.e., surgery) in the ED, the focus of hip fracture management in the ED is primarily on pain control, which can lead to prolonged ED stays^5,35^.
One hip fracture guideline recommends an ED LOS of 4 h^36^, although the underlying evidence remains unclear, whereas other guidelines and protocols do not recommend a target ED LOS^37,38^. The guidelines for ED LOS are likely based on complications associated with prolonged ED stays rather than the time to surgery^26–28^. A recent study categorized patients based on a ED LOS cutoff of 5 h and demonstrated a similar time to surgery (3 days) for both groups, although the rate of surgery within 48 h was not reported^5^. The present study is first to demonstrate that prolonged ED stay can affect the time to surgery. Although we used an ED LOS cutoff of 6 h and found significant results, further studies are needed to determine whether further reduction in the recommended ED LOS to 4 h would be beneficial. A small study used a multidisciplinary approach to reduce the ED LOS from 6 h to < 4 h; however, there was no significant difference in the time to surgery^15^, which might be attributable to the short time to surgery in the hospital before the interventions or to the lack of correlation between reduced ED LOS and time to surgery. It is necessary to select appropriate patients and determine the optimal timing by weighing the disadvantages of prolonged ED stays, such as delirium and suboptimal pain control, against the advantages, like the ability to expedite necessary pre-surgery investigations.
Albumin is a well-established marker of nutritional status, particularly in the elderly, in whom nutritional status significantly impacts both surgical and nonsurgical outcomes. It is closely associated with risks for mortality, infection, prolonged hospital LOS, and overall complications^39–42^. Previous studies on hip fractures associated with albumin have identified albumin levels as a predictor of increased risk of postoperative infections, complications, mortality, and diminished postoperative quality of life following hip surgery^39,43,44^. Additionally, we found that it influences the operative time. Although the exact reason for this finding is unclear, it potentially acts as a marker for overall nutritional status. In cases of poor preoperative nutritional status due to various reasons, additional testing and treatment may be necessary, which may delay surgery. Studies have also emphasized optimizing preoperative serum albumin levels to reduce postoperative complications, and the time required for this process may have caused delays^45–47^. Even after adjusting for comorbidities, albumin level remained a significant influencing factor, suggesting that it indicates the overall health status beyond the presence of comorbidities. General orthopedic surgery studies have indicated that albumin levels < 3.5 g/dL are associated with a higher risk for postoperative complications^39,43^, particularly infections. In particular, studies on bipolar hemiarthroplasty in hip fracture patients have shown that a preoperative albumin level below 3.5 g/dL serves as a major predictor, increasing the risk of inability to walk independently six weeks after surgery^48^. However, these previous studies primarily focus on postoperative outcomes, presenting limitations in evaluating direct associations with the timing of surgery, which is a key variable in this study. Further research is needed to determine the optimal albumin level that can reduce postoperative complications while enabling timely surgery. This will play a crucial role in optimizing patient recovery and improving surgical outcomes.
Mortality rates according to the timing of surgery vary between studies^6,10,49,50^, and in our study, no difference in mortality rates was observed. However, the early surgery group showed a lower incidence of delirium and a shorter hospital LOS. The advantages of the early surgery group, such as less pain, faster functional recovery, and shorter LOS have been consistently demonstrated in previous studies^10,51,52^. Therefore, guidelines recommend early surgery for hip fractures^4,10,11^. In addition to patient benefits, early surgery is associated with hospital benefits. Reduced bed occupancy due to early surgery can be useful for outpatient or ED patients who need an ED bed. A previous study found that for every 7.85 h delay in hip fracture surgery, bed occupancy was expected to increase by an additional day; therefore, even a short delay in surgery leads to a change in bed occupancy of 1 day, and efforts to reduce the time to surgery are needed^51^. Other studies have shown that it is more cost-effective to perform surgery within 48 h than to delay it^53,54^. Thus, while early surgery offers benefits to both patients and hospitals, many hospitals have not yet implemented early surgery for hip fracture patients due to the need for manpower, resources, and multidisciplinary collaboration. Our hospital does not yet operate a fast-track pathway, resulting in an ED stay of 10 h, and more than half of the patients experience delayed surgeries, which complicates hospital operations and patient management. Due to constraints in medical staff and hospital resources, we cannot immediately establish a fast-track pathway, but we have identified key areas to focus on to implement early surgery. We aim not only to provide pain management in the ED but also to address the issue of delayed surgeries. We believe our findings can provide particularly useful information for hospitals without fast-track pathways. When patients arrive at the ED, it is crucial to check for comorbidities and plan necessary exams and consultations in advance. Checking the patient’s albumin levels, identifying any issues with their overall condition, and providing albumin supplementation if necessary can help reduce the time to surgery.
This study had several limitations. First, it was a retrospective study, potentially leading to unmeasured bias. Second, we did not evaluate pain control or investigations conducted in the ED or ward. Furthermore, our hospital does not perform nerve blocks, which could have influenced our findings. Third, the study was performed during the COVID-19 pandemic, potentially impacting our results. However, when considering the COVID-19 pandemic as a potential influencing factor, significant results were not obtained. Fourth, ED LOS may be affected by the time it takes to seek care from an orthopedic surgeon and the availability of hospital or operating rooms, but this could not be measured retrospectively. Fifth, while hospital overcrowding can affect ED stay times, the continuously changing number of available beds due to situations like COVID-19 limited our ability to retrospectively evaluate this. Sixth, this study was conducted at the only tertiary care hospital’s ED in the region. Due to the significant number of patients with multiple comorbidities and other conditions, the operating room is primarily utilized for more severe cases, resulting in many hip fracture patients experiencing delayed surgery. Therefore, our findings may not be generalizable to other institutions. Given these considerations, future multicenter prospective studies are needed to verify the significance of various factors identified in this study, including albumin of 3.5 g/dL.
In patients with hip fractures presenting to the ED, factors related to delayed surgery include ischemic heart disease, presentation on the day before holidays, prolonged ED stay, surgery type, and albumin level ≤ 3.8 g/dL. Delayed surgery is associated with an increased incidence of delirium and longer hospital LOS.
Below is the link to the electronic supplementary material.
Supplementary Material 1