Avoidable and unavoidable delays in hip fracture surgery

Authors: Mitchell Sarkies, Nicholas Murphy, Ramya Kunnath, Seth Tarrant, Erica Epstein, Natasha Weaver, Cameron R. Hemmert, Zsolt J. Balogh

Abstract

Aims

Surgical management of hip fracture is often delayed, which is associated with increased mortality. We aimed to prospectively determine the proportion of potentially avoidable delay to surgery beyond 48 hours, and its causes, as clinically relevant margins for quality improvement.

Methods

A 12-month prospective cohort study from September 2022 to September 2023 was conducted on all 427 hip fracture surgery patients aged ≥ 50 years who were admitted to a trauma centre in New South Wales, Australia. The reasons for delay, medical speciality, and level of seniority initiating the decision, and what response was taken after the delay, were recorded for each case delayed beyond 48 hours from hospital admission. Surgical delays were categorized as either avoidable or unavoidable independently by surgical and medical experts.

Results

From 427 hip fractures, 37% (160/427) had surgery beyond 48 hours, with 29% (124/427) considered avoidable, 6% (27/427) unavoidable, and 2% (9/427) unable to be categorized. Patients experienced a median 43-hour time to surgery (IQR 27 to 63): 30 hours (IQR 24 to 41) for non-delayed, 69 hours (IQR 55 to 93) for avoidable, and 75 hours (IQR 59 to 135) for unavoidable delays. Patients with unavoidable delays had higher American Society of Anesthesiologists grades and acute ward length of stay. Limited operating theatre availability was responsible for 60% of delays (96/160), of which 92% (88/96) were considered avoidable. Orthopaedic trauma operating theatre access was compromised (operating theatre unavailable) for 86% of hip fracture surgery delays that were due to limited operating theatre availability. Reasons unrelated to operating theatre availability accounted for 35% of delays (56/160). It was not possible to categorize 5% of delays (8/160).

Conclusion

Most hip fracture surgery delays are due to limited operating theatre availability. Of the delays, 78% were considered avoidable, representing a margin for improvement of 55% for operating theatre availability, and 23% unrelated to operating theatre availability.

Cite this Bone Jt Open 2025;6(8):876–885.

Introduction

A hip fracture is a devastating injury, constituting a high mortality and costly osteoporotic fracture. One-year mortality after hip fracture is approximately 20%,^1^ with only half of survivors recovering their pre-fracture level of function.^2^ This injury also represents a substantial cost for health and social care, estimated at USD$43,669 per person, attributed mostly to inpatient hospital expenditure.^3^

Most hip fractures are managed surgically in high-income countries, as surgery is associated with improved ambulation and lower risk of mortality.^4,5^ However, it is common for patients to wait more than two days for surgery.^6,7^ Delayed surgery is thought to increase the risk of mortality, in-hospital pneumonia, and pressure injuries.^8^ Subsequently, clinical practice guidelines recommend early surgery within 24 to 48 hours,^9-11^ a standard which is increasingly monitored by audits and clinical registries.^12,13^

Despite extensive research dedicated towards reducing time to surgery,^14^ it remains unknown what proportion of surgery delays are potentially modifiable and whether avoidable or unavoidable delays are associated with care outcomes. Delaying surgery to address medical instability might be considered unavoidable;^14-19^ however, there is no consensus on which clinical presentations should result in a delay. Insufficient availability of operating theatre time is a commonly cited potentially avoidable barrier to reducing time to surgery.^20^ Yet, efforts to further prioritize hip fracture cases can potentially displace other surgical cases unless additional operating theatre slots are available.

Healthcare resources are finite, so efforts towards improving certain hip fracture care indicators come at a cost to other indicators or patient populations. Ideally, avoidable delays that are associated with poor outcomes would be the target for quality improvement interventions. Therefore, it is imperative to develop an understanding of why surgery is delayed, and whether these delays are potentially avoidable or unavoidable, to better inform targeted efforts at quality improvement.

Our aim was to prospectively determine the causes and proportion of potentially avoidable delays to surgery beyond 48 hours as clinically relevant margins for quality improvement.

Methods

Design

A 12-month single-centre prospective observational cohort study of consecutive hip fracture patients was performed. Patients were identified daily by the investigators. The study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.^21^ Ethical approval was obtained from the Hunter New England Local Health District Human Research Ethics Committee (2022/ETH01383).

Setting and population

This study was conducted at the John Hunter Hospital, which a university affiliated level I trauma centre located in Newcastle, New South Wales, Australia. It serves approximately one million people across a region of 131,785 square kilometres, including metropolitan regional, rural, and remote communities. The hospital provides services for approximately 400 to 450 hip fracture patients per year. Typically, two orthopaedic trauma operating theatres are run each one from 00 to 00 (13 hours), and one from 00 to 30 (9.5 hours). Our study was conducted between 13 September 2022 to 12 September 2023, and includes people aged 50 years and over who were admitted to hospital with a low-energy proximal femur fracture.

Patient characteristics

Data were collected for 427 hip fracture patients undergoing surgery during the 12-month study period (Figure 1). Of these, 63% (267/427) had surgery completed within 48 hours from hospital arrival and 37% (160/427) had surgery delayed beyond 48 hours. The median time to surgery was 43 hours (IQR 27 to 63): 30 hours (IQR 24 to 41) for non-delayed, 69 hours (IQR 55 to 93) for avoidable delays, and 75 hours (IQR 59 to 135) for unavoidable delays. There were differences in American Society of Anesthesiologists (ASA)^22^ grade and acute ward length of stay between those with and without surgery delay, driven mostly by higher ASA grades and longer acute ward length of stay for patients with unavoidable surgery delays (Table I).

Variables

Variables from the local Australian and New Zealand Hip Fracture Registry data collection were age (years), sex (male or female), usual place of residence (private residence or residential aged care facility), pre-admission walking ability (without walking aids, with walking aids, or wheelchair/bed bound), pre-admission cognitive status (normal cognition or impaired cognition/known dementia), ASA grade, fracture type (intracapsular undisplaced/impacted displaced, intracapsular displaced, per/intertrochanteric, subtrochanteric), surgery type (cannulated/sliding hip screws, intramedullary nail, hemiarthroplasty, total hip arthroplasty), anaesthesia type (general, spinal, or general and spinal), hospital length of stay (acute ward and total), in-hospital mortality, and discharge place of residence.

The following data were prospectively collected for each surgical delay beyond 48 hours from hospital 1) reasons for delay; 2) medical speciality and level of seniority initiating the decision; and 3) any change in management in response. An orthopaedic registrar not involved directly in the care of these patients requested and recorded the reasons for surgical delay beyond 48 hours from the relevant clinician. This information was collected as close as possible to the decision being made or indicator not being met (ideally within 24 hours). Compromised operating theatre access was defined as fewer than two orthopaedic trauma operating theatres available for one of the days on which the patient was awaiting surgery. At John Hunter Hospital, hip fracture patients are on the same operating list as all trauma patients awaiting surgery, including multitrauma and polytrauma patients. Data collection forms for clinical quality indicators not being met are presented in the Supplementary Material.

Surgical delay beyond 48 hours from hospital arrival was categorized as either avoidable or unavoidable by the data collectors. Two clinicians (NM, EE) independently categorized whether surgical delays unrelated to operating theatre availability were avoidable or unavoidable. The decision to categorize the delay as either avoidable or unavoidable was coded by the two clinicians using to an analytic framework, according to either one of three 1) personal and organizational capacity; 2) clinician decision-making; or 3) scientific and clinical evidence (Table II).^23^ Any disagreements were resolved by a third independent clinician (ZB). A similar process was undertaken for delays due to operating theatre availability reasons, where one orthopaedic surgeon (ST) categorized surgical delays as either avoidable or unavoidable which was independently reviewed by another orthopaedic surgeon (ZB).

Statistical analysis

Analysis was conducted using SPSS v. 28 (IBM, USA). Descriptive data were presented as median (IQR) or frequency and percentages. Statistical analysis was performed using chi-squared test for categorical variables or Mann-Whitney U test for continuous variables. Statistical significance was set at p < 0.05.

Results

Median time to surgery by day of hospital admission, for those with and without delayed surgery, is presented in Figure 2.

Reasons for surgery delay

Table III presents reasons for delay according to whether they were considered avoidable or unavoidable. Approximately 35% of delays (56/160) were unrelated to operating theatre availability, while 60% (96/160) were due to operating theatre availability. Definitive reasons for delay were unable to be identified for 5% of patients (9/160). Of these delays, 78% (124/160) were considered potentially avoidable. Most of these delays were due to limited operating theatre availability, followed by inter-hospital transfers and medical reasons for delay. A total of 17% of surgery delays (27/160) were considered unavoidable, with most of these also being due to operating theatre availability, followed by medical reasons, preoperative study or consultation, and delayed consent signing. Figure 3 presents the reasons for surgery delay according to whether they were 1) personal and organizational capacity; 2) clinician decision-making; or 3) scientific and clinical evidence.^23^

Reasons for delay unrelated to operating theatre availability

The decision to delay surgery was made differently between medical specialties. Anaesthetics more frequently decided to delay surgery (41%), followed by multiple specialties together (37%) and orthopaedics (22%). Anaesthetics and multiple-speciality decisions to delay surgery were more often made when patients were considered medically unfit. Changes in management after delays unrelated to operating theatre availability are presented in Table IV. There was no change in management reported for approximately 24% of delays unrelated to operating theatre availability. Half of the delays that did not lead to a change in management were due to the requirement for preoperative studies or consultation.

Operating theatre availability-related reasons for delay

Table V presents operating theatre availability-related reasons for delay according to whether there was usual or compromised operating theatre access. Orthopaedic trauma operating theatre access was considered compromised when one of the operating theatres was unavailable on any day while the patient awaited surgery. A total of 86% of hip fracture surgery delays due to operating theatre availability occurred when there was compromised orthopaedic trauma operating theatre access. On days where hip fracture surgery was delayed, there were more pending cases on the orthopaedic trauma operating theatre list at 00 when operating theatre access was compromised. The prioritization of hip fracture patient position on the operating theatre list tended to be progressively prioritized higher each day that surgery was delayed on days where there was both usual and compromised access.

Discussion

This prospective study describes the specific reasons for hip fracture surgery delay beyond 48 hours at a level I trauma centre. A total of 37% of hip fracture patients experienced surgery delay beyond 48 hours, waiting a median of 70 hours. Patients with delayed surgery tended to be more unwell on hospital presentation and had a longer acute ward length of stay. Most delays were considered avoidable due to a lack of orthopaedic trauma operating theatre availability, and these delays predominantly occurred when there was compromised access to one of the operating theatres on any day while the patient awaited surgery. Despite higher numbers of pending cases when operating theatre access was compromised, hip fracture patients were generally prioritized similarly on the operating list and higher with each day the case was delayed.

Lack of operating theatre availability is frequently reported as a primary reason for delayed hip fracture surgery.^16,24,25^ Operating theatre time is a limited resource, with different patient presentations competing for prioritization on the operating lists. The use of separate trauma surgery and elective orthopaedic operating theatres is thought to decrease time to surgery for hip fracture patients, where these cases are prioritized.^26,27^ We reported longer delays and higher numbers of pending cases during periods of compromised operating theatre access, despite hip fracture patients being prioritized similarly. This finding indicates that disruptions which compromise access to dedicated trauma operating theatres may lead to more delays regardless of whether prioritization of hip fractures is maintained, supporting the benefit of protecting dedicated trauma surgery lists. Organizational improvements that protect dedicated trauma surgery lists and prioritize hip fracture patients represent a promising target for future implementation research to improve the delivery of care.

Our study identified several other system and organizational reasons for delayed surgery, mostly deemed avoidable due to capacity or resource constraints. In contrast to previous research, we did not find surgical staff unavailability,^25^ or the day of hospital admission,^16,18,28,29^ to influence surgery delay. However, some of the reasons behind unavailable operating theatres could have been nursing or anaesthesiology staff shortage on the given day. The most common avoidable delay was due to inter-hospital transfers. The studied hospital manages a high volume of hip fracture cases for a population dispersed over a large geographical area; however, the time taken to transfer patients across such distances is not unique to our study site. Inter-hospital transfers have been shown to more than double the odds of surgery delay compared to patients who are not transferred between hospitals.^30^ Results from our study, as well as Zeltzer et al,^30^ indicate that 10% to 15% of surgery delays may be attributed to inter-hospital transfers, highlighting the need for improved systems and processes that extend beyond professional boundaries and enhance coordination of services between hospitals.

Consistent with previous research,^24,25^ the need for medical stabilization or preoperative study or consultation was a common reason for delay. While most of these delays were deemed unavoidable, those considered avoidable accounted for approximately 5% of all surgery delays, representing a small potential margin for improvement. It has been argued that standardization of appropriate medical reasons for delay is needed to reduce variation in care between hospitals, including the length of delay balanced with the risk of deterioration due to delay. Clinical practice guidelines and previous research provide lists of potential comorbidities to correct where there is acute correctable derangement.^11,17,31^ In practice, the decision to delay surgery for medical optimization is made on an individual case-by-case basis, often involving multiple potentially correctable comorbidities, which limits the ability to rely on a single list of appropriate medical reasons for delay. However, our study identified around 24% of delays unrelated to operating theatre availability did not result in any change of management, which was concordant with previous data indicating that 15% of patients whose surgery is postponed due to a major abnormality do not have that problem resolved before they went to surgery.^32^

A small proportion of delays (4%) were attributed to antithrombotic therapy, which were mostly considered avoidable. This is lower than the 22% (2022) and 5% (2023) reported for John Hunter Hospital and lower than the average 16% (2022) and 14% (2023) of delay attributed to issues with anticoagulation according to the Australia and New Zealand Hip Fracture Registry.^12^ Tarrant et al^33^ have published on direct oral anticoagulants and timing of hip fracture surgery, and advocate for timely surgery because delays are likely related to worse outcomes, but recognize that there is still a small potential margin for improvement locally. The management of antithrombotic therapy was based on individual surgeon and anaesthetist preferences prior to the availability of consensus guidelines on the management of traditional and direct oral anticoagulants in hip fracture patients.^34^ Guidance has recently become available to empower orthopaedic surgeons and the multidisciplinary teams to avoid unnecessary delays to surgery,^34^ whereby the creation of local protocols may assist with improving adherence.^35^

It is important to note that we considered delayed surgery to be beyond 48 hours from first presentation to hospital. Updated Clinical Care Standards in Australia and New Zealand have recommended surgery be undertaken within 36 hours, providing an even more ambitious target for care delivery.^9^ We recorded the primary reason for delay at the 48-hour timepoint without consideration for whether there were different reasons for delay on each separate day a patient was delayed. Additionally, the use of a relatively small sample size from a single hospital site represents a potential weakness of our study. Previous retrospective studies using large registries and databases have enabled the integration of whether delayed surgery causes increased inpatient mortality. However, our prospective study has revealed the specific reasons for delay and attribution to whether they were considered avoidable or unavoidable. Furthermore, we report on real-time demand for orthopaedic trauma operating theatre time and the prioritization practice for hip fracture patients, in scenarios where there was both usual and compromised operating theatre access. This gives a better understanding of the real-world margin for improvement in time to hip fracture surgery at a high-volume level I trauma centre.

In conclusion, this prospective evaluation of the reasons for delayed hip fracture surgery at a Level 1 trauma centre identified that most were due to limited availability of operating theatre time rather than patients’ comorbidities or preoperative medical optimization. These delays were predominantly considered avoidable, where additional capacity and resources would have enabled timely surgery. A margin for improvement in timely access to surgery was identified for additional operating theatre capacity (55% of delays), enhanced system and organizational processes (15% of delays), and medical optimization (9% of delays). Delays for medical optimization, preoperative study or consultation, and antithrombotic therapy were less often considered avoidable, but remained within the agency of the clinical team to make evidence-informed decisions to delay surgery.

Take home message

• Hip fracture surgery was delayed beyond 48 hours for 37% (160/427) of patients.

• Delays to hip fracture surgery were considered avoidable on 78% (124/160) of occasions.

• A 55% margin for improvement was identified for operating theatre availability and 23% unrelated to theatre availability.