118 patients were treated at our institution during the two time frames of interest. There were similar numbers of patients during each timeframe (COVID-19 cohort, N=60, and the control cohort, N=58). The median age in the COVID-19 cohort was 82 years (min=37, max=95, IQR=14.5), while the median age for the control cohort was 75 years (min=31, max=93, IQR=18.25). The difference in medians between groups was not significant (p = 0.213). Both cohorts had a higher proportion of female patients; 37 females (61.7%) in the COVID-19 cohort and 40 females (69%) in the control group. Fourteen patients (23.3%) were admitted from nursing homes in the COVID-19 cohort compared to five patients (8.6%) in the control group (p = 0.052). Clinical Activity Scores (CAS) were also collected on admission with a mean score of 5.05 +/- 3.52 SD in the COVID-19 cohort and 5.83 +/- 3.23 SD in the control group.
We noted trends towards increased adherence in each of the IHFS, with a proportional improvement in each standard in the COVID-19 time period, though this was not a statistically significant difference (Table 1).
Table 1: Adherence to the Irish Hip Fracture Standards (IHFS)
Details of the type of fractures sustained, operations performed, American Society of Anaesthesiologists Classification (ASA) grades and anaesthesia used for both groups can be found in Table 2. There was a statistically significant reduction in femoral nerve blocks to 65% in the COVID-19 cohort compared to 88% in the control group (p=<0.001)
Table 2: Surgical demographics for both cohorts
The median length of stay (LOS) was 7.5 days (min=2, max=66, IQR=11) in the COVID-19 cohort compared to 10.0 days (min=1, max=66, IQR=18) in the control group (p=0.345).
A significant increase in new admissions to nursing homes occurred during the COVID-19 period (p = 0.04). Concurrent decreases were also noted in the proportion of patients discharged directly home, however this was not statistically significant. Other details pertaining to discharge destination in patients admitted directly from the community are included in Table 3.
Table 3: Discharge destination for patients admitted from the community
Readmission rates and Mortality rates
There was a trend towards an increased 30 day readmission rate for the COVID-19 cohort at 6.7% (n=4) compared to 1.7% in the control cohort (n=1), though this was not statistically significant (p = 0.36). Reason for readmission in the COVID-19 cohort included recurrent falls (n=2), an upper respiratory tract infection (n=1) and persistent pain around the prothesis post-operatively (n=1). The sole readmission in the control group was for a query deep vein thrombosis.
Inpatient mortality for the COVID-19 cohort was 8.3% (n=5) compared to 5.2% (n=3) in the control group. Subsequent 30 day mortality rate was 10% (n=6) in the COVID-19 cohort compared to 6.9% (n=4) in the control group.
In the COVID-19 cohort 48.33% (n=29) of patients had a swab for COVID-19. As per clinical guidance at the time any low risk patients were not swabbed. Three of these patients tested positive for COVID-19 (5%). Two of the these patients were admitted from nursing homes. One of the patients was deemed unfit for surgery and died as an inpatient after four days. The other two COVID-19 positive patients underwent surgical repair of their fractures, their LOS was 26 and 31 days respectively.
Telemedicine clinics became the standard of care for routine 30 day post-operative fracture clinic assessments. There was an improvement in patient follow-up such that 76% of patients in the COVID-19 cohort had complete 30 day assessments versus 36% in the control group. In the virtual clinic cohort of patients there was a high rate of direct discharge (64%) back to GP care following virtual review.