Early surgical treatment using regional clinical pathways reduces the length of postoperative hospitalization in hip fracture patients: Retrospective analysis using the Japanese Diagnosis Procedure Combination database

doi:10.21203/rs.3.rs-1562774/v1

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Research Article

Early surgical treatment using regional clinical pathways reduces the length of postoperative hospitalization in hip fracture patients: Retrospective analysis using the Japanese Diagnosis Procedure Combination database

https://doi.org/10.21203/rs.3.rs-1562774/v1

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Background: Hip fracture is a common injury in elderly people, especially those with weak bone contracture, such as in osteoporosis. Although early surgical treatment is recommended, the optimal timing for hip fracture surgery has not been determined in Japan. To date, regional clinical pathways have been introduced into the clinical field to treat patients in a more effective and unified manner. In this study, we aimed to determine the rate of early surgery among hip fracture patients and the effectiveness of early surgery and the implementation of regional clinical pathways in reducing the length of postoperative hospital stay in hip fracture patients using Japanese Diagnosis Procedure Combination (DPC) database.

Methods: Data of patients diagnosed with femoral neck and femoral peritrochanteric fractures retrieved from the Japanese DPC database between April 2016 and March 2018 were used. Patients were divided into early surgery group (43,928 [34%] patients, surgery within 2 days of admission) and delayed surgery group (84,237 [66%] patients, surgery after 2 days of admission).

Results: The difference in length of stay (LOS) between the early and delayed surgery groups was 2 days (early vs. delayed: 21.00 days vs. 23.00 days). The early surgery group had more cases of intertrochanteric fractures (57.4% vs. 43.4%) and internal fixation (74.3% vs. 55.4%) than the delayed surgery group. In contrast, the delayed surgery group had more cases of femoral neck fractures (42.6% vs. 56.6%) and bipolar hip arthroplasty (24.5% vs. 41.6%) or total hip arthroplasty (1.2% vs. 3.0%). The early surgery group showed a lower incidence of complications, except anemia (12.0% vs. 8.8%), than the delayed surgery group. Multilevel regression analysis showed that early surgery and implementation of regional clinical pathways reduced LOS by 2.58 and 8.06 days, respectively (p < 0.001).

Conclusions: Early surgery was performed in a third of all hip fracture patients. Early surgery and implementation of regional clinical pathways for hip fracture patients are effective in reducing postoperative hospital LOS, with regional clinical pathways having a greater impact. These findings will help acute care providers when treating patients with hip fractures.

hip fracture

early surgery

regional clinical pathway

length of stay in hospital

postoperative complication

Hip fracture is common among elderly people, especially in those with osteoporosis. It has been reported that approximately 200,000 hip fracture cases occurred in 2017 [1]. The number of hip fracture cases has been increasing worldwide, and it is estimated to increase to 7 million by 2050 worldwide [2]. Hip fracture affects not only the patient’s ability to perform activities of daily living (ADL), but also life prognosis. Regarding mortality, as high as 30% of older adults with a fractured hip die within 1 year, and 7% die during hospitalization [3–5]. Therefore, it is crucial to develop a concrete strategy for treating patients with hip fractures, especially in elderly people.

The Japanese Orthopaedic Association has issued clinical guidelines for the treatment of hip fractures; however, there is a lack of clear statements regarding the best surgical treatment, particularly the timing of surgery. This guideline suggests that surgeon should perform surgery “as soon as possible.” On the contrary, the clinical guidelines of the American Association of Orthopaedic Surgeons and the National Health Service (UK) recommend performing surgery “within 48 hours of hospital admission” for the treatment of hip fractures. This indication is supported by previous studies reporting that surgery for hip fracture delayed longer than 48 hours may increase the risk of surgical site infection, pressure sores, other major medical complications, and both in-hospital and 1-year mortality [6–9]. However, some previous studies reported that there was no increased complication or 1-year mortality among patients who underwent surgical treatment delayed by more than 48 hours after hospital admission [10–12].

In Japan, more attention has been paid to the implementation of regional clinical pathways to treat patients more effectively and in a unified fashion. Regional clinical pathways were managed by outpatient clinics, acute care hospitals, rehabilitation hospitals, and care providers within a specific region to provide effective and consistent care. Regional clinical pathways include the disease name, patient’s symptoms at the time of hospitalization, hospital name, scheduled medical examinations and medical procedures, period until a standard transfer, details of care after the transfer, discharge criteria, standard time course for total care period, and other necessary information [13, 14]. The use of the regional clinical pathway will enable a series of support services for fracture treatment and discharge to home, which will be beneficial to patients and is expected to enable more efficient utilization of hospital beds.

In current study, we utilized the data retrieved from the Diagnosis Procedure Combination (DPC) database, which is a Japanese nationally representative clinical database containing discharge abstract and administrative claim data, such as data regarding surgical procedures and medications indexed in the original Japanese codes assigned by the Ministry of Health, Labour, and Welfare of Japan [15].

The objectives of this study were to investigate i) the rate of early surgery among hip fracture patients, and ii) the effectiveness of early surgery and the implementation of regional clinical pathways on the length of postoperative hospital stay and to compare the postoperative complications and changes in ADL between patients who underwent early surgery and those who underwent delayed surgery among hip fracture patients using the DPC database.

Data sources

Data retrieved from the Japanese DPC database between April 2016 and March 2018 were used. The study followed the principles of the Declaration of Helsinki and its later amendments. The study protocol was approved by the Ethics Committee of Medical Care and Research of the University of Occupational and Environmental Health, Japan (approval no. R1-067). Because of the anonymous nature of the data, the requirement for informed consent was waived.

Data collection

Patient data labelled with International Classification of Diseases 10 code S72.0 (femoral neck fracture) and S72.1 (femoral peritrochanteric fracture) were extracted from the DPC database.

We further retrieved data from patients who underwent open reduction and internal fixation (ORIF), bipolar hip arthroplasty (BHA), and total hip arthroplasty (THA) after admission. Data from the following patients were excluded: (1) patients with missing data (n = 10,825) and (2) patients with length of stay (LOS) > 120 days (n = 1,271). Ultimately, this study enrolled 128,165 patients. Patients who underwent surgery within 2 days after admission were assigned as the early surgery group, and those who underwent surgery over 2 days after admission were assigned as the delayed surgery group (Fig. 1). The total number of patients enrolled in this study was 128,165. The number of patients in the early and delayed surgery groups was 43,928 (34%) and 84,237 (66%), respectively.

Factor setting

First, the LOS data of all patients were collected. Data on multiple factors potentially affecting postoperative LOS were then collected as follows: diagnosis for type of fracture, surgical procedure, sex, age, body mass index (BMI), comorbidities at admission (diabetes mellitus, dementia, pneumonia, and osteoporosis), use of an ambulance at admission, ADLs at admission and discharge (transfer, walk on ground, and walk on stairs), postoperative days until the rehabilitation starts, place before admission (outpatient clinic, admission to another hospital, care facility, no further treatment, or other), admission to a university hospital, application of a regional clinical pathway, introduction from another hospital at admission, postoperative complications (anemia, dislocation of bipolar head or artificial hip joint, surgical site infection, deep vein thrombosis, pulmonary embolism, strokes, periprosthetic femoral fracture, bedsore, pneumonia, delirium, and cardiovascular disease), and place of referral at discharge (inpatients in other departments, outpatient clinics, other hospitals, care facilities, death, or other).

Statistical analysis

We analyzed the contextual effect of early surgical treatment within 2 days and hospital-level implementation of regional clinical pathways on LOS using multilevel regression models. In addition, the effects of sex, age, BMI, comorbidities at admission (diabetes mellitus, dementia, and pneumonia), admission to a university hospital, and introduction from another hospital at admission on LOS were also investigated. All calculations were performed using STATA Release 16.1 (Stata, College Station, TX, USA).

Characteristics of patients in early and delayed surgery groups

The results of the distribution and comparison of patient characteristics between the early (surgery within 2 days) and delayed surgery groups (surgery over 2 days) are shown in Table 1. The difference in total LOS (tLOS) in the hospital and postoperative LOS between the early surgery group and the delayed surgery group was 6 days and 2 days, respectively (tLOS: 22 vs. 28 [early vs. delayed]; postoperative LOS: 21 vs. 23 days). The early surgery group had more cases of peritrochanteric fractures (57.4% vs. 43.4%) and internal fixation than the delayed surgery group (74.3% vs. 55.4%). In contrast, the delayed surgery group had more cases of femoral neck fractures (42.6% vs. 56.6%) and BHA (24.5% vs. 41.6%) or THA (1.2% vs. 3.0%). The early surgery group showed the lower rate of comorbidities at admission, except for osteoporosis (diabetes, 15.9% vs. 18.9%; dementia, 3.9% vs. 4.2%; pneumonia, 0.4% vs. 1.0%; osteoporosis, 11.8% vs. 11.3%). In addition, the early surgery group used more ambulances at admission (62.3% vs. 60.8%).

Table 1

Distribution and comparison of patient characteristics between the early and delayed operation group.
Variables	Early operation (n = 43,928; 34%)	Delayed operation (n = 84,237; 66%)
Total length of stay in the hospital, days, (SD)	22.00 (16.00–36.00)	28.00 (21.00–45.00)
Length of stay after surgery, days, (SD)	21.00 (15.00–34.00)	23.00 (16.00–39.00)
Diagnosis, yes, n (%)
Femoral neck fracture	18,701 (42.6%)	47,707 (56.6%)
Peritrochanteric fracture	25,227 (57.4%)	36,530 (43.4%)
Surgical procedure, yes, n (%)
Open reduction and internal fixation	32,660 (74.3%)	46,682 (55.4%)
Bipolar hip arthroplasty	10,756 (24.5%)	35,038 (41.6%)
Total hip arthroplasty	512 (1.2%)	2,517 (3.0%)
Sex, women, n (%)	34,029 (77.5%)	64,198 (76.2%)
Age, years, mean (SD)	86.00 (79.00–90.00)	85.00 (78.00–90.00)
BMI, kg/m², mean (SD)	20.40 (18.10–22.80)	20.40 (18.10–22.90)
Comorbidity at admission, yes, n (%)
Diabetes mellitus	6,972 (15.9%)	15,941 (18.9%)
Dementia	1,722 (3.9%)	3,499 (4.2%)
Pneumonia	191 (0.4%)	827 (1.0%)
Osteoporosis	5,172 (11.8%)	9,519 (11.3%)
Use of ambulance, yes, n (%)	27,342 (62.3%)	51,209 (60.8%)
Place of referral at admission, yes, n (%)
Inpatients in other department	4,240 (8.9%)	10,642 (11.6%)
Outpatient clinic	31,172 (65.5%)	58,526 (64.0%)
Another hospital	3,878 (8.1%)	6,760 (7.4%)
Care facility	8,210 (17.2%)	15,371 (16.8%)
Other	106 (0.2%)	215 (0.2%)
Admission to a university hospital, yes, n (%)	2,139 (4.5%)	5,050 (5.5%)
Using a regional clinical pathway, yes, n (%)	36,077 (75.8%)	67,266 (73.5%)
Introduction from another hospital at admission, yes, n (%)	19,906 (41.8%)	36,831 (40.2%)
Post-operative days until the rehabilitation starts, days	1.00 (1.00–2.00)	1.00 (1.00–1.00)
ADL (transfer) at discharge, yes, n (%)
Independence	12,255 (30.6%)	24,272 (31.6%)
Partial assistance	19,198 (47.9%)	35,491 (46.3%)
High assistance	4,280 (10.7%)	8,112 (10.6%)
Total assistance	4,009 (10.0%)	8,238 (10.7%)
Unknown	316 (0.8%)	623 (0.8%)
ADL (walk on ground) at discharge, yes, n (%)
Independence	9,791 (24.6%)	19,746 (25.9%)
Partial assistance	9,138 (23.0%)	17,317 (22.7%)
High assistance	5,220 (13.1%)	9,726 (12.8%)
Total assistance	14,104 (35.5%)	26,772 (35.1%)
Unknown	1,502 (3.8%)	2,688 (3.5%)
ADL (walk on stairs) at discharge, yes, n (%)
Independence	6,728 (16.9%)	13,531 (17.8%)
Partial assistance	8,438 (21.2%)	16,472 (21.6%)
Total assistance	19,348 (48.7%)	37,394 (49.1%)
Unknown	5,203 (13.1%)	8,785 (11.5%)
Place of referral at discharge, yes, n (%)
Outpatient clinic	11,567 (26.3%)	24,055 (28.6%)
Admission to another hospital	23,924 (54.5%)	43,327 (51.4%)
Care facility	7,588 (17.3%)	14,915 (17.7%)
Death	654 (1.5%)	1,395 (1.7%)
Other	195 (0.4%)	545 (0.6%)

The percentage of those with independent ADL at discharge was slightly lower in the early surgery group (transfer, 30.6% vs. 31.6%; walk on ground, 24.6% vs. 25.9%; walk on stairs, 16.9% vs. 17.8%, respectively). In addition, the early surgery group utilized more regional clinical pathways and introductions from other hospitals (using a regional clinical pathway, 75.8% vs. 73.5%; introduction from another hospital, 41.8% vs. 40.2%).

Postoperative complications in early and delayed surgery groups

The postoperative complications are shown in Table 2. The early surgery group showed significantly lower complication rates with surgical site infection, deep vein thrombosis (DVT), pneumonia, and cardiovascular disease (p < 0.001). However, the incidence rates of anemia and blood transfusion were significantly higher in the early surgery group (anemia: 12.0% vs. 8.8%, p < 0.001; blood transfusion: 41.6% vs. 37.6%, p < 0.001).

Table 2

Postoperative complications
Complication	Early operation (n = 43,928)	Delayed operation (n = 84,237)	P value
Anemia	5,255 (12.0%)	7,410 (8.8%)	< 0.001
Blood transfusion	18,264 (41.6%)	31,634 (37.6%)	< 0.001
Dislocation of bipolar head or artificial hip joint	60 (0.1%)	132 (0.2%)	0.4
Surgical site infection	356 (0.8%)	834 (1.0%)	0.001
Deep vein thrombosis	1,649 (3.8%)	3,832 (4.5%)	< 0.001
Pulmonary embolism	94 (0.2%)	275 (0.3%)	< 0.001
Strokes	271 (0.6%)	524 (0.6%)	0.94
Periprosthetic femoral fracture	38 (0.1%)	102 (0.1%)	0.09
Bedsore	38 (0.1%)	102 (0.1%)	0.09
Pneumonia	416 (0.9%)	1,076 (1.3%)	< 0.001
Delirium	987 (2.2%)	1,863 (2.2%)	0.69
Cardiovascular disease	1,652 (3.8%)	4,072 (4.8%)	< 0.001

Factors associated with LOS among hip fracture patients

The results of the association of variables with postoperative LOS using multilevel regression are shown in Table 3. Factors such as comorbidity at admission (diabetes mellitus and pneumonia), admission to a university hospital, and introduction from another hospital at admission were significantly associated with postoperative LOS; after adjusting for these factors, early surgery significantly reduced postoperative LOS by 2.58 days (p < 0.001). In addition, application of the regional clinical pathway also remarkably reduced postoperative LOS by 8.06 days (p < 0.001). Admission to a university hospital and introduction from another hospital at admission also significantly reduced postoperative LOS by 5.68 and 5.00, respectively.

Table 3

Multilevel regression analysis of length of stay after operation.
	Coefficient	SE	[95% Conf.	Interval]	P value
Operation within 2 days	-2.58	0.12	-2.81	-2.34	< 0.001
Using a regional clinical pathway	-8.06	0.13	-8.32	-7.80	< 0.001
Sex, women	-0.44	0.14	-0.71	-0.17	0.001
Age	0.12	0.01	0.11	0.13	< 0.001
BMI, kg/m², (vs ༞= 18.5, < 25)	0.06	0.01	0.04	0.09	< 0.001
Comorbidity
Diabetes mellitus	1.67	0.15	1.37	1.96	< 0.001
Dementia	-1.18	0.29	-1.74	-0.61	< 0.001
Pneumonia	0.48	0.64	-0.79	1.74	0.458
Admission to a university hospital	-5.68	0.26	-6.19	-5.17	< 0.001
Introduction from another hospital at admission	-5.00	0.12	-5.22	-4.77	< 0.001

In this study, we found that early surgery within 2 days of hospitalization for hip fracture patients, which is performed on one third of all patients, can reduce most postoperative complications except anemia. In addition, patients in the early surgery group were more frequently diagnosed as peritrochanteric fracture and underwent ORIF. Furthermore, early surgical treatment significantly reduced LOS compared to delayed surgical treatment. Surprisingly, our results showed that using a regional clinical pathway to treat these patients had a greater advantage in reducing LOS compared to performing early surgical treatment. As shown in Table 3, early surgical treatment and use of regional clinical pathways decreased the postoperative LOS by 2.58 and 8.06 days, respectively. This study clarified that not only performing early surgery but also implementing the regional clinical pathway is effective in reducing LOS among hip fracture patients.

Difference in patient characteristics between early and delayed operation group

Our data showed that the early surgery group had fewer comorbidities upon admission. In the early group, patients were diagnosed with peritrochanteric fracture and underwent more ORIF, whereas the delayed group patients were diagnosed with femoral neck fracture and underwent more BHA or THA. However, it was surprising that the number of patients in the delayed surgery group was two times larger than that in the early surgery group, even though it is well known that early surgery is preferable. Since internal fixation for intertrochanteric femur fractures is less invasive and has a better prognosis than BHA and THA [16], it is believed that the surgery was planned early after the injury.

With regard to postoperative ADL, the ADL-independent rates in the early surgery group were lower than that in the delayed surgery group. Indeed, the impact of early surgery on various factors have been investigated in many previous studies; however, no study has reported the impact on postoperative ADL, which supports our results. Since LOS in the early operation group was shorter, their rehabilitation might not have advanced further when they were discharged from acute care hospitals.

Difference in postoperative complications between early and delayed surgery groups

In our study, the early surgery group showed remarkably fewer postoperative complications, except anemia, compared to the delayed surgery group.

This result was consistent with those of previous studies that investigated the association between time to surgery within 48 hours and postoperative complications among hip fracture patients [17–19]. It has reached the consensus that early surgery for hip fracture can reduce most postoperative complications and mortality [20]. A lower postoperative incidence probably affected the number of patients referred to other departments and LOS after surgery. As shown in Table 1, the early surgery group had a significantly lower number of patients transferred to other departments and LOS compared to the delayed surgery group. Along with LOS, it has been reported that waiting more than 24 h for hip fracture surgery is related to the increase of medical costs [21]. A previous study investigated the reasons for delayed hip fracture surgery and analyzed the impact of these reasons on 1-year mortality [22]. The results revealed that the patients with delayed surgery for organizational reasons (e.g., operating room or surgeon not available, admission on weekends or holidays, or unavailability of operating room time) showed a significantly higher incidence of postoperative complications and 1-year mortality. The authors concluded that surgery should be performed according to the patients’ general condition and should not be delayed for organizational reasons.

In this study, the early surgery group showed a remarkably higher incidence of anemia and blood transfusion. To our knowledge, no previous study has compared the incidence of anemia and blood transfusion between the early and delayed surgery groups among hip fracture patients. A previous systematic review reported that there are considerable variations in the use of red blood cell transfusion among clinicians for hip fracture patients [23]. It is now recognized that large blood loss among hip fracture patients often occurs immediately after injury and before surgery, and the average blood loss is greater in peritrochanteric fractures than in femoral neck fractures [24]. Therefore, it is assumed that the early surgery group had more cases of anemia and blood transfusion. Bian et al. [25] investigated the preoperative risk factors of postoperative blood transfusion after hip fracture surgery and revealed that older age, general anesthesia, low preoperative hemoglobin, and non-use of tranexamic acid were independent risk factors. Therefore, clinicians should be aware of the optimal use of blood transfusion for hip fracture patients, depending on their general condition and potential risk factors.

In this study, the delayed surgical group showed a significantly higher incidence of DVT. Song et al. [26] reported that delayed hip fracture surgery was a risk factor of preoperative DVT, and most patients who diagnosed as DVT after surgery had already had thrombus before surgery. Zhang et al. [27] investigated the incidence of DVT in both lower extremities before and after hip fracture surgery. They reported that days between fracture and operation, blood loss, venous thrombosis at admission, and coronary heart disease were independent risk factors of postoperative DVT. Fu et al. [28] also conducted a similar study and reported that blood loss was an independent risk factor for postoperative DVT, and ORIF was an independent protective factor for postoperative DVT compared with BHA and THA. Although the early surgery group in our study showed a higher incidence of anemia, these studies are consistent with our study.

Factors contributing to reduce LOS

Our results showed that early surgery within 2 days after admission shortened the postoperative LOS by 2.58 days and reduced the most postoperative complications, except anemia and blood transfusion. Therefore, early surgery for hip fracture patients within 2 days is recommended. Additionally, it was revealed that concomitant diabetes mellitus or pneumonia increased LOS, which suggested that preoperative management of these comorbidities is crucial. Lizaur-Utrilla et al. [22] suggested that waiting time more than 2 days for hip fracture surgery was not related to mortality rate or higher complication if waiting time was to stabilize active comorbidities in patients at admission.

In addition, the use of regional clinical pathways and introduction from another hospital at admission also reduced postoperative LOS for hip fracture patients by 8.06 days and 5.00 days, respectively. Takahashi et al. [29] investigated the factors associated with LOS after hip fracture surgery and reported that admission to a high-volume surgery hospital and surgery performed within 3 days after admission were the positive factors to reduce LOS. Fujino et al. [30] also investigated the relationship between LOS and the implementation of regional clinical pathways among stroke patients. They reported that use of regional clinical pathways among those patients at hospital level and patient level had a great impact on reducing LOS by 9.1 days and 7.2 days, respectively. Since these effects have a greater impact on reducing postoperative LOS than early surgery, it is suggested that sharing the unified postoperative protocol by implementing the regional clinical pathway leads to effective utilization of hospital beds.

Limitations

This study has some limitations. First, since we utilized the DPC database for this study, our data might not represent accurate data for all patients with hip fractures. There might be a selection bias in patients. In addition, the DPC database only includes the patient’s data from acute care hospitals; therefore, patient data after they were discharged from those hospitals were not obtained. Therefore, further studies to assess the impact of early surgical treatment and the use of regional clinical pathways throughout the entire treatment for hip fracture patients should be conducted.

Although the clinical guidelines recommended early surgery for hip fracture patients, the number of patients in the delayed surgery group was two times larger than that in the early surgery group. In addition, early surgery group had more peritrochanteric fracture cases, whereas delayed surgery group had more femoral neck fracture cases. This study revealed that early surgery for hip fracture patients within 2 days after admission reduced postoperative LOS and postoperative complications. Moreover, the implementation of regional clinical pathways to treat these patients had a greater impact on reducing postoperative LOS. The findings of this study will help acute care givers enhance the care of patients with hip fractures.

ADL; activities of daily living, DPC; Diagnosis Procedure Combination, ORIF; open reduction and internal fixation, BHA; bipolar hip arthroplasty, THA; total hip arthroplasty, LOS; length of stay, BMI; body mass index, DVT; deep vein thrombosis

Ethics approval and consent to participate: The study followed the principles of the Declaration of Helsinki and its later amendments. The study protocol was approved by the Ethics Committee of Medical Care and Research of the University of Occupational and Environmental Health, Japan (approval no. R1-067). Because of the anonymous nature of the data, the requirement for informed consent was waived.

Consent for publication: Not applicable

Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due Japanese DPC database is managed by the Ministry of Health, Labor and Welfare but are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This work was supported by a Grant-in-Aid for Scientific Research [grant numbers (C) 20K09421] from the Japan Society for the Promotion of Science (JSPS) to HS.

Authors’ contributions: HN, HS, KT, KM, SM, and AS conceived the idea and designed the study. KT, KM, KF, and SM collected the relevant data. HN, KT, MK, and YY prepared the figures and tables. KT and KM performed the statistical analyses. All the authors interpreted the data and contributed to preparation of the manuscript. HN, SU, and EN wrote the initial draft of the manuscript, and completed the final version. The author(s) read and approved the final manuscript.

Acknowledgments: We would like to thank Editage (www.editage.com) for English language editing.

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No competing interests reported.

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Early surgical treatment using regional clinical pathways reduces the length of postoperative hospitalization in hip fracture patients: Retrospective analysis using the Japanese Diagnosis Procedure Combination database

Status:

Version 1

Abstract

Figures

Background

Methods

Data sources

Data collection

Factor setting

Statistical analysis

Results

Characteristics of patients in early and delayed surgery groups

Postoperative complications in early and delayed surgery groups

Factors associated with LOS among hip fracture patients

Discussion

Difference in patient characteristics between early and delayed operation group

Difference in postoperative complications between early and delayed surgery groups

Factors contributing to reduce LOS

Limitations

Conclusion

Abbreviations

Declarations

References

Competing Interests

Status:

Version 1