Retrospective cohort study in the University Hospital San Juan de Alicante, Spain, a center with a catchment area of 216,610 inhabitants. Included patients were aged 65 or older and underwent surgery for proximal femoral fracture (intracapsular: subcapital fracture, or extracapsular: pertrochanteric and subtrochanteric fracture) between January 2011 and December 2017. Exclusion criteria were conservative treatment, pathological fracture, polytrauma, bilateral hip fracture, and a previous hip fracture during the study period.
Data were collected in patients who were admitted for hip fracture prior to this intervention (unexposed: admissions between January 2011 and December 2014) and following implementation (exposed: admissions between January 2015 and December 2017).
Multidisciplinary shared care protocol
The multidisciplinary care protocol, which took effect in January 2015, sets out the responsibilities and activities among all services that participate in the care of these patients as follows.
Emergency Service: performance of initial assessment, examination and diagnosis.
Orthopedic Surgery and Traumatology Service: coordination of admission and care protocol; re-examination; study of the patient; and decision regarding surgical treatment.
Internal Medicine Service: co-responsibility for the patient during admission; initial assessment of comorbidities; daily clinical evolution; and joint medical decision-making with the Traumatology Service.
Rehabilitation and Physiotherapy Service: physiotherapy during hospitalization and subsequent rehabilitation upon discharge.
Anesthesia Service: assessment of the patient and possible complications before and after surgery; pre-operative study; collaboration with Traumatology and Internal Medicine to estimate the date and time of surgery and postoperative analgesia; preoperative antibiotic prophylaxis with cefazolin, or with vancomycin in case of allergies.
Hematology Service: evaluation of patients with anti-coagulant and/or anti-platelet treatment; pre-operative regimen and reintroduction upon discharge.
Hospital Nursing Service: patient care during admission.
Hospital Pharmacy Service: monitoring of treatment in multi-pathological and polypharmacy patients.
Home Hospitalization Unit (composed of doctors and primary care nurses): assessment of potential discharge from the third postoperative day; home visit and home care (e.g. dressing surgical wound, ambulation) during the first three to four weeks post-discharge. Ambulatory care depends on residence (geographic location, home versus institution) and available family support (presence of caregivers).
Social services: assessment and individualized patient assistance; initiation of necessary steps to apply for admission to geriatric institution upon discharge if deemed appropriate.
After surgery, the Anesthesia Service is in charge of patient care in the recovery room. Once stabilized, the patients return to the Orthopedic Surgery and Traumatology ward.
On the first postoperative day, the attending anesthesiologist, internist, and traumatologist assess patients’ analytical parameters, mobility, pain, and postoperative radiography. The patient starts sitting and joint mobility exercises. On the second postoperative day, the drainage is removed, the wound is dressed, and the patient begins assisted walking. On day 3, the home hospitalization professionals consider whether the patient is ready for discharge. The patient has a blood test, and the multidisciplinary care team reaches a consensus regarding the decision to discharge the patient based on each service’s recommendations and treatment guidelines.
The variables studied during admission were: age, sex, length of hospital stay (as both a quantitative and dichotomous variable, using 10 days as the cutoff), surgical delay, in-hospital mortality, comorbidities (hypertension, coronary heart disease, atrial fibrillation, heart failure, chronic obstructive pulmonary disease [COPD], stroke, Parkinson’s disease, dementia, diabetes, rheumatic disease, and kidney failure), hemoglobin values (g/dL) on admission and postoperatively, blood transfusion and number of preoperative and postoperative red blood cell concentrates, treatment with antiplatelet drugs (yes/no), Charlson index , and total number of comorbidities.
We performed a descriptive analysis of the sample,presenting quantitative variables as means, with range and standard deviation (SD), and dichotomous categorical variables as absolute and relative frequencies. To analyze the impact of the protocol intervention, our primary outcome was a composite measure considering both in-hospital mortality and prolonged (> 10 days) hospital stay.
To compare the characteristics between exposure groups and to analyze the incidence of outcomes, we constructed 2×2 tables for categorical variables, applying the Chi-square test of association. Quantitative variables were analyzed by means of the student's T test.
To estimate the magnitude of association between exposure and outcome, we fit a multivariable logistic regression model, calculating the odds ratio (OR) and 95% confidence interval (CI). Variables for inclusion in the final model were selected using backward stepwise regression, based on the Akaike information criterion (AIC). Potential confounders were taken into account in the final model. The Chi-square value and predictive indicators were calculated as the area under the receiver operating characteristics curve (AUC) and its 95% CI.
We used the SPSS (v.25) statistical package and R (v.3.5.1) software for analyses.