Ami Hommel

Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study

Background: There is an evident need for improved management of elderly patients with trauma in order to avoid common and troublesome complications such as delirium. The aim of this study was to investigate whether an implementation of a multi‐factorial program including intensified pre‐hospital and perioperative treatment and care could reduce the incidence of delirium in elderly patients with hip fracture, cognitively intact at admission to the hospital. In addition, we explored the factors that characterize patients who developed delirium.

Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year.

Hip fractures are a major cause of hospital stay among the elderly, and result in increased disability and mortality. In this study from 1 April 2003 to 31 March 2004, the influence of optimised treatment of hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year were investigated. Comparisons were made between the first 210 patients in the period and the last 210 patients, who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24h, was not associated with reduced mortality, but was significantly associated with reduced length of stay (p<0.001). Significantly more cases of osteosynthesis for femoral neck fracture were reoperated compared with all other types of surgery (p<0.001) when reoperations with extraction of the hook pins in healed fractures were excluded. Mortality was significantly higher among men than women at 4 (p=0.025) and 12 (p=0.001) months after fracture and among medically fit patients with administrative delay to surgery compared with patients with no delay (p<0.001).

Hip fracture and pressure ulcers – the Pan‐European Pressure Ulcer Study – intrinsic and extrinsic risk factors*

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8·8% and 55% have been reported. There are few studies focusing on the specific patient‐, surgery‐ and care‐related risk indicators in this group. The aims of the study were

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

AIM To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers. METHODS A cross-sectional research design was used in a total sample of 35,058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel. RESULTS The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure-reducing mattress (23.3-27.9%) or planned repositioning in bed (50.2-57.5%). CONCLUSIONS Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence-based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.

Influence of age, sex, fracture type and pre-fracture living on rehabilitation pattern after hip fracture in the elderly.

Purpose: To evaluate the influence of background factors on the rehabilitation pattern after a hip fracture in the elderly. Method: Prospective registration based on the Swedish national register for hip fracture patients called RIKSHÖFT/SAHFE (Standardised Audit of Hip Fractures in Europe). The place of living was registered both before fracture and during the following four months period (120 days). Graphs were calculated and drawn based on day-to‐day changes. Also influences of age, sex, fracture type and type of operation were analyzed. Results: The patients pre-fracture functional capacity as evidence by the place they were able to manage to live before the fracture was the most discriminating factor for the rehabilitation; more than sex, fracture type or type of operation. Age was also a highly discriminating factor with a pronounced influence on the rehabilitation pattern. Conclusions: These background parameters are very important factors when planning the rehabilitation of hip fracture patients. A strategy with individualized planning of the rehabilitation procedure will be highly necessary in the future, in view of the increasing amount of elderly with hip fractures prognosticated during the coming decades. The knowledge about influencing factors here presented will be useful when planning and performing the rehabilitation for this resource-consuming group of patients.

Pressure-reducing interventions among persons with pressure ulcers : results from the first three national pressure ulcer prevalence surveys in Sweden

RATIONALE, AIMS AND OBJECTIVES The overall aim of this study was to describe preventive interventions among persons with pressure ulcer (PU) in three nationwide PU prevalence surveys in Sweden. METHODS A cross-sectional research design was used; more than 70 000 persons from different hospitals and nursing homes participated in the three prevalence surveys conducted in March 2011, October 2011 and March 2012. The methodology used was that recommended by the European Pressure Ulcers Advisory Panel. RESULTS The overall prevalence of PU categories I-IV in hospitals was 16.6%, 14.4% and 16.1%, respectively. Corresponding figures for nursing homes were 14.5%, 14.2% and 11.8%, respectively. Heel protection/floating heels and sliding sheets were more frequently planned for persons with PU category I. CONCLUSIONS Despite the three prevalence studies that have showed high prevalence of PU the use of preventing interventions is still not on an acceptable level. Heel protection/floating heels and sliding sheets were more frequently planned for persons with PUs, and individual-planned repositioning also increased. However, when persons already have a PU they should all have pressure-reducing preventive interventions to prevent the development of more PUs. Preventing PUs presents a challenge even when facilities have prevention programmes. A PU prevention programme requires an enthusiastic leader who will maintain the teams focus and direction for all staff involved in patient care.Rationale, aims and objectives The overall aim of this study was to describe preventive interventions among persons with pressure ulcer (PU) in three nationwide PU prevalence surveys in Sweden. Methods A cross-sectional research design was used; more than 70 000 persons from different hospitals and nursing homes participated in the three prevalence surveys conducted in March 2011, October 2011 and March 2012. The methodology used was that recommended by the European Pressure Ulcers Advisory Panel. Results The overall prevalence of PU categories I–IV in hospitals was 16.6%, 14.4% and 16.1%, respectively. Corresponding figures for nursing homes were 14.5%, 14.2% and 11.8%, respectively. Heel protection/floating heels and sliding sheets were more frequently planned for persons with PU category I. Conclusions Despite the three prevalence studies that have showed high prevalence of PU the use of preventing interventions is still not on an acceptable level. Heel protection/floating heels and sliding sheets were more frequently planned for persons with PUs, and individual-planned repositioning also increased. However, when persons already have a PU they should all have pressure-reducing preventive interventions to prevent the development of more PUs. Preventing PUs presents a challenge even when facilities have prevention programmes. A PU prevention programme requires an enthusiastic leader who will maintain the teams focus and direction for all staff involved in patient care.

Cost-effectiveness Analysis of Goal-directed Hemodynamic Treatment of Elderly Hip Fracture Patients: Before Clinical Research Starts.

Background: Health economic evaluations are increasingly used to make the decision to adopt new medical interventions. Before such decisions, various stakeholders have invested in clinical research. But health economic factors are seldom considered in research funding decisions. Cost-effectiveness analyses could be informative before the launch of clinical research projects, particularly when a targeted intervention is resource-intensive, total cost for the trial is very high, and expected gain of health benefits is uncertain. This study analyzed cost-effectiveness using a decision analytic model before initiating a large clinical research project on goal-directed hemodynamic treatment of elderly patients with hip fracture. Methods: A probabilistic decision analytic cost-effectiveness model was developed; the model contains a decision tree for the postoperative short-term outcome and a Markov structure for long-term outcome. Clinical effect estimates, costs, health-related quality-of-life measures, and long-term survival constituted model input that was extracted from clinical trials, national databases, and surveys. Model output consisted of estimated medical care costs related to quality-adjusted life-years. Results: In the base case analysis, goal-directed hemodynamic treatment reduced average medical care costs by &OV0556;1,882 and gained 0.344 quality-adjusted life-years. In 96.5% of the simulations, goal-directed hemodynamic treatment is less costly and provides more quality-adjusted life-years. The results are sensitive to clinical effect size variations, although goal-directed hemodynamic treatment seems to be cost-effective even with moderate clinical effect. Conclusion: This study demonstrates that cost-effectiveness analysis is feasible, meaningful, and recommendable before launch of costly clinical research projects.

Geriatric Rehabilitation and Discharge Location After Hip Fracture in Relation to the Risks of Death and Readmission

OBJECTIVES To investigate the effects of geriatric rehabilitation on short-term risk of death and readmission after a hip fracture were investigated in a nationwide cohort. In addition, the association of discharge location (nursing home or patients home) with the short-term risk of death was assessed. DESIGN, SETTING, AND PARTICIPANTS The cohort consisted of 89,301 individuals at least 50 years of age, with a first hip fracture registered in the Swedish quality register RIKSHÖFT, the years 2004-2012. MEASURES Short-term risk of death and readmission to hospital after discharge was compared at 8 hospitals, where most patients received inpatient care in geriatric wards, and those treated at 71 regular hospitals. RESULTS The risks of death within 30 days of admission were 7.1% in patients admitted to geriatric ward hospitals and 7.4% in those treated at regular hospitals (multivariable-adjusted hazard ratio [HR] 0.91, 95% CI 0.85-0.97), whereas the odds of readmission within 30 days of discharge were 8.7% and 9.8%, respectively (multivariable-adjusted odds ratio 0.86, 95% CI 0.81-0.91). The risk of death was influenced by discharge location and inpatient length of stay (LOS). Thus, for patients discharged to short-term nursing homes with a LOS of at most 10 days, each additional day of LOS reduction increased the risk of death within 30 days of discharge by 13% (HR 1.13, 95% CI 1.08-1.18). This association was reduced in patients discharged to permanent nursing homes (HR 1.04, 95% CI 1.02-1.07), and not significant in those discharged to their own home (OR 1.00, 95% CI 0.91-1.10). CONCLUSION The risks of death and readmission were lower in patients with hip fracture who received care in hospitals with geriatric wards. The risk of death after discharge increased with shorter LOS, especially in patients discharged to short-term nursing homes.

Using national hip fracture registries and audit databases to develop an international perspective

Hip fracture is the commonest reason for older people to need emergency anaesthesia and surgery, and leads to prolonged dependence for many of those who survive. People with this injury are usually identified very early in their hospital care, so hip fracture is an ideal marker condition with which to audit the care offered to older people by health services around the world. We have reviewed the reports of eight national audit programmes, to examine the approach used in each, and highlight differences in case mix, management and outcomes in different countries. The national audits provide a consistent picture of typical patients - an average age of 80 years, with less than a third being men, and a third of all patients having cognitive impairment - but there was surprising variation in the type of fracture, of operation and of anaesthesia and hospital length of stay in different countries. These national audits provide a unique opportunity to compare how health care systems of different countries are responding to the same clinical challenge. This review will encourage the development and reporting of a standardised dataset to support international collaboration in healthcare audit.

Systematic review describing the effect of early mobilisation after dysvascular major lower limb amputations

AIMS AND OBJECTIVES To assess the effect of early mobilisation of patients after dysvascular lower limb amputation and to compare the effectiveness of different mobilisation regimens. BACKGROUND Patients who have undergone dysvascular major lower limb amputations are at high risk of postoperative complications, which include loss of basic functions, and early mobilisation interventions might prevent these complications. DESIGN Systematic review. METHODS Systematic searches were performed on PubMed (including MEDLINE), CINAHL and EMBASE databases to identify studies investigating the effects of (early) mobilisation interventions in dysvascular lower limb-amputated patients. Data collection and quality assessment were performed using the Cochrane Effective Practice and Organization of Care Review Group data collection checklist and the Cochrane Handbook for Systematic Reviews of Interventions, respectively. RESULTS Five studies were included in the review: four pre- to post-case studies and one randomised controlled study. However, none of these studies were of high quality. Four studies investigated early mobilisation promoted by immediate postoperative prosthesis. One study investigated whether reorganizing care increases mobilisation and thereby functional outcome. CONCLUSIONS This systematic review reveals a lack of evidence to determine whether early mobilisation interventions are beneficial to this vulnerable patient group. Nevertheless, ambulation from the first postoperative day with temporary prosthesis is possible among the heterogeneous population of dysvascular lower limb-amputated patients if the necessary interdisciplinary team is dedicated to the task. RELEVANCE TO CLINICAL PRACTICE Mobilisation is a fundamental care task often missed for several reasons. Moreover, mobilisation of the newly amputated patient is complex, and knowledge of effective strategies to promote postoperative mobilisation in this vulnerable population is desired. Nurses are urged to take responsibility for this fundamental care task and to engage the necessary collaborative interdisciplinary team to develop, implement and evaluate ambitious early mobilisation interventions.