Irish Hip Fracture Database Research Articles

Mining the Irish hip fracture database: learning factors contributing to care outcomes

Data analytics has opened the door for improving many aspects pertaining to the delivery of healthcare. This study avails of unsupervised machine learning to extract knowledge from the Irish hip fracture database (IHFD). The dataset under consideration contained patient records over three years 2013-2015. The process of knowledge discovery included using data clustering and rule mining. With cluster analysis, possible correlations were explored related to patient characteristics, care-related factors or outcomes. Further, association rules were discovered to learn the potential factors leading to a prolonged length of stay (LOS). In essence, our results highlight the significant impact of the pre-surgery waiting time on the LOS. The cluster analysis and association rules consistently emphasised that patients who experienced longer periods of pre-surgery waiting time tended to have longer LOS periods. The insights delivered are believed to yield practical implications to be considered within the treatment of hip fractures, especially in the case of elderly patients.

Mining the Irish hip fracture database: learning factors contributing to care outcomes

Mining the Irish hip fracture database: learning factors contributing to care outcomes

Predictors of in-hospital mortality post hip fracture in Ireland 2013-2017

Abstract Background Hip fractures are associated with considerable mortality, morbidity and healthcare expenditure. There are approximately 3,500 hip fractures in Ireland per annum with this figure set to increase considerably over the coming years due to the ageing population. Internationally, mortality following hip fracture is approximately 10% at 1 month and 30% at 1 year, with less than half of survivors regaining their preoperative level of function. The authors aimed to identify the determinants of in-hospital mortality post hip fracture in the Republic of Ireland 2013-2017, with specific reference to the Irish Hip Fracture Standards. Methods A secondary analysis of 15,603 patients in the Irish hip fracture database was conducted. Results 31% (n = 4,769) were male and 69% (n = 10,807) were female. Mean age for males was 75 years (SD 13.5) and 79 years for females (SD 10.5). The largest proportion of hip fractures occurred in the 80-89 age category, with 72.3% (n = 4,600) of these being female. Median in-hospital mortality was 4.7% (n = 711) (Range 2.7-6.2). Univariate logistic regression revealed 11 statistically significant predictors of in-hospital mortality; however, only 4 remained statistically significant on multivariate analysis [mobilised day of/after surgery (OR 1.46, 95% CI 1.25-1.70, p < 0.000), pre-fracture mobility (OR 0.84, 95% CI 0.79-0.89, p < 0.000), gender (OR 0.56, 95% CI 0.41-0.76, p < 0.000) and age (OR 1.05, 95% CI 1.03-1.06, p < 0.000)]. Conclusions Older males with poor pre-fracture mobility who were not mobilised the day of/after surgery had the highest risk of in-hospital mortality. The ability to be mobilised on the day of/after surgery is a good composite measure of both patient and organisational factors in hip fracture care. This research supports the inclusion of mobilisation on the day of/after surgery as a new formal best practice standard. Key messages Patients not mobilised on the day of/after surgery are 46% more likely to die in hospital. In-hospital mortality of 4.7% in Ireland is comparable internationally. None of the IHFSs significantly influenced in-hospital mortality after multivariate analysis, but may well affect other outcomes such as ability to return home.

273 Characteristics of Centenarians in the Irish Hip Fracture Database

Abstract Background In 2017 the Central Statistics Office reported that there were 465 people over the age of 100 in Ireland. This number is likely to increase and, as hip fracture increases exponentially with age, we can expect to see more centenarians experiencing hip fracture. In the UK we have comparative data on such a cohort. We sought to define and describe those aged 100 years and over included in the Irish Hip Fracture Database from 2013-2017. Methods A secondary analysis of the 15,603 data entries in the IHFD between 2013 and 2017 was conducted. Those patients aged 100 years and over were identified and the cohort described. Results 57 patients 100 years and over (average 101 range 100-105) were registered in the IHFD over these 5 years. 91% were female. The most common fractures were intertrochanteric (46%) and displaced intracapsular (30%). 55 patients underwent an operative procedure, the most common being bipolar hemiarthroplasty (28%). Over one third were mobilised on the day of or day after surgery. The average length of stay was 22.5 days with only 13 ICU days for the entire cohort. 7 patients died in hospital. Of those surviving to discharge, discharge destination was recorded for 20. 10 patients returned to nursing home, 5 admitted de novo to nursing home, 5 to offsite rehabilitation and one person discharged directly to home. Conclusion This data provides the first insight into hip fractures in the oldest old in an Irish context. Rate of operative intervention was reassuringly high with in-hospital mortality outcomes of 12% which is low by international standards. The age of those sustaining hip fractures is increasing with numbers of the oldest old expected to rise. Orthogeriatric input results in improved care for this population and will require increased resourcing for future cohorts of patients.

327 The Impact of Implementation of Recommendations from the IFHD 2017 Annual Report in an Irish Model 3 Hospital

Abstract Background Hip fractures in the older person are associated with high mortality rates (NICE, 2011). Up to 40% of patients never regain their pre-fracture mobility, 10-20% never return to live at home. The Irish Hip Fracture Database (IHFD) National Report 2017 recommends appointment of an orthogeriatric consultant in this hospital to achieve IHFD standards 4 to 6. Methods We analysed a subset of HIPE data collected for the IHFD in patients over 60 years over a three month period from September – November 2017 and compare it to September – November 2018 after introduction of an orthogeriatric service. We looked at geriatrician review, bone health assessment, falls assessment, discharge destination, 30-day re-admission rate and mortality during admission. Results There were 45 hip fracture patients in each group. In the 2017 group, mean age was 79, female 64%; compared to mean age of 80, female 62.2% in 2018. In 2018, after the appointment of an orthogeriatrician, 95.6% of patients were seen by a geriatrician compared to 4.4% in 2017. In 2018, 97.7% received bone health assessment compared to 26.8% in 2017. In 2018 95.3% received specialist falls assessment, compared to 2.4% in 2017. Mean length of stay was 18 days in 2018 versus 13 days in 2017. 2.2% of patients were discharged to convalescence in 2018, 26.7% in 2017. 57.8% of patients were discharged to off-site rehabilitation in 2018 compared to 40% in 2017. 2.2% patients died during admission in 2018, 8.9% in 2017. In 2018, 6.7% of patients were readmitted within 30 days, 8.8% in 2017. Conclusion Provision of rapid Comprehensive Geriatric Assessment to all hip fracture patients, reduces falls and fracture risk. There is evidence of improvement in IHFD standards 4-6, mortality rate and 30-day readmission rate. Moreover, the orthogeriatric service has led to increased referral to rehabilitation services ensuring optimal functional recovery.

148 Orthogeriatrics, Just the Beginning

Abstract Background The most common cause of admission to the orthopaedic ward are low trauma falls resulting in a hip fracture. These fragility fractures occur in older, frail, multi-morbid patients and they are associated with a high mortality rate and significant loss of independence. The Irish Hip Fracture Database is a national clinical audit that aims to improve hip fracture care and patient outcomes. Using the Irish Hip Fracture Standards, we aimed to audit the care of hip fracture patients in an Irish Model 3 Hospital pre- and post- implementation of an orthogeriatrics service. Methods Local Irish Hip Fracture Database was reviewed to assess the six Irish Hip Fracture Standards prior and 4 months following the introduction of a consultant-led dedicated orthogeriatrics service. Results There were 63 hip fracture patients (mean age 81) in the pre-service group and 69 (mean age 81) in the post-service group. Standard 1: 3.2% of hip fractures were admitted to the orthopaedic ward within 4 hours in the pre-service group versus 18.8% post-service introduction (national average 11%, 2017). Standard 2: 67.9% underwent surgery within 48 hours and during working hours versus 67.8% (national average 69%, 2017). Standard 3: 3.5% developed a pressure ulcer during their stay pre-service versus 1.6% post-service (national average 3%, 2017). Standard 4: 4.8% were assessed by a Geriatrician pre-service versus 84% post-service (national average 50%, 2017). Standard 5: 24.6% received a bone health assessment versus 87.5% post-service (national average 73%, 2017). Standard 6: 1.8% received a falls assessment prior to discharge versus 82.8% post-service (national average 47%, 2017). Conclusion The introduction of a dedicated orthogeriatrics service has led to a more collaborative multi-disciplinary approach to patient care with evidence of improvements in all Irish Hip Fracture Standards. Commitment to a resourced orthogeriatric service providing rapid comprehensive geriatric assessments is essential to advance improvements in older patients’ care.

284 Improving Adherence to Irish Hip Fracture Database Standards 1 and 2

Abstract Background The Irish Hip Fracture Database (IHFD) National Report 2017 demonstrated poor performance across all six IHFD standards in our hospital. For the purpose of this study we focused on standards 1 and 2. IHFD standard 1: All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of ED presentation/ brought directly to theatre from ED within 4 hours, and IHFD standard 2: All patients with hip fracture who are medically fit should have surgery within 48 hours of admission and during normal working hours. Methods We examined IHFD standards 1 and 2 from August 2017-January 2018 and August 2018-January 2019 after the appointment of an orthogeriatrician and use of the first Hip Fracture Pathway in August 2018. We also analysed data collected from February-April 2019 after amendment of the hip fracture pathway for patients presenting to the ED. Results IHFD Standard 1: From August to January 2017, 2.5% of patients were admitted to an orthopaedic ward within 4 hours versus 18.1% in 2018. IHFD Standard 2: in 2017, 64.8% underwent surgery within 48 hours during working hours, versus 65.3% in 2018. From February to April 2019, 32.1% of patients were admitted to an orthopaedic ward within 4 hours (IFHD 1) and 56.6% of patients underwent surgery within 48 hours and during working hours (IFHD 2). Conclusion Close collaboration between Emergency Medicine, Orthopaedic Surgery, Radiology, Nursing colleagues, Allied Health Professionals and Orthogeriatrics and amendment of the Hip Fracture Pathway have led to improvements in Standards 1 and 2. The addition of an orthogeriatric service in the hospital has resulted in an improvement in adherence to all IFHD standards. However, there are ongoing challenges to achieving Standard 2 including limited theatre access and increasing numbers of older patients on novel oral anticoagulants.

26 Predictors of In-Hospital Mortality Post Hip Fracture: What Really Matters?

Abstract Background The Irish Hip Fracture Database is a national clinical audit developed to improve fracture care and outcomes. Lack of integration with other databases, such as a National Death Register makes determination of longer term outcomes challenging. In hospital mortality is one quality indicator that can be very accurately measured. We sought to determine in-hospital mortality in the Irish Hip Fracture Cohort between 2013 and 2017 and to determine which factors most influenced this outcome with particular reference to the IHFD quality standards. Methods A secondary analysis of the 15,603 patients in the IHFD between 2013 and 2017 was conducted. Descriptive and analytical statistics were produced. Results In-hospital mortality was 4.5% for the 5 years. Univariate logistic regression revealed 11 statistically significant predictors of in-hospital mortality of which only 4 (age, gender, pre-fracture mobility, mobilised day of/after surgery) remained significant after multivariate analysis. The most striking finding was that those patients not mobilised on the day of/after surgery were 46% more likely to die in hospital (OR 1.46, p<0.000, 95% CI 1.25-1.70). Conclusion Measuring care is challenging and often one standard cannot reflect all aspects. The ability to be mobilised on the day of or day after surgery is a good composite measure of both patient and organisational factors in hip fracture care: timely surgery, adequate pain relief, prevention of delirium, admission to a ward with philosophy, skills and resources to encourage early mobility. While early mobility has always been encouraged this data suggests its adoption as a formal standard to which all units must comply.

The long-term outcomes following internal fixation for intracapsular hip fractures in an Irish tertiary referral centre.

The burden associated with hip fractures is increasing worldwide. Arthroplasty procedures are more commonly performed for intracapsular fractures due to increased risk of compromise to the femoral head blood supply. However, we know from the Irish Hip Fracture Database that a significant proportion of these fractures undergo internal fixation. We sought to investigate the long-term outcomes for these patients including revision rates, functional outcome and mortality rates. All intracapsular fractures treated by internal fixation (IF) from 2005 to 2009 were identified. Pre-operative anatomical fracture location and level of fracture displacement was established. Hospital records were used to record mortality and revision rates. The modified Harris hip score was our primary functional outcome measure. One hundred twelve intracapsular fractures underwent IF over a 5-year period. The mean age was 68.6 (range 14-95years). A mean follow-up time of 8.15years (range 6.7-10.1years) was achieved. There was a 5-year mortality rate of 36.6%. There was a significantly higher revision rate in displaced fractures (24.4%) than in undisplaced fractures (11.1%) (p = 0.01). We found no difference in functional outcome between displaced fractures [85.9 (± 16.9)] and undisplaced fractures [86.01 (± 18.8)]. Those aged younger than 65 at the time of surgery had a significantly better MHHS (p = 0.02) at long-term follow-up; however, there was a revision rate of 43.8% in this group. Whilst a good functional outcome can be achieved with internal fixation, particularly in younger patients, the risk of requiring revision surgery approaches 50% for these patients.

Identifying Disparities in the Management of Hip Fractures Within Europe: A Comparison of 3 Health-Care Systems.

Introduction:This study investigates the management of hip fractures in a German maximum care hospital and compares these data to evidence-based standard and practice in 180 hospitals participating in the UK National Hip Fracture Database (NHFD) and 16 hospitals participating in the Irish Hip Fracture Database (IHFD). This is the first study directly comparing the management of hip fractures between 3 separate health-care systems within Europe.Methods:Electronic medical data were collected retrospectively describing the care pathway of elderly patients with a hip fracture admitted to a large trauma unit in the south of Germany “University Hospital Freiburg” (UHF). The audit evaluated demographics, postoperative outcome, and the adherence to the 6 “Blue Book” standards of care. These data were directly compared with the data from the UK NHFD and the IHFD acquired from 180 and 16 hospitals, respectively.Results:At 36 hours, 95.8% of patients had received surgery in UHF, compared to 71.5% in the NHFD and 58% of patients in the IHFD. The rate of in-hospital mortality was 4.7% compared to 7.1% in the NHFD and 5% in the IHFD. The mean average acute length of stay was 13.4 days compared to 16.4 days in the NHFD and 20 days in the IHFD. Reoperation rates are 3.3% compared to 1% in the NHFD and 1.1% in the IHFD; 50.5% of patients were discharged on bone protection medication, compared to 47% in the IHFD and 79.3% in the UK NHFD.Discussion:Despite uniformly acknowledged evidence-based treatment guidelines, the management of hip fractures remains heterogeneous within Europe.Conclusion:These data show that different areas of the hip fracture care pathway in Germany, England, and Ireland, respectively, show room for improvement in light of the growing socioeconomic burden these countries are expected to face.

8Changing the Landscape of Hip Fracture Care - The Irish Hip Fracture Database (IHFD)

8Changing the Landscape of Hip Fracture Care - The Irish Hip Fracture Database (IHFD)

The effect of indirect admission via hospital transfer on hip fracture patients in Ireland.

Current best practice states that hip fracture patients should undergo surgery within 48 hours to minimise perioperative complications. There are 10 emergency departments (EDs) in Ireland that receive hip fracture patients without a trauma and orthopaedic surgery unit on site. Idle periods and duplicated preoperative investigations can lead to a prolonged time to surgery. The aim of this study was to identify the effect of admission route on the time to surgery, length of stay and pressure ulcer development in patients who sustain a hip fracture in Ireland. A retrospective cohort study was performed, using 2013 and 2014 data from the Irish Hip Fracture Database. Age, gender and ASA grade were identified as confounders and adjusted for accordingly. Of the 3893 hip fractures identified, indirect admissions via hospital transfer occurred in 8.6% of cases. Surgery was performed within 48 h in 72.0% of indirect admission and 73.7% of direct admission cases (p = 0.502). The length of stay was significantly prolonged for patients admitted via hospital transfer (25.6 compared to 19.6 days, p < 0.001). Delayed discharges post hip fracture have been shown to expose patients to increased perioperative morbidity and mortality rates, as well as reduced rehabilitation potential and less chance of returning home on discharge. This has significant cost implications for the health service and justifies the introduction of hospital bypass protocols for patients with hip fractures.

How accurate is the data provided to the Irish hip fracture database?

National databases, such as the Irish Hip Fracture Database (IHFD), are known to contain inaccuracies. The coordination of services, national funding and future research rely on the integrity of the IHFD so as to avoid policy and budget planning being based on misrepresentative data. An audit was performed to assess the accuracy of the 2016 IHFD data collected in our trauma unit. The Hospital In-Patient Enquiry (HIPE)-recorded fracture classification, IHFD-recorded fracture classification and IHFD-recorded operation performed for each hip fracture patient was identified. Each variable was compared with the classifications and procedures derived by the authors. Two hundred fifty-two cases were identified. The HIPE-recorded fracture classification was accurate in 29% of cases, and the IHFD-recorded fracture classification in 61% (p< 0.001). The IHFD-recorded operation performed was accurate in 76% of cases. Thirty-six cases (14%) were omitted by HIPE, and eight (3%) from the local IHFD (p< 0.001). Errors resulted from poor documentation, in determining the presence of fracture displacement, prosthesis coating and intramedullary nail length. Diagnoses and procedures were identified from ward and theatre logbooks that the data coordinator was unable to record. The data coordinator in our unit doubled the accuracy of the data, and reduced the rate of omitted cases by a factor of 4.5. Accuracy levels would be significantly improved with clear, thorough documentation by the medical team following education of junior surgical trainees on hip fracture classification and procedural coding. Inaccurate data has a negative effect on hospital reimbursement and compromises the integrity of the IHFD.

Improving integration and care through clinical audit: The Irish Hip Fracture Database

Background : Hip fractures are an increasing socio-economic burden. They are the leading cause for surgery in hospitalised older adults (typically aged 80 and older) and cause high levels of disability and mortality. The Irish Hip Fracture Database (IHFD) collects data in all 16 trauma units in Ireland to measure the care we deliver to hip fracture patients against defined care standards. There is good evidence to show that the combination of care standards, clinical audit and feedback can significantly improve the outcomes of hip fracture patients. Each year our national report informs policymakers, hospital management and a wide range of healthcare professionals about how well hip fracture care is delivered in Irish hospitals. It also, importantly, informs patients about what standard of care to expect when they are hospitalised with a broken hip. To date three national reports have been published by the IHFD including data on a total of 7,576 hip fracture patients. In 2015 the IHFD captured clinical audit data for 81% (2962) of all hip fracture cases nationally. With an ageing population the IHFD is the catalyst towards addressing what is a significantly growing healthcare and societal challenge. Using this data at a local level each hospital can improve the quality of care they deliver by improving the integration between specialities such as orthopaedics, geriatrics, emergency medicine, anaesthesia, nursing and allied health professionals. Nationally this data enables strategic planning for the future development of care for older people in Ireland. The mission statement of the IHFD is to optimise the surgical, medical, nursing, rehabilitation and secondary prevention care for all hip fracture patients. Results : In the 2015 IHFD Report we show that 70% of hip fracture patients are female and over 55% of patients are 80 years and older, 83% are admitted from home and 48% can mobilise unaided pre-fracture, 57% have significant co-morbidities. The dominant fracture types are intracapsular displaced and intertrochanteric. Only 10% of patients are being admitted to a specialist orthopaedic ward within 4 hours however 9% of patients went directly from the emergency department to theatre, 74% patients are receiving surgery witinh 48 hours, 15% patients were seen pre-operatively by a geriatrician, 73% being mobilised the day of or after surgery, 4% developed a pressure ulcer, and less than half of patient’s are receiving secondary prevention for osteoporosis and falls. Patients who do not present directly to the ED in the operating hospital spend an average of two days longer in hospitals than those patients who present directly. We are recommending that all suspected hip fracture patients should be brought directly to the trauma operating hospital. The mean length of stay is 20 days in the acute hospital and only 30% patients are discharged directly home. With the support and endorsement of the National Office of Clinical audit (NOCA) the IHFD enables integrated and quality improvement in care and outcomes for hip fracture patients.

Dedicated orthogeriatric service reduces hip fracture mortality.

Hip fracture is a common serious injury afflicting the geriatric population and is associated with poor clinical outcomes, functional and walking disabilities and high 1-year mortality rates. A multidisciplinary approach has been shown to improve outcomes of geriatric patients with fragility fracture. We piloted a dedicated orthogeriatric service for hip fracture patients to determine if the service facilitated a change in major patient outcomes, such as mortality, length of stay and dependency. A dedicated orthogeriatrics service for hip fracture was established as a collaborative project between the Department of Geriatric Medicine and Department of Orthopaedic Surgery at a university teaching hospital. Orthogeriatrics service data were collected prospectively on an orthogeriatric filemaker database from July 2011 to July 2012 (N=206). Data were compared to previously recorded data (Irish Hip Fracture Database) on a cohort of hip fracture patients admitted to the same orthopaedic trauma unit from July 2009 to July 2010 (N=248). Patients in the orthogeriatric service group experienced significant reductions in 1-year mortality (χ2=13.34, P<0.001), length of acute hospital stay (U=-3.77, P<0.001) and requirements for further rehabilitation (χ 2=26.59, P<0.001). Patients in the pre-service establishment group were significantly more dependent following their fracture than the patients in the orthogeriatric service group (χ 2=5.34, P=0.021). A multidisciplinary management approach to fragility fracture of the femoral neck that involves comprehensive geriatric assessment, daily medical involvement of a geriatric team and specialised follow-up assessment leads to a significant reduction in mortality and improved outcomes.

Improving hip fracture care in ireland: a preliminary report of the irish hip fracture database.

Introduction. Hip fractures are common injuries in the older persons, with significant associated morbidity and mortality. The Irish Hip Fracture Database (IHFD) was implemented to monitor standards of care against international standards. Methods. The IHFD is a clinically led web-based audit. We summarize the data collected on hip fractures from April 2012 to March 2013 from 8 centres. Results. There were 843 patients with the majority being (70%) female. The 80–89-year age group accounted for the majority of fractures (44%). Most (71%) sustained a fall at home. Intertrochanteric fractures (40%) were most common. Only 28% were admitted to an orthopaedic ward within 4 hours. The majority (97%) underwent surgery with 44% having surgery within 36 hours. Medical optimization (35%) and lack of theatre space (26%) accounted for most of the surgical delay. While 29% were discharged home, 33% were discharged to a nursing home or other long-stay facilities. There was a 4% in-hospital mortality rate. Conclusions. Several key areas in both the database and aspects of patient care needing improvement have been highlighted. The implementation of similar databases has led to improved hip fracture care in other countries and we believe this can be replicated in Ireland.

Data from the Irish Hip Fracture Database, IHFD

Data from the Irish Hip Fracture Database, IHFD