773428 research-article2018
HPI0010.1177/1120700018773428HIP InternationalChoi et al.
HIP
Original Research Article
Impact of postoperative haemoglobin on length of stay post fractured hip repair in patients with standardised perioperative management
HIP International
HIP International 1–5 © The Author(s) 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/1120700018773428 DOI: 10.1177/1120700018773428 journals.sagepub.com/home/hpi
Siu-Wai Choi1, Frankie K L Leung2, Tak-Wing Lau2 and Gordon T C Wong1
Abstract Introduction: Perioperative blood transfusion is not without risk and effort should be made to limit patients’ exposure to allogeneic blood. However, there is conflicting data regarding the impact of anaemia on postoperative recovery in patients with repaired hip fractures. It is hypothesised that for a given baseline functional status and fracture type, lower postoperative haemoglobin will increase rehabilitation time and prolong total length of hospital stay. Methods: This is a retrospective study on data collected prospectively on patients entered into the Clinical Pathway aged >65 years admitted to Queen Mary Hospital (QMH) with a fractured neck of femur during 2011–2013. Potential predictor variables were analysed with linear regression with respect to total length of stay and those that reached a significance level of 0.05 were included in further analysis. Results: 1092 patients were admitted to QMH with a suspected fractured neck of femur; data from 747 patients were analysed. The fracture sites were neck of femur (50%), intertrochanteric (48%) and subtrochanteric fracture (2%). Approximately 30% of patients received blood transfusions. Of these only the development of postoperative medical complications statistically prolonged hospital stay. No relationship was seen with haemoglobin levels cut-off above and below 10 g/dl with the result remaining non-significant down to a cut-off of above and below 8 g/dl. Discussion: This study revealed that post-surgical haemoglobin level of between 8 g/dl and 10 g/dL did not have an impact on the total length of hospital stay. The development of postoperative medical complications was the only factor that prolonged the total length of stay. Keywords Haemoglobin, hip fracture repair, perioperative management Date received: 10 October 2017; accepted: 12 February 2018.
Introduction Among those involved in providing perioperative care, there is awareness of the adverse effects of blood transfusion and the perils of indiscriminate trigger-based transfusion practices. A substantial amount of effort has been directed towards limiting exposure to allogeneic blood. Whether there are disadvantages to a restrictive transfusion regime on patients with repaired fractured hips is still to open to debate.1–3 There is conflicting data regarding the impact of anaemia on postoperative recovery with some
1Department
of Anaesthesiology, The University of Hong Kong, Hong Kong, China 2Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong, China Corresponding author: Gordon T C Wong, Department of Anaesthesiology, The University of Hong Kong, Queen Mary Hospital, 102 Pokulam Road, K424, Block K, HKSAR, China. Email:
[email protected]
2 data showing it to be associated with a longer length of hospital stay post-surgery, and higher odds of re-admission with 60 days of discharge.4 Studies have shown that severe anaemia (Hb < 80 g/l) is associated with increased postoperative mortality.5,6 In a large multi-centre trial involving 2000 patients with clinical evidence of risk factors for cardiovascular disease, the investigators have shown no difference between a liberal or restrictive transfusion regime.7 Part of the reason for such discrepancies may lie in variations in perioperative care, and the noise created by differences in clinical management may mask the impact of haemoglobin on recovery. Since 2007, all patients presenting with fracture neck of femur admitted to Queen Mary Hospital Hong Kong were managed according to a clinical pathway where perioperative management has been standardised as far as possible.8 All patient data were prospectively entered into a geriatric fracture pathway database. The indication for transfusion was left to the discretion of the anaesthesiologist or management team without strict criteria and as such was opened to a natural experiment. We hypothesised that for a given baseline functional status and fracture type of a patient, a lower postoperative haemoglobin would increase rehabilitation time and prolong total length of hospital stay. In this study, we endeavoured to perform a multivariate analysis of a prospectively collected database.
Methods Institutional Review Board approval was sought and granted for this study by Hong Kong West Cluster Research Ethics Committees. Since this study was retrospective in nature, no informed consent from patients was necessary. All patients with suspected fractured necks of femur (NOF) admitted to the Emergency Department were considered for entry into the clinical pathway.8 Patients may subsequently be withdrawn from the pathway should factors be identified that render them unsuitable for fast track management. These include among others, pathological fractures or development of acute medical conditions such as gastrointestinal bleed, chest infection or cerebral vascular accidents. Notable aspects of this pathway include the minimisation of time to surgery, effective pain relief preand postoperatively, early mobilisation and discharge to rehabilitation facility. Demographic and outcome data of the patients from time of admission to discharge from the rehabilitation facility had been prospectively collected and kept in a central database. Admission functional scores as determined by the Modified Barthel Index (MBI) and Mini Mental Status Examination (MMSE) were calculated and recorded. Based on these data, the team were able to calculate a predicted discharge MBI which would act as an aid to help families or carers in discharge planning. We reviewed patients in the database including those aged 65 years or older who were admitted to Queen Mary
HIP International 00(0) Hospital (QMH) with a fractured neck of femur between the years 2011 and 2013. Information on age, sex, pre-surgery related variables (comorbidities and previous fracture history), surgical variables (fracture side, fracture sites, surgery performed) and postsurgery related variables (haemoglobin level, medical and orthopaedic complications, number of days from surgery to rehabilitation commencement) were entered into the study database. Postoperative haemoglobin was assessed postoperative day 1. As there were no guidelines on the transfusion trigger, some patients received blood transfusion whilst others did not. Data (pass or fail) on the MMSE before and after surgery, and MBI score were also recorded. The presence or absence of postoperative medical and orthopaedic complications post-surgery was noted as a binary (yes/no) outcome. Potential predictor variables were analysed with simple linear regression with respect to total length of stay and those that reached a significance level of 0.05 were included in further analysis. All analyses were conducted using the Statistical Package for the Social Sciences (version 23.0). Descriptive statistics including means, standard deviation or frequencies were calculated for all variables. Variables such as total length of stay (TLOS) and age at admission were treated as continuous data and reported as means (SD). Categorical variables were dichotomised based on clinical judgement and were presented as percentages. Impact of all predictor variables on the inpatient rehabilitation TLOS in days (primary outcome) was analysed with simple linear regression. Any predictors that were significant at the p < 0.05 level were selected for multiple regression analysis.
Results A total 1092 patients were admitted to QMH with a suspected fractured neck of femur; data from 747 patients were analysed. Of the 345 excluded patients, 65 were not enrolled into the pathway because of a variety of reasons, including not having a diagnosis of fractured hip, poor rehabilitation potential or having sustained multiple fractures. Thirty-one were discharged to non-affiliated institutions such as other hospitals or old age facilities and 65 came off the pathway in a convalescent home not affiliated with QMH. One hundred and eighty-four had missing essential data, often occurring with admission or surgery on weekends or public holiday. The socio-demographic and pre-surgery related characteristics of the included patients are summarised in Table 1. Mean (standard deviation [SD]) age of the cohort was 83.8 (7.06) years, and 66.4% were female. The average preoperative stay was 1.3 days. Total length of stay (TLOS) ranged from 3 days to 88 days with a mean of (SD) 24 (8.6) and this included both time in the acute ward and in the rehabilitation facilities. The fracture sites were neck of femur (50%) and intertrochanteric (48%), while subtrochanteric fracture were the least common (2%). The haemoglobin levels and
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Choi et al. Table 1. Socio-demographic and pre-surgery related characteristics (n = 747). Demographics Age (years) 65–69 70–79 80–89 90–99 100–109 Gender Male Female Pass Mini Mental State Examination (MMSE) result on admission Modified Barthel Index Score (MBI) on admission Independent (100) Mild dependent (91–99) Moderate dependent (61–90) Severe dependent (21–60) Totally dependent (0–20) Pre-surgery related variables No. with premorbid previous fracture Previous fracture before 65 No. with comorbidities 9.5 ≤9.5 >9.0 ≤9.0 >8.5 ≤8.5 >8.0 ≤8.0
No No No No No No No No No No
insufficient numbers of patients with haemoglobin above 10.5 g/dl and below 7.5 g/dl to investigate comparisons beyond that range. A previous local study has indicated that an Abbreviated Mental Test score of lower than 6 and a Functional Independence Measures score of lower than 75 at the time of admission to the rehabilitation setting were found to be related to rehabilitation outcomes.15 In the current study, patients were assessed using the Mini Mental State Examination (MMSE), which only 31.3% of our current cohort passed. This examination is an assessment of mental status that includes asking patients to name the date and season, to remember items in a list, to repeat a sentence backwards, to make up a sentence with a noun and a verb and to perform subtraction calculations. It is clearly aimed at those individuals who are literate and although the majority of patients did not pass this exam, there was no impact on rehabilitation as measured by TLOS. The Modified Barthel Index (MBI) was also administered to each patient upon admission. Only 10% of our patients were classified as severely or totally dependent, indicating that the majority of our patients were able to perform daily functions such as bathing, grooming, and walking for at least 4.5 metres without aid. This too had no impact on the length of hospital stay. This study has all the limitations inherent in retrospective analyses as well as having a number of patients with missing data and a limited range of haemoglobin values on which we could perform the analysis.16 No statistical power analysis was performed for this study, as we could only maximise the use of every patient in our database with no missing essential data. The strength of this current study is that the data was collected prospectively and therefore no recall bias would contaminate the data. However, the message of this study is that in the context of consistent perioperative management, haemoglobin levels between 8 g/dl and 10 g/dl did not affect the length of hospital stay in patients undergoing management.
Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from AOTRAUMA Asia Pacific Research Grant 2014.
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