COVID-19 pandemic and hip fracture audit:

Impact and lessons learnt

Hip Fracture Summit

05/11/2021

Dr S Nesar - Orthogeriatric Registrar

Mr. M Arafa- SCF; Orthopaedics

Dr. H. Abu-Jabeh – JCF; Orthopaedics

SCP O. Jayme- SCP

Mr. Y. Kalairajah- Consultant Orthopaedic Surgeon

 Background
• The COVID-19 pandemic led to unprecedented emergency measures introduced
in the NHS.

• Second wave of COVID-19 led to a second lockdown which occurred in

December 2020

• There are approximately 80,000 hip fractures in the UK each year.

• Hip fractures are the subject to NICE guidance CG124, BPT and NHFD.

• Expedited surgical management is associated with a reduction in morbidity and

mortality.
 Trauma Service
 Consultant on call
 Hot week: Monday - Friday 08:00
 Weekend: Friday Monday 08:00
 Trauma Meeting 08:00 am
 Board round: MDT
 Ward round

 Trauma Lists:
 Monday-Saturday: 08:00-18:15 and Sunday: 08:00-14:00

 Orthogeriatric Ward round: Monday - Friday

 Fracture Clinics: Two daily clinics Monday –Friday
 Hip fracture team: monthly meeting
Patient Pathway

• ED checklist
 Patient Pathway

Orthopaedic Checklist
 Patient
Pathway

Nursing Checklist
 Changes during first wave of COVID-
19

 The orthopaedic registrar was solely clerking patients and completing the NOF
checklist.

 The orthogeriatric team looked after the patients post operatively with only one
registrar and junior doctor.

 Availability of dedicated orthopaedic trauma lists were variable.

 The anaesthetists would only assess patients in theatres.

 All patients were recovered in the same operating theatre.

 Study Aims

To assess:

• The impact of COVID-19 pandemic on the hip fracture care

service

• Audit our local practice during the first COVID-19 pandemic

• The emerging lessons to facilitate any future outbreaks

• Re-audit data to compare results and conclude whether 1 st audit

recommendations were effective
 Methods
 Retrospective observational descriptive study

 Single NHS hospital trust

 1st audit cycle

 157 patients

 During March-May 2019 and March –May 2020

 2nd audit cycle

 51 patients

 During December 2020 – February 2021

 Variables
• 32 variables were studied among the three groups:

• A- Demographics
• B- COVID status and relation to NHFS
• C- Pre-operative assessment
• D- Theatre management
• E- Post-operative review
• F- Key performance indicators (KPIs)
• G- Post-operative complications
• H- 30-day mortality
• I- Length of the hospital stay
 Results & Discussion
Number of patients

Group 2019 Group 2020

Number of (n = 60) (n = 97)
patients
No. % No. %

Not operated 3 5.0 3 3.1

Operated 57 95.0 94 96.9

% of Increase 61.7%
COVID-19 status in 2020 group
 Demographic data
Group 2020
Group 2019
  COVID Negative COVID Positive
(n = 60) p-value
(n = 78) (n = 19)
  No. No. No.
Gender        
Male
19 21 9
      0.225
Female
41 57 10
Age (years)        
Min. – Max. 60.0 – 100.0 60.0 – 99.0 68.0 – 96.0
0.288
Mean ± SD. (SE.) 83.33 ± 8.28 (1.07) 83.05 ± 7.64 (0.86) 86.21 ± 7.71 (1.77)
Type Fracture        
IC
43 49 11
      0.418
EC
17 29 8
 Impact of COVID-19 on imaging
The time to XR was not statistically significant
Mean time 50mins [2019] vs 50.5mins [2020]

 For inconclusive fractures on XR

 CT scans were used instead of MRI scans

Limited USS for post operative complications

Significant rise in patients requiring CTPAs

Pre-operative assessment
 Pre-operative assessment

• Six patients (two in COVID positive, one in COVID negative and three in

2019 group) were medically unfit for surgery and died pre-operatively.

• Two patients in 2020 group underwent conservative management though

they failed and needed surgery.

Hours to operation (mean)
 Theatre Management
1- Sending time: time from calling the ward to send the patient until the patient
arrives in theatres.

2- Holding bay time: time from the arrival of the patient in theatres holding bay till
arrival in the anaesthetic room.

3- Anaesthetic preparation time: time from the arrival of the patient in the
anaesthetic room till induction of anaesthesia. This timing was regarded in COVID
months as doffing time and was done in the operating room.
 Theatre Management

4- Anaesthesia Time: time from induction of anaesthesia till knife to skin.

5- Operation time: time taken from knife to skin to completion of skin closure.

6- Recovery time: time of the patient in the recovery room till patient arrival back
on the ward. Due to Covid regulations, recovery was done mostly in theatres in
2020 group.
 Theatre Management
Group 2020
Group 2019 COVID Negative COVID Positive
  p
(n = 57) (n = 77) (n = 17)
Sending time (min)        
Min. – Max. 6.0 – 96.0 8.0 – 80.0 11.0 – 66.0
0.806
Mean ± SD. (SE.) 30.79 ± 14.23(1.88) 29.69 ± 11.94(1.36) 33.29 ± 15.73(3.81)
Holding bay time (min)        
Min. – Max. 1.0 – 160.0 0.0 – 240.0 0.0 – 44.0
0.159
Mean ± SD. (SE.) 34.60 ± 34.69(4.60) 31.39 ± 35.73(4.07) 18.18 ± 17.31(4.20)
Anesthetic preparation time
       
(min)
Min. – Max. 1.0 – 60.0 1.0 – 45.0 3.0 – 40.0
0.009*
Mean ± SD. (SE.) 8.30 ± 8.05(1.07) 12.19 ± 9.15(1.04) 14.06 ± 11.62(2.82)
Anesthetics time (min)        
Min. – Max. 26.0 – 66.0 30.0 – 104.0 33.0 – 128.0
<0.001*
Mean ± SD. (SE.) 43.60 ± 9.89(1.31) 56.90 ± 15.13(1.72) 68.88 ± 25.62(6.21)
OP time (min)        
Min. – Max. 27.0 – 130.0 39.0 – 199.0 38.0 – 235.0
0.497
Mean ± SD. (SE.) 67.18±22.30(2.95) 71.13±29.64(3.38) 82.88±45.93(11.14)
Recovery time (min)        
Min. – Max. 40.0 – 425.0 3.0 – 286.0 15.0 – 145.0
0.005*
Mean ± SD. (SE.) 105.0 ± 57.70(7.64) 83.39 ± 46.39(5.29) 76.71 ± 33.16(8.04)
 Theatre Management
Group 2020
Group 2019
  COVID Negative COVID Positive
(n = 57) p
(n = 77) (n = 17)

  No. % No. % No. %

Types of anesthesia              

GA 24 42.1 39 50.6 9 52.9

0.557
Spinal 33 57.9 38 49.4 8 47.1

Intra-operative
             
complications

No 55 96.5 74 96.1 16 94.1

MC
p=
Yes 2 3.5 3 3.9 1 5.9 0.721
Post-operative review
 KPIs
 KPI 1 – Prompt orthogeriatric assessment: Percentage of hip fracture patients
assessed by a senior orthogeriatrician within 72 hours.

 KPI 2 – Prompt surgery: Percentage of patients receiving hip fracture surgery

by the day following admission.

 KPI 3 – NICE compliant surgery: Percentage of patients who received a NICE

compliant surgical approach to their hip fracture surgery.
 KPIs
• KPI 4 – Prompt mobilisation after surgery: Percentage of patients mobilised
by the day following hip fracture surgery.

• KPI 5 – Not delirious when tested after surgery: Percentage of patients who
were assessed and found not to be delirious after their surgery.

• KPI 6 – Return to original residence by 120 days: Percentage of patients

known to have returned to their original residence by 120 days after their hip
fracture.
KPIs
Reasons for delay in surgery more
than 36 hrs.
Post-operative complications
 Post-operative complications

 The post-operative wound infection rate remained as low as 0 % in in 2020

group despite the modified intra-operative measures done in response to COVID.

 These included limited use of diathermy, lack of the pulsed lavage, use of nibbler

instead of the saw to level the neck cut and the use of absorbable subcuticular
sutures instead of skin clips.
 As a department, we made these choices to minimize droplet and aerosol

formation and reduce need for direct patient contact e.g. suture removal
 Area for further research.
30-day mortality
Causes of death
 The length of hospital stay
Group 2020

Group
Length of hospital stay
2019 p
(days) COVID COVID
(n = 60)
Negative Positive
(n = 78) (n = 19)

Min. – Max. 1.0 – 34.0 4.0 – 38.0 3.0 – 79.0

0.039*

Mean ± SD. (SE.)

12.38±6.73 12.58±7.65 24.21 ±
(0.87) (0.87) 19.29(4.43)
 NHFS & COVID

COVID state

NHFS t p
Negative Positive
(n = 78) (n = 19)

0.0 – 9.0 4.0 – 8.0

Min. – Max.

5.10 ± 1.53 (0.17) 5.79 ± 1.08 (0.25)

Mean ± SD. (SE.) 1.849 0.068

5.0 6.0
Median
 Lessons Learned from first wave

 Significant increase in the incidence of hip fractures.

 Significant 30-day mortality of COVID positive hip fracture patients.

 The increase incidence of conservative management due to COVID-19 should have been

avoided

 Swifter screening times required

 Wards or areas of identified high risks patients remain adequately staffed.

 Maintain dedicated trauma lists

 Careful redeployment strategies

 Additional support required after discharge

Re-audit
Similar study and analysis performed during the
second wave of pandemic
Dec 2020 – February 2021
The aim was to compare the statistically significant
findings to see whether our first audit’s
recommendations which were presented locally and
nationally (between the two waves) have had a
positive effect on their department's performance
 Re-audit results
Criteria First wave Second wave
Number of patients 97 51
Time till XR performed 50.5 51
(min)
COVID positive (%) 17.5 27
Checklist compliance (%) 76.5 92
Operated within 36 hours (%) 81 88
Mean Anaesthetic time (min) 62.5 37
Mean Recovery time (min) 80 98
Average Length of stay 18.3 14.7
(days)
Return to original residence 68.5 74
(%)
Mortality breakdown:
Mortality (%)
 8 deaths 24.2 15.6
 6 COVID pneumonitis
 2 cardiac causes
KPI comparison
KPI First wave Second wave
Prompt Orthogeriatric 96.4 97.3
review (%)
Prompt Surgery 81.1 88
NICE compliant surgery 85.3 81
Prompt mobilisation 100 82
Not delirious post op 83.4 93
Return to original residence 68.5 74
 Conclusions
All patients in second wave were clerked by orthopaedic
SHOs +/- registrars compared to sole registrar clerking's
previously
47% decrease in total number of patients
10% rise in patients who tested positive during admission
?Better testing
25 minute shorter mean anaesthetic time and mean LOS
reduced by almost 4 days
8.6% decrease in mortality
Overall lessons learnt
 Retention of junior doctors, anaesthetists, theatre staff and MDT
members has had a positive effect on outcomes

 Swifter testing and results facilitated anticipation and treatment

of disease

 The reinstating of social care and community support is likely

to have led to the reduced number of patients

 Introduction of step-down facilities for COVID positive patients

helped in reducing the LOS and the availability of acute beds
 Limitations of the study

• Retrospective observational design

• Single-centre nature.

• Relatively small sample.

 Acknowledgment

 I would like to thank all the staff of our trauma & orthopaedic department and
orthogeriatric team in Luton and Dunstable hospital (LDH).

 Special thank you to the NOF team in LDH under the leadership of Mr
Shobhit Verma.
Question Time