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The main objective of this study was to answer two questions about treatment of proximal femoral fractures: "What is the right thing to do?" and "Are we doing the right thing?", and then to develop evidence-based clinical guidelines for hip-fracture treatment. A systematic approach was taken, with a focus on health outcomes;⁵ we aimed to make recommendations that would optimise functional outcome while minimising length of stay in hospital.

What is the right thing to do?
We performed a systematic review of randomised controlled trials (RCTs) and meta-analyses that included patients over 50 years with proximal femoral fractures. In the absence of an RCT (there were none published for "time to surgery" and "time to mobilisation after surgery"), we searched for observational studies.

The main literature source was English language articles identified from MEDLINE and CINAHL from 1966 to December 1995. Search words used were "hip fractures", "proximal femoral fractures", "fractured neck of femur", together with specific interventions and clinical indicators (Box 1). The searches were limited to English language, RCTs, meta-analyses, age 50 years or over, and proximal femoral fractures not due to metastatic disease.

In addition, manual searches were conducted of current issues of key specialty and general journals, our personal literature, libraries, bibliographies of the published articles and personal contact with those working in areas relevant to hip fracture, including the Cochrane Collaboration Musculoskeletal Injuries Group.

Articles were distributed randomly to the assessors by the use of a random numbers table. The assessors, who were all experienced in the critical appraisal of scientific literature, were blinded to the authors, institutions and journal of publication of the articles. Articles were read independently by two assessors. Disagreements were resolved by a third assessment and a consensus meeting.

Results and data on study quality were recorded according to Cochrane Collaboration guidelines for the assessment of study quality.⁶ Guidelines for ranking the level of evidence were those devised by the National Health and Medical Research Council (NHMRC).⁷

Are we doing the right thing?
The study population for the medical audit came from the five acute-care Northern Sydney Area Health Service public hospitals during the 1993-94 financial year. All admissions for proximal femoral fracture in the 12 months were included. Patients with multiple injuries or fractures due to metastatic cancer were excluded. Data were extracted by trained medical record reviewers. A second audit, conducted by an independent reviewer in a 10% random subsample, showed more than 90% agreement.

Patients were identified by ICD-9 code 820 (fracture of neck of femur) and by the following procedural codes:

79.15 Closed reduction of fracture with internal fixation -- femur

79.35 Open reduction of fracture with internal fixation -- femur

81.51 Total hip replacement

81.52 Partial hip replacement

81.53 Revision of hip replacement

Development of evidence-based guidelines
The key steps in the process of care for the acute management of hip fracture were identified by discussion with clinical staff and review of medical records (Box 1) and a specific clinical question was asked for each (eg, "Do low pressure mattresses reduce the number and severity of pressure sores?"). All supporting trial evidence was summarised in table format with author, year, interventions tested, number of subjects, ranking of bias (low, moderate, high), adequate concealment of allocation to groups (yes/no), summary of results of the individual articles with odds ratios and 95% confidence limits and, where possible, a calculation of the number needed to treat.⁶ Data were in a suitable format for meta-analysis for "prophylactic antibiotics" and "type of anaesthesia", but summary statistics were not generated for the other treatment modalities. Full details of all articles and these summaries are available from the authors and are on the Internet.¹

From these tables, a one-page summary was generated for each clinical intervention, together with recommendations for clinical practice and suggestions for future study. These were circulated among the review team and the orthopaedic clinical groups.

The results of the medical literature review and medical record audit were presented to medical and nursing staff in each hospital in oral and written form. Local practice was compared with practice in the other hospitals and to evidence-based best practice.

After all these steps, a single page of draft guidelines was developed with NHMRC levels of evidence listed for each clinical recommendation. These were circulated and presented for further discussion before being adopted.

The right thing to do
Of the 120 articles published between 1966 and December 1995, 97 met the inclusion criteria. Articles were excluded if they did not report randomised trials, if they had insufficient numbers of patients with hip fracture, or if they were judged to be of poor quality by two independent assessors.1 Our conclusions from the literature review addressed 15 issues, and what we found, on the basis of available evidence, is given in Box 1. Box 2 presents the evidence-based clinical guidelines and average practice (1993-94) for each of the clinical interventions (as well as for acute-care-hospital length of stay) among the five acute-care hospitals audited. Average practice is given as unweighted averages across all five hospitals of the frequency of adherence to evidence-based best practice, plus the range from lowest to highest frequency.

The guidelines can be applied to most, but not all, patients who sustain a proximal femoral fracture. Individual circumstances and comorbidities will always influence decision-making. These guidelines should be updated as new evidence becomes available.

What we are doing
In all, 729 consecutive admissions were audited and will be the subject of a more detailed report evaluating the implementation of the guidelines. No significant variation was shown among the five acute-care hospitals with respect to the patients' age (mean, 82.4 years; 18% were 90 years or older), sex (81% female), admissions from nursing homes (28.7%) and fracture type (51% intracapsular, 43% extracapsular, 6% unknown). All patients had at least one comorbidity, 71.7% had two or more and almost a third had five or more.

Mortality at 12 months was 18%¹ for non-nursing-home patients and 38% for nursing-home patients. At the four-month follow-up, 16% of patients required a new nursing-home admission.

There was considerable variation in the clinical interventions (Box 2), particularly evident for "time to surgery", "preoperative traction", "pressure gradient stockings", "type of anaesthesia" (spinal) and "urinary catheterisation".

• Prophylactic antibiotics (intravenous) were used in the majority of patients in all five hospitals, but most continued their use longer than evidence and basic principles require. Giving additional oral antibiotics, for which there is no supporting evidence, was also common practice (lowest hospital rate, 32%; highest hospital rate, 83%).

• Surgical wound drains were used almost universally, with most remaining in place beyond 24 hours.

• Delay in mobilisation after surgery was associated with an increased length of stay. The hospital with the longest time to mobilisation also had the longest acute-care stay (median, 13 days v. overall median, 9 days).

• Three-quarters of patients who were admitted from their own home were discharged to a rehabilitation facility. Acute-care stay for these patients (median, 11 days) was considerably longer than for those returning to a nursing home (median, 6 days).

• The day of the week on which a patient was admitted was also found to be associated with length of stay, and this effect occurred both between and within the five hospitals. Patients admitted on a Thursday were likely to spend an extra two days in the acute-care facility (median, 11 days) compared with those admitted on other days (median, 9 days).

Current practice, identified by medical record audit, was compared with evidence-based best practice and areas of care requiring modification were identified. A number of steps in patient treatment were supported by high level evidence, but wide variability in the routine use of these treatments was seen among the five participating hospitals.

There was little or no supporting evidence for some common practices, including preoperative traction and the extended use of wound drains. Although not measured systematically, we observed great variability in clinicians' response to this information, ranging from relief to frank disbelief, and many showed considerable reluctance to drop a "time-honoured practice".

Prevention strategies involving medical therapies, such as prophylactic anticoagulants and antibiotics, were in widespread use and compared favourably with other audits.^105,106 However, non-pharmaceutical prevention strategies, including pressure-decreasing mattresses, oxygen saturation monitoring and nutritional supplements, were not in routine use in any hospital.

Despite high level evidence for the use of prophylactic anticoagulants, the exact timing of initial administration of anticoagulation remained in doubt, with surgical and anaesthetic staff expressing concern about its use in combination with regional anaesthesia. There is an extremely small, but nevertheless serious, risk of spinal haematoma with this combination. On the balance of available evidence, the benefits appear to outweigh the risk of harm, but it remains a controversial area, suggesting that further trials on types and timing of anticoagulants are required.

The evidence that regional anaesthesia was associated with reduced mortality and morbidity compared with general anaesthesia also met with a mixed response, with anaesthetists being completely polarised in their views. The published meta-analysis on this topic⁴¹ did have flaws (duplication of patients, not all RCTs), but our review team reassessed the original articles according to the Cochrane Collaboration protocol and performed a repeat analysis, excluding studies which appeared to be duplicated, and reached the same conclusion, albeit with a more conservative estimate of benefit (summary odds ratio for mortality, 0.68; 95% CL, 0.49, 0.96).

The optimum time from admission to surgical operation has long been a vexed question. Only observational studies,^8-12 with their inherent biases and conflicting results, were available to guide recommendations. Longer time to surgery is likely to increase the risk of complications and the total length of stay, and early surgery on patients who are medically stable has not been shown to cause any harm. We found considerable variability in time to surgery, with up to 20% of patients waiting longer than 72 hours. This may reflect the lack of availability of out-of-hours surgical facilities and, to a lesser extent, the achievement of medical stability, but these patients continue to be "poor surgical relations" and are not given the priority they deserve.

Earlier mobilisation also has resource implications and is dependent, in part, on the availability of physiotherapy staff, but also on a patient's general condition. While there are no randomised controlled trials to indicate the optimal time for mobilisation, a review of all trials of surgical treatment showed that ambulation on the first or second day after surgery had no adverse effects,^56-88,98 and a cohort study has now reached the same conclusions.¹⁰⁷

The day of admission appeared to influence both delay to surgery and overall acute length of stay, suggesting that the practice of adding these patients to a routine list, rather than making special arrangements for them, may be a factor in prolonging length of stay.

Patients requiring transfer to rehabilitation facilities generally stayed several days longer in the acute-care ward compared with those discharged to nursing-home care. This suggests a need to address difficulties with the process of assessment for rehabilitation and/or the availability of rehabilitation beds. Costs could be reduced by earlier transfer to rehabilitation from the more expensive acute-care ward, but whether this would mean longer-term cost savings remains to be determined.

Our study identified considerable variation in current management of patients who have sustained hip fractures. It has some limitations, being restricted to English language articles and to evidence published up to January 1996. As a result, a few relevant references may have been missed. However, we recommend that these guidelines be applied to most elderly patients admitted with hip fracture, as we have shown that sufficient information now exists to challenge treatments based solely on tradition or individual perceptions. The current "epidemic" of proximal femoral fractures¹⁰⁸ makes it essential that the best possible use is made of scarce resources to achieve optimal outcomes.

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(Received 28 Jul 1998, accepted 19 Mar 1999)

Reprints: Associate Professor L M March, Department of Rheumatology, The Royal North Shore Hospital, St Leonards, NSW 2065.
Email: lmarcATdoh.health.nsw.gov.au

©MJA 1999
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