An unowned delay: a wait that nobody decided

Review and sources

Not clinically reviewed. No clinician has signed this scenario.

• Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, Kreder HJ, Jenkinson RJ, Wodchis WP. Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery. JAMA. 2017;318(20):1994-2003. Population-based retrospective cohort of adults undergoing hip fracture surgery between April 2009 and March 2014 at 72 hospitals in Ontario, Canada. Among 42,230 patients (mean age 80.1 years, 70.5% women), overall 30-day mortality was 7.0%. Risk-adjusted restricted cubic splines placed the inflection point at which complications began to increase at a wait greater than 24 hours, irrespective of the complication considered. Compared with 13,731 propensity-score matched patients operated earlier, the 13,731 operated after 24 hours had 30-day mortality of 6.5% versus 5.8% (absolute risk difference 0.79%; 95% CI 0.23-1.35) and a composite of mortality or medical complications of 12.2% versus 10.1% (absolute risk difference 2.16%; 95% CI 1.43-2.89).
• Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, Bhandari M. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182(15):1609-16. Systematic review of prospective studies of early surgery in hip fracture; 1,939 citations screened and 16 observational studies met inclusion criteria, with 13,478 patients for whom mortality data were complete and 1,764 total deaths. Based on the five studies reporting adjusted risk of death (4,208 patients, 721 deaths), and irrespective of whether the cut-off for delay was 24, 48 or 72 hours, earlier surgery was associated with a significant reduction in mortality (relative risk 0.81, 95% CI 0.68-0.96, p=0.01). Unadjusted data indicated earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37-0.93) and pressure sores (RR 0.48, 95% CI 0.34-0.69). All included studies were observational.
• HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet. 2020;395(10225):698-708. International randomised controlled trial at 69 hospitals in 17 countries; patients aged 45 or older with a hip fracture requiring surgery were randomly assigned 1:1 to accelerated surgery (goal of surgery within 6 hours of diagnosis) or standard care. Of 27,701 patients screened and 7,780 eligible, 2,970 were enrolled (1,487 accelerated, 1,483 standard care). Median time from diagnosis to surgery was 6 hours (IQR 4-9) in the accelerated group and 24 hours (10-42) in the standard-care group (p<0.0001). Mortality at 90 days was 140 (9%) versus 154 (10%), hazard ratio 0.91 (95% CI 0.72-1.14), absolute risk reduction 1% (-1 to 3; p=0.40). Major complications occurred in 321 (22%) versus 331 (22%), hazard ratio 0.97 (0.83-1.13), absolute risk reduction 1% (-2 to 4; p=0.71). The authors conclude that accelerated surgery did not significantly lower the risk of mortality or major complications.