Optimising fast track care for proximal femoral fracture patients using modified early warning score.

INTRODUCTION: The care for patients with a proximal femoral fracture has been dramatically overhauled with the introduction of 'fast track' protocols and the British Orthopaedic Association guidance in 2007. Fast track pathways focus on streamlining patient flow through the emergency department where the guidance addresses standards of care. We prospectively examined the impact these protocols have on patient care and propose an alternative 'streamed care' pathway to provide improved medical care within existing resource constraints. METHODS: Data surrounding the treatment of 156 consecutive patients managed at 4 centres were collated prospectively. Management of patients with a traditional fast track protocol allowed 17% of patients to leave the emergency department with undiagnosed serious medical pathology and 32% with suboptimal fluid resuscitation. A streamed care pathway based on the modified early warning score was developed and employed for 48 further patients as an alternative to the traditional fast track system. RESULTS: The streamed care pathway improved initial care significantly by treating patients according to their physiological parameters on admission. Targeted medical reviews on admission instead of the following day reduced the rates of undiagnosed medical pathology to 2% (p = 0.0068) and inadequate fluid resuscitation to 11% (p < 0.0001). CONCLUSIONS: Implementation of a streamed care pathway can allow protocol driven improvement to initial care for patients with a proximal femoral fracture and results in improved access to initial specialist medical care.

The continued value of clinical and radiological surveillance: the Charnley Elite Plus hip replacement system at 12 years.

We report the follow-up at 12 years of the use of the Elite Plus total hip replacement (THR). We have previously reported the results at a mean of 6.4 years. Of the 217 patients (234 THRs), 83 had died and nine had been lost to follow-up. The patients were reviewed radiologically and clinically using the Oxford hip score. Of the 234 THRs, 19 (8.1%) had required a revision by the final follow-up in all but one for aseptic loosening. Survivorship analysis for revision showed a survival of 93.9% (95% confidence interval (CI) 89.2 to 96.5) at ten years, and of 88.0% (95% CI 81.8 to 92.3) at 12 years. At the final follow-up survival analysis showed that 37% (95% CI 37.3 to 44.7) of the prostheses had either failed radiologically or had been revised. Patients with a radiologically loose femoral component had a significantly poorer Oxford hip score than those with a well-fixed component (p = 0.03). Radiological loosening at 6.4 years was predictive of failure at 12 years. Medium-term radiographs and clinical scores should be included in the surveillance of THR to give an early indication of the performance of specific implants.