A comprehensive hip fracture program reduces complication rates and mortality.

OBJECTIVES: To evaluate the rate of postoperative complications, length of stay, and 1-year mortality before and after introduction of a comprehensive multidisciplinary fast-track treatment and care program for hip fracture patients (the optimized program). DESIGN: Retrospective chart review with historical control. SETTING: Orthopedic ward (110 beds) at a university hospital (700 beds). PARTICIPANTS: Five hundred thirty-five consecutive patients aged 40 and older (94%>or=60) hospitalized for hip fracture between January 1, 2003, and March 31, 2004. Three hundred and thirty-six patients (70.3%) were community dwellers before the fracture and 159 (29.7%) were admitted from nursing homes. INTERVENTION: The fast-track treatment and care program included a switch from systemic opiates to a local femoral nerve catheter block; an earlier assessment by the anesthesiologist; and a more-systematic approach to nutrition, fluid and oxygen therapy, and urinary retention. RESULTS: In the intervention group, the rate of any in-hospital postoperative complication was reduced from 33% to 20% (odds ratio=0.61, 95% confidence interval=0.4-0.9; P=.002). Rates of confusion (P=.02), pneumonia (P=.03), and urinary tract infection (P<.001) were lower in the intervention group than in the control group, and length of stay was 15.8 days in the control group, versus 9.7 days in the intervention group (P<.001). For community dwellers, 12-month mortality was 23% in the control group versus 12% in the intervention group (P=.02). Overall 12-month mortality was 29% in the control group and 23% in the intervention group (P=.2). CONCLUSION: The optimized hip fracture program reduced the rate of in-hospital postoperative complications and mortality. Randomized clinical trials are needed to confirm these results and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality.

Pulse oximetry for perioperative monitoring: systematic review of randomized, controlled trials.

Monitoring with pulse oximetry might improve patient outcome by enabling an early diagnosis and, consequently, correction of perioperative events that might otherwise cause postoperative complications or even death. The aim of the study was to clarify the effect of perioperative monitoring with pulse oximetry and to identify the adverse outcomes that might be prevented or improved by its use. Trials were identified by computerized searches of the Cochrane Library, MEDLINE, EMBASE, and by checking the reference lists of trials and review articles. All controlled trials that randomized patients to either pulse oximetry or no pulse oximetry during the perioperative period, including in the operating and recovery room, were included in the study. The search identified six reports. Of these 6 reports, 4 studies with data from 21,773 patients were considered eligible for analysis. Two studies specifically addressed the outcomes in question; both found no effect on the rate of postoperative complications using perioperative pulse oximetry. Hypoxemia was reduced in the pulse oximetry group both in the operating room and in the recovery room. During observation in the recovery room, the incidence of hypoxemia in the pulse oximetry group was 1.5-3 times less. There were postoperative complications in 10% of the patients in the oximetry group and in 9.4% in the control group. The duration of hospital stay was a median of 5 days in both groups, and an equal number of in-hospital deaths was registered in both groups. The studies confirmed that pulse oximetry could detect hypoxemia and related events. However, given the relatively small number of patients studied and the rare events being sought, the studies were not able to show an improvement in various outcomes.