An interesting article by S. M. Tarrant et al from John Hunter Hospital and University of Newcastle in Australia appeared in the Bone Joint J 2014;96-B:1178–84 this month.

Most of us know that any shocking incident to someone who is over 65 may have serious consequences to that person’s health. They may never again be as sprightly or as well as they were before the incident. If that person also required surgery after the incident their recovery may not be as predictable as in a younger patient who underwent a similar procedure.

This article of course is not about that. It is about the outcome of surgical treatment following a hip fracture in the elderly patient. We all know that there is a high rate of mortality in elderly patients who sustain a fracture of the hip. The team were trying to determine the rate of preventable mortality and errors during the management of these patients.

A 12 month prospective study was performed on patients aged > 65 years who sustained a fracture of the hip. Patients who met inclusion criteria were identified and those who died as inpatients were subjected to review by a panel of multidisciplinary experts consisting of a geriatrician, orthopaedic surgeon, an anaesthetist and general physician. All were chosen due to their experience and interest in managing orthogeriatric patients and all had a knowledge and understanding of the resources and expectations of the orthopaedic trauma and medical services of the institution.

During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have been potentially preventable.
Ultimately, deaths could therefore be classified as ‘unpreventable’, ‘possibly preventable’, ‘probably preventable’ or ‘definitely preventable’. Preventable death was defined as one that satisfies three tenets: 1) the general condition on admission was survivable, 2) the delivery of care was sub-optimal and 3) the error in care was directly or indirectly implicated in the death of the patient.

Results
A total of 14 of this group presented to the emergency department during normal working hours (defined as 7am to 7pm, Monday to Friday); 14 had general medical and/or medical subspecialty review during the admission.
A total of 13 of those who died as an inpatient underwent operative intervention. This was performed at a mean of 25.9 hours (2 to 52) after admission, and 11 of these had their operation within normal working hours. Only two of the operative candidates had their surgery postponed due to insufficient operative availability. The mean length of the anaesthetic was 120 minutes (92 to 160). The ASA grade was 2 for one patient, 3 for eight patients and 4 for four patients. There were no intra-operative deaths. A total of three patients died within 24 hours of surgery. The median time between the operation and death was 4.6 days (0.33 to 26.4).
Only six of the 20 deaths occurred in normal working hours: six of the 20 deaths were due to myocardial infarction, four to sepsis, four to pneumonia, two to gastrointestinal haemorrhage, one to stroke, one to pulmonary embolus, one to intestinal ischaemia and one to acute renal failure.

In the delivery of care a total of 152 errors were identified in the 20 deaths and 54 errors were identified in the control group.
The errors noted by the reviewers for those who died as an inpatient were
• Insufficient medical team involvement (n = 22, 14.1%),
• poor management of medical conditions (n = 19, 12.3%),
• poor fluid or haemodynamic management (n = 15, 9.9%),
• poor management of arrhythmia (n = 13, 8.6%),
• poor management of medication (n = 13, 8.6%),
• poor pre-operative medical assessment (n = 11, 7.4%),
• delay of operative intervention (n = 8, 4.9%),
• poor electrolyte management (n = 8, 4.9%),
• inadequate orthopaedic skill (in geriatric patient management; n = 6, 3.7%) and
• poor communication between specialties (n = 6, 3.7%).
• Other less represented errors accounted for the remainder (n = 33, 21.7%).

Discussion
In this study, preventable errors were found in the care of geriatric patients with hip fractures, some of which were considered to have contributed to the patients’ death. They concluded that an element of preventable mortality exists in their institution, as do inadequacies in management.

Very few errors occurred during the operation. Most were deemed to have had minimal effect on death and occurred pre-operatively involving inadequate medical involvement in patient care and inadequate management of medical conditions. A wide range of errors was made, of which most were thought to have been probably preventable and had at least a moderate effect on the eventual outcome. Deaths with a higher degree of preventability featured more errors, despite there being no difference in age, ASA score, or time to surgery, all of which are considered to be independent predictors of mortality.

More than half of all inpatient deaths were thought to be at least possibly preventable. Despite the fact that most patients presented had their surgery during normal working hours, more than two-thirds of deaths happened outside this time, and from a wide variety of conditions.

It is currently recommended that fixation of fractures of the hip should be undertaken within 36 hours of presentation, with delays of more than 48 hours leading to increased mortality. However in their patients they note that, timely operative management was achieved but may have limited the time available for medical preparation or pre-operative planning. Shorter times between admission and surgery had been shown to be a predictor of increased inpatient mortality, possibly for this reason. As shown in large trauma studies, it is not the lack of availability of sophisticated personnel or institutional resources that leads to preventable deaths, but inadequate management.

The fact that more than 50% of deaths were at least possibly preventable, suggests that mortality can be reduced with improved care pathways. In the event that preventable mortality is overestimated, it certainly does not diminish the importance of trying to reduce the medical errors that may result in death. Even if a patient’s life expectancy is short, preventable errors that lead to death in hospital should still not be acceptable for the medical profession.

They conclude that a proportion of elderly patients who die while in hospital after treatment for a fracture of the hip do so for preventable reasons. The need for timely senior input in peri-operative medical optimisation is evident. The prevalence of preventable mortality and errors in care can be used as an indicator of quality in the management of these patients.

My attention was drawn to this study for 2 reasons. Firstly what was found in this hospital probably happens widely in many hospitals around the world and it confirms my view that older patients admitted to hospital for whatever reason do not get the same attention and treatment as a younger patient would. The second reason is it emphasises my point raised at the beginning of this post that even a minor injury suffered by an older patient has serious consequences to his or her health. It should be the duty of all primary care physicians/gen.practioners to stress to their older patients to take a little extra care when they go about their daily chores. “Do not trip or fall” should be the message