Preoperative goal directed therapy in geriatric hip fracture patients – a retrospective quality improvement study.

Luzerner Kantonsspital Klinik für Orthopädie und Unfallchirurgie Dissertation unter der Betreuung von Prof. Dr. med. Reto Babst, Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital Preoperative goal directed therapy in geriatric hip fracture patients – a retrospective quality improvement study DISSERTATION Zur Erlangung der Doktorwürde der Humanmedizin (Dr. med.) An der Fakultät für Gesundheitswissenschaften und Medizin der Universität Luzern Vorgelegt von Nicole Vollenweider Dissertation genehmigt am 12.02.2025 Publikationshinweis Preoperative goal directed therapy in geriatric hip fracture patients – a retrospective quality improvement study Publiziert am: 18.11.2024 Journal: BMC Geriatrics, Volume 24, article number 959 (2024) https://doi.org/10.1186/s12877-024-05554-5 Publikation RESEARCH Open Access © The Author(s) 2024. 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To view a copy of this licence, visit h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / . Vollenweider et al. BMC Geriatrics (2024) 24:959 https://doi.org/10.1186/s12877-024-05554-5 BMC Geriatrics †Dirk Lehnick and Björn-Christian Link share the last authorship. *Correspondence: Nicole Vollenweider nicole.vollen[email protected] 1Klinik für Anästhesie, Luzerner Kantonsspital, Spitalstrasse, Luzern 6000, Switzerland 2Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, Luzern 6000, Switzerland 3Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, Luzern 6002, Switzerland 4Faculty of Health Sciences and Medicine, University of Lucerne, Inseliquai 10, Luzern 6002, Switzerland Abstract Background Hip fractures in older adults are common and carry a high risk of morbidity and mortality. Preoperative dehydration, a key risk factor for adverse outcomes, is often underdiagnosed at admission. It is important to identify high risk patients and optimize modifiable risk factors to improve the postoperative outcome. The p-POSSUM Score is a useful predictor of postoperative mortality risk. Implementing a defined fluid resuscitation protocol early in high-risk groups has proven effective in reducing both postoperative morbidity and mortality. Materials and methods We conducted a single-center, retrospective quality improvement study at a Level 1 trauma center in Switzerland, focusing on geriatric patients over 70 with a p-POSSUM Score > 5% and a proximal femur fracture, undergoing surgery between February 2015 and September 2019. We hypothesized that our institutional goal-directed fluid resuscitation protocol (GDT) would result in lower 30and 90-day mortality rates and fewer complications for these high-risk patients. Outcome changes over time were analyzed annually. Results 312 patients were included in our study. 147 followed our institutional GDT protocol, while 165 patients received standard care and were used as a control group. Initially, the odds ratio (OR) for 30-days mortality favored the GDT group; 2015 0.30 (CI: 0.07–1.18), 2016 0.28 (CI: 0.07–1.07), 2017 0.51 (CI: 0.13–2.04). This shifted toward the NonGDT group in the year 2018 with a OR of 2.14 (CI: 0.59–7.84) and 2019 with 1.92 (CI 0.47–7.83). The pattern for 90-day mortality results was similar and slightly more pronounced. The estimates for the odds ratios remained consistent even after adjustment for the p-POSSUM score. The relative frequencies of complications showed no remarkable differences between the groups (GDT vs. Non-GDT). Conclusion In our study, the treatment according to our GDT protocol was associated with survival advantage in the first three years. However, this trend reversed in 2018, with Non-GDT patients faring better. Although our retrospective study does not provide enough evidence of causality between the protocol and the mortality rates, it revealed that continuous critical evaluation of internal processes is essential in healthcare for quality management. This allows timely identification and adaptation of processes to issues, especially after initially positive results. Keywords Goal-directed therapy, Hip fracture, Geriatric trauma patients, Quality improvement Preoperative goal directed therapy in geriatric hip fracture patients – a retrospective quality improvement study NicoleVollenweider1,3*, BeatePoblete1, RetoBabst2,3, Frank J. P.Beeres2,3, DirkLehnick4† and Björn-ChristianLink2,3† Page 2 of 11Vollenweider et al. BMC Geriatrics (2024) 24:959 Background Due to the ageing population, the incidence of geriatric trauma, particularly hip fractures, is rising [1–3]. These fractures are notably prevalent among older adults and significantly increase the risk of morbidity and mortality [2, 4–8]. The one-year mortality after a hip fracture in the geriatric patient is reported to range from 14 to 58% [9]. Key risk factors contributing to poor outcomes in these patients include age-related physiological limitations, multiple comorbidities, polypharmacy, and frailty [2, 4, 7, 10]. A critical, but often overlooked risk factor is preoperative dehydration, which is linked to higher mortality rates, increased in-hospital complications, and poor functional recovery [11–13]. Notably, studies indicate that up to 50% of geriatric patients exhibit dehydration at hospital admission [11, 14]. Geriatric patients have a reduced responsiveness to fluid loss and hypovolemia. Age-related changes in the cardiopulmonary system lead furthermore to a decline of oxygen uptake, delivery, and organ perfusion. This exposes the patients to a greater risk for organ dysfunction or general ischemia, resulting in higher morbidity and mortality [11]. On the other hand, an aggressive intravenous fluid therapy (“over-resuscitation”) in the geriatric population may lead to fluid overload, heart failure exacerbation and increased mortality [15]. Optimizing modifiable preoperative risk factors is essential for enhancing surgical outcomes. Focusing preoperative optimization efforts on high-risk patients has proven more effective in reducing morbidity and mortality [2, 16, 17]. The p-POSSUM score, assessing 12 physiological and 6 surgical factors, has been shown to be a reliable predictor of postoperative mortality [8, 17, 18]. Detailed information about which parameters contribute to the score can be found in Table1. Evidence suggests that improving oxygen delivery to match the increased demands during surgery can offer a survival advantage. This optimization can be achieved through appropriate fluid resuscitation, avoiding fluid overload, and the use of vasoactive drugs [16, 20]. Goal-directed therapy (GDT) involves continuous hemodynamic monitoring and therapeutic interventions to achieve specific hemodynamic targets. A clearly and well-defined fluid resuscitation protocol, particularly when applied early in high-risk groups with a mortality risk of > 5%, has been effective in reducing postoperative morbidity and mortality [20]. We hypothesized that preoperative treatment of geriatric hip fracture patients with a p-POSSUM Score > 5% (high risk group for mortality) using a goal-directed fluid resuscitation protocol will result in lower mortality and complication rates. This protocol aims to hemodynamically stabilize patients, ensuring adequate perfusion and Table 1 Physiological and Surgical parameters of the p-POSSUM score [18, 19] Score 1 2 4 8 Physiological Parameters Age (Years) < 60 61–70 > 70 Cardiac History No Cardiac failure Medication with Diuretics, Digoxin, for Angina pectoris or Hypertension Peripheral Oedema, Warfarin, Borderline Cardiomyopathy Raised Jugular vein pressure, Cardiomegaly Pulmonary History No Dyspnea Dyspnea on exertion, mild COPD Limiting dyspnea, Moderate COPD Dyspnea at rest, Pulmonary Fibrosis, Consolidation on X-Ray Electrocardiography Normal Atrial fibrillation, Rate 60–100/min Atrial fibrillation, Rate > / <60–100/min Any other abnormal rhythm, > 4 ectopic beats per minute, Q-waves, ST-Segment / T-Wave changes Systolic blood Pressure (mmHg) 110–130 100–109 or 131–170 90–99 or > 170 < 90 Pulse rate (bpm) 50–80 40–49 or 81–100 101–121 < 40 or > 120 Hemoglobin (g/dl) 13–16 11.5–12.9 or 16.1–17 10–11.4 or 17,1–18 < 10 or > 18 White Blood Cell Count 4–10 × 109/l 10.1–20 × 109/l or 3.1–4 × 109/l > 20 × 109/l or < 3 × 109/l Urea (mmol/l) < 7.6 7.5–10 10.1–15 > 15 Sodium (mmol/l) > 135 131–135 126–130 < 126 Potassium (mmol/l) 3.5–5 3.2–3.4 or 5.1–5.3 2.9–3.1 or 5.4–5.9 < 2.9 or > 5.9 Glasgow Coma Scale 15 12–14 9–11 < 9 Surgical Parameters Operation Type Minor Moderate Complex Major Complex Number of procedures 1 2 > 2 Estimated blood loss < 100ml 101500ml 501999ml > 1000ml Peritoneal Contamination None Minor Gross Malignancy Status None Primary only Node Metastases Distant Metastases Page 3 of 11Vollenweider et al. BMC Geriatrics (2024) 24:959 oxygenation. The primary endpoints of this exploratory study were the mortality rates at 30 and 90 days postoperatively, while secondary endpoints included complication rates during hospitalization. Materials and methods This study was a single-center, retrospective quality improvement analysis a Level 1 trauma center in Switzerland. It focused on geriatric patients with hip fractures. Ethical clearance was obtained from the Ethikkomission Nordwestund Zentralschweiz, (EKNZ 2014 − 343). Fig. 2 Our institutional GDT-protocol since May 2017. SpO2 = Oxygen Saturation, Hb = Hemoglobin, MD = Medical Doctor, RF = Ringerfundin Fig. 1 Our institutional GDT-protocol from February 2015 – May 2017. RF = Ringerfundin, MAP = mean arterial pressure Page 4 of 11Vollenweider et al. BMC Geriatrics (2024) 24:959 We hypothesized that patients with a proximal femur fracture and a p-POSSUM-Score > 5% would experience lower morbidity and mortality rates, when treated preoperatively according to our institutional goal-directed therapy protocol (GDT). From February 2015 to September 2019, patients over 70 years with an isolated proximal femur fracture were assessed. Inclusion criteria were a p-POSSUM Score > 5% at admission and surgical intervention. Exclusion criteria included a P-POSSUM Score ≤ 5%, missing p-POSSUM Score, non-surgical treatment, periprosthetic or pathological fractures, hip dislocations and polytraumas. An independent researcher compiled patient data from the clinical information system, including surgical and anesthesiologic notes. Baseline data contained age, sex, ASA-classification, time to surgery and p-POSSUM score, as well as preoperative treatment-protocol. Postoperative data consisted of 30and 90-day mortality rates and complication rates. Complications included pneumonia, myocardial infarction, cerebrovascular insults, delirium, decubitus, anemia, wound and urinary tract infection. Mortality data were obtained from the national registry of the federal office for statistics. The protocol was first implemented in February 2015 and then regularly checked for feasibility. In 2017 there was a major adjustment to the protocol process. Since we wanted to check the continuous quality of our work, we decided to analyze our data annually. Our results will have an impact on further treatment protocol. The GDT-Protocol On admission, patients with a p-POSSUM Score > 5% were identified as high-risk and admitted to the recovery room for hemodynamic optimization via the GDT protocol. If recovery room capacity was full, patients received standard ward therapy. All patients received peripheral nerve block analgesia on admission. Anticoagulated patients were given a single shot femoral nerve block, while in others a femoral catheter was inserted. A few exceptions did not receive loco-regional-analgesia [21]. Basic monitoring in the recovery room consisted of an electrocardiogram (EKG), invasive blood pressure measurements, pulse oximetry (SpO2) and urinary output. Until May 2017 all patients also received a Pulse control cardiac output (PiCCO)-catheter for invasive hemodynamic monitoring, measuring stroke volume variation (SVV), cardiac index (CI) and mean arterial pressure (MAP). Interpretation of hemodydnamic parameters in a clinical setting can be challenging and it requires a lot of experience [22]. Given the fact that the absolute quantity of patients was relatively limited, the use of the PiCCOcatheter did not become routine of the personnel in the recovery room. Due to application issues and to make the process more user friendly, this was changed to a less invasive continuous hemodynamic monitoring and regular examinations by an anesthesiologist post-May 2017. Hemodynamic optimization followed the specific flowcharts below (Figs.1 and 2). Fig. 3 Inclusion and exclusion criteria Page 5 of 11Vollenweider et al. BMC Geriatrics (2024) 24:959 Throughout the study, repeated arterial blood gas analyses (aBGA) were conducted. Regular checks included serum lactate, hemoglobin, blood sugar, electrolytes, paO2 and paCO2. The goals were to maintain normovolemia, normoxemia, normocapnia, normoglycemia and normal electrolyte levels. Immediate intervention was initiated for serum lactate levels > 2 mmol/l, diuresis < 0.5 ml/kg/h, hemoglobin < 70g/l, or any pathological change in blood pressure, SpO2 and heart rate. Surgery was scheduled as soon as a patient was hemodynamically stable, and an operating room was available. Stability criteria included mean arterial pressure (MAP) 60–100 mmHg, capillary refill ≤ 2 s, diuresis > 0.5ml/ kg/h and SpO2 > 90%. There was no specialized GDT protocol for the intraand postoperative period. Therefore, all patients received standard care. Relocation criteria to go from the recovery room to the ward were hemoglobin > 80g/l, MAP 60–100 mmHg, Pulse rate 60–100 /min or deviation from the individual baseline < 20% as well as a urine output of > 0.5ml/kg/h. All patients received geriatric co-management after surgery. Statistical analysis Statistical analyses were performed using Stata (Version 18.0, Stata Corp, College Station, Texas, USA). Baseline characteristics, mortality rates, and complication rates were evaluated descriptively by group (GDT vs. NonGDT) and annually. For the comparison of baseline characteristics, the Wilcoxon Rank-Sum test was applied for age, ASA classification, p-POSSUM Score, and time to surgery, while the Fisher’s exact test was used for sex. Given the divergent development of the 30and 90-day mortality rates in the two groups over time, the associated odds ratios were calculated with 95% confidence intervals annually and illustrated with forest plots. Both unadjusted and p-POSSUM Score-adjusted odds ratios were computed to assess the robustness of the findings. The p-POSSUM Score adjusted odds ratios were calculated to correct for possible confounders as it is a summary score for comorbidities, vital-signs and intraoperative events combined. To determine the p-value for complications, the Fisher’s exact test was used. Results Between February 2015 and September 2019, a total of 312 patients were included in our analysis. Of these, 147 patients were treated according to our GDT-Protocol. The remaining 165 patients, also with a p-POSSUM Score > 5%, did not receive the GDT treatment and served as the control group. Figure3 shows study identification, inclusion, and exclusion criteria as a flow chart. Baseline characteristics Both groups were comparable in terms of age, ASA Score and time to surgery. Notably, during 2017 and 2018, patients in the GDT group presented higher p-POSSUM Scores, compared to the Non-GDT group. Table2 shows the baseline characteristics overall and by admission year. Primary outcomes Mortality rates at both 30and 90 days, presented in absolute numbers and percentages are summarized in Table3. This table covers the entire study period and provides a yearly breakdown. Initially mortality rates in the GDT group decreased for the first three years, then subsequently increased. In contrast, mortality rates in the Non-GDT group showed a consistent decrease over time. Figures4 and 5 show the development of the unadjusted OR for the 30and 90-days mortality in relation to the GDT versus Non-GDT group. Due to the higher p-POSSUM Scores in the GDT group, odds ratios for 30-day and 90-day mortality were also adjusted for the p-POSSUM Score, as shown in Table4. Secondary outcomes Anemia was the most frequent complication in both the GDT and the Non-GDT group, followed by delirium. One fifth of the patients in both groups experienced other complications. However, these various complications occurred too infrequently for a more detailed analysis. Tables5 and 6 provide a comprehensive overview of these complications. Table5 presents the data in absolute numbers and percentages for the entire study period, while Table6 breaks down the complications by year of admission. Throughout the study duration, the incidence of complications does not seem to show time-dependent patterns, possibly except for myocardial infarction (7 cases in 2015, followed by one case in all the following years). Discussion Our analysis revealed that neither the GDT nor the NonGDT group demonstrated a significant superiority in primary and secondary outcomes over the study period. This finding is particularly important given the fluctuating mortality rates and complication incidences observed over time. It suggests that factors beyond the immediate application of the GDT protocol may be influencing the patient outcomes. To our knowledge, this is the first study to analyze the data per year. Page 6 of 11Vollenweider et al. BMC Geriatrics (2024) 24:959 Table 2 Baseline characteristics overall and by year of admission 02/2015–09/2019 02/2015–12/2015 01/2016–12/2016 01/2017–12/2017 01/2018–12/2018 01/2019–09/2019 GDT (n = 147) NonGDT (n = 165) P-Value GDT (n = 33) NonGDT (n = 14) P-Value GDT (n = 41) NonGDT (n = 25) P-Value GDT (n = 30) NonGDT (n = 50) P-Value GDT (n = 19) NonGDT (n = 49) P-Value GDT (n = 24) NONGDT (n = 27) PValue Age (years) Median (IQR) 87 (82–90) 87 (83–90) 0.53 87 (83–90) 85 (81–90) 0.56 87 (83–90) 86 (81–89) 0.24 86 (81–91) 88 (85–91) 0.12 88 (85–90) 87 (84–90) 0.5 84 (76–89) 87 (84–89) 0.27 Gender 0.31 1 1 0.19 1 0.55 Male n (%) 35 (23.8) 48 (29.1) 7 (21.2) 3 (21.4) 12 (29.3) 8 (32.0) 5 (23.8) 16 (32.0) 5 (26.3) 12 (24.5) 6 (25.0) 9 (33.3) female n (%) 112 (76.2) 117 (70.1) 26 (78.8) 11 (78.6) 29 (70.7) 17 (68.0) 25 (83.3) 34 (68.0) 14 (73.7) 37 (75.5) 18 (75.0) 18 (66.7) ASA Classification 0.001 0.91 0.57 0.37 0.034 0.18 ASA 1 n (%) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) ASA 2 n (%) 5 (3.4) 15 (9.1) 0 (0.0) 1 (7.1) 1 (2.4) 2 (8.0) 2 (6.7) 4 (8.0) 0 (0.0) 3 (6.1) 2 (8.3) 5 (18.5) ASA 3 n (%) 109 (74.2) 132 (80.0) 26 (78.8) 10 (71.4) 30 (73.2) 18 (72.0) 24 (80.0) 43 (86.0) 14 (73.7) 43 (87.8) 15(62.5) 18 (66.7) ASA 4 n (%) 33 (22.5) 18 (10.9) 7 (21.2) 3 (21.4) 10 (24.4) 5 (20.0) 4 (13.3) 3 (6.0) 5 (26.3) 3 (6.1) 7 (29.2) 4 (14.8) p-POSSUM Score (%) Median (IQR) 12.6 (9-21.5) 10.5 (7.7–16.3) 0.014 10.4 (9-18.8) 12.4 (9-16.3) 0.84 10.5 (7.7–18) 10.6 (7.7– 14.1) 0.88 15.8 (10.5– 23.9) 12.2 (7.7– 21.5) 0.087 13.8 (9-18.7) 9 (6.6– 12.7) 0.004 15 (8.6– 31.4) 12 (7.7–20) 0.49 Time to Surgery (h) Median (IQR) 20.4 (14.3– 25.1) 18.8 (9.1–30.4) 0.22 21.4 (16.7– 24.9) 20.2 (12.028.7) 0.69 19.7 (14.5– 24.6) 20 (6.7– 29.6) 0.57 18.4 (12.5– 22.8) 21.5 (10.2– 32.1) 0.92 24.2 (18.7– 29.5) 18.1 (10.3– 34.8) 0.46 21.5 (12.1– 29.6) 16.8 (8.2– 25.4) 0.17 Curriculum Vitae Nicole Vollenweider 08.05.1992 geboren in Affoltern am Albis, ZH, Schweiz 1999 - 2005 Primarschule Hausen am Albis, ZH 2005 - 2011 Kantonsschule Wiedikon, Zürich, Altsprachliches Profil 2012 - 2018 Medizinstudium an der Universität Zürich 09/2018 Eidg. Examen Humanmedizin an der Universität Zürich 01/2019 – 03/2021 Assistenzärztin Chirurgie, Spital Schwyz Seit 07/2021 Assistenzärztin Anästhesie, Luzerner Kantonsspital, Luzern