Factors Associated with Timely Surgery for Semi-elective Distal Radius Fracture Fixation

Abstract

Background  In the United Kingdom, national guidance recommends intra-articular distal radius fractures should undergo surgery within 72 hours and extra-articular fractures within 7 days.

Purpose  We investigated if hospitals can provide timely surgery and meet national guidelines in patients who are sent home following distal radius fracture (DRF) to return for planned surgery. The influence of patient, hospital, and seasonal factors on wait to surgery are investigated.

Patients and Methods  We reviewed Hospital Episode Statistics (HES) data between April 2009 and March 2013. Proportion of procedures being performed within 3 and 7 days was calculated. A linear regression model was created to investigate the relationship between wait for surgery and patient and hospital factors.

Results  A total of 9,318 patients were sent home to return for planned acute DRF surgery during the 4-year study period. Mean time to surgery was 3.04 days (range 1–days, standard deviation [SD] 3.14). A total of 6,538 patients underwent surgery within 3 days (70.2%) and 8,747 within 7 days (93.9%). Patients listed for surgery and sent home to return waited longer if listed toward the end of the week. Less surgery was performed at weekends, and patients were less likely to be listed for semielective trauma surgery.

Conclusions  Acute semielective DRF fixation is generally performed within targets for extra-articular fractures but there is scope for improvement for intra-articular fractures. Day of presentation and increasing number of comorbidities increase wait for surgery. Hospital trusts should focus on improving pathways for patients with multiple comorbidities and strategies to improve accessibility of these services at weekends.

Distal radius fracture (DRF) treatment is a huge burden on health care resources around the world. ¹ Displaced fractures frequently require reduction and surgical fixation.

Recent National Institute for Clinical Excellence (NICE) guidance in the United Kingdom has recommended that intra-articular fractures should undergo surgery within 72 hours and extra-articular fractures undergo surgery within 7 days. ² The rationale for the recommendation for intra-articular fractures is that within 72 hours organized hematoma may form, which will prevent accurate reduction of intra-articular fragments. A significant proportion of DRFs requiring surgery will have intra-articular displacement. These complex fractures will often require treatment by a senior trauma or hand surgeon. To ensure these guidelines are met, hospitals must therefore have experienced specialist surgeons available at almost all times.

Increasingly, trauma patients are discharged home to return for planned semi-elective trauma surgery, often performed as a day case. ^{3 4} This has been shown to be safe, cost-efficient, and popular with patients. ^{5 6} Fractures of the upper limb can be safely treated in this manner with patients sent home after an initial review with analgesia, advice, and a date for planned surgery. ^{7 8} This frees up hospital beds and saves resources. The NICE guidelines state that if DRF surgery can be delayed without compromising outcome then other more urgent procedures on the surgery list can be planned more effectively. Some concern does exist that if patients are sent home to wait for this semi-elective trauma surgery, that they may be delayed if other patients are admitted with more serious injuries, or injuries which necessitate hospital admission, such as a fractured neck of femur. As they are not occupying a bed and may not be seen as a clinical priority, then they are more likely to be cancelled or delayed in times of numerous acute admissions.

In this observational study, we set out to investigate if hospitals are able to provide timely surgery and meet national guidelines in those patients who are sent home following DRF to return for planned trauma surgery. The influence of patient, hospital, and seasonal factors on the wait to surgery are investigated. This information can be used in other health care systems to enable timely surgery while minimizing hospital bed occupancy.

Methods

We reviewed Hospital Episode Statistics (HES) data between April 2009 and March 2013. All hospital episodes involving emergency surgery for acute DRF were included (International Classification of Diseases [ICD] 108 codes S525—fracture of lower end of radius and S526—fracture of both lower end of radius and ulna). Office of Population Censuses and Survey (OPCS) codes were used to identify all methods of fixation, including plating, Kirschner wires, and external fixation. Local audit approval was obtained.

HES data is collected for all English National Health Service (NHS) and private patients, which has specific codes to state when a patient is listed for surgery and when they undergo surgery after being discharged home. Wait to surgery can therefore be accurately counted. Proportion of procedures being performed within 3 and 7 days was calculated. A linear regression model was created to investigate the relationship between wait for surgery and a large number of relevant patient and hospital factors.

Variables included in the regression model are as follows:

Patient details: age, gender, ethnicity, number of comorbidities, Charlson index, patient index of multiple deprivation (IMD) score, procedure performed.

Hospital trust details: total population, number of people aged 65 years or over, number of women, cases performed per year, cases performed that month.

Date/seasonal details: year, day of week, month, minimum temperature.

Population of the hospital trust aged 65 years and over and the number of women within the trust catchment area were included as separate factors. Older patients and women sustain DRFs at the highest rate, and these injuries are usually fragility fractures, which are often displaced and require reduction and internal fixation. Deprivation was included in the model, as this is known to influence fracture incidence ⁹ . This was measured using the IMD score, which is the official United Kingdom government measure of deprivation and was available for every patient.

Patient's individual comorbidities were assessed by counting the total number of comorbidities and the Charlson index. The Charlson comorbidity index predicts 10-year mortality based on medical comorbidities. ¹⁰ Scores are given for significant comorbidities and increasing age. A higher score indicates increased mortality rate. An algorithm was used to calculate the Charlson score for each patient from the HES data.

Initial model testing revealed large differences dependent on hospital trust. While this was useful information, we wished to investigate the effect of other factors while also acknowledging the effect of the hospital trust in the model. A solution to this was to include the hospital trust in the model as a random effect term. These random effects are treated as variables with a mean of zero and an unknown variance.

p values are not part of the output of a random effects mixed model, as there is uncertainty about the degrees of freedom of the t statistic. p values were therefore estimated using the Kenward–Rogers method. ¹¹ The method involves adjusting both the F statistic and its degrees of freedom to calculate an approximate p value.

Results

A total of 9,318 patients were sent home to return for planned acute DRF surgery in 130 hospital trusts during the 4-year period. Mean time to surgery was 3.04 days (range 1–30 days, standard deviation [SD] 3.14). A total of 6,538 patients underwent surgery within 3 days (70.2%) and 8,747 within 7 days (93.9%). A total of 891 patients were listed at the weekend (9.5%) ( Fig. 1A ). A total of 1100 procedures were performed at the weekend (12%) ( Fig. 1B ).

Fig.

1 ( A, B ) number of patients seen and listed for semi-elective distal radius fracture (DRF) surgery and number of semi-elective DRF surgical procedures performed per day of the week during the 4-year study period.

Linear regression modelling demonstrated that patients who are listed for surgery and sent home to return on a planned date wait longer if they are listed toward the end of the week ( Table 1 ). Those listed from Wednesday onward wait on average more than 3 days ( Fig. 2 ). Those with a higher number of comorbidities also had a significantly longer wait for surgery, although Charlson score was not significant. No other factors influenced wait to surgery.

Table 1. Patient and hospital trust factors which interact significantly with wait for semi-elective trauma surgery in patients who required surgical treatment for an acute DRF day of the week is the day the patient was listed for surgery.

Variable	Coefficient	p -Value
Comorbidity	0.066	0.020
Wednesday	0.413	< 0.001
Thursday	0.594	< 0.001
Friday	1.032	< 0.001
Saturday	0.728	< 0.001
Sunday	0.879	< 0.001

Abbreviation: DRF, distal radius fracture.

Fig. 2.

Mean wait for semi-elective trauma surgery in patients who required surgical treatment for an acute distal radius fracture dependent on the day they were listed for surgery with 95% confidence intervals.

Further analysis showed patients with two (mean wait 3.1 days) or three (mean wait 3.2 days) comorbidities waited significantly longer for surgery than those with one comorbidity (mean wait 2.9 days, p  < 0.005) ( Fig. 3 ).

Fig. 3.

Mean wait for semi-elective trauma surgery in patients who required surgical treatment for an acute distal radius fracture grouped by number of medical comorbidities per patient with 95% confidence intervals.

Discussion

There is an increasing drive for more trauma surgery to be performed as an outpatient, ideally as a day case. As much as 17% of trauma surgery can be performed on a semi-elective basis. ¹² Our results are generally reassuring and demonstrate that most patients undergo surgery within the NICE guidelines. Increasing number of medical comorbidities was associated with increased wait to surgery. Differences existed between hospitals, which were eliminated when hospitals were added to the model as a random effect. Significant findings are reported concerning surgery at the weekend.

Evidence regarding the relationship between radiographic parameters and outcome after DRF is controversial. Some studies suggest even a small persistent intra-articular step or gap may lead to poorer outcome, while others suggest malunion is well-tolerated. ^{13 14 15} When establishing the guidelines NICE reported that no published evidence was available concerning the effect of time to surgery on radiological and functional outcome, recommendations were made by consensus of the expert group. Despite the lack of clinical evidence, the guideline development group felt that this was an urgent issue, and many patients were waiting too long, so recommendations for time to surgery should be established.

Fixation rate within 7 days was excellent at 94%. As much as 70% of fractures underwent surgery within 72 hours. National data for United Kingdom detailing which fractures were intra-articular is not available. An estimation of intra-articular fracture rate can be made from the DRAFFT. ¹⁶ Approximately 34% of adult fractures reviewed were intra-articular. If these proportions are applied to the 4-year HES data from this study, then 3,168 patients undergoing semielective trauma surgery would have sustained intra-articular fractures; of these 950 (237 per year) underwent surgery after 72 hours, potentially leading to difficult joint surface reduction and suboptimal result. While the NICE guidelines focus on encouraging timely surgery for intra-articular fractures, it must be remembered that many extra-articular fractures are complex injuries with significant displacement and soft-tissue injury. These injuries will also require rapid intervention and an experienced surgical team.

Higher mortality and poorer outcome has been reported for patients undergoing elective and emergency surgical procedures at weekends. ^{17 18} We identified that patients waited longest when listed on Friday, Saturday or Sunday and less DRF surgery was performed at the weekend. Patients listed from Wednesday onward wait on average more than 3 days, which is longer than NICE guidance for fixation of intra-articular DRFs. Theater capability is likely to be limited at the weekend, with preference given to urgent cases and in patients. Only 9.5% (891) of patients listed to return for semi-elective surgery were seen at the weekend. As the number of patients presenting with DRF does not reduce at the weekend, this suggests that not only do patients attending at the weekend wait longer for surgery, but they are also less likely to be listed for semi-elective surgery.

Specialist surgeons will often be required to operate on complex DRF. Many hospitals, particularly smaller ones, will only have one or two surgeons available over weekend periods. It is therefore unlikely that they will have necessary subspecialty cover available to operate on complex fractures over the weekend. Therefore, for a fracture that is seen on a Friday, it may be difficult for the surgery to be performed over the weekend by a necessary specialist surgeon. Larger hospitals may be able to plan their weekend and holiday on-call cover to ensure there are surgeons available to deal with the majority of common fractures. Dedicated DRF lists on Mondays could provide capacity to operate on complex fractures presenting during the weekend period. Initial regression modelling, with individual hospitals included as a variable, showed clear differences between hospitals. Trust population was taken into account within the model, so these differences were not related to the size of the unit. Some small trusts performed well, suggesting strategies are available which enable guidelines to be met.

Day case elective surgery has been shown to be safe for older patients, obese patients, and those with severe systemic disease. ^{19 20 21} Day case surgery is less likely to disrupt the daily routine of patients with stable chronic diseases such as diabetes or epilepsy. ²² Increased number of comorbidities was associated with a longer wait for semi-elective DRF surgery. This is not surprising and may relate to withholding anticoagulants, provision of senior anesthetic cover, or need for some form of preassessment, but a potential area for improvement has been identified. The increasing use of wide awake surgery for trauma may help mitigate these delays. While the results reached significance, the increased wait of patients with three comorbidities compared with one was actually only 7.2 hours (0.3 days).

Several limitations of this study have already been alluded to. Classification of all fractures is not available in HES data, so the number of extra-articular fractures is unknown, but we have used up to date, high-quality data to estimate this. HES data records the day the patient was listed for surgery; some may have been seen in the Emergency Department then asked to return before being listed, so wait may actually be longer. This is likely to be the case at weekends when a smaller than expected number of case are listed. We have not compared our findings with those admitted as inpatients, as our aim was to investigate whether NICE guidelines are met in this specific group only. The NICE guidelines themselves are not based on strong evidence, so we do not know if meeting these guidelines does actually help patients. However, having standards encourages prompt surgery, enables audit and research, and adherence to the guidelines influences funding which a hospital trust receives. Our findings that day of presentation and comorbidities influence wait for surgery may seem intuitive to most clinicians. These problems may be longstanding, but there is minimal literature reporting this or discussing possible solutions, particularly in the context of semi-elective wrist trauma.

This study demonstrates acute semi-elective DRF fixation has been largely performed within the 7-day target for extra-articular fractures, but there is scope for improvement for intra-articular fractures. Many hospitals of differing sizes are able to meet these targets, so other trusts can learn from these units. Day of presentation and number of comorbidities are the factors which increase wait for surgery. Hospitals should focus on improving pathways for patients with multiple comorbidities and aim to improve accessibility and capability of these services at weekends.

Funding Statement

Funding None.