Timing of Adverse Events Following Geriatric Hip Fracture Surgery: A Study of 19,873 Patients in the American College of Surgeons National Surgical Quality Improvement Program
TAKE-HOME POINTS
- The median postoperative day of diagnosis for myocardial infarction was 3, 3 for cardiac arrest requiring cardiopulmonary resuscitation, 3 for stroke, 4 for pneumonia, 4 for pulmonary embolism, 7 for urinary tract infection, 9 for deep vein thrombosis, 9 for sepsis, 11 for mortality, and 16 for surgical site infection.
- For the earliest diagnosed adverse events, the rate of adverse events had diminished by postoperative day 30; however, for the later diagnosed adverse events, the rate of adverse events remained high at postoperative day 30.
- The proportions of adverse events diagnosed prior to discharge were 81.0% for myocardial infarction, 77.8% for stroke, 76.1% for cardiac arrest requiring cardiopulmonary resuscitation, 71.9% for pulmonary embolism, 71.1% for pneumonia, 58.0% for urinary tract infection, 52.1% for sepsis, 46.9% for deep vein thrombosis, 44.3% for mortality, and 27.6% for surgical site infection.
- These results facilitate targeted clinical surveillance, guide patient counseling, and inform the duration of follow-up required in research studies.
- Clinicians should have the lowest threshold for testing for each adverse event during the time period of greatest risk.
Geriatric hip fracture surgery is associated with a higher rate of occurrence of postoperative adverse events than any other commonly performed orthopedic procedure.1-4 Indeed, the 90-day mortality rate following a geriatric hip fracture surgery may be as high as 15%2 and the 30-day morbidity rate as high as 30%.3 Furthermore, more than half of postoperative mortalities following orthopedic procedures occur after surgery for hip fracture.4 Therefore, extensive research has been conducted regarding interventions to reduce the rates of adverse events following a hip fracture surgery.5-12 For example, randomized trials have been conducted involving venous thromboembolism prophylaxis,5,6nutritional supplementation,7 delirium prevention,8-10 anemia correction,11 geriatrics consultation,9 and anesthetic technique.12
Despite these extensive research efforts, there is currently little information in the literature regarding when postoperative adverse events occur. A clear depiction of the timing of adverse events could help target clinical surveillance, inform patient counseling, and determine the duration of follow-up required for studies. The reason that the timing of adverse events has not been previously characterized may be that the sample sizes available through standard single- or multi-institutional studies may be insufficient to accurately characterize the timing of rare adverse events (eg, myocardial infarction, stroke, etc.). Moreover, although administrative datasets have become common data sources for investigation of rare postoperative adverse events,13-16 such data sources often do not contain data on the timing of diagnosis.
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is a relatively new and growing surgical registry.1,3,13-22 The registry follows up patients undergoing surgical procedures at several hundred community and academic institutions nationwide. Unlike the administrative datasets discussed above, the ACS-NSQIP characterizes the postoperative day of diagnosis of well-defined adverse events during the first 30 postoperative days.22
In this study, data collected by the ACS-NSQIP are used to characterize the timing of 10 specific postoperative adverse events following a geriatric hip fracture surgery.
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