Title : Non-compliance or clinical prioritisation? An audit of timing of surgical fixation for NOFs in young patients and the impact of polytrauma cases
Abstract:
Background: NICE guidance recommends surgical fixation for Neck of Femur fractures (NOFs) on the day of or the day following admission. Compliance is commonly assessed with a 36-hr target. However, interpretation may be challenging, especially in major trauma centres and for younger patient cohorts frequently dealing with high energy traumas associated with polytrauma and competing injuries requiring clinical prioritisation for management. This audit evaluated compliance with national guidance on timing of surgical fixation for NOFs at a tertiary MTC in a cohort of patients younger than 60 and investigated the contribution of polytrauma to delays in surgical intervention.
Methods: This was a retrospective closed-loop audit conducted at a tertiary MTC. Patients younger than 60 admitted with NOFs were identified during two different audit periods. Time between admission and surgical fixation recorded. Subgroup analysis was conducted following cycle 1 to identify the proportion of polytrauma cases in the non-compliant group. Findings were discussed at a multidisciplinary departmental governance meeting and a poster prepared for display. A second cycle was conducted to assess compliance following these interventions.
Results:
Cycle 1: included 236 patients, for 76 of whom the target was not met (32.8%). Subgroup analysis revealed 22 of these patients (28.9%) were patients with polytrauma with multiple complex injuries. Other factors noted to have contributed to operative delays included need for anticoagulation reversal and logistical issues surrounding theatre availability.
Cycle 2: revealed persisting challenges in meeting the national targets with non-compliance at 45% (n=20).
Conclusion: Meeting national guidelines for timing of surgical fixation of NOFs remained a challenge at this tertiary MTC. A substantial proportion of non-compliant cases involved polytrauma patients were delays in surgical fixation may be partially attributed to appropriate clinical prioritisation. A binary assessment of compliance with timing targets may overlook case complexity particularly in younger patient cohorts presenting with polytraumas.
