title: Isolated hip fracture care in an inclusive trauma system: A trauma system wide evaluation.
abstract: BACKGROUND
  Elderly patients with a hip fracture represent a large proportion of the trauma population; however, little is known about outcome differences between different levels of trauma care for these patients. The aim of this study is to analyse the outcome of trauma care in patients with a hip fracture within our inclusive trauma system.
  
  
  METHODS
  Retrospective cohort study. Data were collected from the electronic patient documentation of patients, with an isolated hip fracture (aged ≥ 60), admitted to a level I or level II trauma centre between January 2008 and December 2012. Main outcomes were time to operative treatment, complications, mortality, and secondary surgical intervention rate.
  
  
  RESULTS
  A total of 204 (level I) and 1425 (level II) patients were admitted. Significantly more ASA4 patients, by the American Society of Anesthesiologists (ASA) classification, were treated at the level I trauma centre. At the level II trauma centre, median time to surgical treatment was shorter (0 days; IQR 0-1 vs 1 day; IQR 1-2; P < 0.001), which was mainly influenced by postponement due to lack of operation room availability (14%, n = 28) and co-morbidities (13%, n = 26) present at the level I trauma centre. At the level II trauma centre, hospital stay was shorter (9 vs 11 days; P < 0.001) and the complication rate was lower (41%; n = 590 vs 53%; n = 108; P = 0.002), as was mortality (4%; n = 54 vs 7%; n = 15; P = 0.018). Secondary surgical intervention was performed less often at the level II trauma centre (6%; n = 91 vs 12%; n = 24; P = 0.005). However, no differences in secondary surgical procedures due to inadequate postoperative outcome or implant failure were observed.
  
  
  CONCLUSIONS
  The clinical pathway and the large volume of patients at the level II centre resulted in earlier surgical intervention, lower overall complication and mortality rate, and a shorter length of stay. Therefore, the elderly patient with a hip fracture should ideally be treated in the large-volume level II hospital with a pre-established clinical pathway. However, complex patients requiring specific care that can only be provided at the level I trauma centre may be treated there with similar operative results.
authors.affiliation: Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: J J E M
authors.initials: JJ
authors.lastname: van Laarhoven
authors.affiliation: Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: G W
authors.initials: GW
authors.lastname: van Lammeren
authors.affiliation: Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands; Department of Trauma Care Central Netherlands, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: R M
authors.initials: RM
authors.lastname: Houwert
authors.affiliation: Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: C J H C M
authors.initials: CJ
authors.lastname: van Laarhoven
authors.affiliation: Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: F
authors.initials: F
authors.lastname: Hietbrink
authors.affiliation: Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands. Electronic address: lleenen@umcutrecht.nl.
authors.forename: L P H
authors.initials: LP
authors.lastname: Leenen
authors.affiliation: Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.
authors.forename: E J M M
authors.initials: EJ
authors.lastname: Verleisdonk
mesh_terms: D015897:Comorbidity; D003422:Critical Care; D019091:Critical Pathways; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D006620:Hip Fractures / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction; D011184:Postoperative Period; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D014193:Trauma Centers
keywords: Clinical pathway; Geriatric trauma; Hip fracture; Trauma system