Differences in complications and length of stay between patients with a hip fracture treated in an orthopaedic department and patients treated in other hospital departments

Article Outline

• Summary
• Introduction
• Methods
  • Data collection
  • Intervention
  • Statistical methods
• Results
• Discussion
• References
• Copyright

Summary 

The health care system has to deal with substantial health care costs, which are expected to continue to rise due to increasingly elderly populations. One way of saving has been a reduction of the number of beds in hospitals. The consequence is that acute patients are inappropriately admitted to non-specialized wards because of limited beds. These patients are also known as “outliers”. In this study, consecutive patients with a hip fracture treated at the orthopaedic department (n=273) are compared with patients treated at other departments (n=147) according to the incidence of complications and the length of stay (LOS) before and after the introduction of an evidence-based clinical pathway. There was no medical difference between the populations. However, the strict demands of saving costs, with limited beds, have resulted not only in economic consequences with prolonged hospitalization, but also in patient suffering and the inconvenience of increased postoperative complications.

Patients treated at non-specialized wards had an extra LOS of 3.7 days in the acute hospital settings and furthermore, 13.6 days of LOS including rehabilitation compared to patients treated at the orthopaedic department. In addition, we consider the implemented evidence-based clinical pathway to be successful since the number of complications was reduced. It is a major challenge to establish effective treatment and rehabilitation for patients after a hip fracture aiming to avoid complications and reduce LOS. These fragile patients with a hip fracture ought to be treated at the orthopaedic department, or at departments with geriatric and rehabilitation knowledge. Physiotherapists, occupational therapists and nurses specialising in orthopaedics and geriatricians should take an active part in the care of these patients.

Keywords: Hip fracture, Length of stay, Orthopaedic wards, Specialized wards, Clinical pathway, Postoperative complications, Outliers, Rehabilitation

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Introduction 

Most patients with a hip fracture in Sweden are treated at the orthopaedic department or in a few hospitals at the geriatric department. In both settings, the personnel are specialized in the care of elderly orthopaedic patients. However, the strict demands of saving costs are often imposed following scarce health resources. The health care system has to deal with substantial health care costs, which are expected to continue to rise (Avenell and Handoll, 2000) due to the increasingly elderly population (Khaw, 1999). One way of saving has been a reduction of the number of hospital beds. The consequences are that patients admitted to the hospital may be admitted to wards wherever a bed is available. For example, a patient with a hip fracture can be treated on a gastroenterological medical ward. Patients inappropriately admitted to other wards because of limited beds are also known as “outliers”. This may be a problem today when all personnel tend to be specialized in narrow areas and patients might run the risk of not having optimal care.

A hip fracture is a common injury sustained by older people after a fall. It is well known that hip fracture is one of the diagnoses that have become a major problem with significant postfracture disability, morbidity and mortality (Liporace et al., 2005, Roberts and Goldacre, 2003, Zuckerman, 1996). The increasingly ageing population will lead to an increasing number of patients with a hip fracture. This type of fracture is regarded as the most severe of the osteoporotic fractures in the elderly (Vidal et al., 2006). Time trend analyses have shown that incidence rates of hip fractures are increasing even after adjusting for age (Cumming et al., 1997). Epidemiological studies have reported the highest incidence of patients with a hip fracture in Scandinavian countries and North America (Bacon et al., 1996, Gullberg et al., 1997, Lundstrom et al., 2003).

Despite advancement in anaesthesia, surgical technique and nursing care, one-year mortality ranges from 14% to 36% and increases when patients suffer from postoperative complications (Aharonoff et al., 1997, Lawrence et al., 2002, Vidal et al., 2006). Hamlet et al. (1997) have reported that mortality will double in patients with postoperative complications, In addition, Sexson and Lehner (1987) have shown a 3-fold increase of mortality rates when compared to patients without postoperative complications. There is a wide spectrum of complications that may affect patients, including cardiopulmonary events, thromboembolism, bleeding, infection, delirium and pressure ulcers (Johnstone et al., 1995, McLaughlin et al., 2006, Zuckerman et al., 2000). Many studies have focused on the association between in-hospital surgical delay and the healing of the fracture (Manninger et al., 1985, Sorbie, 2003, Szita et al., 2002), and mortality in patients with a hip fracture from a quality assessment perspective (Elliott et al., 2003, Sund and Liski, 2005) and from length of stay (LOS) (Olsson et al., 2006, Siegmeth et al., 2005). However, to our knowledge no study has focused on the consequences of treating patients with a hip fracture in wards not specialising in orthopaedics because of limited beds. Furthermore, long-term rehabilitation and care in community dwellings should be taken into consideration in the discussion about LOS.

The aim of this study was to investigate whether there were differences in complications and LOS between patients with a hip fracture treated at an orthopaedic department compared to patients with a hip fracture admitted to other departments within the hospital due to limited beds.

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Methods 

We compared 273 patients with a hip fracture treated at an orthopaedic department with 147 patients with a hip fracture admitted to other departments within the hospital due to bed shortages. A total of 478 patients with a hip fracture were consecutively included in this quasi-experimental study conducted at the Lund University Hospital, Sweden between April 1st 2003 and March 31st 2004. On October 1st 2003, the evidence-based clinical pathway was introduced. The transition period for implementing the new pathway was 44 days and the 58 patients from this washout period are not reported here to reduce confounding factors in the transition period.

Comparisons are made between patients treated at an orthopaedic department and patients treated because of a hip fracture at other departments not specialising in orthopaedics within the hospital. Patients admitted to an orthopaedic department only for the first few days and transferred to other wards due to limited beds are also included in patients treated at other wards. When a patient was treated at a non-orthopaedic ward, the personnel at this ward were supervised by an orthopaedic surgeon. The care personnel were always welcome to contact the orthopaedic wards if they had any questions about patient care. Regardless of which type of ward the patients were treated on, the patients in the control group followed the clinical pathway used before the intervention and the patient in the intervention group followed the new evidence-based clinical pathway.

Among the first 210 patients in the control group, 71 patients were inappropriately admitted to other departments not specialised in orthopaedics compared to 76 out of the 210 last patients. In most cases, patients admitted to other departments were transferred to the orthopaedic department after some days, only 13 patients spent their whole hospitalization at other departments within the hospital. During the study, 15 patients fell and sustained a hip fracture at different wards at the hospital. Nine of them were transferred to an orthopaedic department and the remaining six patients stayed at the ward where they originally were enrolled. One of these six patients fell the same day as he was supposed to return home after a coronary bypass operation. There was no bed available at the orthopaedic department and he was transferred to the rehabilitation unit after five days. Five patients fell at medical wards and remained as medical patients. One was admitted because of a cerebral accident and died after 70 days; two were admitted because of acute confusional state (ACS) and returned to their homes 8 and 14 days postoperatively, respectively. One was admitted because of Parkinson’s disease and was transferred to the rehabilitation unit 15 days postoperatively. Eventually, one was admitted because of a pulmonary problem and was transferred to the rehabilitation unit 11 days postoperatively. These patients are included in calculations regarding patients treated on other departments.

Written informed consent was obtained from all lucid patients before they entered the study. We used the Short Portable Mental State Questionnaire (SPMSQ) (Pfeiffer, 1975), with a cutoff level of ⩾8, for normal mental functioning. Not lucid patients were included after obtaining permission from their next of kin. No exclusion criteria were used. The study was approved by the Ethics Committee of the Medical Faculty of Lund University (LU 39-03) and has been performed in accordance with the Helsinki declaration.

Data collection 

Two doctoral students, clinical nurse specialists in orthopaedic (AH) and anaesthesia (KBB) respectively, were responsible for collecting all data from the medical records and interviewed the patients and/or their next of kin, and were available 24h a day, seven days a week, during the study period.

Within 30min from arrival at the Acute and Emergency (A&E) department, a patient with a suspected hip fracture was tested for lucidity by the researcher, using the SPMSQ. All patients’ demographic data were registered in the Swedish national quality register RIKSHÖFT. The basic RIKSHÖFT data collection set includes three forms, which can be used to elicit basic information about background factors, the type of fracture, the surgical method and the patient’s place of living, functional capacity, re-operations and mortality.

An additional form recorded complications diagnosed by clinical criteria or postmortem. The complications registered were pneumonia with signs in the chest, and antibiotic treatment, cardiac failure necessitating treatment, deep vein thrombosis diagnosed with ultrasound or venography, pulmonary embolism diagnosed with lung scan or angiography, superficial wound infection, redness of the wound requiring antibiotics, deep wound infection diagnosed as an infection around the implant, wound haematoma requiring drainage, urine retention necessitating catheterisation, urinary tract infection confirmed by culture, acute renal failure with doubling of serum urea or creatinine, gastrointestinal haemorrhage with haematemesis or melaena, myocardial infarction with electrocardiogram (ECG) changes on cerebrovascular accident diagnosed clinically, other complications and pressure ulcers. Other complications included, for example, constipation, ileus and infections other than urinary tract infection, pneumonia and wound infection. In-hospital complications were defined as complications that occurred after admittance to hospital but were not known as present prior to admission and were documented in the medical record. All patients were followed up after four and 12 months by a home visit from one of the researchers (AH). At that time the patient, or a proxy, was interviewed and complications, if any, were noted. One patient in the intervention group had moved abroad and it was not feasible to contact him/her at the 12 month follow-up. Furthermore, three patients declined the follow-up at 12 months.

In the demographic data, the use of four or more prescribed drugs was recorded as it is described as a risk factor of falling in the elderly (Tinetti et al., 1993). Haemoglobin <99g/L was defined as anaemia (Wolters et al., 1996).

Spinal anaesthesia was administered to 70% and general anaesthesia to 30% of the patients. All patients underwent anticoagulation prophylaxis with low-molecular heparin for approximately 10 days postoperatively.

During the study’s control period, as well as intervention period, all patients at risk of developing pressure ulcers were placed on pressure relief mattresses irrespective of department and ward. For patients with a high risk of developing pressure ulcers an alternating pressure relief mattress was used. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel’s (EPUAP) classification (EPUAP, 1999) (Table 1).

Table 1. European Pressure Advisory Panel’s classification of pressure ulcers

Intervention 

A systematic literature review was undertaken to determine the clinical pathway components. The clinical pathway introduced was based upon the following clinical evidence:

Statistical methods 

Baseline characteristics and complications were compared using standard statistical methods. Non-parametric data were tested with the Pearson chi-square test, and when appropriate, Fisher’s exact test. Student’s T-test was used for parametric data. The level of significance was set at p<0.05. All analyses were undertaken using the Statistical package for the Social Sciences version 14.0 for Windows.

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Results 

There were no statistically significant differences between patients according to age, gender, lucidity, place admitted from, fracture type, ASA-classification or smoking neither between patients treated at an orthopaedic department and patients treated at other departments (Table 2), nor between patients in the control group and the intervention group. More patients in the intervention group were affected by three or more diseases (p<0.001) (Table 2), however, this was not noted between patients at an orthopaedic department compared to patients treated in other departments (Table 3). There was no significance in medical history between patients treated in an orthopaedic department and patients treated at other departments (Table 4). Of the 416 patients operated on, 269 patients were treated in an orthopaedic department and 147 patients were treated in other departments. Within 24h, 60% of the patients treated in an orthopaedic department were operated on compared to 48% of the patients treated at other departments. Administrative delay as a reason was noted in 33% of the patients treated at an orthopaedic department and in 40% of the patients treated at other departments. Seven percent of the patients treated at an orthopaedic department in both control and intervention groups compared to 4% of the patients treated at other departments in both control and intervention groups were identified as anaemic (haemoglobin level below 99g/L) on admission. In total, 79% of the anaemic patients were affected by a complication (p<0.010). It was 78% in patients treated at an orthopaedic department versus 83% in patients treated at other departments.

Table 2. Characteristics of patients treated in orthopaedic department compared to patients treated in other department in control group (CG) and intervention group (IG)

Variable	Groups	Orthopaedic department	Other department	p-Value
		n=139 in CG	n=71 in CG
		n=134 in IG	n=76 in IG
Mean age (SD)
	CG	81.8 (10.5)	80.8 (10.5)	0.52
	IG	80.1 (11.0)	80.8 (8.8)	0.67
Gender (%)
Female	CG	102 (73.9)	46 (63.9)	0.15
	IG	92 (68.7)	48 (63.2)	0.45
Male	CG	36 (25.9)	26 (36.6)	0.15
	IG	42 (31.0)	28 (36.8)	0.45
SPMSQ (%)
⩽2	CG	33 (23.7)	13 (18.3)	0.48
	IG	26 (19.4)	13 (17.1)	0.72
⩽7	CG	59 (42.4)	22 (31)	0.13
	IG	49 (36.6)	25 (32.9)	0.65
⩾8	CG	80 (57.6)	49 (69)	0.13
	IG	85 (63.4)	51 (37.1)	0.65
Admitted from (%)
Own home	CG	92 (66.2)	48 (67.6)	0.88
	IG	86 (64.2)	55 (72,4)	0.28
Fracture type (%)
Cervical	CG	69 (49.6)	45 (63.4)	0.79
	IG	74 (55.2)	39 (51.3)	0.67
Trochanteric	CG	70 (50,4)	26 (36.6)	0.79
	IG	60 (44.8)	39 (48.7)	0.67
Morbidity (%)
⩾3 diseases	CG	31 (22.3)	13 (18.3)	0.59
	IG	48 (35.8)	28 (36.8)	0.88
⩾4 medication	CG	49 (35.3)	34 (47.9)	1.00
	IG	16 (34.3)	24 (31.6)	0.76
ASA class (%)
I–II	CG	53 (38.1)	29 (40.8)	0.77
I–II	IG	59 (44.0)	37 (48.7)	0.57
III–V	CG	87 (62.6)	42 (59.2)	0.66
III–V	IG	75 (56.0)	40 (52.6)	0.58
Ever smoker (%)
	CG	33 (23.7)	17 (23.9)	1.00
	IG	30 (22.4)	13 (17.1)	0.38

SPMSQ, Short Portable Mental Status Questionnaire, ASA, American Society of Anaesthesiologists.

Table 3. Characteristics of patients treated in Control group (CG) and in intervention group (IG)

Variable	CG n=210	IG n=210	p-Value
Mean age	81.5±10.5	80.4±10.3	0.27
Sex (%)
Female	148 (70.5)	140 (66.7)	0.46
Male	62 (29.5)	70 (33.3)	0.46
SPMSQ (%)
⩽2	46 (21.9)	39 (18.6)	0.47
⩽7	81 (36.8)	71 (35,2)	0.54
⩾8	129 (61.4)	136 (64.8)	0.54
Admitted from (%)
Own home	140 (66.7)	141 (67.1)	1.00
Rehabilitation	3 (1.4)	6 (2.9)	0.50
Inst care	57 (27.1)	56 (26.7)	1.0
Hospital	8 (3.8)	7 (3.3)	0.51
Fracture type (%)
Cervical	114 (54.2)	113 (53.8)	1.00
Trochanteric	96 (45.8)	97 (46.2)	1.00
Morbidity (%)
⩾3 diseases	44 (21)	76 (36.1)	0.001
⩾4 medication	127 (47.6)	140 (52.4)	0.22
ASA class (%)
I–II	127 (60.5)	114 (47.3)	0.24
III–V	82 (56.3)	95 (53.7)	0.24
Ever smoker (%)	50 (53.8)	43 (46.2)	0.48

SPMSQ, Short Portable Mental Status Questionnaire ASA, American Society of Anaesthesiologists.

Table 4. Medical history at admission in patients with a hip fracture treated at the orthopaedic department and other departments in control group CG and intervention group IG

Before discharge from the acute hospital a significant difference (p<0.02) was noted in the amount of patients affected by any complication between patients treated in an orthopaedic department of whom 48.7% were affected, compared to the patients treated at other departments, 60.5%. However, the difference was only noted in the intervention group. More patients treated at other departments were affected by cardiac failure (p<0.04) and by urinary tract infections (p<0.05) (Table 5). These differences were noted in the intervention group. When the groups were split up between men and women a statistical significance in any complication was noted in women in the intervention group, 45% of the women treated in an orthopaedic department were affected by any complication compared to 73% of women treated at other departments (p<0.002). Furthermore, 19% of the women in the intervention group were affected by urinary tract infections compared to 42% of the women treated at other departments (p<0.005).

Table 5. Incidence of complications at discharge between patients treated in orthopaedic department and patients treated in other departments in control group (CG) and in intervention group (IG)

At four-months follow-up significantly more patients in the control group treated at an orthopaedic department had been affected by a complication (p<0.04) or died (p<0.001) compared to patients treated at other departments (Table 6). Of women treated at an orthopaedic department 51% were affected by a complication compared to 28.3% of women treated at other departments (p<0.012). The control group’s difference in mortality was noted in men. It was 33% of the men treated at the orthopaedic department, versus 8% of men treated at other departments (p<0.03). At 12 months, no statistical differences in complications or LOS between patients treated at an orthopaedic department and other departments were noted. Of the 61 patients who were deceased, 49 (80.3%) (p<0.001) were affected by a complication before discharge from hospital.

Table 6. Incidence of complications at four month follow-up treated in orthopaedic department and patients treated in other departments in control group (CG) and in intervention group (IG)

In both the control group and the intervention group for patients treated at other departments the LOS at the hospital was prolonged (p<0.001). Furthermore, the total number of days in acute care and different rehabilitation units was significantly more in patients treated at other departments. The divergence was in the control group 14.8 more days (p<0.002) and in the intervention group 12.4 more days (p<0.008) (Table 7).

Table 7. Length of stay (LOS) in acute hospital and total number of days before patient able to return to previous living

		Orthopaedic department	Other departments	p-Value
		CG/IG n=139/234	CG /IG n=71/76
LOS (SD)
In acute hospital		10.0 (6.0)	13.8±7.1	0.001
In acute hospital	CG	9.5 (4.3)	13.3±7.2	0.001
In acute hospital	IG	10.6 (7.2)	14.1±7.0	0.001
Before returning home		23.1 (26.5)	36.7±36.2	0.001
Before returning home	CG	23.2 (27.1)	38.0±27.6	0.004
Before returning home	IG	23.0 (26.0)	35.4±35.0	0.008

Overall, patients affected by a complication had a prolonged hospitalization of four days (p<0.001) and furthermore six days (p<0.048) prolonged stay in rehabilitation units before they were able to return home. Patients 85 years or older who had suffered from a complication had a prolonged stay of 14 days (p<0.001) before returning home.

The mean age of patients (n=193) with a trochanteric fracture was 81.8 (SD 9.8) compared to 80.2 (SD 10.9) in patients (n=227) with a cervical fracture. Patients with a trochanteric fracture were significantly (p<0.008) more often, 60.1% (n=116), affected by complications compared to patients with a cervical fracture, 46.7% (n=106). Among patients with a trochanteric fracture treated at an orthopaedic department 58.5% were affected by a complication compared to 63.5% of patients with a trochanteric fracture treated at other departments.

In the whole sample, 155 (36.9%) patients were identified as not lucid (SPMSQ<8). The only complication which showed significant differences (p<0,001) between lucid and not lucid patients was the development of pressure ulcers. Of the lucid patients, 9% had developed pressure ulcers compared to 21.9% of the not lucid patients.

In the control group, 5 (3.9%) of the lucid patients were affected by other complications compared to 9 (11%) among not lucid patients. Pressure ulcers were identified in 17 (13.1%) of the lucid patients and in 22 (27, 1%) of not lucid patients (p<0.017). Pressure ulcers were the only statistically significant complication between lucid patients (n=7, 5.1%) and (n=12, 16.2%) not lucid patients in the intervention group (p<0.011). Cardiac failure was the only complication with significant difference (p<0.03) between not lucid patients treated at an orthopaedic department (of whom 29% were affected) compared to 71% of the not lucid patients treated at other departments. In total, 165 patients had suffered a complication at the four-month follow-up. Of the not lucid patients 73 patients (47%) were affected compared to 92 (35%) of the lucid patients (p<0.013). Of the 61 patients deceased, 39 (25%) were not lucid and 22 (8.3%) lucid (p<0.001).

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Discussion 

The consequences, suffering and inconvenience of postoperative complications, are strong enough reasons to motivate the implementation of evidence-based care (Beaupre et al., 2006). In this study, patients in the intervention group followed a new clinical pathway which has now been implemented at the hospital.

Patients with a hip fracture treated in wards not specialised in orthopaedics were affected by more complications before discharge from hospital. Furthermore, LOS in acute hospital care and LOS including days in rehabilitation units were prolonged for those patients. Earlier studies have focused on the patients prefracture medical condition related to mortality (Parker et al., 2000, Roche et al., 2005) and/or LOS (Beaupre et al., 2006, Nawata et al., 2006). In this study no significant difference was found between patients characteristics at admission compared to patients treated at an orthopaedic department and patients treated at other departments or between patients in the control and intervention groups. More patients in the intervention group were affected by three or more diseases. This, however, was not noted between patients at an orthopaedic department compared to patients treated at other departments.

Postoperative ACS is a serious complication. Nevertheless, it tends to be under diagnosed and not always documented in the medical record. In this study, patients lucid at admission and recognised with ACS by the researchers will be reported in a separate paper.

One study has described that patients identified as anaemic on admission were at risk of poor outcome (Gruson et al., 2002). Our study confirms that 79% of the patients identified as anaemic were affected by a complication before discharge which highlights the importance of preventative strategies in these patients.

It is generally agreed that the treatment of hip fractures should be surgical. The impact of operative delay, defined as >48h after admission, has been extensively studied according to mortality, yet the association remains inconclusive. Several studies have shown an increased rate of mortality (Fox et al., 1994, Hamlet et al., 1997, Hoerer et al., 1993, Sexson and Lehner, 1987, Todd et al., 1995), while other studies have shown no association. Scottish data from 2006 support an association between delay to surgery, defined as >24h after admission, and mortality after hip fracture. The association persisted for a year after admission for hip fracture. On the other hand, no evidence of an association between delay to surgery and mortality for patients whose operation was delayed for administrative reasons was found (Mackenzie et al., 2006). In-hospital surgical delay is sometimes defined as more than one day (Bottle and Aylin, 2006, Elliott et al., 2003, Freeman et al., 2002) and sometimes as more than 48h (McGuire et al., 2004, Siegmeth et al., 2005). The Swedish national guidelines for hip fracture treatment recommend operation within 24h of admission to hospital which we have used. We found no association between delay and mortality. In this study, 60% of patients treated in the orthopaedic department were operated on within 24h as recommended, compared to 48% of the patients treated at other departments. The somewhat higher incidence of administrative delay to operation may be explained both by prolonged waiting time at the A&E before a ward with an available bed is recognized and by ineffectiveness of placing patients on wards where the nurses are not used to organise care of patients with a hip fracture. Furthermore, a discussion about the ethical issue of letting old and vulnerable people with a hip fracture wait more than 24h to be operated on should be highlighted. The waiting time imposes pain, and increases the risk of developing complications.

At discharge, more patients treated at other departments were affected by complications. This was noted in the intervention group. Significantly more patients were affected by cardiac failure and urinary tract infections. These findings could suggest that patients in the control group were less healthy, which they were not, or that something in the care of the patients were different. Early ambulation after hip fracture surgery accelerates functional recovery and is associated with more discharges directly to home and less to high-level care (Oldmeadow et al., 2006). Patients initially treated in other departments were not mobilized as effectively as patients treated in the orthopaedic department. This may depend on the fear of doing something wrong among the personnel at the ward not specialised in orthopaedics. It is a routine at the hospital that patients with a hip fracture before surgery receive a urinary catheter, which is supposed to be removed in the morning the day after surgery. However, patients at other departments tend to have the urinary catheter for more days than the patients in the orthopaedic departments.

At the four-months follow-up, patients treated in an orthopaedic ward were more affected by complications and more patients were deceased. However, this was only noted in the control group, indicating that the patients might not have been medically fit before discharge to their own home, where most patients were living alone. However, we found nothing that confirms this. It was 28% of the patients treated at an orthopaedic ward and 32% of the patients treated at other departments who returned directly from the hospital to independent living.

Several studies have shown that male gender is associated with increased risk of mortality (Elliott et al., 2003, Endo et al., 2005, Schroder and Erlandsen, 1993, Trombetti et al., 2002). Significantly more men treated in an orthopaedic department in the control group were deceased after four months. We were not able to find any explanation, there was, however, a difference in the intervention group as well. More men treated at other departments were deceased (25% compared to 14%), nevertheless the difference was not significant. Yet there was no difference in mortality between patients treated at the orthopaedic department and patients treated at other departments. At 12 months follow-up, there were no differences between the groups.

Advanced age is associated with an increased prevalence of disease (von Heideken Wagert et al., 2006) and risk of developing complications. The patients in our study with a trochanteric fracture were older than the patients with a cervical fracture, and were significantly more often affected by complications compared to patients with a cervical fracture. Some loss of function is to be expected in most patients with a hip fracture (Parker and Johansen, 2006). The patient’s age is nothing we can have influence on, however, different ways to reduce postoperative complications should be considered.

Length of stay is frequently reported (Gilchrist et al., 1988, Koval et al., 2004, Roberts et al., 2004). However, when comparison is made between studies it is important that days spent in different settings such as rehabilitation units or community dwellings should be included in the total LOS. With declining lengths of stay at the acute hospital care more patients might be discharged to other institutions for continuing care which should be included in the health economic calculation. In this study, when patients either from the beginning are admitted to an inappropriate ward not specialised in orthopaedic care or a few days after surgery transferred from the orthopaedic wards to other wards, LOS was increased in both the acute hospital care and in rehabilitation units. The difference was LOS of 3.7 days in acute hospital setting and LOS of 13.6 days in rehabilitation. The strict demands of saving costs with limited beds have resulted not only in economic consequences with prolonged hospitalization, but also in patients suffering and inconvenience of postoperative complications because of increasing numbers of complications.

It is a major challenge to establish effective treatment and rehabilitation for patients after a hip fracture aiming to avoid complications and reduce LOS. When patients with a hip fracture are not treated in the orthopaedic department, it is probably essential that they are treated at departments with a geriatrician physician, who together with physiotherapists, occupational therapists and nurses specialising in orthopaedics takes an active part in patient care to improve the quality of care and patient safety.

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