Surgical Timing

This recommendation was upgraded from Limited to Moderate strength due to the potential magnitude of benefit to patients. 

Eight low strength studies (Elliot 2003, Moran 2005, Parker 1992, Siegmeth 2005, Orosz 2004, McGuire 2004, Novack 2007, Radcliff 2008) evaluated patient outcomes in relation to timing of hip fracture surgery. Potential confounding effects of patients with increased comorbidities also having delays to surgery was accounted for with statistical techniques (instrumental variable analysis, regression) and excluding patients delayed due to medical reasons.

The majority of studies favored improved outcomes in regard to pain, complications, and length of stay with decreased time to surgery.  After controlling for patent comorbidities, the influence of delay to surgery on mortality was mixed but increased delay was in general associated with increased mortality. The studies varied on the optimal time frame from admission to surgery (24 hours to 4 days); however, the majority favored surgery within 24-48 hours.

Benefits/Harms of Implementation

Benefits from numerous studies have been outlined. There is minimal harm in adopting early surgical timing of hip fractures.  The evidence is limited partly due to the difficulty and potential ethical issues with performing a randomized controlled trial on this topic. The committee felt that the cited evidence, along with other lower quality studies supports this recommendation as there is potential patient harm with delay in surgery. Further, the potential benefit to patients is large enough that the committee voted it to be a moderate strength recommendation despite the limited level of evidence.  

Cost Effectiveness/Resource Utilization

Decreasing time to surgery decreases cost and health care resources.

Feasibility

Intervention has been used extensively and has been proven feasible.  However, it should be noted that these studies were performed predominantly at high volume, well-resourced, academic centers.  While decreased time to surgery from admission should always be the goal, in some cases this target may not be met due to patient comorbidities, or factors related to the medical center (staffing, OR availability, surgeon availability, medical sub-specialist availability).

Future Research 

Future research improving controls for bias relating to increased medical severity of patients delayed for surgery is needed to better identify critical timing related issues regarding patient specific populations. Understanding which perioperative medical issues and co-morbidities are modifiable and can impact patient outcomes would help in optimizing surgical timing. Further, exploring whether race has an impact on timing to surgery could help decrease heath disparities.