Despite the imposed lockdown during the study period (1st March – 15th May), admission rates at our centre related to APFFs remained stable (based on our data from previous years). The overriding majority of these patients suffer APFF as a result of falls experienced in their own homes, meaning lockdown measures had minimal effects on reducing APFF risk and rate.[11] We experienced a situation where these multimorbid patients at high-risk of COVID-19, presented to a stripped-back acute trauma and orthopaedic service in similar numbers to pre-pandemic times.
Regarding the primary outcome measure, compared to pre-pandemic mortality rates, our results indicate increased mortality directly related to concurrent infection with COVID-19 in patients admitted to our trust with APFFs during the first peak of the coronavirus pandemic. All patients in the COVID-positive group who were deceased at 30-day follow up had COVID-19 documented as Part Ia (Disease or Condition directly leading to death) on their death certificate, with the exception of one patient who’s documented Part Ia was post-operative pulmonary embolus. However, in this patient’s case, COVID-19 was documented as Part II (contributing factor to death). COVID-19 has also been associated with increased risk of pulmonary embolism.[15] Despite the majority of patients in the COVID-positive group surviving to 30-day follow up, it is unsurprising that we found a higher mortality in this group; given that they represent a high-risk group for mortality from COVID-19, as a result of their demographics.[6]
Increased mortality was also observed in the study group as a whole. We report an overall 30-day mortality rate during the study period of 17.9%, which is triple the reported rate for the UK in the National Hip Fracture Database’s (NHFD) latest report – 6.1%.[8]
Patient demographics is a likely contributor to this overall mortality, with deceased patients in the COVID-negative group exhibiting various characteristics associated with poor prognosis from APFF (advanced age, cognitive decline, male gender etc.).[6] Deceased patients from the COVID-negative group also had a higher incidence of dementia and were on average 6-years older than others in the study. In addition, patients who died in the negative group were predominantly admitted from nursing homes (73%), with a lower mean AMTS, indicating a level of dependency and significant cognitive impairment on admission. The ratio of men to women in the COVID-negative group was 2:1 and 1:1 in the sub-group of these patients who died, therefore, men disproportionately died compared to women in this group, although the sample size is too small for this to be of any significance. Nottingham Hip Score is a reliable predictor of 30-day mortality and functional outcomes.[16] The score for those who died in the COVID-negative group was almost 10% higher than that in the COVID-positive group (4.2% in the COVID-positive & 13.3% in COVID-negative), indicating that patients who died in the COVID-negative group were at higher risk for mortality based on their demographics.
RT-PCR is continues to be the predominant testing method for active COVID-19 infection, with reported sensitivities of 71–98%.[17] This indicates that 2–29% of patients with negative test results may in fact be infected. The likelihood of undiagnosed infection decreases in patient with multiple negative tests;[17] however, the possibility of undiagnosed infection is never fully negated. The increased mortality also observed in the COVID-negative group may be explained to an extent by undiagnosed infection due to false-negative testing. In our study, we are limited in further discussing this point as there were 6 patients for which the cause of death was not accessible from hospital records.
Atypical COVID-19 presentations are also a potential cause of undiagnosed infection and are becoming more recognised, especially in the elderly.[18] Reported incidences of asymptomatic COVID-19 infection within sample populations is highly variable and ranges from 1.6–51.7%.[19] 45.3% of patients in our study’s COVID-negative group were not tested at all for the infection due to not displaying classic symptoms. Atypical infection could have contributed to the mortality in this group.
Mortality and other secondary outcome measures (delay to surgery, length of operating time, post-operative complications and length of inpatient stay) were also affected by the functional changes to orthopaedic and all other health care services during the peak of the pandemic.
“…and there are no more surgeons, urologists, orthopaedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us…”.[11]
Hospitals re-structuring themselves to manage the forecasted influx of medical patients requiring respiratory support led to reduced theatre capacity, which continues to be a problem as we experience further peaks of the virus. A key prognostic indicator for fractured neck of femur patients is prompt operative management.[8, 10] 21% of patients in our study did not undergo surgical management within this recommended period due to decreased theatre capacity. Increased operating time across all surgical interventions also contributed to delays to theatre, as anaesthetic staff followed strict time-consuming protocols and theatres were also deep-cleaned between cases. Provision of prompt surgical management of APFF should be maintained throughout periods of re-deployment and restructuring due to viral surge in order to minimise 30-day mortality in elderly patients. In fact, almost half of patients in both groups of our study (41% of COVID-positive and 46% of COVID-negative) did not receive surgery within the recommended time-frame during the first peak of the pandemic. Given that delayed operative management is associated with increased 30-day mortality[10], this goes someway to explaining the increased 30-day mortality amongst our sample of patients.
In the latest NHFD report a mean acute hospital length of inpatient stay of 15.1 days was reported.[8] Patients in this study had significantly longer inpatient stays than the average reported figures (25 days in COVID-positive and 21.7 days in COVID-negative group). Increased length of inpatient stay is associated with higher risk of post-operative complications and mortality.[20] Patients in this study suffered a number of post-operative complications which may have been contributory to the high 30-day mortality rates. Discharging patients to institutes (residential and nursing homes) was more challenging during the first peak of the pandemic, as a specified number of negative swabs were required before discharge, and each swab result could take up to 72 hours. This created a further barrier to early discharge. Furthermore, amendments to the architecture of trauma and orthopaedic services during the peak of the pandemic meant orthopaedic patients were often moved between different wards and did not always receive continuous care from the same expert team. Both of these factors may also have contributed to the increased rate of mortality at 30-days for our patients during this time. In addition, increased time in hospital is also associated with increased risk of hospital-acquired COVID-19 and possibly increased mortality.