Skip to main content
I would like to praise the authors on this article, and commend them on their ongoing work. As a community based Orthopaedic Surgeon who works in a medium sized hospital which services rural to very-rural areas, I believe there is an area identified in the article that merits further review in the scope of rural practice - the fact that hospital level delays seem to be the at root of much variation in wait times.
The authors address the fact that hip fracture care needs to be streamlined and have clear algorithms, such as the one developed in Manitoba. This initiative focused on expediting transfers, cutting down on unnecessary pre-operative tests and steps, increasing the availability of OR time for hip fractures, and collaboration with referral centres to repatriate patients post-operatively. While this model is efficacious and is likely to be embraced by surgeons and patients alike, without strong administrative support, it remains an unachievable aspiration.
Our current benchmark is set at 48 hours from time of admission to time of surgery, but this is likely and justifiably going to be shortened to 24 hours, and perhaps even less. The most recent CMAJ paper from Sobolev et al. leans this way in suggesting that hip fractures should be done on the day of admission, or the day thereafter. The fallout of the same for medium and small sized community hospitals is likely to be tremendous.
The article by Sheehan et al. (In-hospital mortality after hip fracture by treatment setting, CMAJ 2016) provides further insight, suggesting that medium community hospitals fare the worst in terms of mortality in post-surgical death, and medium and small community hospitals also fare poorly on the risk of in-hospital death following hip fracture. The study recognizes one of their limitations not being able to stratify patients into urban, rural or remote geographical origin. I think we need to look very critically at our small and medium sized community hospitals, especially those in rural areas, and the Orthopaedic Surgical care given therein, as I fear that funding and resources are not keeping pace with heightened standards of care. As such, the strain being heaped on the system may be approaching unsustainable levels at some of these centres; and I for one can attest that it is being felt acutely.
Where I work, my colleagues and I can access the OR for after hours work (evenings, nights, and weekends) only if life or limb is imminently threatened, which is not the case with hip fractures. We have access to 9.45 hours of OR time weekly, split over 3 days, to do acute fracture care; but it is available in defined blocks. If a hip cannot meet benchmark to be done in these 3 slots, we are expected to cancel elective cases to facilitate it, but are not given extra time to rebook those patients. We are reminded of the goal to reach benchmarks, but responsibility to make this happen is left with the surgeon, while the system does little to support this goal. My colleagues in similar sized hospitals across the country echo these sentiments.
This article suggests that surgeons are trying their best to maintain standard of care, but that system-level factors are often what is holding them back. My postulation is that this is likely even more true in rural and very rural areas. I am a rural Orthopaedic Surgeon, but I grew up in a very rural area - in a town of 100 people in costal Newfoundland and Labrador, where transfer to the nearest small hospital is 100 km, and transfer to the medium community hospital where I now work (and the nearest Orthopaedic care) is 200 km. These roads in winter are, at times, completely impassible. People who live in these areas accept the fact that their emergency care is not held to the same standard as that of their less-rural and urban counterparts. While some of the factors that make this true cannot be changed (blizzards cannot be halted), some of them can. We can do better with hip fracture care – in timeliness, in post operative rehabilitation, and in ensuring that there is equity with regards to allied health services across the specture of hospital settings – but we cannot do this without strong administrative support. I believe it is our duty as physicians to raise awareness and bring our administrators on board to enact system-wide collaboration and change. In a world of increasing negativity, we have to be the leaders to ignite positive change where it can be made.