高龄髋部骨折救治绿色通道的建立和效用评估

The efficacy of green surgery pathway on senile hip fractures

目的建立高龄髋部骨折救治绿色通道并评估其临床效用。方法采用历史性对照试验研究设计,根据诊疗流程的不同,将我院骨关节外科2016年3月至2017年3月间收治的97例高龄髋部骨折患者列为干预组,将2015年3月至2016年3月间78例高龄髋部骨折患者列为对照组。记录患者的一般情况,包括性别、年龄、骨折类型、内科疾病情况、手术情况、美国麻醉医师协会分级(the American Association of Anesthesiologists classification of physical status,ASA)等。比较两组患者的手术等待时间、手术时间、住院时间、住院期间并发症、术后一周和半年一年髋关节Harris评分、术后1年死亡率等指标。结果两组患者性别、年龄、骨折类型、手术方式、ASA分级、合并基础疾病情况等基线资料组间比较,差异无统计学意义。绿色通道组手术等待时间(36.3±7.8)h短于对照组(46.9±11.4)h,差异有统计学意义(t=6.995,P=0.000);绿色通道组手术时间(45.4±17.5)min,对照组(43.8±20.8)min,差异无统计学意义;绿色通道组住院时间(6.8±2.4)d短于对照组(9.5±2.8)d,差异有统计学意义(t=6.866,P=0.000)。绿色通道组1例术后15 h发生急性心肌梗死,抢救无效死亡;对照组1例术后3 d发生急性脑出血,抢救无效死亡。绿色通道组肺部感染、尿路感染、褥疮发生率明显低于对照组,差异有统计学意义(χ^2肺感染=5.081,P肺感染=0.024;χ^2尿路感染=6.841,P尿路感染=0.009;χ^2褥疮=11.768,P褥疮=0.001),两组患者急性心肌梗死、急性脑血管意外、下肢深静脉血栓等发生率差异无统计学意义。术后1周时,绿色通道组髋关节功能评分(72.6±13.1)分,高于对照组的(962.2±15.4)分,差异有统计学意义(t=4.826,P=0.00);术后半年和1年时,绿色通道组髋关节功能评分分别为(93.8±16.8)分和(94.1±18.3)分,均稍高于对照组的(90.5±14.7)分和(92.4±15.9)分,但差异无统计学意义。术后1年内绿色通道组死亡率6.19%,略低于对照组的8.97%,但差异无统计学意义(χ^2=0.489,P=0.484)。结论实施高龄髋部骨折救治绿色通道计划需多学科合作,可缩短术前等待时间、降低卧床并发症发生率、促进髋关节功能早期康复、有效缩短住院时间,具有良好的社会效益和卫生经济学效益。

Objective To evaluate the efficacy of green surgery pathway on senile hip fractures. Methods The green surgery pathway was implement in senile (≥75 years) hip fracture cases in our department since March 2016. A historically controlled trial study was designed: 97 senile hip fracture patients admitted between March 2016 and March 2017 were included in the intervention group and 78 senile hip fracture patients admitted between March 2015 and March 2016 were included in the control group. The patients’ general information were recorded, including gender, age, type of fracture, internal medical conditions, surgery method, the American Association of Anesthesiologists classification of physical status (ASA) classification, et al. The hip function was evaluated by the Harris score system at one week,6 months and one year after surgery. The waiting time for operation, operation time, length of hospital stay, complications during hospitalization and hip Harris score were compared between the two groups. Results For the baseline data between the two groups in terms of gender, age, fracture type, surgery method, ASA classification, and combined underlying disease, the differences were not statistically significant. The waiting time for operation of the green surgery pathway group (36.3±7.8 h) was significantly shorter than that in the control group (46.9±11.4 h, t=6.995, P=0.000). The operation time of the green surgery pathway group was 45.4±17.5 min, and that of the control group was 43.8±20.8 min, the differences were not statistically significant. The length of hospital stay in the green surgery pathway group (6.8±2.4 d) was significantly shorter than that in the control group (9.5±2.8 d), the difference was statistically significant (t=6.866, P=0.000). In the green surgery pathway group, one patient developed acute myocardial infarction at 15 h after surgery and died of invalid rescue. In the control group, one patient developed acute cerebral hemorrhage 3 d after surgery and died of invalid rescue. The incidence of pulmonary infection, urinary tract infection, and acne in the green surgery pathway group were lower than that in the control group, the differences were statistically significant (χ^2PI=5.081, PPI=0.024;χ^2UI=6.841, PUI=0.009;χ^2acne=11.768, Pcne=0.001). For the incidence of acute myocardial infarction, acute cerebrovascular accident, pulmonary embolism and deep vein thrombosis between the two groups, the differences were not statistically significant. The Harris score of hip in the green surgery pathway was higher than that in the control group (72.6±13.1 points vs 62.2±15.4 points, t=4.826, P=0.000) one week after the surgery, the difference was statistically significant. While the score was slightly higher than that of the control group in the half year (93.8±16.8 vs 90.5±14.7) and one year (94.1±18.3 vs 92.4±15.9) after surgery, but the differences were not statistically significant. The mortality rate of the green surgery pathway was slightly lower than that of the control group within one year after surgery (6.19% vs 8.97%), but the difference was not statistically significant. Conclusion The implementation of green surgery pathway can reduce the occurrence of complications in bed, promote the early hip rehabilitation, effectively shorten the hospitalization time. It is worth further promotion because of its social benefits and health economic benefits.