With the increasing aging of the population, the number of elderly patients with hip fracture increases accordingly, posing a tough challenge to health departments and orthopedic trauma surgeons. Although the surgical methods for hip fracture in elderly patients have been relatively mature, the delayed discharge of hip fracture patients still occurs frequently due to more complications and poor functional status after fracture in elderly patients. The median LOS of elderly patients with hip fracture in the present study was 10.8 days. Chen’s [7] studies have shown that patients with hip fractures have an median LOS of 12 days, indicating that discharge delays still occur in most Chinese hospitals. And studies have found that hospital stays for elderly patients with hip fractures can be reduced to four to eight days within the USA [8,9,10]. The differences in LOS of hip fracture patients at home and abroad may be related to the differences in discharge residence and health care system. It should be noted that the definition of LOS varies from study to study. In some studies reported, the length of hospital stay includes the acute nursing period and the early rehabilitation period. While in others, the length of hospital stay is defined as the acute period of admission, after which patients enter nursing institutions or rehabilitation institutions [11]. In addition, discharge patterns differ between hospitals and geographic regions. Most patients from private homes abroad are not discharged directly from acute wards to home, but are released to rehabilitation units [12]. In Australia and New Zealand, major trauma centers and most rehabilitation units are located in major cities. Tayhla Ryder et al. [13] found that for patients living in geriatric care institutions prior to admission, 70.8% were discharged from acute wards to geriatric care institutions and 21.2% to rehabilitation units; for patients who lived in private homes before admission, 65.8% were transferred to rehabilitation units and 18.7% went straight home. In China, due to the lack of rehabilitation units and the poor state of national economy, patients are most likely to be discharged directly to their private homes, with just a small number of wealthy patients admitted to nursing homes. Therefore, most patients in China can only complete follow-up rehabilitation in the hospital, resulting in prolonged hospital stay. In addition, for rural patients, after they return to private homes, they cannot get effective home rehabilitation services to exercise their body function, leading to a poor prognosis. As in rural hospitals, there are fewer rehabilitation beds, and rehabilitation services are dominated by a large proportion of health workers who are not rehabilitation doctors. The literature shows that long-term hospitalization can lead to adverse health outcomes in patients later in life [14, 15]. Additionally, the prolonged LOS of patients decreases the utilization rate of hospital beds and causes the waste of medical resources [16]. Therefore, the author constructed a predictive model based on logistic regression and analyzed the risk factors for prolonged LOS in patients with hip fracture, so as to take measures to maximumly avoid delayed discharge.
Preoperative waiting time
Preoperative waiting time greater than 48 h is an influencing factor for delayed discharge of hip fracture patients. Consistent with the research results of Muhm et al. [17], the waiting time before operation has effect on the time of hospitalization. With the increase of patients’ bed time before operation, the incidence of complications will increase, such as periprosthetic infection, pneumonia, urinary tract infection, stroke, myocardial infarction, septic shock, etc., and the deterioration of nutritional status will also lead to the decline of physical function, which will eventually lead to the extension of hospitalization time [18, 19]. Sexson and Lehner et al. [20] found that early surgery can relieve pain and improve mobility, and may reduce the risk of delirium and lung infection. According to foreign studies, treatment within the first 24–72 h of fracture can achieve lower mortality and reduce postoperative complications [21]. A consensus has been reached that hip fracture patients should be operated as soon as possible, preferably within 48 h after admission [22]. Therefore, it is of great importance to give priority to a quick evaluation of hip fracture patients, and delay of operation should be avoided. At present in China, the single orthopedic mode for the treatment of elderly patients with hip fractures has a long waiting time and is of low efficiency, which can no longer meet the current clinical requirements. Therefore, it is particularly important to establish a 48-hour green channel and geriatric orthopedic ward, and adopt a multidisciplinary collaborative diagnosis and treatment mode to stabilize the physiological state of patients, avoid delayed surgery and reduce perioperative risks. For elderly patients with hip fracture, the waiting time for surgery should be shortened as far as possible in accordance with their physical conditions, and preoperative examination should be improved as soon as possible to avoid unnecessary auxiliary examination. Although patients with hip fractures can benefit from an early surgery, the surgery should also be actively optimized for patients with multiple comorbidities and poor underlying conditions.
CCI
In this study, it was found that the hospitalization delay of hip fracture patients with CCI ≥ 8 increased by 3.326 times. The CCI scores, including the patient’s age and various complications, can reflect the overall health condition of the patient at the time of admission. Similar to the conclusions of this study, Wei [23] found that the co-disease weight of elderly patients with hip fracture (based on age-adjusted CCI assessment) was associated with the prolonged LOS. A meta-analysis also showed that there is a positive correlation between comorbid disease and the LOS of patients with hip fracture [24]. It is possible that patients with severe comorbidities may be more prone to complications and require multiple medication, so they will be given longer hospital stay for treatment and care [25, 26]. In addition, although these patients with a variety of chronic diseases are of poor self-care ability, they still need a longer period to recover to their original self-care level. Therefore, clinical attention should be focused on the occurrence of complications in hip fracture patients with a history of comorbidities. For patients with a history of chronic disease, various complications can be prevented early and preoperative health conditions can be optimized. For high-risk groups, early intervention should be taken to avoid postoperative complications and reduce the length of hospital stay.
Anemia
Anemia is closely related to prolonged hospitalization of patients with hip fractures. Nissen Holtz et al. [27] found that anemia has a significant effect on the LOS of elderly patients with hip fracture. On the one hand, anemic patients should supplement blood volume and they need an allogeneic blood transfusion after operation, which will cause a variety of adverse reactions, affect the patient’s immune system and blood coagulation system, and increase the incidence of complications [28]. On the other hand, as the postoperative anemia in patients with hip fracture is relatively severe, the transport of nutrients in the fracture site will be affected, which weakens the body’s defense barrier and hinders the ability of self-repair, thus resulting in the invasion of pathogenic microorganisms, with the final manifestation being a rise in the incidence of complications [29]. Uncorrected anemia after hip fracture may hinder the functional recovery of patients with hip fracture and have effect on medical complications and LOS [28]. Therefore, the medical staff should evaluate the possibility of delayed discharge by reviewing the laboratory test results of patients with hip fracture and check whether they have a history of anemia before the nursing. For patients with anemia, iron supplementation can be used, and blood transfusion can also be adopted if necessary. Although blood transfusion has the risk of cross infection, low hemoglobin will lead to more complications, greatly increasing the length of hospital stay and the cost of hospitalization.
Hypoalbuminemia
Hypoalbuminemia is associated with osteoporosis, fractures and falls. It slows down the early postoperative recovery of patients with fractures, increases the incidence of postoperative complications, prolongs the hospital stay, and causes a serious economic burden to patients’ families. Hypoalbuminemia is closely related to postoperative hematoma formation, renal insufficiency and cardiovascular adverse events. Besides, it directly impacts wound healing by affecting fibroblast proliferation and collagen synthesis [30, 31]. Moreover, hypoproteinemia will lead to the decline of patients’ immune function and the increase of the incidence of wound infection and postoperative pneumonia [32]. BOHL et al. [33] found that preoperative hypoproteinemia can significantly prolong the hospital stay and increase the postoperative readmission rate (by 40%). Similar studies have shown that preoperative hypoproteinemia can significantly increase the cost of total hip replacement and prolong the patients’ length of hospital stay [32]. In the present study, the serum albumin level of patients with hip fracture was monitored in the early postoperative stage, and it was found that patients with hypoalbuminemia and poor nutrition status should be supplemented with more nutrition, and the best nutrition supplement program should be identified.
Arteriosclerosis of lower limbs
It was found in this study that preoperative arteriosclerosis obliterans of lower limbs were significantly related to delayed discharge of hip fracture. Patients with severe illness are featured by persistent and serious pain, ulcer and necrosis of the affected limb or toe, which may result in secondary infection and systemic toxemia. In addition, lower limb ASO will increase the prevalence of cardiovascular and cerebrovascular diseases. Studies have found that 40% of lower limb ASO patients suffer from coronary artery or cerebrovascular diseases, and 8.18% of patients suffer from three diseases at the same time [34, 35]. Therefore, the length of hospital stay of patients with hip fracture may be prolonged due to the above reasons. Antithrombotic therapy is the basic treatment of ASO, which can not only alleviate the progression of ASO, but also reduce the incidence of cardiovascular and cerebrovascular events [36, 37]. At present, low molecular weight heparin drugs are used for clinical prevention, showing sound curative effect. The combined treatment of traditional Chinese and western medicine can play the role of promoting blood circulation and Qi, removing blood stasis and relieving pain, thus increasing the tissue metabolism, so as to achieve the effect of the same treatment of specimens, and better prevent and cure thrombosis.
In this study, the construction of the prediction model for hip fracture patients with prolonged hospital stay risk was conducted. Whether the model or the internal verification of the data were of good sensitivity and specificity were investigated, and the results indicate that the prediction effect of the model is reliable and the result is stable (AUC = 0.817). The model can directly reflect the risk factors of delayed hospitalization in the formula, which can not only predict the risk of discharge delay in patients with clinical hip fracture, but also provide a basis for the follow-up medical staff to systematically evaluate the influencing factors of discharge delay. Based on this nomogram, nurses can evaluate the hospitalization time of patients with hip fracture in advance. They can speculate whether patients may have delayed discharge risk in accordance with their preoperative waiting time, CCI, anemia, hypoproteinemia, Arteriosclerosis of lower limbs and other influencing factors. It is conducive to shortening hospital stay, reducing the occurrence of postoperative complications, promoting postoperative rehabilitation, and optimizing the rational allocation of medical resources.
To shorten the LOS for elderly hip fracture patients without increasing the incidence of postoperative mortality or complications is exactly embodied by the concept of rapid rehabilitation surgery in orthopedics. Foreign scholars have confirmed that ERAS(enhanced recovery after surgery), has achieved good results in orthopedics for elderly patients with hip fracture: it can shorten the length of hospital stay for elderly patients with hip fracture, enhance community satisfaction, reduce the overall cost and improve the availability of ward beds [38,39,40]. However, the concept of rapid rehabilitation surgery has not been popularized in China. Over the course of the present study, although the benefits of the ERAS pathway were identified, the progress in daily practice was still slow. On the one hand, we found that the implementation of the new ERAS pathway requires multidisciplinary communication, including the emergency department, laboratory, radiology department, color ultrasound room, cardiology department, respiratory department, anesthesiology department, endocrinology department, etc., so as to rapidly improve the evaluation efficiency of admitted patients. On the other hand, it was found that the replacement of the traditional perioperative model of care progresses slowly. In order to make a difference, we put forward the following suggestions. First, it is necessary to make some changes to the internal organization of the hospital so that consensus can be reached within the hospital. In addition, the application of ERAS concept in clinical practice not only depends on orthopedic surgeons, but also on multidisciplinary cooperation, routine training and education level of doctors and nurses. Therefore, beside multi-disciplinary cooperation, rapid and effective implementation also requires nursing and other departments to develop their respective clinical pathways in advance according to ERAS pathways. Meanwhile, the concept of accelerated rehabilitation surgery is not simple optimization or blindly rote, but to develop a reasonable set of treatment plan according to the actual situation of patients. Based on the variables of this model, several measures can be taken, such as improving auxiliary examination, multidisciplinary consultation, perioperative nutrition management, early functional exercise, correction of anemia and thrombosis, etc., so as to identify a new way to solve the problem of hospitalization of hip fracture patients and optimize the quality of surgery.
Limitations
This study is a retrospective, single-center study, some indicators are not available; the inclusion of disease heterogeneity, underlying diseases, different etiology of primary diseases, these confounding factors to establish predictive models. The effectiveness of the prediction model still needs to be further verified by multicenter, prospective studies.