Waiting for a theatre, not for a cardiologist, kills hip fracture patients

Design

Retrospective matched cohort with propensity-score matching, prognostic level III, single UK teaching hospital 2020-2024

Population

2,358 patients aged 65 or over with operatively managed native proximal femoral fracture, medical delays excluded

Primary outcome

Mortality at 30 and 365 days

Effect

365-day mortality HR 1.37 (95 per cent CI 1.15 to 1.63); 30-day HR 1.71 (1.11 to 2.65); frail patients 30-day OR 1.76 (1.06 to 3.02)

Every study of hip fracture timing runs into the same confounder: patients delayed because they were too unwell to operate on are also the patients most likely to die. This UK teaching hospital cohort excluded them. Of 3,094 screened, 2,358 patients aged 65 and over with an operatively managed native proximal femoral fracture between January 2020 and June 2024 were analysed, with anyone delayed for medical optimisation removed. Capacity delay was defined as anaesthesia starting more than 36 hours after arrival in the emergency department.

Fifty-four per cent, 1,271 patients, were delayed by capacity alone. After propensity-score matching - median age 85, 73 per cent female - capacity delay carried a hazard ratio of 1.37 for death at 365 days (95 per cent CI 1.15 to 1.63), and the effect was concentrated early: 1.71 (1.11 to 2.65) in the first 30 days. The most frail patients, those with a Clinical Frailty Scale score above 4, carried the highest short-term risk (OR 1.76, 1.06 to 3.02), while less frail patients showed no significant effect.

That last finding is the operational one. If a list is oversubscribed and someone must wait, the evidence here says the frail patient should not be the one who waits - which is the reverse of the intuition that a fitter patient will tolerate surgery better whenever it happens. This is a level III retrospective cohort from a single, 98 per cent White UK population, so the size of the effect will not transfer directly to an Indian trauma service. The principle - that theatre capacity is a clinical variable and should be prioritised by frailty - transfers entirely.

• Prioritise the frailest patient for the earliest slot, not the fittest; the mortality effect concentrated there.
• Record a Clinical Frailty Scale score on admission so prioritisation can be defended.
• Separate capacity delay from medical delay in your own audit; combining them hides the actionable half.
• Use 36 hours from emergency department arrival as the measurable threshold rather than time from ward admission.
• Escalate a capacity delay as a clinical incident, since that is what the data say it is.

The statistics, in plain English

Isolating capacity delay is what makes these hazard ratios more believable than earlier timing studies, because the sickest patients have been removed rather than adjusted for. Even so, propensity matching balances only the variables recorded, and unmeasured reasons for being deprioritised may persist. The 30-day interval of 1.11 to 2.65 is wide, so the early effect is certainly present but its size is loosely estimated; the frailty subgroup, at 1.06 to 3.02, only just clears significance.

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