加速康复外科理念下多学科共管模式在急诊老年髋部骨折围手术期中的应用

目的探讨加速康复外科(enhanced recovery after surgery,ERAS)理念下多学科共管模式在急诊老年髋部骨折围手术期护理中的应用效果,以期提高老年髋部骨折的治疗效果。方法采用不同病例前-后对照研究方法,将2015年5月—2017年2月在本院急诊住院手术的375例老年髋部骨折患者设为对照组,采用围手术期常规治疗护理;将2017年3月—2018年10月在本院急诊住院手术的401例老年髋部骨折患者设为试验组,采用ERAS理念下多学科共管模式治疗护理程式。比较两组患者入院至手术的时间,48h内手术的比例,术后并发症发生率,总住院时间和围手术期死亡率。结果两组患者入院至手术的时间,48h内手术的比例,术后并发症发生率,总住院时间和围手术期死亡率比较,均P0.05,差异具有统计学意义,试验组患者入院到手术的时间短于对照组,48h内手术率高于对照组,术后并发症发生率与围手术期死亡率低于对照组。结论急诊老年髋部骨折患者采用ERAS理念下多学科共管模式治疗护理,可提高48h手术率,降低术后并发症发生率,缩短住院时间及降低围手术期死亡率。     

康复团队治疗老年髋部骨折患者的疗效观察

目的研究康复团队治疗老年髋部骨折患者的有效性。方法将2008年9月-2010年8月入住且行手术治疗的194例老年髋部骨折患者随机分为团队康复组92例和传统康复组102例,分别采用由康复治疗师、骨科医师、内科医师及护士共同完成的团队康复治疗和仅由康复治疗师完成的传统康复治疗。比较两组患者术后功能、并发症发生率、病死率、住院时间、再次住院率。结果团队康复组和传统康复组患者住院时间分别为（28.7±4.1）、（34.7±5.8）d,出院时Harris评分分别为（83.5±9.4）、（78.2±12.1）分,出院后3个月评分分别为（87.5±7.4）、（80.2±10.4）分,差异均有统计学意义（P〈0.05）。两组住院期间病死率及并发症发生率差异无统计学意义（P〉0.05）。结论康复团队治疗老年髋部骨折,可提高术后功能、缩短住院时间。     

痴呆对老年髋部骨折预后影响及老年髋部骨折预后危险因素分析

目的探讨痴呆对老年髋部骨折预后影响及老年髋部骨折预后危险因素。方法选取老年髋部骨折521例作为研究对象,根据术前认知功能状态将其分为痴呆组和非痴呆组两组,痴呆组49例,非痴呆组472例;根据术后1年随访结局将其分为病死组和存活组,病死组103例,存活组418例。分析比较患者一般数据、术中情况、住院期间并发症、术后1年病死率及独立生活能力等,并对老年髋部骨折术后1年内死亡的危险因素进行分析。结果本研究老年髋部骨折合并痴呆患者占老年髋部骨折患者的9. 4%。与非痴呆组比较,痴呆组≥80岁、其他神经系统合并症、全身麻醉、呼吸系统并发症、脑卒中及谵妄发生率较高,住院时间较长,围手术期及术后1年病死率较高,差异有统计学意义(P 0. 05)。单因素分析结果显示,年龄≥80岁、男性、痴呆、心血管系统合并症、呼吸系统合并症、合并症≥3项及美国麻醉协会麻醉(ASA)分级Ⅲ~Ⅳ级是老年髋部骨折术后1年内死亡的危险因素。多因素Logistic回归分析显示仅有呼吸系统合并症、合并症≥3项及ASA分级Ⅲ~Ⅳ级是老年髋部骨折术后1年内死亡的独立危险因素。结论痴呆在老年髋部骨折人群中发病率较高。与非痴呆老年髋部骨折患者相比,老年髋部骨折合并痴呆患者住院时间长、术后并发症多,且病死率高。呼吸系统合并症、合并症≥3项及ASA分级Ⅲ~Ⅳ级是老年髋部骨折术后1年内死亡的独立危险因素。     

手术时机对老年髋部骨折患者术后并发症及病死率的影响

目的 探讨手术时机对老年髋部骨折患者术后并发症及病死率的影响.方法 回顾性分析2021年1—8月北京积水潭医院收治的402例老年髋部骨折患者(年龄65≥周岁)的临床资料.根据手术时机分为早期手术组177例(入院至手术时间≤48h)和延期手术组225例(入院至手术时间>48h),对比两组患者术后并发症、住院时间、术后IC...     

髋关节固定支具在髋部骨折老年患者非手术治疗中的应用效果

目的探讨髋关节固定支具在髋部骨折老年患者非手术治疗中的应用效果。方法选取2016年1月—2017年4月收治于上海市浦东新区公利医院的髋部骨折老年患者84例,随机分为观察组(n=45)和对照组(n=39)。观察组应用髋关节支具固定,对照组应用下肢皮肤牵引固定,比较两组患者住院时间和住院期间疼痛情况、发生压力性损伤和病死情况、并发症发生情况和护理满意度。结果两组患者住院时间、病死率及并发症发生率比较,差异无统计学意义(P0.05);观察组住院期间疼痛评分低于对照组,压力性损伤发生率低于对照组,患者护理满意度高于对照组,差异均有统计学意义(P0.05)。结论髋部骨折老年患者应用髋关节固定支具进行非手术治疗,可更好地缓解骨折后疼痛,降低压力性损伤发生率,提高患者护理满意度。     

快速康复围术期护理模式在老年髋部骨折患者中的应用

目的:探讨快速康复围术期护理模式在老年髋部骨折患者中的应用方法及效果。方法:将2018年2月1日~12月31日53例老年髋部骨折患者设为对照组,实施常规护理模式;将2019年1月1日~10月31日53例老年髋部骨折患者设为加速康复外科(ERAS)组,实施快速康复围术期护理模式。比较两组护理效果。结果:ERAS组术前等待时间、住院时间短于对照组(P<0.05),术后1、3、5 d疼痛评分低于对照组(P<0.05),术后1个月髋关节功能评分高于对照组(P<0.05),并发症发生率低于对照组(P<0.05)。结论:快速康复围术期护理模式可缩短老年髋部骨折患者的术前等待时间、住院时间,减轻疼痛,改善术后髋关节功能,降低并发症发生率。     

多学科联合制定规范化防治路径对老年髋部骨折术后谵妄影响的研究

目的探讨多学科联合制定规范化防治路径对老年髋部骨折患者术后谵妄的影响及应用效果评价,旨在降低术后患者不适及并发症的发生,为临床护理实践提供参考依据。方法选取2016年6月~2017年6月于本院骨科行手术治疗的78例老年髋部骨折患者为研究对象,采用简单随机化方法将其分为研究组和对照组,各39例。对照组采用常规护理,研究组采用多学科合作模式下制定的术后谵妄规范化防治路径护理方案。比较2组术后低氧血症、谵妄的发生率、谵妄持续时间、每日总睡眠时间及睡眠质量、疼痛评分以及住院时间。结果研究组术后低氧血症、谵妄的发生率均显著低于对照组,每日总睡眠时间显著多于对照组,睡眠评分及疼痛评分均显著低于对照组,住院时间显著少于对照组,差异均具有统计学意义(P0.05)。结论多学科合作模式下老年髋部骨折患者术后谵妄规范化防治路径的护理方案可降低其术后低氧血症和谵妄的发生率,减轻疼痛,改善睡眠质量以及缩短住院时间,值得推广。     

基于快速康复理论的多模式镇痛在老年髋部骨折患者中的应用

目的 观察基于快速康复理论的多模式镇痛在老年髋部骨折患者中的应用效果。 方法 选取2015年6月-2016年9月住院的72例老年髋部骨折患者,随机分为对照组35例和观察组37例,对照组采用传统的镇痛方法,观察组实施多模式镇痛。比较2组患者疼痛情况、首次下床时间、住院时间和术后并发症的发生情况。 结果 观察组患者的疼痛评分明显低于对照组(F_组间=6.046,P<0.001),术后首次下床时间和住院时间均短于对照组(t=5.255,P<0.001; t=9.719,P<0.001),术后并发症的发生率低于对照组(P=0.005)。 结论 基于快速康复理论的多模式镇痛方法能明显减轻老年髋部骨折患者的疼痛,使患者能够尽早下床活动,减少并发症的发生。     

临床康复护理路径在老年股骨颈骨折术后的应用效果观察

目的:探讨临床康复护理路径在老年股骨颈骨折术后中的应用效果。方法:选择2014年1月~2016年5月于我科行股骨颈骨折术后的80例老年患者并随机等分为对照组和观察组,对照组在术后仅给予骨科常规护理;观察组则采用临床康复护理路径。比较两组患者的住院时间、术后并发症、康复效果及护理满意度。结果:与对照组比较,观察组住院时间明显缩短、术后DVT并发症发生率明显减低、髋关节恢复效果明显提高,且护理满意度高于对照组(P0.05)。结论:老年股骨颈骨折术后实施临床护理路径不仅有效缩短住院时间,降低术后并发症发生率,提高髋关节功能恢复程度及患者和家属的满意度。     

应用快速康复外科理念对56例老年髋部骨折的护理分析

目的探讨应用快速康复外科护理对髋部骨折老年患者的效果并进行分析。方法将2014年8月~2015年5月收治的56例患者作为试验组,应用快速康复外科理念,制订出特定护理干预方案进行护理。将2013年1月~2014年7月收治的52例采用常规护理方法的患者作为对照组进行回顾性分析。记录两组患者从受伤到手术时间、住院时间、术后并发症发生情况、患肢疼痛程度和髋关节功能。结果两组患者从受伤到手术时间、住院时间、术后并发症发生率和不同时间髋关节Harris评分比较,差异有统计学意义(P0.01);两组患者术后不同时间患肢疼痛视觉模拟评分比较,差异有统计学意义(P0.05)。结论对老年髋部骨折手术患者采用快速康复外科理念下的特定护理,能明显缩短从受伤到手术时间和住院时间,显著降低术后并发症,促进髋关节功能的恢复,缓解术后不同时期患肢疼痛程度,显著提高老年髋部骨折手术患者的生活质量。     

Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients

BACKGROUND AND PURPOSE: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period. METHOD: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine. RESULTS: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 +/- 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 +/- 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low. CONCLUSIONS: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

Relationship between the length of hospital stay after hip fracture surgery and ambulatory ability or mortality after discharge in Japan

Aim:  To examine whether the length of hospital stay after hip fracture surgery is related to patients' ambulatory ability or mortality after discharge.
Methods:  This is a retrospective observational study of patients who had undergone hip fracture surgery at one of three hospitals in Japan. The medical records of patients who were ≥65 years and who had hip fracture surgery within the past 2.5 years were reviewed regarding the demographics, treatments, and health outcomes during the hospital stay. A mail survey, asking about health outcomes after discharge, was sent to the study participants and/or their family members. The response rate of the survey was 70% ( n  = 149).
Results:  The patients who were discharged between 30 and 39 days after surgery had significantly lower current ambulatory ability, compared to the patients who stayed for ≥40 days, after adjusting for patient characteristics, treatments, and hospital. The patients who were discharged within 2 weeks after surgery and the patients who were discharged between 30 and 39 days after surgery had a significantly higher risk of mortality, compared to the patients who stayed in the hospital for ≥40 days, after adjustments were made.
Conclusions:  If patients are discharged to a rehabilitation hospital before they are totally recovered from surgery, the emphasis might be on their rehabilitation without adequate management of their comorbidities. Additional prospective studies are needed to determine the effects of a shorter length of hospital stay after hip fracture surgery on patient outcomes.     

Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period.

Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine.

Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 ± 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 ± 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low.

Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period.

Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine.

Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6?±?2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3?±?7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low.

Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

大于等于80岁的老年髋部骨折患者术后1年内死亡的独立危险因素

目的探讨高龄（≥80岁）老年髋部骨折患者术后1年内死亡的危险因素。方法以2016~2019年204例经手术治疗的高龄髋部骨折患者作为研究对象,记录年龄、性别、术前合并疾病、骨折类型、麻醉方式、美国麻醉医师协会（ASA）评分、术前血红蛋白水平、术前白蛋白水平、术前血钙水平、住院时间等临床资料,以术后1年内死亡为观察结局。采用多因素logistic回归模型分析高龄老年髋部骨折患者术后1年内死亡的独立危险因素。结果术后1年内,共有82例患者术后死亡,死亡率为40.2%。性别、BMI、骨折类型、麻醉方式、术前血红蛋白水平、术前血钙水平及住院时间不影响80岁患者髋关节术后死亡率,差异无统计学意义（P>0.05）;年龄、术前合并疾病数量、ASA评分以及术前白蛋白水平是高龄老年髋部骨折患者术后1年内死亡的独立危险因素（P < 0.05）。结论年龄、术前合并疾病数量、ASA评分、术前白蛋白水平是高龄老年髋部骨折患者术后1年内死亡的独立危险因素。      

Laparoscopic anterior resection for rectosigmoid cancer: Patient outcomes after implementation of a clinical pathway

Introduction: A clinical pathway designed for a single type of laparoscopic colorectal surgery for cancer might be helpful in decreasing complication rates and total hospital costs. It has been reported to be effective in reducing costs and shortening length of hospital stays in many situations such as laparoscopic cholecystectomy, colon resection, total colectomy, and gastrointestinal bleeding, as well as when caring for patients in the intensive care unit. Materials and Methods: A clinical pathway, including surgical details and perioperative management, for patients undergoing laparoscopic anterior resection for rectosigmoid cancer was designed and implemented. From January 2003 to December 2006, it was applied to 80 patients. Results: The average length of a hospital stay for these patients was 9.06 d. The mean hospital stay and total cost decreased year by year. The overall complication rate was 8.75% without perioperative mortality, and 47.5% of patients with underlying diseases were treated safely. Discussion: Laparoscopic anterior resection for rectosigmoid cancer, with curative or palliative intent, was safe after standardization of surgical details and perioperative management. The total hospital costs for each patient was predictable and decreased year by year.     

缺血性脑卒中临床路径在整体护理中的应用

目的探讨缺血性脑卒中临床路径在整体护理中的应用。方法采用纵向队列研究,对比实施临床路径之前(传统组)与实施临床路径之后(路径组)患者的相关情况(住院时间、住院费用、治疗护理效果等)。结果患者平均住院时间传统组为21·82d,路径组为17·85d,路径组住院总费用下降,患者综合满意度达99·66%,在治疗后90d随访,路径组患者日常生活能力明显优于传统组(P<0·05)。结论实施缺血性脑卒中临床路径与整体护理相辅相成,能缩短患者住院时间,降低住院费用,提高临床疗效、护理质量和患者的综合满意度。同时,丰富了整体护理内容,培养锻炼了护士的全面综合能力。     

Functional recovery and length of stay after recurrent hip fracture.

OBJECTIVE: To evaluate the functional recovery and the rehabilitation length of stay after the sequential fracture of both hips in elderly patients. DESIGN: A total of 372 in-patients with hip fractures consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 333 out of 372 were admitted for rehabilitation of their first hip fracture, and the other 39 patients had a second contralateral fracture. The functional recovery was evaluated by the Barthel index. The comparison between the two groups was performed by unpaired t test. Stepwise linear multiple regression analysis was performed, including nine prognostic factors together with the number of hip fractures (first or recurrent) as independent variables and the Barthel index score on discharge as the dependent variable. The statistical analysis was repeated, substituting hospital length of stay for Barthel index. RESULTS: Both the functional recovery and the length of stay of the patients affected by recurrent fracture were similar to the ones of the patients suffering from a single fracture. Regression analysis showed that the previous hip fracture was associated neither with the Barthel index nor with the length of stay. CONCLUSIONS: Our data suggest that the functional recovery in elderly patients with hip fractures is not significantly influenced by a previous fracture of the contralateral hip and that no significant prolonged rehabilitation length of stay is needed after the recurrent fracture.     

A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling

Aim. The objective of this study was to examine the effectiveness of a discharge plan in hospitalized elderly patients with hip fracture due to falling. Background. Hip fractures are an important cause of morbidity and mortality among older people. Hip fracture patients require ongoing medical and long‐term care services. Discharge plan services can play a very important role for these patients, since the services improved their outcome conditions. Methods. Hip fracture patients aged 65 years and older (n = 126), hospitalized due to falling and discharged from a medical centre in northern Taiwan, were randomly assigned to either a comparison group (the routine care) or experimental group (the discharge planning intervention). The outcomes used to determine the effectiveness of the intervention were: length of hospitalized stay, rate of readmission, repeat falls and survival, and activities of daily living. Results. The discharge planning intervention decreased length of stay, rate of readmission and rate of survival and improved activities of daily living for intervention group compared with those of control group. Mean total SF‐36 scores of patients in the experimental group were higher than for the control group and both groups had improved quality of life. Conclusion. The discharge planning benefited older people with hip fractures. Relevance to clinical practice. A discharge planning intervention by a nurse can improve physical outcomes and quality of life in hip fracture patients.     

The impact of post-operative pain on outcomes following hip fracture

Untreated pain is a major health care issue and very little is known about the treatment of pain and the effect of pain on post-operative outcomes in older adults. This study was performed to identify the impact of pain on outcomes following hip fracture in older adults. Four hundred and eleven consecutive cognitively intact patients admitted with hip fracture to four New York hospitals were enrolled in a prospective cohort study. Patients were interviewed daily using standardized pain assessments. We used multiple logistic regression and ordinary least squares linear regression to examine the association of post-operative pain on immediate post-operative outcomes (duration of stay, physical therapy sessions missed or shortened, ambulation following surgery, and post-operative complications) and outcomes 6 months following fracture (locomotion, mortality, return to the community, residual pain). Patients with higher pain scores at rest had significantly longer hospital lengths of stay (P=0.03), were significantly more likely to have physical therapy sessions missed or shortened (P=0.002), were significantly less likely to be ambulating by post-operative day 3 (P<0.001), took significantly longer to ambulate past a bedside chair (P=0.01), and had significantly lower locomotion scores at 6 months (P=0.02). Pain at rest was not significantly associated with post-operative complications, nursing home placement, survival at 6 months, or residual pain at 6 months. Post-operative pain is associated with increased hospital length of stay, delayed ambulation, and long-term functional impairment. Whereas appropriate caution is warranted in administering opioid analgesics to older adults, these data suggest that improved pain control may decrease length of stay, enhance functional recovery, and improve long-term functional outcomes.