Bedeutung der Einflussfaktoren Schmerz und Medikation in Bezug auf die Länge der Hospitalisationsphase und der perioperativen Rekonvaleszenz nach proximalen Femurfrakturen

The fracture of the proximal femur is a typical injury of the elderly and is increasing worldwide due to the demographic change. The trauma is posing both an economic challenge for society and a huge burden for the frail, mostly multi-morbid population. Meanwhile it is scientifically proven that a prolonged hospital stay is associated with higher risk of postoperative complications and mortality, but an optimal date of discharge has not been defined yet. In order to discharge the patient as soon as possible, the variables influencing the length of stay need to be determined. Perioperative pain, such as polypharmacy, increases the rate of complications. The main goal of the study was to identify the influence of pain and medication on the length of stay. The prospective study evaluated all patients who experienced a fracture of the proximal femur and were operated in the Universitätsklinikum Marburg in between November 2013 and November 2014 during the hospital stay. Amongst others, data of BMI, ASA-classification and MMST were collected. The actual date of discharge was compared to a hypothetical earliest possible date of discharge and their difference was evaluated. Perioperative pain was assessed daily using a numeric combined pain scale. Moreover, the number of drugs was collected at admission and discharge, determining their difference. The drugs were distributed into six groups and listed numerically. Polypharmacy was defined as consumption of >5 drugs. The mean age of the 135 patients was 81,9 (±7,6) years and 73% were female. The actual date of discharge took place after 14,4 (±5,1) days on average, while the earliest possible date of discharge was achieved after 10,7 (±5,1) days. A statistically highly significant difference between the two dates of discharge was found and their mean difference was 3,7 (±3,7) days. SxA was 3,0 (±3,2), while SxER was lowest with 1,8 (±2,5) and SxEB was highest with 3,5 (±2,6) on the pain scale. The mean of MedA was 6,7 (±4,2); of MedE was 9,7 (±3,0). Perioperatively the number of drugs increased in 82,1%, polypharmacy in 47,4% and extreme polypharmacy in 50,4%. With only one exception all patients took at least one cardiovascular, metabolic and central-nerve-system drug. A correlation with length of stay was not found for the number of the drugs, nor for the perioperative pain. Based on the age and sex as well as multi-morbidity, the examined population coincides with the typical profile of a patient with a proximal femur fracture. The large gap between the two dates of discharge emphasizes the need of change in discharge management. Due to the differences in recovery of the patients, no general, concrete discharge date could be defined. Collectively SxA and SxEB were lower than in other studies, though it cannot be concluded whether this is a result of better analgesia or other factors. MedA and MedE mostly correspond with the results of other studies, but there was an increase in the perioperative number of drugs, a high use of drug classes with major risk of side effects and interactions and nearly consistent polypharmacy. Therefore, the collective was classified as a high risk group. The lack of correlation between length of stay and perioperative pain, such as polypharmacy, in this study compared to others, require more studies with a larger study sample and a study design to further investigate causality. The main goal of future studies should be to develop high quality criteria of discharge or an assessment tool being able to establish a patient-individual, optimal date of discharge. The identification of more influencing factors could help to design an improved discharge management. The implementation of the optimization in discharge management could improve the patient outcome and lower the logistic-economic burden of this trauma.