THE MEDICAL CONSULTANTS ROLE IN CARING FOR PATIENTS WITH HIP FRACTURE

Background: Hip fractures are an important cause of death and function al dependence in the United States. Purpose: To review the evidence fo r clinical decisions that medical consultants make for patients with h ip fracture and to develop recommendations for care.Data Sources: Publ ished reports of clinical studies were found by searching MEDLINE and selected bibliographies. Study Selection: Studies were included if dat a were presented on clinical interventions to improve care of conditio ns typically encountered by medical consultants in the care of patient s with hip fracture. Such conditions include timing of surgery, infect ion prophylaxis, thromboembolic prophylaxis, postoperative nutritional management, urinary tract management, prevention and management of de lirium, application and timing of rehabilitation services, and prevent ion of subsequent falls. Meta-analyses; randomized, controlled trials; or other controlled studies were included if possible. If no such tri als were identified, the best evidence from studies with other designs was included. Data Extraction: Interventions were selected on the bas is of their efficacy or potential efficacy in improving functional out come. Trials with positive and negative results were compared for diff erences in intervention and strength of study methods. Data Synthesis: Strong evidence supports medical recommendations for decisions about timing and duration of prophylactic antibiotics, selection of thromboe mbolic prophylaxis, urinary tract and nutritional management, and reha bilitative services. Many case series support early surgical repair, a lthough patients who would benefit from delay and further medical work -up have not been well identified. Evidence for decisions about assess ment of subsequent risk for fall and risk for and management of deliri um is based largely on data from patients without hip fracture but is probably applicable. Future research should target optimal duration of thromboembolic prophylaxis, cost-effectiveness of low-molecular-weigh t heparin compared with that of other thromboembolic prophylactic regi mens, management of delirium, rehabilitative services, and efficacy of assessment of risk for later falls. Conclusions: The data suggest tha t evidence-based medical care can improve hip fracture outcomes. The m edical consultant has a key role in providing this care and managing t he preoperative conditions and postoperative complications that may af fect optimal functional recovery.