The impact of first wave of COVID-19 on the nursing-sensitive and rehabilitation outcomes of patients undergoing hip fracture surgery: a single centre retrospective cohort study

The global health emergency due to the spread of COVID-19 has caused unprecedented pressure on the health systems at all levels [1]. COVID-19 has had a direct impact on the health status of populations due to the extremely high numbers of Intensive Care Unit (ICU) admissions and deaths [2, 3], but it has also resulted in several equally strong indirect consequences in different fields, even in patients not affected by COVID [4‐7]. In order to cope with the great demand of health resources, hospitals have had to invest human and physical resources, redirecting them from other care activities [8]. Aiken et al. [9] highlighted how the redirection of nurses to COVID units, which resulted in the reduction of nurses involved in standard care, as well as the employment of nursing personnel lacking context-specific clinical skills due to the reorganization of care, are to be correlated with an increase in complications such as pressure ulcers, falls and urinary tract infections, and mortality, in any type of patient. Stifer et al. [10] highlight the importance of focusing attention on the "Nurse-Sensitive Indicators" in order to evaluate the patient care quality.

In the first phase of spread of the COVID pandemic, all non-essential orthopaedic surgical interventions were postponed, at the same time the decision to create ad hoc pathways to manage essential interventions ensured the provision of emergency care during the pandemic. This organizational model has led to a reduction in the overall number of hospitalized patients, although the number of patients surgically treated for fragility hip fracture has not decreased [11‐13].

Fragility fractures are associated with higher chances of clinical worsening in terms of quality of life and disability in the medium and long term [14]. Following this traumatic event, more than half of the patients are unable to recover pre-fracture motor skills such as walking ability [15]. Considering the pandemic impact on patient care, data on patients surgically treated for hip fracture, either COVID-19 positive or not, are lacking.

The aim of this study was therefore to investigate the effects of the COVID-19 pandemic on nursing-sensitive and rehabilitation outcomes of frail patients undergoing hip fracture surgery.

There were 360 patients who underwent hip fracture surgery in this study, which comprised 108 patients in PP group and 252 patients in P group. The patient flowchart is shown in Fig. 1. The increase in number of patients admitted with a hip fracture diagnosis was of 133% during the pandemic period compared with pre-pandemic period in 2019. On the contrary, overall inpatient hospital admissions decreased by 44% in pandemic period in 2020 (1956 patient admitted) compared to pre-pandemic period in 2019 (3645 patients admitted). The percentage of patients who underwent hip fracture surgery in PP group was almost 3%, without no significant month-to-month variation. On the contrary, during pandemic the rate of hip fracture patients surgically treated has changed over time with a percentage increase by 8.9% in March, 19.7% in April, 15.4% in May, 9.8% in June compared to 2019. Overall, in-hospital mortality rates (calculated on all admitted patients) increased from to 0.1% (N = 4) in the PP period to 0.9% (N = 17) in the P period (p < 0.001).

The COVID -19 pandemic forced the settings of an orthopaedic surgery hospital into a deep transformation of its organizational model, with a consistent modification of both its admission volumes and the most frequent type of surgery performed. The data of this research study highlight a 44% reduction in the number of admissions, with a simultaneous increase in the number of surgical operations due to fragility hip fracture. These results are confirmed by the findings of Wong et al. [26] in Hong Kong and by Hampton et al. [12] as regarding the English context, they both present similar trends.

From a perspective of “Nurse-Sensitive Indicators”, the results of our study indicate that the incidence of PUs in patients with fragility hip fractures increased notably: between the pre-pandemic period and the pandemic the incidence of this outcome went from 10 to 22%. As regarding the characteristics of the ulcers, no significant changes were noticed in terms of day of onset and lesions stage, on the contrary the PUs place of occurrence varied notably compared to the pre pandemic period. In 2019, 91% of all pressure ulcers were located in the sacrum area, however in 2020 the PUs incidence at the sacrum decreased to 38%, while the frequency of PUs located in other pressure points, such as heels, increased to 31%. Prior to the pandemic, Chiari et al. [25] explored the PUs incidence in a cohort with characteristics comparable to our current study population and reported a 64% incidence to the sacrum, 23% to the heels and 13% to other locations. Due to the small number of events recorded over the pandemic period, it hasn’t been possible to ascertain if the difference registered over this period may be related to the reorganization of the daily activities of clinical practice in many units or if it may be due to other factors. However, given the results of this study, we consider important to remind to all the health professionals that PUs prevention and monitoring cannot be focused only on the most commonly affected areas such as sacrum and heels, but they must include close monitoring of all body pressure points.

The unadjusted risk ratio for the development of pressure ulcers in relation to both the periods under exam, the pre-pandemic period in 2019 and the pandemic in 2020, has been found to be 2.07. The calculation of the relative risk ratio, adjusted for the significant risk factors emerged from the study, specifically age and length of stay, did not confirm the initial unadjusted score and its statistical significance. This demonstrates how these two risk factors have been the main responsible for the incidence variations found in the two periods.

In this regard, it is also interesting to notice that the difference of median age among the two cohorts is 4 years. The results of the present study indeed highlight age as a risk factor for the development of PUs and this is confirmed by multiple other studies [24, 25] in this patient population. In the same way, length of stay was identified as a risk factor for the development of Pus, confirming results of previous studies [27, 28]. On this matter it should also be considered that the pandemic has heavily affected the hospital length of stay of any patient category, not just COVID-19 patients, leading to difficulties in the organization of post-discharge rehabilitation pathways. Many outpatient rehab facilities and long-term care facilities either had to convert units or had to become hubs dedicated the treatment and care of COVID patients, therefore disrupting their usual capacity to receive orthopaedic patients discharged from the hospital. Furthermore, community medicine services were also heavily impacted by the high number of patients in need to be followed at home and by the new laws imposed by the Italian government in order to contain the spread of the virus.

Nevertheless, the analysis of the median time to PUs onset for the 2020 cohort showed similar timing to the pre-pandemic period, suggesting that patients tend to develop pressure ulcers during the first period/phase of their admission.

On the other hand, the investigation of other indicators of nursing sensitive outcomes, which have been previously found in the literature to be associated with pressure ulcers prevention, such as prolonged urinary catheterization, use of the anti-decubitus mattress, bed mobilization and early walking, did not underwent variations over the two periods examined. These findings allow us to assume that the quality of care received by the patients did not decrease during the pandemic period and that the healthcare workers continued to correctly apply the standard procedures for PUs prevention. These positive outcomes are confirmed also looking at the physiotherapy treatment administered to the patients over the pandemic period. The recovery of the ability to stand and to walk was achieved at an early stage, with an identical timing compared to 2019.

These results witness that the healthcare professionals were able to maintain and offer to the patients the same levels of care guaranteed prior to the pandemic, although under extremely stressful conditions. The qualitative evaluation of the care administered and the emotional impact of the pandemic on the patients are very interesting topic which would deserve further investigation.

Over the pandemic period, the clinical activities, as well as the nursing and physiotherapy care administered to fragility hip fracture patients maintained high standards of care, similar to the pre-pandemic standard of care. The development of pressure ulcers over the pandemic period increased, probably due to the older age of the patients admitted to the hospital.