Multicenter Study

. 2022 Dec;20(6):e429-e446.

doi: 10.1016/j.surge.2022.02.009. Epub 2022 Mar 28.

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

Andrew J Hall¹, Nicholas D Clement²; IMPACT-Global Group; Cristina Ojeda-Thies³, Alasdair Mj MacLullich⁴, Giuseppe Toro⁵, Antony Johansen⁶, Tim O White⁷, Andrew D Duckworth⁷

Collaborators, Affiliations

Collaborators

IMPACT-Global Group:
Hani Abdul-Jabar, Rashid Abu-Rajab, Ahmed Abugarja, Karen Adam, Héctor J Aguado Hernández, Gedeón Améstica Lazcano, Sarah Anderson, Mahmood Ansar, Jonathan Antrobus, Esteban Javier Aragón Achig, Maheswaran Archunan, Mirentxu Arrieta Salinas, Sarah Ashford-Wilson, Cristina Assens Gibert, Katerina Athanasopoulou, Mohamed Awadelkarim, Stuart Baird, Stefan Bajada, Shobana Balakrishnan, Sathishkumar Balasubramanian, James A Ballantyne, Leopoldo Bárcena Goitiandia, Benjamin Barkham, Christina Barmpagianni, Mariano Barres-Carsi, Sarah Barrett, Dinnish Baskaran, Jean Bell, Katrina Bell, Stuart Bell, Giuseppe Bellelli, Javier Alberto Benchimol, Bruno Rafael Boietti, Sally Boswell, Adriano Braile, Caitlin Brennan, Louise Brent, Ben Brooke, Gaetano Bruno, Abdus Burahee, Shirley Burns, Giampiero Calabrò, Lucy Campbell, Guido Sebastian Carabelli, Carol Carnegie, Guillermo Carretero Cristobal, Ethan Caruana, M A Concepción Cassinello Ogea, Juan Castellanos Robles, Pablo Castillon, Anil Chakrabarti, Antonio Benedetto Cecere, Ping Chen, Jon V Clarke, Grace Collins, Jorge E Corrales Cardenal, Maurizio Corsi, Gara María Cózar Adelantado, Simon Craxford, Melissa Crooks, Javier Cuarental-García, Rory Cuthbert, Graham Dall, Ioannis Daskalakis, Annalisa De Cicco, Diana de la Fuente de Dios, Pablo Demaria, John Dereix, Julian Díaz Jiménez, José Luis Dinamarca Montecinos, Ha Phuong Do Le, Juan Pablo Donoso Coppa, Georgios Drosos, Andrew Duffy, Jamie East, Deborah Eastwood, Hassan Elbahari, Carmen Elias de Molins Peña, Mamoun Elmamoun, Ben Emmerson, Daniel Escobar Sánchez, Martina Faimali, Maria Victòria Farré-Mercadé, Luke Farrow, Almari Fayez, Adam Fell, Christopher Fenner, David Ferguson, Louise Finlayson, Aldo Flores Gómez, Nicholas Freeman, Jonathan French, Santiago Gabardo Calvo, Nicola Gagliardo, Joan Garcia Albiñana, Guillermo García Cruz, Unai García de Cortázar Antolín, Virginia García Virto, Sophie Gealy, Sandra Marcela Gil Caballero, Moneet Gill, María Soledad González González, Rajesh Gopireddy, Diane Guntley, Binay Gurung, Guadalupe Guzmán Rosales, Nedaa Haddad, Mahum Hafeez, Petra Haller, Emer Halligan, John Hardie, Imogen Hawker, Amr Helal, Mariana Herrera Cruz, Ruben Herreros Ruiz-Valdepeñas, James Horton, Sean Howells, Alan Howieson, Luke Hughes, Flavia Lorena Hünicken Torrez, Ana Hurtado Ortega, Peter Huxley, Hytham K S Hamid, Nida Ilahi, Alexis Iliadis, Dominic Inman, Piyush Jadhao, Rajan Jandoo, Lucy Jawad, Malwattage Lara Tania Jayatilaka, Paul J Jenkins, Rathan Jeyapalan, David Johnson, Andrew Johnston, Sarah Joseph, Siddhant Kapoor, Georgios Karagiannidis, Krishna Saga Karanam, Freddy Kattakayam, Alastair Konarski, Georgios Kontakis, Gregorio Labrador Hernández, Victoria Lancaster, Giovanni Landi, Brian Le, Ignatius Liew, Kartik Logishetty, Andrew Carlomaria Daniel Lopez Marquez, Judit Lopez, Joann Lum, Gavin J Macpherson, Suvira Madan, Sabreena Mahroof, Khalid Malik-Tabassum, Ravi Mallina, Afnan Maqsood, Ben Marson, M José Martin Legorburo, Encarna Martin-Perez, Tania Martínez Jiménez, Javier Martinez Martin, Alistair Mayne, Amy Mayor, Gavan McAlinden, Lucille McLean, Lorna McDonald, Joshua McIntyre, Pamela McKay, Greg McKean, Heather McShane, Antonio Medici, Chelsea Meeke, Evonne Meldrum, Mijail Mendez, Scott Mercer, Josu Merino Perez, María-Pilar Mesa-Lampré, Shuna Mighton, Kirsty Milne, Muhammed Mohamed Yaseen, Iain Moppett, Jesus Mora, Sira Morales-Zumel, Irene Blanca Moreno Fenoll, Adham Mousa, Alastair W Murray, Elspeth V Murray, Radhika Nair, Fiona Neary, Giacomo Negri, Oliver Negus, Fiona Newham-Harvey, Nigel Ng, Jess Nightingale, Sumiya Noor Mohamed Anver, Perrico Nunag, Matthew O'Hare, Ben Ollivere, Raquel Ortés Gómez, AnneMarie Owens, Siobhan Page, Valentina Palloni, Andreas Panagiotopoulos, Elias Panagiotopoulos, Paul Panesar, Antonios Papadopoulos, Papagiannis Spyridon, Teresa Pareja Sierra, Chang Park, Hammad Parwaiz, Paul Paterson-Byrne, Sam Patton, Jack Pearce, Marina Porter, Achille Pellegrino, Arturo Pèrez Cuellar, Raffaele Pezzella, Ashish Phadnis, Charlotte Pinder, Danielle Piper, Matilda Powell-Bowns, Rocío Prieto Martín, Annabel Probert, Ashwanth Ramesh, Manuel Vicente Mejía Ramírez de Arellano, Duncan Renton, Stephen Rickman, Alastair Robertson, Adrian Roche Albero, José Alberto Rodrigo Verguizas, Myriam Rodríguez Couso, Joanna Rooney, Pilar Sáez-López, Andres Saldaña-Díaz, Adriano Santulli, Marta Isabel Sanz Pérez, Khaled M Sarraf, Christine Scarsbrook, Chloe E H Scott, Jennifer Scott, Sachi Shah, Sharief Sharaf, Sidharth Sharma, Denise Shirley, Antonio Siano, James Simpson, Abhinav Singh, Amit Singh, Tim Sinnett, Gurudatt Sisodia, Philomena Smith, Eugenia Sophena Bert, Michael Steel, Avril Stewart, Claire Stewart, Kapil Sugand, Niall Sullivan, Lauren Sweeting, Michael Symes, Dylan Jun Hao Tan, Francesco Tancredi, Irini Tatani, Philip Thomas, Fraser Thomson, Niamh S Toner, Anna Tong, Antonio Toro, Theodoros Tosounidis, Stylianos Tottas, Andrea Trinidad Leo, Damien Tucker, Krishna Vemulapalli, Diego Ventura Garces, Olivia Katherine Vernon, Juan Carlos Viveros Garcia, Alex Ward, Kirsty Ward, Kate Watson, Thisara Weerasuriya, Udara Wickramanayake, Hannah Wilkinson, Joseph Windley, Janet Wood, William Wynell-Mayow, Giovanni Zatti, Moez Zeiton, Miriam Zurrón Lobato

Affiliations

¹ Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), UK; Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK; Department of Orthopaedics, Golden Jubilee National Hospital, UK. Electronic address: Andrew.Hall@ed.ac.uk.
² Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), UK; Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK.
³ Department of Traumatology and Orthopaedic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain.
⁴ Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK; Department of Geriatric Medicine & Usher Institute, University of Edinburgh, UK.
⁵ Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy.
⁶ University Hospital of Wales; Cardiff University, National Hip Fracture Database, Royal College of Physicians, Cardiff, London, UK.
⁷ Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), UK; Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, UK.

PMID: 35430111
PMCID: PMC8958101
DOI: 10.1016/j.surge.2022.02.009

Multicenter Study

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

Andrew J Hall et al. Surgeon. 2022 Dec.

. 2022 Dec;20(6):e429-e446.

doi: 10.1016/j.surge.2022.02.009. Epub 2022 Mar 28.

Authors

Andrew J Hall¹, Nicholas D Clement²; IMPACT-Global Group; Cristina Ojeda-Thies³, Alasdair Mj MacLullich⁴, Giuseppe Toro⁵, Antony Johansen⁶, Tim O White⁷, Andrew D Duckworth⁷

Collaborators

IMPACT-Global Group:
Hani Abdul-Jabar, Rashid Abu-Rajab, Ahmed Abugarja, Karen Adam, Héctor J Aguado Hernández, Gedeón Améstica Lazcano, Sarah Anderson, Mahmood Ansar, Jonathan Antrobus, Esteban Javier Aragón Achig, Maheswaran Archunan, Mirentxu Arrieta Salinas, Sarah Ashford-Wilson, Cristina Assens Gibert, Katerina Athanasopoulou, Mohamed Awadelkarim, Stuart Baird, Stefan Bajada, Shobana Balakrishnan, Sathishkumar Balasubramanian, James A Ballantyne, Leopoldo Bárcena Goitiandia, Benjamin Barkham, Christina Barmpagianni, Mariano Barres-Carsi, Sarah Barrett, Dinnish Baskaran, Jean Bell, Katrina Bell, Stuart Bell, Giuseppe Bellelli, Javier Alberto Benchimol, Bruno Rafael Boietti, Sally Boswell, Adriano Braile, Caitlin Brennan, Louise Brent, Ben Brooke, Gaetano Bruno, Abdus Burahee, Shirley Burns, Giampiero Calabrò, Lucy Campbell, Guido Sebastian Carabelli, Carol Carnegie, Guillermo Carretero Cristobal, Ethan Caruana, M A Concepción Cassinello Ogea, Juan Castellanos Robles, Pablo Castillon, Anil Chakrabarti, Antonio Benedetto Cecere, Ping Chen, Jon V Clarke, Grace Collins, Jorge E Corrales Cardenal, Maurizio Corsi, Gara María Cózar Adelantado, Simon Craxford, Melissa Crooks, Javier Cuarental-García, Rory Cuthbert, Graham Dall, Ioannis Daskalakis, Annalisa De Cicco, Diana de la Fuente de Dios, Pablo Demaria, John Dereix, Julian Díaz Jiménez, José Luis Dinamarca Montecinos, Ha Phuong Do Le, Juan Pablo Donoso Coppa, Georgios Drosos, Andrew Duffy, Jamie East, Deborah Eastwood, Hassan Elbahari, Carmen Elias de Molins Peña, Mamoun Elmamoun, Ben Emmerson, Daniel Escobar Sánchez, Martina Faimali, Maria Victòria Farré-Mercadé, Luke Farrow, Almari Fayez, Adam Fell, Christopher Fenner, David Ferguson, Louise Finlayson, Aldo Flores Gómez, Nicholas Freeman, Jonathan French, Santiago Gabardo Calvo, Nicola Gagliardo, Joan Garcia Albiñana, Guillermo García Cruz, Unai García de Cortázar Antolín, Virginia García Virto, Sophie Gealy, Sandra Marcela Gil Caballero, Moneet Gill, María Soledad González González, Rajesh Gopireddy, Diane Guntley, Binay Gurung, Guadalupe Guzmán Rosales, Nedaa Haddad, Mahum Hafeez, Petra Haller, Emer Halligan, John Hardie, Imogen Hawker, Amr Helal, Mariana Herrera Cruz, Ruben Herreros Ruiz-Valdepeñas, James Horton, Sean Howells, Alan Howieson, Luke Hughes, Flavia Lorena Hünicken Torrez, Ana Hurtado Ortega, Peter Huxley, Hytham K S Hamid, Nida Ilahi, Alexis Iliadis, Dominic Inman, Piyush Jadhao, Rajan Jandoo, Lucy Jawad, Malwattage Lara Tania Jayatilaka, Paul J Jenkins, Rathan Jeyapalan, David Johnson, Andrew Johnston, Sarah Joseph, Siddhant Kapoor, Georgios Karagiannidis, Krishna Saga Karanam, Freddy Kattakayam, Alastair Konarski, Georgios Kontakis, Gregorio Labrador Hernández, Victoria Lancaster, Giovanni Landi, Brian Le, Ignatius Liew, Kartik Logishetty, Andrew Carlomaria Daniel Lopez Marquez, Judit Lopez, Joann Lum, Gavin J Macpherson, Suvira Madan, Sabreena Mahroof, Khalid Malik-Tabassum, Ravi Mallina, Afnan Maqsood, Ben Marson, M José Martin Legorburo, Encarna Martin-Perez, Tania Martínez Jiménez, Javier Martinez Martin, Alistair Mayne, Amy Mayor, Gavan McAlinden, Lucille McLean, Lorna McDonald, Joshua McIntyre, Pamela McKay, Greg McKean, Heather McShane, Antonio Medici, Chelsea Meeke, Evonne Meldrum, Mijail Mendez, Scott Mercer, Josu Merino Perez, María-Pilar Mesa-Lampré, Shuna Mighton, Kirsty Milne, Muhammed Mohamed Yaseen, Iain Moppett, Jesus Mora, Sira Morales-Zumel, Irene Blanca Moreno Fenoll, Adham Mousa, Alastair W Murray, Elspeth V Murray, Radhika Nair, Fiona Neary, Giacomo Negri, Oliver Negus, Fiona Newham-Harvey, Nigel Ng, Jess Nightingale, Sumiya Noor Mohamed Anver, Perrico Nunag, Matthew O'Hare, Ben Ollivere, Raquel Ortés Gómez, AnneMarie Owens, Siobhan Page, Valentina Palloni, Andreas Panagiotopoulos, Elias Panagiotopoulos, Paul Panesar, Antonios Papadopoulos, Papagiannis Spyridon, Teresa Pareja Sierra, Chang Park, Hammad Parwaiz, Paul Paterson-Byrne, Sam Patton, Jack Pearce, Marina Porter, Achille Pellegrino, Arturo Pèrez Cuellar, Raffaele Pezzella, Ashish Phadnis, Charlotte Pinder, Danielle Piper, Matilda Powell-Bowns, Rocío Prieto Martín, Annabel Probert, Ashwanth Ramesh, Manuel Vicente Mejía Ramírez de Arellano, Duncan Renton, Stephen Rickman, Alastair Robertson, Adrian Roche Albero, José Alberto Rodrigo Verguizas, Myriam Rodríguez Couso, Joanna Rooney, Pilar Sáez-López, Andres Saldaña-Díaz, Adriano Santulli, Marta Isabel Sanz Pérez, Khaled M Sarraf, Christine Scarsbrook, Chloe E H Scott, Jennifer Scott, Sachi Shah, Sharief Sharaf, Sidharth Sharma, Denise Shirley, Antonio Siano, James Simpson, Abhinav Singh, Amit Singh, Tim Sinnett, Gurudatt Sisodia, Philomena Smith, Eugenia Sophena Bert, Michael Steel, Avril Stewart, Claire Stewart, Kapil Sugand, Niall Sullivan, Lauren Sweeting, Michael Symes, Dylan Jun Hao Tan, Francesco Tancredi, Irini Tatani, Philip Thomas, Fraser Thomson, Niamh S Toner, Anna Tong, Antonio Toro, Theodoros Tosounidis, Stylianos Tottas, Andrea Trinidad Leo, Damien Tucker, Krishna Vemulapalli, Diego Ventura Garces, Olivia Katherine Vernon, Juan Carlos Viveros Garcia, Alex Ward, Kirsty Ward, Kate Watson, Thisara Weerasuriya, Udara Wickramanayake, Hannah Wilkinson, Joseph Windley, Janet Wood, William Wynell-Mayow, Giovanni Zatti, Moez Zeiton, Miriam Zurrón Lobato

Affiliations

¹ Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), UK; Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK; Department of Orthopaedics, Golden Jubilee National Hospital, UK. Electronic address: Andrew.Hall@ed.ac.uk.
² Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), UK; Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK.
³ Department of Traumatology and Orthopaedic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain.
⁴ Scottish Hip Fracture Audit (SHFA), NHS National Services Scotland, UK; Department of Geriatric Medicine & Usher Institute, University of Edinburgh, UK.
⁵ Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy.
⁶ University Hospital of Wales; Cardiff University, National Hip Fracture Database, Royal College of Physicians, Cardiff, London, UK.
⁷ Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; Scottish Orthopaedic Research Trust Into Trauma (SORT-IT), UK; Department of Orthopaedics & Trauma and Usher Institute, University of Edinburgh, UK.

PMID: 35430111
PMCID: PMC8958101
DOI: 10.1016/j.surge.2022.02.009

Abstract

Aims: This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.

Methods: A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.

Results: A total of 7090 patients were included, with a mean age of 82.2 (range 50-104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.

Conclusion: The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.

Keywords: Audit; COVID-19; Communicable disease; Frailty; Geriatric; Hip fracture; Infection; Meta-audit; Nosocomial; Orthopaedic; Outcomes; Prognosis; Reporting standards; Risk; Trauma.

PubMed Disclaimer

Conflict of interest statement

Declaration of competing interest The authors declare that they have no conflict of interest.

Figures

**Fig. 1**
Flow chart showing all patients, included and excluded patients, mortality outcomes according to COVID-19 status, and distribution of patients from participating nations.

**Fig. 2**
Kaplan Meier curve for 30-day survival according to whether a patient was COVID negative (black) or COVID positive (red) within 30-days of admission. Log rank p < 0.001, 92.6% (95% CI 92.4 to 92.8) versus 72.7% (95% CI 69.4 to 76.0) at 30-days.

**Fig. 3**
Kaplan Meier curve for 30-day survival according to whether a patient was COVID negative (black), COVID positive at admission (red) or COVID positive after admission (grey). Log rank p = 0.661, between COVID positive patients preoperatively (75.1%, 95% CI 69.4 to 80.8) versus postoperatively (71.4%, 95% CI 67.1 to 75.7) at 30-days.

**Fig. 4**
ROC curve for lymphocyte count (grey) and albumin (black dashed) as a predictor of COVID-19 on admission. Lymphocyte: Area under the curve 60.7% (95% CI 56.7%–64.6%, p < 0.001). Threshold of 0.93 or less has 58.2% specificity and 56.6% sensitivity. Albumin: Area under the curve 61.3% (95% CI 57.5%–65.2%, p < 0.001). Threshold of 36 g/dL or less has 59.1% specificity and 57.1%sensitivity.

**Fig. 5**
ROC curve for length of hospital stay (dashed line) as a predictor of developing COVID-19 following admission. Area under the curve 71.6% (95% CI 68.8%–74.4%, p < 0.001). Threshold of 10 days or more has 65% specificity and sensitivity.

**Fig. 6**
Suggested reporting standards for studies investigating COVID-19 in hip fracture patients.

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References

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IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

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IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

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