Earlier IV fluid prescription reduces day-1 post operative hypotension following hip fracture surgery in older people

Following hip fracture surgery, post-operative hypotension is associated with reduced wound mobilisation, delirium, AKI, and impaired wound healing. A baseline audit on a geriatric hip fracture ward showed that 56% (49/87) of patients developed day 1 post-operative hypotension preventing early engagement with physiotherapy and potentially prolonging hospital stay.

Process mapping demonstrated a mean delay of 11 (±4) hours from injury to ward admission, during which patients were largely kept nil by mouth. Only 23.5% (n=17) received intravenous fluids before ward arrival. Week-by-week analysis demonstrated an inverse relationship between pre-operative fluid administration and post-operative hypotension (r =-0.739, p<0.05) Two PDSA cycles were undertaken. PDSA1 introduced routine fluid prescription by the orthogeriatric team on ward admission. Following poor improvement, process evaluation identified that only 44% of prescribed fluids were administered before theatre due to limited time between prescription and surgery. PDSA2 moved fluid prescription to orthopaedic clerking in the emergency department. 

Before intervention, the median incidence of day-1 post-operative hypotension was 51% (n=49). PDSA1 increased fluid prescription to 92% (n=14) but did not reduce hypotension incidence(median 67%). Following PDSA2, 89% (n=46) of patients were prescribed fluids and all patients received prescribed fluids pre-operatively. Median day-1 hypotension decreased to 38%. No patients developed pulmonary oedema requiring intravenous diuretics.

Moving intravenous fluid prescription from ward admission to emergency department clerking substantially increased pre-operative fluid administration and reduced incidence of day-1 post-operative hypotension without evidence of fluid overload. This low-cost, sustainable intervention has been adopted locally and further evaluation will assess its effect on mobilisation and length of stay.