TOGA: a multidisciplinary pre-operative meeting to improve outcomes following neck of femur fracture
Abstract
Introduction
Neck of femur (NOF) fractures disproportionately affect older patients with complex medical needs and are associated with significant mortality. Many deaths are attributable to comorbidities rather than the fracture alone. NICE recognises that NOF fractures should not be viewed exclusively as surgical problems, but require multidisciplinary management with timely medical and anaesthetic input. We introduced a structured pre-operative multidisciplinary meeting involving trauma and orthopaedic surgeons, geriatricians and anaesthetists (TOGA) to improve shared decision-making, timely surgery and patient outcomes.
Methods
This quality improvement project compared patients managed during the two months before and after TOGA implementation. Outcomes included surgery >36 hours after admission (or fracture discovery following an inpatient fall), 30-day survival and hospital length of stay (LOS). Thirty-three patients were included pre-intervention and 43 post-intervention, with mean age at admission of 75.9 and 81.0 years, respectively. Categorical outcomes were compared using Fisher’s exact test and LOS using the Mann–Whitney U test.
Results
Surgery >36 hours after admission decreased from 30.3% (10/33) pre-intervention to 20.9% (9/43) post-intervention (p=0.42). Thirty-day survival increased from 93.9% (31/33) to 100% (43/43) (p=0.19). Median LOS decreased from 15 days (IQR 7–24) to 13 days (IQR 9–20) (p≈0.59). Of 43 post-intervention patients, 29 (67.4%) were discussed at TOGA. Non-discussion was primarily due to weekend surgery or patients bypassing the orthopaedic ward.
Conclusions
TOGA was associated with clinically favourable trends in time-to-surgery, 30-day survival and hospital LOS, although differences were not statistically significant. Improving TOGA coverage, particularly for weekend admissions and patients bypassing the orthopaedic ward, will be the priority for the next QI cycle.