{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T01:19:38Z","timestamp":1789348778177,"version":"build-2803163510"},"reference-count":21,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2023,8,26]],"date-time":"2023-08-26T00:00:00Z","timestamp":1693008000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Multimorbidity Doctoral Training Programme for Health Professionals","award":["223499\/Z\/21\/Z"],"award-info":[{"award-number":["223499\/Z\/21\/Z"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>The aims of this study were to assess whether completion of the emergency department (ED) Big 6 interventions (provision of pain relief, screening for delirium, early warning score (EWS) system, full blood investigation and electrocardiogram, intravenous fluids therapy, and pressure area care) in those presenting with an acute hip fracture were associated with mortality risk and length of acute hospital stay. A retrospective cohort study was undertaken. All patients aged \u226550 years that were admitted with a hip fracture via the ED at a single centre during a 42-month period were included. A total of 3613 patients (mean age 80.9; 71% female) were included. The mean follow up was 607 (range 240 to 1542) days. A total of 1180 (32.7%) patients had all six components completed. Pain relief (90.8%) was the most frequently completed component and pressure area assessment (57.6%) was the least. Completion of each of the individual Big 6 components, except for pressure areas assessment, were associated with a significantly (p \u2264 0.041) lower mortality risk at the 90-days, one-year and final follow-up. The completion of all components of the Big 6 was associated with a significantly (2.4 hours, p = 0.002) shorter time to theatre. Increasing number of Big 6 components completed were independently associated with a lower mortality risk: when all six were completed, the hazard ratio was 0.64 (95% CI 0.52 to 0.78, p &lt; 0.001). Completion of an increasing number of Big 6 components was independently associated with shorter length of hospital stay and completion of all six was associated with a 2.3 (95% CI 0.9 to 3.8)-day shorter acute stay. The findings provide an evidence base to support the ongoing use of the Big 6 in the ED.<\/jats:p>","DOI":"10.3390\/jcm12175559","type":"journal-article","created":{"date-parts":[[2023,8,28]],"date-time":"2023-08-28T05:46:47Z","timestamp":1693201607000},"page":"5559","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Completion of the Emergency Department \u201cBig 6\u201d in Patients with an Acute Hip Fracture Is Associated with a Lower Mortality Risk and Shorter Length of Hospital Stay"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8792-0659","authenticated-orcid":false,"given":"Nick D.","family":"Clement","sequence":"first","affiliation":[{"name":"Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7023-7108","authenticated-orcid":false,"given":"Rose S.","family":"Penfold","sequence":"additional","affiliation":[{"name":"Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH25 9RG, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Duffy","sequence":"additional","affiliation":[{"name":"Lothian Analytical Services, NHS Lothian, Edinburgh EH4 2XU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krishna","family":"Murthy","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Royal Infirmary Edinburgh, Edinburgh EH16 4SA, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alasdair M. J.","family":"MacLullich","sequence":"additional","affiliation":[{"name":"Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH25 9RG, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew D.","family":"Duckworth","sequence":"additional","affiliation":[{"name":"Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK"},{"name":"Department of Orthopaedics and Usher Institute, University of Edinburgh, Little France, Edinburgh EH16 4SA, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,8,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1176","DOI":"10.1302\/0301-620X.103B7.BJJ-2020-2582.R1","article-title":"The association between surgical fixation of hip fractures within 24 hours and mortality: A systematic review and meta-analysis","volume":"103","author":"Welford","year":"2021","journal-title":"Bone Jt. J."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Moja, L., Piatti, A., Pecoraro, V., Ricci, C., Virgili, G., Salanti, G., Germagnoli, L., Liberati, A., and Banfi, G. (2012). Timing Matters in Hip Fracture Surgery: Patients Operated within 48 Hours Have Better Outcomes. A Meta-Analysis and Meta-Regression of over 190,000 Patients. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0046175"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1111\/anae.15291","article-title":"Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists","volume":"76","author":"Griffiths","year":"2021","journal-title":"Anaesthesia"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e2231911","DOI":"10.1001\/jamanetworkopen.2022.31911","article-title":"Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients with Hip Fractures: A Systematic Review","volume":"5","author":"Tewari","year":"2022","journal-title":"JAMA Network Open."},{"key":"ref_5","unstructured":"(2023, January 03). Full Guideline|Hip Fracture: Management|Guidance|NICE. Available online: https:\/\/www.nice.org.uk\/guidance\/cg124\/resources\/cg124-hip-fracture-full-guideline."},{"key":"ref_6","unstructured":"(2023, May 08). The Scottish Hip Fracture Audit. Available online: https:\/\/www.shfa.scot.nhs.uk\/index.htm."},{"key":"ref_7","unstructured":"Scottish Government (2023, August 23). Scottish Standards of Care for Hip Fracture Patients. Available online: https:\/\/www.shfa.scot.nhs.uk\/_docs\/2020\/Scottish-standards-of-care-for-hip-fracture-patients-2020.pdf."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"o51","DOI":"10.1136\/bmj.o51","article-title":"Is the NHS overwhelmed?","volume":"376","author":"Alderwick","year":"2022","journal-title":"BMJ"},{"key":"ref_9","unstructured":"(2023, April 25). Scottish Hip Fracture Audit 2022 Dashboard\u2014Scottish Hip Fracture Audit\u2014Reporting on 2021\u2014Publications\u2014Public Health Scotland. Available online: https:\/\/publichealthscotland.scot\/publications\/scottish-hip-fracture-audit\/scottish-hip-fracture-audit-reporting-on-2021\/scottish-hip-fracture-audit-2022-dashboard\/."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1016\/j.mporth.2016.03.006","article-title":"The multidisciplinary management of hip fractures in older patients","volume":"30","author":"Riemen","year":"2016","journal-title":"Orthop. Trauma"},{"key":"ref_11","unstructured":"(2022, March 30). Scottish Index of Multiple Deprivation 2020\u2014gov.scot, Available online: https:\/\/www.gov.scot\/collections\/scottish-index-of-multiple-deprivation-2020\/."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1016\/S0140-6736(20)30058-1","article-title":"Accelerated surgery versus standard care in hip fracture (HIP ATTACK): An international, randomised, controlled trial","volume":"395","author":"Borges","year":"2020","journal-title":"Lancet"},{"key":"ref_13","first-page":"e429","article-title":"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 7090 patients conducted in 14 nations during the C","volume":"20","author":"Hall","year":"2022","journal-title":"Surgery"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"888","DOI":"10.1302\/0301-620X.103B.BJJ-2020-2027.R1","article-title":"IMPACT-Scot 2 report on COVID-19 in hip fracture patients","volume":"103","author":"Hall","year":"2021","journal-title":"Bone Joint J."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1016\/j.jss.2020.11.062","article-title":"A Closer Look into Global Hospital Beds Capacity and Resource Shortages During the COVID-19 Pandemic","volume":"260","author":"Sutherland","year":"2021","journal-title":"J. Surg. Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1016\/j.surge.2021.04.007","article-title":"IMPACT of COVID-19 on hip fracture services: A global survey by the International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics","volume":"20","author":"Hall","year":"2022","journal-title":"Surgeon"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Porter, S.B., Pla, R., Chow, J.H., Keneally, R., Douglas, R., Desvarieux, T., Crowe, M.M., and Mazzeffi, M.A. (2022). Preoperative Pressure Ulcers, Mortality, and Complications in Older Hip Fracture Surgery Patients. J. Am. Acad. Orthop. Surg. Glob. Res. Rev., 6.","DOI":"10.5435\/JAAOSGlobal-D-22-00117"},{"key":"ref_18","first-page":"1","article-title":"Trends in incidence, health care consumption, and costs for proximal femoral fractures in the Netherlands between 2000 and 2019: A nationwide study","volume":"1","author":"Zeelenberg","year":"2023","journal-title":"Osteoporos. Int."},{"key":"ref_19","unstructured":"Ward, K. Personal communication."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"103957","DOI":"10.1016\/j.archger.2019.103957","article-title":"Efficacy of an interdisciplinary pathway in a first level trauma center orthopaedic unit: A prospective study of a cohort of elderly patients with hip fractures","volume":"86","author":"Bano","year":"2020","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1101","DOI":"10.1007\/s41999-022-00686-6","article-title":"The Clinical Frailty Scale can be used retrospectively to assess the frailty of patients with hip fracture: A validation study","volume":"13","author":"Kay","year":"2022","journal-title":"Eur. Geriatr. 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