Completion of the Emergency Department “Big 6” in Patients with an Acute Hip Fracture is Associated with a Lower Mortality Risk and Shorter Length of Hospital Stay

The aims 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 ≥50 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. 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%) the least. Completion of each of the individual Big 6 components, except for pressure areas assessment, were associated with a significantly (p≤0.041) lower mortality risk at 90-days, one-year and at final follow up. Completion of all components of the Big 6 was associated with a significantly (2.4 hours, p=0.002) shorter time to theatre. Increasing proportions of Big 6 completion were independently associated with a lower mortality risk: when all 6 were completed the hazard ratio was 0.64 (95% CI 0.52 to 0.78, p<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 ongoing use of the Big 6 in the ED.