COMMENTARY

Commentary on Nyman MH, Johansson JE, Persson K & Gustafsson M

(2011) A prospective study of nosocomial urinary tract infection in hip
fracture patients. Journal Clinical Nursing 20, 2531–2539
Christopher CK Ho and Ton Nor A’tikah

Nyman et al. (2011) did an excellent study investigating
nosocomial urinary tract infection (UTI) in hip fracture
patients where diabetes was shown to be a risk factor and
prophylactic cloxacillin seemed to offer a certain protection.
We wish to discuss some important facts related to the topic.
Hip fractures among the older are a major cause of
morbidity and mortality. It has been shown that mortality
and morbidity increases if surgery is delayed. The 30-day
mortality for patients for whom the surgery had been delayed
for more than four days was 10Æ7%, and this small group had
significantly increased mortality at 90 days (hazard
ratio = 2Æ25; p = 0Æ001) and 1 year (hazard ratio = 2Æ4;
p = 0Æ001) (Moran et al. 2005). Delaying surgery with the
consequence of patients being bed-bound, predisposes
patients to infections, including UTI.
UTI has not been shown to be cause a significant increase
in mortality although the studies carried out were small
(Hedstrom et al. 1999, Nyman et al. 2011). The more
pertinent issue that has surfaced is the association between
hospital-wide nurse staffing levels and mortality rates for hip
fractures. Schilling et al. (2011) in their recent pilot study
demonstrated that the odds of in-hospital mortality decreased
by 0Æ16 for every additional full-time equivalent registered
nursing staff (FTE-RN) added per patient day, even after
controlling for covariates. This association suggests the
absolute risk of mortality increases by 0Æ35% points for
every one unit decrease in FTE-RN per patient day, a 16%
increase in the risk of death. Besides more meticulous nursing
care, operating room availability also increases in tandem
with better staffing and this will result in a shorter time to
surgery.
It cannot be denied that nurses are integral in the care of
hip fracture patients. Further studies are required to establish
a direct causal link between nurse staffing and patient
outcomes. The relevant authorities should take note of this
in planning the healthcare of the nation.

References
Hedstrom M, Grondal L & Ahl T (1999)
Urinary tract infection in patients with
hip fractures. Injury 30, 341–343.
Moran CG, Wenn RT, Sikand M & Taylor
AM (2005) Early mortality after hip
fracture: is delay before surgery
important? Journal of Bone Joint Sur-
gery America 87, 483–489.
Nyman MH, Johansson JE, Persson K &
Gustafsson M (2011) A prospective
study of nosocomial urinary tract
infection in hip fracture patients.
Journal Clinical Nursing 20, 2531–
2539.
Schilling P, Goulet JA & Dougherty PJ
(2011) Do higher hospital-wide nurse
staffing levels reduce in-hospital
mortality in elderly patients with hip
fractures: a pilot study. Clinical
Orthopaedics and Related Research
469, 2932–2940.

Authors: Christopher CK Ho, MD, MS, MRCSEd, AM, FICS,
Associate Professor, Department of Surgery, Universiti Kebangsaan
Malaysia Medical Centre, Kuala Lumpur; Ton Nor A’tikah, SRN,
SCM, Staff Nurse, Hospital Segamat, Johor, Malaysia
Correspondence: Christopher CK Ho, Associate Professor,
Department of Surgery, Universiti Kebangsaan Malaysia Medical
Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala
Lumpur, Malaysia. Telephone: +006 03 91546202.
E-mail: chrisckho2002@yahoo.com

Ó 2012 Blackwell Publishing Ltd, Journal of Clinical Nursing, 21, 597 597
doi: 10.1111/j.1365-2702.2011.03978.x
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