Background: Hip fractures are one of the most common causes for surgery in the elderly and the burden of care extends beyond the perioperative period as many are discharged to a long-term facility and have significant morbidity and mortality despite advances in perioperative care. To date, trials of interventions and standardized multidisciplinary hip fracture programs have not demonstrated a reduction in readmissions or mortality. Our institution is a tertiary referral center for complex fractures and acute geriatric hip fracture patients are admitted to a hospital medicine service. We designed a novel multidisciplinary pathway in collaboration with cardiology, anesthesia, orthopedic surgery, hematology, endocrine, vascular medicine, physical therapy, nutrition, and emergency medicine to improve perioperative outcomes and encompass provider education regarding best practices in perioperative care.
Purpose: This pathway improves care quality in key areas that show improved outcomes for hip fracture patients. Metrics include operative repair within 24 hours, reduction of opioid use with improvement in nerve block utilization to reduce delirium, and adherence to guidelines for consultation utilization and perioperative testing to reduce delays to operative repair, and early ambulation with physical therapy. We also included initiatives to reduce blood transfusion with proactive management of anemia, use of enhanced recovery pathways to improve nutrition, and bridging to preventive treatment with endocrine, Our goal is to demonstrate the creation of a multidisciplinary pathway on a hospitalist comanagement service combining multiple components of evidence based practice as there is a paucity of evidence on the effect of combining these components.
Description: Once a hip fracture alert is initiated in the ER, there is a delirium screen and the patient is admitted to a hospitalist service with orthopedic surgery consultation and the acute pain management service expedites a nerve block catheter within 2 hours to limit opioid use. There is an expedited medical evaluation, erythropoetin and iron are provided for anemia to limit transfusion, VTE prophylaxis within the first hour of admission, cardiology consultation for active cardiac conditions in accordance with published guidelines. There is an endocrine evaluation for secondary causes of osteoporosis with a bridge to follow up care, and all patients are started on calcium and vitamin D. Nutrition is consulted for frailty and carbohydrate clear drinks are used until 2 hours before surgical repair as part of an enhanced recovery pathway. There is a goal of operative repair within 24 hours with comanagement with orthopedic surgery. Post operatively patients have a physical therapy evaluation on POD 1 and nerve block catheter remains in place for 48-72 hours postoperatively to avoid opioid use. There is a goal for discharge within 72 hours and outpatient follow up is arranged with orthopedic surgery and endocrinology.
Conclusions: Over the past year we demonstrate a significant reduction in length of stay, decrease in time to admission orders, decrease in the number of cardiology consultations and completion of cardiology consultation, and increased time to the operating room, those receiving a nerve block, and meeting the goal of OR within 24 hours, there is a statistically significant (P<.05) improvement over the past year. This is a simple pathway that can easily be replicated at other institutions and further data analysis is pending into outcomes.