A Geriatric Hip Fracture Care Pathway: An Operational Approach to Quality Improvement

Abstract

Introduction: Geriatric hip fractures are a devastating injury that decrease patient independence, increase morbidity and mortality, and have a significant economic impact. Although early operative intervention decreases mortality, hospitals often do not meet these benchmarks. The purpose of this study was to use a methodological approach to optimize the care and outcomes of patients sustaining geriatric hip fractures at a single level I trauma center by minimizing time to surgery and length of stay (LOS). Methods: A process map that outlined the paths that a hip fracture patient could take through our system from the time of injury to discharge was created. Classical operations management tactics known as Lean Synchronization and Six Sigma were used to identify bottlenecks in the system that led to delays in time to surgery or discharge. The pathway was systematically revised to address additional inefficiencies. Results: The initial process map revealed that time to surgery was increased by extensive preoperative testing and LOS was increased by admission to a non-orthopaedics service. By creating a standardized protocol for risk stratification and admitting all hip fracture patients to the orthopaedics service, improvements were seen within 6 months, including reductions in time to surgery (32.4 vs 17.5 hours), LOS (7.1 vs 5.6 days), 30-day readmissions (14.29% to 8.33%), and in-hospital mortality (2.79% vs 0%). Additional areas for improvement were later identified to reduce delirium rates and cost of care. Discussion: We conclude that the use of an operational management approach to address the inefficiencies in a clinical care pathway produced substantial and sustainable improvements in relevant outcome measures in patients sustaining geriatric hip fractures. By systematically identifying the bottlenecks in the system, we generated an ideal state pathway, which has allowed us to deliver higher quality care to our patients while simultaneously decreasing cost of care.