Hip Fracture Care Pathway Research Articles

Quality of Life and Depression Status of Caregivers of Patients with Femoral Neck or Intertrochanteric Femoral Fractures during the First Year after Fracture Treatment.

The burden placed on caregivers can negatively affect the functional recovery of patients with hip fractures. It is therefore essential to consider caregivers' well-being during the hip fracture care pathway. The aim of this study is to evaluate caregivers' quality of life and depression status during the first year after hip fracture treatment. We prospectively enrolled the primary caregivers of patients with hip fractures admitted to the Faculty of Medicine Siriraj Hospital (Bangkok, Thailand) between April 2019 and January 2020. The quality of life of each caregiver was evaluated using the 36-Item Short Form Survey (SF-36), EuroQol 5-Dimensions 5-Levels (EQ-5D-5L), and EuroQol Visual Analog Scale (EQ-VAS). Their depression statuses were assessed using the Hamilton Rating Scale for Depression (HRSD). The outcome measures were collected during admission as baseline data and 3, 6 months, and 1 year after hip fracture treatment. The repeated measures analysis of variance was used to compare all outcome measures from baseline to each indicated time point. Fifty caregivers were included in the final analysis. The mean SF-36 physical and mental component summary scores decreased significantly from 56.6 to 54.9 (p = 0.012) and 52.7 to 50.4 (p = 0.043), respectively, during the first 3 months after treatment. The physical and mental component summary scores returned to baseline values 12 and 6 months posttreatment, respectively. Although the mean EQ-5D-5L and EQ-VAS scores significantly declined at 3 months, they returned to baseline values within 12 months. As for HRSD, 6%, 56%, 36%, and 6% of the caregivers reported mild depression symptoms at baseline and 3, 6, and 12 months posttreatment, respectively. The quality of life and depression status of hip fracture patients' caregivers worsen substantially in the first 3 months and return to baseline 1 year after hip fracture treatment. Specific attention and support should be given to caregivers, particularly during this difficult period. Caregivers should be regarded as "hidden patients" who need to be integrated into the hip fracture treatment pathway.

Cost-effectiveness analysis of routine follow-up for hip fracture patients after dynamic hip screw and intramedullary nail fixation

• Determining the appropriate outpatient management for patients following IM Nail or DHS for neck of femur fractures should be directed by clear objectives. • Routine post-operative surgical encounters with these patients rarely alter their clinical management. • We propose more selective follow-up protocols and adequately resourcing virtual alternatives. • The current outpatient hip fracture care pathway should be optimised to focus on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation. The rising number of hip fractures has incentivised several quality improvement initiatives aimed at improving outcomes. These include the national hip fracture audit and the best practice tariff. Whilst there is an established standard of care for inpatients, the optimal outpatient management of patients after hip fracture fixation remains undefined. We aim to evaluate the cost-effectiveness of routine surgical appointments and provide evidence to support an improved outpatient hip fracture care pathway that focuses on more comprehensive multidisciplinary treatment. This study retrospectively examined all patients who underwent either dynamic hip screw or intramedullary nail fixation for hip fragility fracture at our hospital over a 3-year period. Data was obtained from the Irish Hip Fracture Database (IHFD), the national integrated imaging system (NIMIS) and the medical charts. The number of outpatient appointments, postoperative radiographs and estimated cost of these patient encounters was examined. The rate of revision surgery as well as the type and timing of these interventions was also analysed. We included 272 patients. The mean number of inpatient and outpatient radiographs was 1.13 and 1.54 per patient respectively. There were 428 outpatient appointments scheduled, an average of 1.6 (SD 1.5) per patient. The median length of stay was 12 days (IQR 8-17). Only 16 (5.8%) patients had abnormal X-ray findings and only 8 (2.9%) patients underwent revision surgery. The majority (15/16, 94%) of patients with surgical complications presented with significant symptoms. There was a 13.1% DNA rate resulting in a cost to the health service of €1,400. The combined total cost of follow-up for all patients over the 3 year period was €92,252. Routine postoperative surgical encounters rarely alter a patient's management and contribute significantly to healthcare costs, resources and time loss for patients and their carers. We propose more selective follow-up protocols, adequately resourcing virtual alternatives and an improved outpatient hip fracture care pathway that focuses on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation.

No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used.

No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used.

Integrated hip fracture care pathway (IHFCP): reducing complications and improving outcomes.

Introduction:Hip fractures in elderly people are increasing. A five-year Integrated Hip Fracture Care Pathway (IHFCP) was implemented at our hospital for seamlessly integrating care for these patients from admission to post discharge. We aimed to evaluate how IHFCP improved process and outcome measures in these patients.Methods:A study was conducted over a five-year period on patients with acute fragility hip fracture who were managed on IHFCP. The evaluation utilised a descriptive design, with outcomes analysed separately for each of the five years of the programme. First-year results were treated as baseline.Results:The main improvements in process and outcome measures over five years, when compared to baseline, were: (a) increase in surgeries performed within 48 hours of admission from 32.5% to 80.1%; (b) reduced non-operated patients from 19.6% to 11.9%; (c) reduced average length of stay at acute hospital among surgically (from 14.0 ± 12.3 days to 9.9 ± 1.0 days) and conservatively managed patients (from 19.1 ± 22.9 to 11.0 ± 2.5 days); (d) reduced 30-day readmission rate from 3.2% to 1.6%; and (e) improved Modified Functional Assessment Classification of VI to VII at six months from 48.0% to 78.2%.Conclusion:The IHFCP is a standardised care path that can reduce time to surgery, average length of stay and readmission rates. It is distinct from other orthogeriatric care models, with its ability to provide optimal care coordination, early transfer to community hospitals and post-discharge day rehabilitation services. Consequently, it helped to optimise patients’ functional status and improved their overall outcome.

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

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.

Higher Charlson Comorbidity Index Increases 90-Day Readmission Rate with Poorer Functional Outcomes in Surgically Treated Hip Fracture Patients.

IntroductionThe associated mortality and morbidity in hip fracture patients pose a major healthcare burden for ageing populations worldwide. We aim to analyse how an individual’s comorbidity profile based on age-adjusted Charlson Comorbidity Index (CCI) may impact on functional outcomes and 90-day readmission rates after hip fracture surgery.Materials and MethodsSurgically treated hip fracture patients between 2013 and 2016 were followed up for 1-year and assessed using Parker Mobility Score (PMS), EuroQol-5D (EQ-5D) and Physical and Mental Component Scores (PCS and MCS, respectively) of Short Form-36 (SF-36). Statistical analysis was done by categorising 444 patients into three groups based on their CCI: (1) CCI 0–3, (2) CCI 4–5 and (3) CCI ≥ 6.ResultsPMS, EQ-5D and SF-36 PCS were significantly different amongst the CCI groups pre-operatively and post-operatively at 3, 6 and 12 months (all P < 0.05), with CCI ≥ 6 predicting for poorer outcomes. In terms of 90-day readmission rates, patients who have been readmitted have poorer outcome scores. Multivariate analysis showed that high CCI scores and 90-day readmission rate both remained independent predictors of worse outcomes for SF-36 PCS, PMS and EQ-5D.DiscussionCCI scores ≥6 predict for higher 90-day readmission rates, poorer quality of life and show poor potential for functional recovery 1-year post-operation in hip fracture patients. 90-day readmission rates are also independently associated with poorer functional outcomes. Peri-operatively, surgical teams should liaise with medical specialists to optimise patients’ comorbidities and ensure their comorbidities remain well managed beyond hospital discharge to reduce readmission rates. With earlier identification of patient groups at risk of poorer functional outcomes, more planning can be directed towards appropriate management and subsequent rehabilitation.ConclusionFurther research should focus on development of a stratified, peri-operative multidisciplinary, hip-fracture care pathway treatment regime based on CCI scores to determine its effectiveness in improving functional outcomes.

After hours surgery for elderly hip fracture patients: How safe is it?

The recent focus on early surgery for hip fractures to reduce complications and improve morbidity, has led some resource-constrained institutions to perform after hours surgery in a bid to meet these timelines. However, there are concerns about the potential increase in complications and poorer outcomes in after hours surgery. This study aims to evaluate the safety of after hours hip fracture surgery and its related complications. This is a retrospective review of hip fracture patients admitted over a 2-year period to a tertiary centre with an established orthogeriatric co-managed hip fracture care pathway. Patients were divided into two groups based on their operating start time: (1) office hours surgery was defined as surgery conducted between 8am to 5pm on weekdays and 8am to 12noon on Saturdays; and (2) after hours surgery was defined as surgery conducted between 5pm to 8am on weekdays, and between Saturday 12noon to Monday 8am, as well as those that were conducted on public holidays. Demographic data, comorbidities, fracture details, operative details and outcome measures (complications, mortality and functional scores) were collated. A total of 903 patients were surgically treated for per- and intertrochanteric or femoral neck fractures. 76.7% (n = 693) of the patients underwent operation during office hours while 23.3% (n = 210) of the patients underwent after hours operation. 12.4% (n = 26) of the after hours group underwent surgery within 24h of admission, compared with 6.8% (n = 47) in the office hours group (p = 0.009). We did not find any significant difference between the two groups in terms of complications, mortality and functional outcomes (p > 0.05). In conclusion, our study did not show that after hours surgery increases complication rates in hip fracture surgery and had equivalent functional outcomes.

Bypass: an integrated hip fracture care pathway.

The incidence of hip fractures is expected to increase over the coming years, placing a greater burden on limited resources. A high volume of patients is brought to hospitals that do not have the resources necessary to provide definitive care. Optimal care involves a coordinated and integrated system of trauma care. The hip fracture care pathway introduced between a referring peripheral hospital and our institution represents a coordinated multidisciplinary approach to patient care. To describe and report on the outcomes over an 18-month period of the integrated hip fracture care pathway between referring peripheral hospitals and our institution. A retrospective analysis of the prospectively maintained hip fracture database over an 18-month period. Between March 2017 and September 2018, 86 consecutive patients were referred to our institution through a new referral pathway. Of these, 69 patients came from the Emergency Department of the referring hospital and 17 arrived via bypass. All 86 patients were managed on a specialist orthopaedic ward. The average length of stay was 4.28days, with maximum of 13 and minimum of 2days. Over 84% of patients underwent definitive treatment within 48h of a diagnosed hip fracture. The fragmented approach to the management of trauma patients both in a pre-hospital and hospital care setting is a cause for concern. Our integrated hip fracture referral pathway, incorporating bypass of the referring hospital, represents a multidisciplinary care pathway for the management of patients with fractured neck of femur and can have potential benefits including improved patient outcomes, allowing the optimal allocation of resources and providing training opportunities.

Results after introduction of a hip fracture care pathway: comparison with usual care

Background and purpose — We established a care pathway for hip fracture patients, a “Hip Fracture Unit” (HFU), aiming to provide better in-hospital care and thus improve outcome. We compared the results after introduction of the HFU with a historical control group.Patients and methods — The HFU consisted of a series of measures within the orthopedic ward, such as reducing preoperative waiting time, increased use of nerve blocks, early mobilization, and osteoporosis treatment. 276 patients admitted from May 2014 to May 2015 constituted the HFU group and 167 patients admitted from September 2009 to January 2012 constituted the historical control group. Patients were followed prospectively up to 12 months post fracture.Results — Mean preoperative waiting time was 24 hours in the HFU group and 29 hours in the control group (p = 0.003). 123 patients (47%) in the HFU were started on anti-osteoporosis treatment while in hospital. “Short Physical Performance Battery” score (SPPB) was mean 5.5 in the HFU group and 3.8 in the control group at 4 months (p < 0.001), and 5.7 vs. 3.6 at 12 months (p < 0.001). The mortality rate at 4 months was 15% in both groups. No statistically significant differences were found in readmissions, complications, new nursing home admissions, in Barthel ADL index or a mental capacity test at the follow-ups.

65 Fragility Fracture Network (FFN) Malaysia - A Call to Action for Better Outcome in Malaysia

Abstract Introduction The incidences of hip fractures are increasing worldwide and over 50% of all hip fractures are projected to occur in Asia. Malaysia is predicted to have the highest rate of increase in numbers of hip fracture in Asia Pacific by 2050. Despite the health and economic burden associated with fragility fractures, there is limited systematic guidance or nationwide interventions set up to address this foreseeable tsunami in Malaysia. This has called for the formation of a national Fragility Fracture Network to bring together experts from different disciplines nationally to drive policy change and improve quality of care in patients with fragility fracture. Method The Asia Pacific Regional Fragility Fracture Summit held in Singapore in May 2018 brought together representatives of regional societies from geriatrics, orthopedic, osteoporosis and rehabilitation to share key challenges in providing optimal fragility fracture care. Three clinicians from Malaysia representing three different societies in Asia Pacific who attended the summit initiated the idea of forming a national multidisciplinary network to focus on improving acute hip fracture care, post-acute care rehabilitation and secondary fracture prevention. Results After the first meeting held in June 2018 with only 4 members in Kuala Lumpur, the network has expanded to include members from 7 different states in Malaysia. This has led to the formation of the Fragility Fracture Network (FFN) Malaysia in August 2018. The key goals of the network include the development of clinical hip fracture care pathway, initiating national hip fracture registry and fracture liaison service. Conclusion FFN Malaysia serves as a platform to unite healthcare providers and policy makers in prioritizing and having co-ownership in improving fragility fracture care in the country.

Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay.

Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. III.

Identifying Disparities in the Management of Hip Fractures Within Europe: A Comparison of 3 Health-Care Systems.

Introduction:This study investigates the management of hip fractures in a German maximum care hospital and compares these data to evidence-based standard and practice in 180 hospitals participating in the UK National Hip Fracture Database (NHFD) and 16 hospitals participating in the Irish Hip Fracture Database (IHFD). This is the first study directly comparing the management of hip fractures between 3 separate health-care systems within Europe.Methods:Electronic medical data were collected retrospectively describing the care pathway of elderly patients with a hip fracture admitted to a large trauma unit in the south of Germany “University Hospital Freiburg” (UHF). The audit evaluated demographics, postoperative outcome, and the adherence to the 6 “Blue Book” standards of care. These data were directly compared with the data from the UK NHFD and the IHFD acquired from 180 and 16 hospitals, respectively.Results:At 36 hours, 95.8% of patients had received surgery in UHF, compared to 71.5% in the NHFD and 58% of patients in the IHFD. The rate of in-hospital mortality was 4.7% compared to 7.1% in the NHFD and 5% in the IHFD. The mean average acute length of stay was 13.4 days compared to 16.4 days in the NHFD and 20 days in the IHFD. Reoperation rates are 3.3% compared to 1% in the NHFD and 1.1% in the IHFD; 50.5% of patients were discharged on bone protection medication, compared to 47% in the IHFD and 79.3% in the UK NHFD.Discussion:Despite uniformly acknowledged evidence-based treatment guidelines, the management of hip fractures remains heterogeneous within Europe.Conclusion:These data show that different areas of the hip fracture care pathway in Germany, England, and Ireland, respectively, show room for improvement in light of the growing socioeconomic burden these countries are expected to face.

Implementation of a Hip Fracture Care Pathway Using Lean Six Sigma Methodology in a Level I Trauma Center.

The application of Lean Six Sigma (LSS) methodology with regard to hip fracture care remains unexamined. The aim of this study is to illustrate the application of LSS principles in the implementation of a hip fracture integrated care pathway (ICP). A multidisciplinary team at a level I trauma center formed a hip fracture ICP using LSS principles. An ICP aimed toward decreasing time to surgery to <48 hours was implemented in April 2012. A total of 505 hip fracture patients met inclusion criteria. A total of 221 patients entered the preimplementation cohort, and 284 were incorporated in the postimplementation cohort. The percentage of patients who received surgical fixation beyond 48 hours significantly decreased (9.50% versus 4.23%; P = 0.01). Significantly more complications were detected in the postimplementation cohort (62.44% versus 80.10%; P < 0.01). The postimplementation cohort showed a significantly shorter length of stay (P = 0.02) and decreased hospital cost (P = 0.016). Our findings suggest that using LSS methods in an ICP at our institution resulted in markedly greater percentage of patients receiving surgical care within 48 hours, greater detection of complication, and reduced resource consumption.

Management of elderly hip fractures by an orthopaedic trauma surgeon reduces surgical delays but does not improve outcomes compared to non-trauma surgeons.

Recent literature on hip fractures has focussed on the optimal environment for best outcomes. One factor that has not been studied is the managing surgeon's training background. Our study aims to examine if hip fracture patients managed by fellowship-trained orthopaedic trauma surgeons have better outcomes compared to non-trauma trained general orthopaedic surgeons. This is a retrospective study performed at a tertiary hospital with an established orthogeriatric co-managed hip fracture care pathway. All surgically treated elderly hip fracture patients over a period of 2years were included and divided into 2 groups based on the managing surgeon: trauma and non-trauma. Patient characteristics, fracture and surgery information, post-operative complications, 1year mortality and the Modified Barthel Index (MBI) scores were collected and compared. 871 patients were included. 32.1% (N = 280) were managed by trauma surgeons and 67.9% (N = 591) by non-trauma surgeons. There was no significant difference in the MBI scores pre-operatively and at 6 and 12 months post-operatively between the 2 groups. There was no difference in the incidence of postoperative complications and mortality. However, patients managed by trauma surgeons had significantly shorter time to surgery (p = 0.028) and higher proportion of surgeries performed within 48h (p = 0.039). Trauma surgeons also took a shorter time to fix intertrochanteric fractures (p = 0.000). This study did not find any difference in the functional outcomes of hip fracture patients managed by trauma surgeons or non-trauma surgeons. However, trauma surgeons had faster times to surgery and shorter surgical times when fixing intertrochanteric fractures.

Improved outcomes following implementation of a multidisciplinary care pathway for elderly hip fractures.

Hip fractures in patients 65years and older are associated with significant morbidity and mortality. With the steady increase in the elderly population, we implemented an evidence-based clinical practice guideline for the management of hip fractures to optimize patient care and surgical outcomes. To evaluate the effects of a multidisciplinary hip fracture care pathway on patient outcomes in the care of elderly patients. A retrospective analysis of the differences in outcomes prior to (January-October 2014) and after (November 2014-April 2016) implementation of a hip fracture care pathway at a regional Level I trauma center was performed. There were 80 patients in the pre-pathway group and 191 patients in the post-pathway group with an average age of 83.18 ± 8.24years. The analysis demonstrated that the post-pathway group had a lower incidence of in-hospital complications (9.95 vs 30.00%; p ≤ 0.001), shorter emergency room length of stay (3.76 ± 2.43 vs 6.78 ± 2.88h; p ≤ 0.0001), and shorter overall hospital length of stay (5.03 ± 3.46 vs 7.44 ± 6.66 days; p = 0.0028). The in-hospital mortality rate was similar between groups (4.71 vs 6.25%; p = 0.6018). The development of a multidisciplinary approach to the care of elderly patients with hip fractures improved morbidity and showed a downward trend in mortality. Elderly patients with hip fractures treated at our trauma center had improved clinical outcomes after the implementation of a multidisciplinary care pathway.

The comparison of hip fractures care in Lithuania and Sweden

Aim The aim of this study was to audit hip fracture patients’ care in Lithuania and compare it to Sweden’s, identifying the differences in Lithuania, changes required for further care improvement, for a country where no integrated care pathways had been introduced. Methods We investigated 64 hip fracture patients treated in Lithuania and 90 hip fracture patients treated in Sweden for a period of one year according our “fast track” protocol. Information about medical interventions, mean time period from admission to surgery, length of stay in the orthopedic department, incidence of pressure ulcers and information about discharge location was collected and compared in both institutions. Results No oxygen therapy, infusion therapy, blood sampling and ECG were conducted in Lithuania during patients’ transportation to the institution, but that was not the case in Sweden. Contrary to Lithuania, patients at Lund University Hospital do not attend the Acute & Emergency room and Swedish patients are supposed to be operated on within 24 h. Time to surgery in Lithuania was more than twice as long, but a rather similar in-hospital stay was observed. However, most patients in Lithuania are discharged to a rehabilitation clinic for 18 days. Conclusion Audit results of hip fracture care in Lithuania compared to Sweden showed potentially some benefits using the hip fracture care pathway, which was particularly associated with shorter time to surgery, thus reducing the risk of complications in this vulnerable group of old patients. Making comparisons like this in other countries may be useful, but must be taken in context along with the local culture and health care system.

Evaluation of a Care Pathway in the Initiation of Calcium and Vitamin D Treatment of Patients after Hip Fracture

Hip fractures, fragility fractures, indicate an increased risk for further fragility fractures. Although the way to define osteoporosis, requiring antiresorptive therapy, is not clear, all patients who have had hip fractures should be prescribed calcium and vitamin D at a minimum. In a retrospective chart review, we have explored the effectiveness of incorporating a standing recommendation (but not a standing order) for calcium and vitamin D treatment in a hip fracture care pathway, comparing units where the pathway had been implemented with those where it had not yet been started. The pathway resulted in significantly more initiation of calcium and vitamin D compared to patients not on the pathway (72% vs. 13.5%, p < 0.01). However, a follow-up study after four years showed a marked decline in the frequency of the initiation of calcium and vitamin D, suggesting the need for ongoing encouragement for the intervention to continue to be successful.