Geriatric Hip Fracture Program

1. Geriatric Hip Fracture Program Christina McQuiston M.B.Ch.B. Mission Hospitals, Asheville, NC

2. The Problem • 300,000 Americans experience a hip fracture annually • In 2005 fragility fractures cost around $19 billion • By 2025 it is predicted that these costs will rise to around $25billion. • Around 24% of such patients over 50 will die in the year following a fracture

3. Hip Fracture Repair per 1,000 Medicare Enrollees (2003) Source: Dartmouth Atlas 2003

4. Hip Fracture Repairs NC Hospitals Medicare volumes

5. Mission Hospitals All payers

6. Mission Hospitals: Net income per Case

7. Environmental Survey • Reviewed literature on co-management models. Shows decreased LOS and readmissions. • Reviewed anesthesia literature. Less delirium with spinal anesthesia. • Reviewed and incorporated CHEST guidelines for VTE prophylaxis. • Reviewed orthopedic literature regarding post hip fracture weight bearing status. • Reviewed current recommendations for osteoporosis treatment. • Site visit to Highland hospital in Rochester NY to review their process. (data published this summer)

8. Plan Outline All patients with fragility hip fractures(>65yr) Orthopedist remains attending physician. All patients co-managed by hospitalist. Elder specific pre and post op order sets. Consistent early weight bearing. Chest guidelines for VTE prophylaxis. Incorporate osteoporosis treatment.

9. Current Work • Improve collaboration among ER physicians, orthopedists, hospitalists and anesthesiologists. • Develop a protocol driven medical co-management process. • Streamline throughput from admission to discharge. • Create elder specific computerized power plans.

10. Medical Co-Management • Standardize the initial medical consult with attention to geriatric syndromes. • Accurately document medical co-morbidities. • Stratify risk. • Coordinate additional consults. • Actively manage the discharge process.

11. Everyone Wins • Door to OR in <24 hrs. • Reduce length of stay.(4 day goal) • Reduce costs. • Reduce complications. • Reduce hospital acquired delirium. • Reduce readmissions. • Increase patient and family satisfaction.

12. Door to OR data

13. Readmissions

14. Barriers • Hospitalists fears over “scope creep” • Surgical outliers regarding delays from admission to OR • Inter-hospital transfers (we have 2 campuses) • OR availability • Weekend discharges to rehabilitation facilities • Medicare part A reimbursement for SNF care and VTE prophylaxis.( Coumadin vs Arixtra/lovenox)

15. Facilitators • Administrative advocate • Support from orthopedic service line leader • Access to data collection and statistician. • Enthusiastic and supportive nursing staff.

16. Time Line • October 2008 . Turn on geriatric specific pre and post op order sets. • November . Formalize agreement with hospitalists. • January. Roll out new discharge process. • February. Incorporate delirium prevention and management and the HELP program.

17. Year 2 • Work with SNF’s on post hip fracture care. • Develop out patient falls prevention program with community partners. • Develop osteoporosis management strategy for SNF’s.

18. Delirium Task Force • Develop standardized tools for documentation (CAM) • Non pharmacological approaches to prevention and management, • Streamline medication options for treatment. • HELP pilot.

19. Long Term Goals To provide a best practice model for the hospitalized older patient . The hospitalist as geriatrician. To heighten visibility of Senior Services in my institution. Earn a “place at the table” for geriatrics

20. What I’ve Learned • “A prophet is not without honor except in his or her own country.” • That and the importance of data to administrative support.