Geriatric Hip Fracture Program

Christina McQuiston M.B.Ch.B.

Mission Hospitals, Asheville, NC

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

Hip Fracture Repair per 1,000 Medicare Enrollees (2003)

Source: Dartmouth Atlas 2003

National Average

7.53

1. Oklahoma 9.06

2. Tennessee 8.87

3. Georgia 8.78

3. North Carolina 8.78

11. South Carolina

8.28

23. Florida 7.46

2005 COUNT

Mission Hospitals 414Duke University Medical Center 389New Hanover Regional 302Moses Cone 283Forsyth Memorial 243Presbyterian 215Carolinas Medical Center 197Pitt County 197The NC Baptist Hospitals 182First Health Moore Regional 167WakeMed 165Gaston Memorial 161UNC Hospitals 161Northeast Medical Center 160Rex Healthcare 157Cape Fear Valley 141High Point Regional 140Rowan Regional 120Alamance Regional 116Cleveland Regional 106Pardee Hospital 102

2006 COUNT

Mission Hospitals 402Duke University Medical Center 342Moses Cone 309Forsyth Memorial 284New Hanover 278Carolinas Medical Center 238Presbyterian 237WakeMed 203The NC Baptist Hospitals 187Pitt County Memorial 186First Health Moore Regionsl 185Gaston Memorial 178Rex Healthcare 173UNC Hospitals 153Cape Fear Valley 141Northeast Medical Center 141High Point Regional 135Rowan Regional 121Durham Regional 118Frye Regional 117Alamance 116Pardee Hospital 112

Hip Fracture Repairs NC Hospitals

Medicare volumes

Mission Hospitals All payers

2006 2007

Total number 586 563

Total number over age 64

492 454

ALOS all pts 5.8 days 6.36 days

Mission Hospitals: Net

income per

Case

Patients with CC and MCC

($2,000)

($1,800)

($1,600)

($1,400)

($1,200)

($1,000)

($800)

($600)

($400)

($200)

$0

FY 06 FY 07 FY 08 Q1

Patients without CC or MCC

($1,000)

($800)

($600)

($400)

($200)

$0

$200

$400

FY 06 FY 07 FY 08 Q1

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)

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.

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.

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.

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.

Door to OR dataED to OR

79% fall under 24 hoursn=101

0

10

20

30

40

50

60

70

80

0 20 40 60 80 100

Volume

Ho

urs

ED to OR

20.79%

6.93%

19.80%

10.89%

18.81%18.81%

3.96%

0

5

10

15

20

25

≤ 4 4-8 8-12 12-16 16-20 20-24 > 24

Hours

Vo

lum

e

Readmission-Reasons 46 Patients

Anemia 1

Aspiration Pneumonia 1

Atrial Fibrillation 3

C Diff Colitis 2

CHF 2

Cholelithiasis 1

Dehydration 3

Dysphagia 1

Fever 1

Gangrene non-operative leg 1

GI bleed 1

Hip dislocation 7

HTN 1

Ileus 1

Lag screw cut femoral head 1

Nausea 2

New fracture 9

Non-union 1

Pain 1

Pancreatitis 1

Pneumonia 6

Septic Shock 2

Thrombus 1

UTI 3

Wound Erythema 2

Wound Infection 6

Readmissions – Timing 46 Patients

Returned within 7 days 16

Returned between 8-14 days 12

Returned between 15-21 days 8

Returned between 22-31 days 10

APR DRG

Cases

APRReadmissi

onRate

Expected APR

Readmission

Rate

Expected APR

Readmission Rate Index

308 418 7.56% 10.45% 0.76

309 51 9.80% 10.93% 0.74

Readmissions

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)

Facilitators

• Administrative advocate• Support from orthopedic service line

leader• Access to data collection and

statistician.• Enthusiastic and supportive nursing

staff.

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.

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.

Delirium Task Force

• Develop standardized tools for documentation (CAM)

• Non pharmacological approaches to prevention and management,

• Streamline medication options for treatment.

• HELP pilot.

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

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.