Evolutions tions in Geriatr tric ic Fractu ture e Ca Care Preparing ring for th the Silver Tsu sunami mi Jam ames es Holst stine ine, , DO DO Medical Director for the Joint Replacement Center, Geriatric Fracture Center, Orthopedic Surgeon PeaceHealth Whatcom Region Medical Director for Orthopedic Quality, PeaceHealth System Shevaun aun Rudkin, in, RN, , BSN Program Manager Orthopedics and Neurosurgery Joint Replacement Center, Spine Care Center and Geriatric Fracture Program
Dis iscla claime imer • I am a program consultant and board member of Stryker Performance Solutions / Marshall Steele
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • 76 y/o female • Independent ambulator • Lives at home alone • Drives herself to Church • Does her own shopping ---------------------------------------------------------------------- • Falls at home and fractures her hip • Transported by EMS to ED
Cli lini nica cal l Appearan pearance ce of of Hip ip Fr Frac acture ture
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • ED – Triaged as non-urgent – Foley catheter placed – Narcotics started for pain control – X-rays and labs obtained – Spends 4-5 hours in ED
2011 2011 – Prior to Fracture cture Progra ram • Admission – Admitted by orthopedist by telephone – Transferred to floor (anywhere there is a bed) • Standard room – Buck’s traction sometimes applied – Medical consult sometimes ordered
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Pre-op – Extensive medical work up over next 48 hours – Cleared for surgery at that time – Placed on surgery waiting list as non-urgent – No social work visit until after surgery OR – No medical work up – Put on OR schedule as add on
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Surgery – Surgery completed 11 pm next evening after patient was “bumped” for more urgent cases – Fracture stabilized 48-72 hours after injury – Procedure performed by on-call team
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Post-operative course – Post-op delirium occurs lasting 48 hours • No PT during this time • Foley catheter left in place • Family very anxious over patients altered mental status
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Post-operative course – Slow progress with PT • Therapist with little geriatric experience – UTI requiring antibiotics • Due to extended use of Foley catheter – Family anxious about “where we go next” • Social workers begin to explain options
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Post-operative course – Transferred to SNF post-op day 7-8 – Discharged on Narcotic pain meds – Discharged on Antibiotic for UTI – No meds for osteoporosis
2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Outcome – Patient transferred to long term care – Expires 4-12 months after surgery having never returned home (mortality rate 20-40%) – Average number of handoffs is 3.5 times OR – Returns to hospital for medical resources
porosis Ep Epidemiol emiology ogy of of Oste teoporosi • 350,000 Hip fractures per year • 650,000 by 2050 • Incidence is increasing • 80% occur in females • Most common when age > 80 years • The peak of the “Baby Boom” will be within next 0 – 10 years • 72 million people projected to be > 65 in next 10 years in US • Responsible for > 2 million fractures in 2005 • By 2050, the worldwide incidence of hip fracture in men is projected to increase by 310% and 240% in women
Epid idemi emiolog logy y of Os Oste teoporo oporosis sis • Women have 1/7 lifetime chance of Hip Fracture! (more than Breast cancer) • 1/2 lifetime fracture of any kind risk for women < than 50 • 25% of Trauma is 65 years and older • Fatal injuries occur at 3 times higher rate in this population • 28% of deaths in this population are associated with trauma
Os Oste teoporosi oporosis s In n The he Eld lderly erly • 2 million bone breaks occur each year due to osteoporosis 5,500 every day, 1 every 15 seconds • 90 % of all women over the age of Less than 20% of hip fracture pts are 75 are receiving osteoporosis follow up osteopenic
Prevalence of Osteoporosis and Low Bone Mass Americans Age 50 and Above Affected by Osteoporosis/Low Bone Mass, 2010 to 2030 (projected) 54 million of 99 million Americans age 50+ (2010) 17% of the +27% change ENTIRE U.S. from 2010 to POPULATION 2030 (2010) Millions
Incid ciden ence ce of Frag agili lity ty Fractures actures
Os Oste teoporosi oporosis Osteoporosis is Normal characterized by a decrease in bone mass and density “Fragility Fracture” – fracture resulting from Osteopenic “ standing height” or less
Os Osteopo teoporosis rosis – A Ch Chronic onic Dis isease ease Morbidity Hip fracture Vertebral fracture Added morbidity from fractures Colles' fracture No fractures – increasing morbidity due to ageing alone 50 60 70 80 90 Age
Risk Fac acto tors rs for Ger eriat atric ric Hip Frac acture ture • Osteoporosis • Dementia • Unstable Gait • Poor muscle strength • Poor vision or neurologic disease • Poor nutrition
Pa Pati tien ents ts ar arrive e wi with th more e th than an frac actu ture... re... • Osteoporosis • Arthritis • Parkinson's Disease • Cancer • Respiratory Disease • Cardiovascular • Pressure ulcers • Strokes • Sleep problems • Dementia • Thyroid Disease • Depression • Urinary Disorders • Diabetes • Sensory impairment • Memory Loss
All l fractures ctures are associa sociated ted wi with th morbidi rbidity ty Unable to carry out at least one independent activity of daily living 80% Unable to walk independently Permanent disability 40% Death within one year 30% 24% Cooper. Am J Med. 1997; 103(2A):12s-19s
The e Vis isio ion • To develop a geriatric fracture center of excellence that enables Peacehealth St Joseph to provide a multi disciplinary, multi specialty team that facilitates quality team care and improved outcomes for this growing population over the next 10 years.
Prog ogram rammatic matic Go Goals ls • Address increasing volume of fracture patients • Transition from ER to Nursing Floor within less than 4 hours • Transition from ER to Surgery within 12 to 24 hours • Reduce pain • Reduce LOS to 3.5 days or less • Enhance functional outcomes • Reduce nursing home placements
Programmatic grammatic Go Goals ls • Reduce mortality in the first year following fracture • Maintain HealthGrades quality ratings • Increase patient and family satisfaction scores • Provide education for bone health and injury prevention • Provide screenings for Osteoporosis • Care for non operative fragility fractures for smooth transfer to home
Me Menu u for r Succ cces ess 1. Medical Director / Physician Champion 2. GFP Coordinator 3. Streamlined Evaluation and admission process 4. Co-Admission by Hospitalist and Orthopedic Surgeon 5. Clinical Pathway and Standardized Orders Physician “Buy In” 6. 7. Reserved O.R. time 5 days/week 8. Multidisciplinary Team from ER through rehabilitation 9. Dedicated Beds
Me Menu u for r Succ cces ess 10. Dedicated / Specially trained OR, Nursing & Therapy staff 11. Aggressive Therapy 12. Early D/C Planning 13. Patient / Family Education 14. Regular Team Meetings 15. Dashboard Development 16. Administrative Support 17. Delirium Prevention Program 18. Continuous process improvement
Doc ocumented umented Cli lini nica cal l Benefits nefits • Streamlined Admissions • Interdisciplinary team cooperation • Daily evaluation/communication • Management of pain/delirium • More timely surgery/lower mortality • Clearer path of communication to the patient/family • Earlier, more effective discharge planning
Nut uts s and nd Bol olts s of of Ge Geria riatri tric c Care re Disclaimer: I am an Orthopedic Surgeon! • Aging is not a disease • Occurs at different rates • Does not cause symptoms • Has common characteristics • Increases vulnerability to disease and decreases the ability to adapt • Normal aging begins at the age of 30
Syste stem m by System tem Fly ly By • Neuro – Decrease step height – Increase reaction time – Decrease vibratory sense – Basil Ganglia atrophy • Renal – GDR Decrease – Decrease tubular function – Decrease Plasma flow – CRCL change to be age specific
• CV – Systolic Hypertension – Maintenance of resting left ventricular function – Decrease ability to compensate for stress – Blunted heart rate response to max heart rate requires compensatory increase in stroke volume to maximize cardiac output – Decrease peripheral vascular compliance
Qu Quic ick k tho houghts ughts on on ha handl ndling ing com omorbi orbidit dities ies • “ No such thing as a healthy geriatric hip fracture ” – 90% of these patients come in with comorbidities – Mortality is 9.2% greater with each comorbidity – Renal failure is highest comorbidity – 50% of patient over 65 have CAD
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