mi Jam ames es Holst stine ine, , DO DO Medical Director for - - PowerPoint PPT Presentation

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

Evolutions tions in Geriatr tric ic Fractu ture e Ca Care Preparing ring for th the Silver Tsu sunami mi

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

• f 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

Ep Epidemiol emiology

• gy of
• f Oste

teoporosi porosis

• 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

• porosis

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

• porosis

s In n The he Eld lderly erly

• 2 million

bone breaks

• ccur each

year due to

• steoporosis

5,500 every day, 1 every 15 seconds

• 90 % of all

women over the age of 75 are

• steopenic

Less than 20% of hip fracture pts are receiving osteoporosis follow up

Prevalence of Osteoporosis and Low Bone Mass

Americans Age 50 and Above Affected by Osteoporosis/Low Bone Mass, 2010 to 2030 (projected) Millions

54 million of 99 million Americans age 50+ (2010)

+27% change

from 2010 to 2030

17% of the

ENTIRE U.S. POPULATION (2010)

Incid ciden ence ce of Frag agili lity ty Fractures actures

Os Oste teoporosi

• porosis

Osteoporosis is characterized by a decrease in bone mass and density “Fragility Fracture” – fracture resulting from “standing height” or less Normal Osteopenic

Os Osteopo teoporosis rosis – A Ch Chronic

• nic Dis

isease ease

Morbidity 50 60 70 80 90 Colles' fracture Vertebral fracture Hip fracture

No fractures – increasing morbidity due to ageing alone Added morbidity from fractures

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...

• Arthritis
• Cancer
• Cardiovascular
• Strokes
• Dementia
• Depression
• Diabetes
• Memory Loss
• Osteoporosis
• Parkinson's Disease
• Respiratory Disease
• Pressure ulcers
• Sleep problems
• Thyroid Disease
• Urinary Disorders
• Sensory impairment

All l fractures ctures are associa sociated ted wi with th morbidi rbidity ty

• Cooper. Am J Med. 1997; 103(2A):12s-19s

40%

Unable to walk independently

30%

Permanent disability

24%

Death within

• ne year

80%

Unable to carry out at least one independent activity of daily living

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

• gram

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 6. Physician “Buy In” 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

• 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

Doc

• cumented

umented Cli lini nica cal l Benefits nefits

Nut uts s and nd Bol

• lts

s of

• f 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

• utput

– Decrease peripheral vascular compliance

Qu Quic ick k tho houghts ughts on

• n ha

handl ndling ing com

• morbi
• rbidit

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

Co Co-morbidities…

• CHF

– Daily weights important – Easier to deal with CHF than a dry patient – Cardiology consult when not responsive to traditional care

• CAD

– ASA, Beta Blockers, avoid Hypoxemia, maintain HCT, control pain – Highest rate of infarctions is 72 hours

• COPD

– May need to avoid Beta Blockers – Know patients baseline

• DM

– Early return to regular diet – Avoid dehydration – Maintain glucose levels less than 170- 180 – Hold sulfonamides

• Renal Disease

– Avoid NSAIDs – Avoid BP changes – Avoid fluids with diuretics, not a role for both

By the numbers ers

• Whatcom Co. has demonstrated a 24% increase in total

population from the year 2000 to 2013 (US Census Bureau)

• Whatcom Co. has projected a:

– 15% increase in the 55 and over age cohort in the next 5 years 2015-2020 – 28% increase in the 55 and over age cohort in the next 10 years 2015-2025

• Falls are the leading cause of injury related hospitalizations
• The rate for hospitalization for falls in Whatcom Co is 1700

per 100,000 population

By the numbers ers

• LOS for Hip fractures is currently 4.56 days! (5.7 Nationally)

DC Disposition % 2014 2013 2012 2011

Home

10 12 11 14

Skilled Nursing Facility

77 73 69 71

Hospice

2 4 4 3

Rehab – South Campus

6 8 12 3

Hip ip Frac acture ture Volu lume me by Yea ear

Program started Dec 2011

GF GFP Rates tes

• * 30-day readmit

rate is between 5% and 9% depending

• n definitions in our

institution

• * 30-day mortality

rate is between 2% and 5% depending

• n whose data we

use

Qu Questi stions

• ns and Comment

ents

Tha hank nk You

• u!