Hip Fracture and the Orthogeriatrician. Antony Johansen

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1 Hip Fracture and the Orthogeriatrician Antony Johansen

$The geriatric orthopaedic unit Irvine and Devas. J Bone Joint Surgery 1963; 49-B:186-7 Management of the fractured neck of femur in the elderly female: a joint approach Clarke and Wainwright.$

2 The geriatric orthopaedic unit Irvine and Devas. J Bone Joint Surgery 1963; 49-B:186-7 Management of the fractured neck of femur in the elderly female: a joint approach Clarke and Wainwright. Gerontology Clinics 1966; 8:321-6 the surgical procedure must never be considered to be the whole treatment but merely an incident in the general rehabilitation of the patient BMJ 1974; 1:190-2

3 Effectiveness of geriatric rehabilitation after proximal femur fracture in the elderly Kennie et al. BMJ 1988; 297: GP run, geriatrician led orthopaedic rehab. ward - earlier discharge, better mortality and independence Prospective randomised study of an orthopaedic geriatric inpatient service Gilchrist et al. BMJ 1988; 297: Surgeon run rehab. ward, with weekly combined OG round - better care of medical conditions, but no effect on outcome

$Geriatric rehabilitation following fractures in older people: a systematic review Cameron et al.$

4 Geriatric rehabilitation following fractures in older people: a systematic review Cameron et al. NHS HTA 2000;4:2 Specific therapy, nursing, medical input Miscellaneous hospital programmes Clinical pathways Early supported discharge Prospective payment systems Geriatric orthopaedic rehabilitation unit Hip fracture programme

5 Payment by Results Guidance for Gateway reference:

6 Galvard 1995 (Sweden) OG rehabilitation trial Orthogeriatric Rehabilitation Cohort studies Hospital-based coordinated MDT care for hip fracture patients 7 Randomised controlled Hempsall trials 1990, Fox 1993, Fordham 1995 Gilchrist 1988 (Scotland) Post-surgical Off-site orthopaedic vs. off-site orthogeriatric ward Hip Fracture Programme Orthogeriatrician-led peri-op. care leading into MDT rehabilitation Huusko 2002 (Finland) Post-surgical Acute 5 hospital Randomised geriatric controlled rehab. (MARU) trials vs. off-site local health centre hospital Kennie 1988 (Scotland) Swanson 1998 (Australia) Post-surgical acute orthopaedic Early intervention ward vs. standard move to orthopaedic off-site geriatrician-led care vs. HFP GP-run orthop. ward Naglie 2002 (Canada) Vidan 2005 (Spain) Post-surgical Acute Acute site routine phase post-op. HFP vs. care standard vs. acute care site intensive multidisciplinary rehab. Stenvall 2007 (Sweden) Shyu 2008 (Taiwan) Post-op. care in conventional MDT intervention orthop. ward programme vs. specific for hip intervention fracture vs. programme usual care in geriatric ward Fordham 1986 Marcantonio 2001 (USA) OG rehab vs. controls Acute setting HFP vs. controls (this is definitely an HFP, even though outcome focuses on delirium) Galvard 1995 (Sweden) Cameron 1993/4 (Australia) OG rehabilitation trial Acute accelerated hip fracture rehabilitation programme Cohort studies Case controlled trial Hempsall 1990, Fox 1993, Jette Fordham Cohort studies Hip Fracture Programme Zuckerman Orthogeriatrician-led 1992, Elliot 1996, peri-op. Miura 2009, care Fisher leading 2006 into MDT rehabilitation 5 Randomised controlled Farnworth trials 1994 (Antonia's economic analysis, an Australian observational study) Swanson 1998 (Australia)

9 564! APPENDIX!H! Table!98:!Incremental!resource!use!for!GORU/MARU!programme!versus!usual!care! Staff!resources!! Incremental!resources! used,!based!on!a!los!of! 32.88!days!! Source! Unit!cost!(source:! PSSRU!2008/09),!!per!hour! Orthogeriatrician!! Two!consultant!ward! rounds!(0.25/hour!per! patient!each)!and!one! weekly!conference! (0.25/hour!=!0.75!hour! per!week!per!patient!! 0.75*4.6!weeks!=!3.45! hours!per!patients!! Kennie!et!al! (1988) 176! Incremental! cost! 108! 372.6! Physiotherapist!! 8.5!hours!per!patient!!! Naglie! ! 23! 195.5! Occupational! therapist!! Nurse!! 5!hr/patient!!!! Initial!assessment! within!72!hours!(0.5! hour!per!patient)!and! twice!weekly! assessment!afterwards! (0.25*2)/hour!per! patient!!! *4.6!weeks=!2.8! hours!per!patient! GDG!adjustment! from!the!7.5! hr/pt!reported!in! Naglie 222!! Naglie! ! 23! 115! Nurse!team! leader:! 27! Nurse!day!ward:! 21! Social!worker! b0.4!hour!per!patient!!! Naglie! ! 29!(from! community!data)! 75.6! 58.8! b 11.6! Dietician! b0.4!hour!per!patient!!! Naglie! ! 23/! b 9.2! Total!incremental!cost!for!GORU/MARU!over!usual!care:!! 721!(with!

10 NICE economic model HFP vs. usual care

11 Hip Fracture CG124 Guideline Summary NICE 2011

$Pre-operative investigations All patients If indicated Mental state assessment Hb Result Sent Result Clock Face Drawing INR If taking warfarin Patients with suspected hip fracture Admitted from: Home$ Assessment Presenting complaint WCC Clotting screen Known dementia Details: Ask the patient to: "Fill in the numbers of this clock face, and draw in the hands of the clock pointing to 3 o clock

Assessment Presenting complaint WCC Clotting screen Known dementia Details: Ask the patient to: "Fill in the numbers of this clock face, and draw in the hands of the clock pointing to 3 o clock

$bound frame ph Mental test scores are the most powerful predictors of outcome following hip fracture, and the early assessment of a patient s residential home institutional care wheel-chair/bed-bound$

12 Pre-operative investigations All patients If indicated Mental state assessment Hb Result Sent Result Clock Face Drawing INR If taking warfarin Patients with suspected hip fracture Admitted from: Home support: Usual mobility: Usual walking aids: What is the time (to the nearest hour) Yes but what does an orthogeriatrician actually do? Assessment Presenting complaint WCC Clotting screen Known dementia Details: Ask the patient to: "Fill in the numbers of this clock face, and draw in the hands of the clock pointing to 3 o clock Platelets Recent memory decline Social circumstances Previous confusion in hospital Na + Liver function tests house living alone able to do own shopping none bungalow living with someone able to get out of home Urea one aid (stick, crutch) Arterial gases downstairs flat living with carer -but unable to shop two aids Creatinine Trauma consultant : upstairs flat home care package Date: home Time: bound frame ph Mental test scores are the most powerful predictors of outcome following hip fracture, and the early assessment of a patient s residential home institutional care wheel-chair/bed-bound Ca 2+ cognitive state is key to anticipating and preventing the onset of delirium. po2 nursing home no fixed abode Albumin Admitting doctor: hospital Bleep Abbreviated number: Mental Test Score Result / 10 pco2 BE Correct Incorrect 8-10 is normal Sent What is your age? 0-7 is abnormal Medication Group & save Blood culture What year is it? Can you repeat this address 42 West Street, X-match... units (see following pages) and I will ask you to remember it at the end of the test What is the name of the place we are in now? Recognition of two people (doctor, nurse etc.) Chest X-ray (if aged >65) What is your date of birth (day and month) K + Pelvis and lateral hip X-ray If liver disease or clinical concern If severe chronic airways disease, or clinical pointer to respiratory failure If concern over possible infection ECG Glucose If possible diabetes Give the year in which the First World War began Give the name of the present monarch Count back from 20 to 0 Can you remember the address I gave you earlier? Senior review or post-take ward round Sputum culture MSU MRSA screen Proforma Events leading to any fall: Drug allergies: Details: Clear story of trip, slip or accident Palpitations, chest pain, SOB Aura, fit, tongue biting, incontinence Dizzy, light headed, pale, sweaty Other associated medical symptoms Temperature Unexplained loss of consciousness Pulse Clock Face Drawing (see back page of assessment form) is an alternative This is a quick, simple test - highly sensitive in identifying cognitive problems, and a validated predictor of hip fracture outcome Systematic scoring is not needed - 'if it looks right, it is right', and abnormalities speak for themselves Diagnosis and management plan Examination MI/angina Heart failure Pacemaker Defibrillator BP Medical history Respiratory rate Hip Details: Fracture Service BM University Hospital of Wales HT DM Asthma/COPD DVT/PE Anticoagulated Jaundice Stroke/TIA Epilepsy Smoking Alcohol/addiction Previous cancer Oxygen saturation Fracture: Underlying cause: Planned procedure: undisplaced intracapsular none / osteoporosis screws displaced intracapsular malignant 2 0 DHS basocervical malignant 1 0 nail 2-part trochanteric bone-cyst hemiarthroplasty multi-part trochanteric Paget s disease THR Hip Fracture Service - Patient assessment document - Johansen, 2012 sub-trochanteric Atypical/bisphosphonate other peri-prosthetic other.....

13 Hip Fracture Assessment pro forma initial management protocols 2012

14 Hip Fracture Assessment pro forma initial management protocols 2012

15 Hip Fracture Assessment pro forma initial management protocols 2012

16 Hip Fracture Assessment pro forma initial management protocols 2012

17 Yes but what does an orthogeriatrician actually do?

$fracture outcome$

18 Frailty Index integrating the results of Comprehensive Geriatric Assessment to predict hip fracture outcome Krishnan, Johansen et al. Age and Ageing (in press) R=0.59, p<0.0001

19 Reducing delirium after hip fracture: a randomised trial Marcantonio et al. JAGS 2001; 49: consenting patients with hip fracture aged >65 (mean 79) years Randomized to usual care, or Geriatrics consultation - pre-op. or <24 hours post-op. - plus daily geriatrician visits Offered a mean of 10 management suggestions per patient - 77% adherence achieved

20 1. Adequate CNS oxygen delivery: Supplemental oxygen to keep saturation >90%, preferably >95% Treatment to raise systolic BP >2/3 baseline or >90 mmhg Transfusion to keep haematocrit >30% 2. Fluid/electrolyte balance: Treatment to restore normal Na +, K +, Glucose Treat fluid overload or dehydration detected by examination or blood tests 3. Treatment of severe pain: Regular paracetamol (1g qds) Early-stage break-through pain: low-dose subcutaneous morphine Late-stage break-through pain: oxycodone as needed 4. Elimination of unnecessary medications: Discontinue/minimize benzodiazepines, anticholinergics, antihistamines Eliminate drug interactions, adverse effects, modify drugs accordingly Eliminate medication redundancies

21 5. Regulation of bowel/bladder function: Bowel movement by post-op. day 2 and every 48 hours Urinary catheter out by post-op. day 2, screen for retention/incontinence Skin care program for patients with established incontinence 6. Adequate nutritional intake: Dentures used properly, proper positioning for meals, assist as needed Supplements: 1 can Ensure (3 cans Ensure for poor oral intake) If unable to take food orally, feed via temporary NGT 7. Early mobilization and rehabilitation: Out of bed on post-op. day 1, and for several hours daily Mobilise with nursing staff as tolerated, such as to bathroom Daily physiotherapy, with OT if needed

22 8. Prevention, early detection, and treatment of major complications: MI/ischemia - ECG, cardiac enzymes if needed SVT/AF - rate control, U&E adjustments, anticoagulation Pneumonia/COPD - screening, treatment, including chest therapy PE - appropriate anticoagulation Screening for and treat UTI 9. Appropriate environmental stimuli: Appropriate use of glasses and hearing aids Provision of clock and calendar If available, use of radio, tape recorder, and soft lighting 10. Treatment of agitated delirium: Appropriate diagnostic workup/management Relieve agitation - calm reassurance, family presence, and/or sitter - if absolutely necessary, low-dose haloperidol/lorazepam

$Reducing delirium after hip fracture: a randomized trial Marcantonio et al.$

23 Reducing delirium after hip fracture: a randomized trial Marcantonio et al. JAGS 2001; 49: Controls CGA n Delirium 64 50% 62 32% * Severe delirium 29% 12% * Duration (days) LOS (days) 5 5 Discharge home 12% 8%

24 OK so how are orthogeriatricians actually doing?

25 Wales Performance data for individual hospitals compared with Wales and Overall figures

$Surgery in 48 hours Excludes patients who were: - in hospital pre-fracture$

26 Surgery in 48 hours Excludes patients who were: - in hospital pre-fracture - died before 48 hours - managed conservatively - medically unfit at 48 hours

27 Received operation before 48 hours (%) UK Wales Haverford West Carmarthen Wrexham Cardiff Llantrisant Abergavenny Swansea Bangor Rhyl Aberystwyth

Web-site data on time to theatre UHW 100 90 80 70 Monthly admissions

28 Web-site data on time to theatre UHW Monthly admissions Mean hours to operation Linear (Mean hours to operation)

29 Pre-operative assessment Best Practice Tariff requires assessment by: - geriatrician or physician - grade ST3 or above

30 Pre-operative geriatrician assessment (%) UK Wales Haverford Carmarthen Wrexham Cardiff Llantrisant Abergave Swansea Bangor Rhyl Aberystwyth Orthogeriatrician Other assessment

31 Network of Orthogeriatrics in Wales (NOW) Survey of existing hip fracture services December 2012 Orthogeriatrician Majority of hip fracture patients will be offered: NHFD Consultant in post Pre-op. OG assessment OG-led rehabilitation Secondary prevention 2012 data reported Abergavenny Aberystwyth Bangor Bridgend Cardiff Carmarthen Haverford West Llantrisant Merthyr Newport Rhyl Swansea Wrexham

$Network of Orthogeriatrics in Wales (NOW) Survey of existing hip fracture services December 2012 0 2 4 6 8 10 12 14 Abergavenny Aberystwyth Bangor Bridgend$

32 Network of Orthogeriatrics in Wales (NOW) Survey of existing hip fracture services December Abergavenny Aberystwyth Bangor Bridgend Cardiff Carmarthen Haverford West Llantrisant Merthyr Newport Rhyl Orthogeriatrician sessions Hip # admissions per week Hours per hip # patient Swansea Wrexham

33 Expansion in OG provision NHFD Facilities Audit

34 No orthogeriatric input Orthogeriatrician assessment

35 NICE Quality Standards QS16

36 NICE economic model room for improvement

37 QS16 focus for an NHFD Sprint Audit - Jointly agreed protocols from admission into EU - Acute ward with continuity of orthogeriatrician-led MDT care - Documentation of goals and early discharge planning - Physio day 1 post-op., then daily mobilisation by physio/nurse - Named clinician from each speciality leading within the HFP - Mortality, LOS, and adverse events monitored in HFP meetings - Follow-up data to show HFP-team influence over IC rehab.

Hip Fracture from audit into action

Hip Fracture from audit into action Antony Johansen Orthogeriatrician Trauma Unit University Hospital of Wales, Cardiff National Hip Fracture Database Royal College of Physicians, London Global projections