Solution Title: An Orthopaedics Approach to Population Health Management Development of a Geriatric Hip Fracture Program (GHF)

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2 Solution Title: An Orthopaedics Approach to Population Health Management Development of a Geriatric Hip Fracture Program (GHF) Program/Project Description, including Goals What was the problem to be solved? How was it identified? What baseline data existed? What were the goals how would you know if you were successful? In today s healthcare environment, organizations are continuously challenged to meet the Institute for Healthcare Improvement s Triple Aim, a cornerstone of the revised Global Budget Revenue (GBR) model. The GBR model emphasizes better care, better health and lower costs for all Maryland patients [1]. Until recently, no formalized program had been developed to address a small but impactful patient population seen in our emergency departments. In focusing on optimizing care for a vulnerable patient population, The University of Maryland Upper Chesapeake Health has recently taken many significant steps in this journey to achieve the goals of the Triple Aim. As the population in Maryland continues to age, the number of acute hip fractures presenting to our emergency department will likely continue to increase. To achieve the goals set forth by the Triple Aim, health systems will need to continue to expand their focus on high-risk patient populations that can have an impact on future healthcare resources. A hip fracture in an elderly person is not just a broken bone; it can be a life altering medical condition. It is estimated that only 50% of hip fracture patients return to their baseline activity level prior to the injury and even more staggering is that elderly adults who suffer a hip fracture are 5 times more likely to be placed in a nursing home for continuous care. Most alarming, according to a study published by JAMA in 2013, the estimated 1-year all-cause mortality rate for an elderly hip fracture patient was 24% [2]. There is a growing trend among health systems to address this vulnerable patient population by developing a coordinated Geriatric Hip Fracture (GHF) program focused on improving outcomes by implementing evidence based clinical practice guidelines. The development of a program focuses on expedited surgical intervention, early mobilization, and standardized clinical care pathways following surgery, all factors proven to drastically influence both a patient s clinical outcomes as well as quality of life following a traumatic hip fracture. UM Upper Chesapeake Health sees an average of 220 acute hip fractures each year and nearly 90% require surgical intervention. Knowing that early intervention is key to improving patient outcomes, the UM UCH Department of Orthopaedics wanted to evaluate our current performance with caring for this population to determine if a coordinated Geriatric Hip Fracture program was needed. UM UCH engaged DePuy Synthes Advantage, a program consulting division within Johnson & Johnson, to help evaluate the need for developing a program, DePuy 2

3 Synthes provided four key indicators that are directly associated with improved patient outcomes for acute hip fracture patients: 1. Average Admission to Surgery 2. Average Length of Stay Day All-Cause Readmission Rate 4. One Year All-Cause Mortality Rate UM UCH examined all acute hip fractures treated at either UM UCMC or UM HMH between July 2014 and June 2015 (Fiscal Year 2015). In that period, UM UCH treated 212 acute hip fractures and outlined in Table 1 are the UCH metrics compared to benchmarks provided by DePuy Synthes to measure the performance of coordinated Geriatric Hip Fracture programs. Based on the comparative date outlined in Table 1, the UM UCH Department of Orthopaedics was able to demonstrate to UM UCH Leadership the valve of developing a coordinated Geriatric Hip Fracture Program with a focus on expedited care to achieve improvements in the following key areas: 1. Decrease in Average Admission to Surgical Intervention 2. Decrease in Average Length of Stay 3. Decrease in 30 Day All Cause Readmissions 4. Decrease 1 Year All-Cause Mortality Rate to 16% Table 1: Outcome Metrics UCH compared to GHF Program Benchmarks 2015 UM UCH GHF Benchmarks Admission to Surgery 32h 52m 24h 00m Average Length of Stay Readmission Rate 12.5% 8.0% 1 Year Mortality 24% 16% These indicators are commonly used in the evaluation of a program related to hip fractures with the ultimate goal for any hip fracture program being - #4 Decrease One-Year All-Cause Mortality. Because hip fractures typically occur in elderly adults with multiple medical comorbidities, a hip fracture can be the catalyst event that ultimately leads to a downward spiral in that patients overall health. The ultimate goal associated with developing a program focused on this patient population would be to utilize evidence based best practice, to extend independence and a return patient to their previous function, ultimately decreasing mortality and morbidity in this predominately elderly and more fragile population. Process & Solution What methodology or process was used to develop the solution? What Solution was developed? How was it implemented? IMPRV (Identify, Measure, Process, Re-Think and Validate) is a best-in-class methodology founded upon the key tenets of Lean, Six Sigma, project management, and change management theories. IMPRV provides a structured way for UM UCH teams to identify opportunities for improvement, analyze the situation, and develop a solution to solve the problem at hand. 3

4 In late 2016, UM UCH engaged an outside consultant (DePuy Synthes Advantage) to assist in the management / development of the Geriatric Hip Fracture Program (GHF). UM UCH choose to utilize an outside consultant in this project because DePuy Synthes Advantage had successfully collaborated with over 150 health systems throughout the U.S. to implement GHF programs. In addition, DePuy Synthes had access to the latest in evidence based clinical pathways, standardized order sets, patient and family education materials and data / metric tracking solutions. One of the most critical aspects of the program was to hire a dedicated Fragility Fracture Coordinator to lead the program develop and also act as a patient navigator once the program was implemented. Led by a Fragility Fracture Coordinator and three physician sponsors (2 Orthopaedic Surgeons & 1 Geriatrician), the team applied the IMPRV Methodology to meet their goal as detailed below. Identify: The key objective of the Identify Phase is to clearly define the problem, identify the current state, and develop a solid business justification for executive and organizational sponsorship. The multidisciplinary team consisting of members from Orthopedic Surgery, Nursing Leadership, Medical Staff Leadership, Quality, Geriatric Medicine, IT, Anesthesia, Perioperative Services, Case Management, and Physical Therapy assembled to outline the opportunity for improvement, scope, and goals of the project. Once the team felt they had a keen understanding of the problem to be solved, they moved on to the Measure Phase. Opportunities for improvement identified were as follows: Standardized geriatric friendly order sets, care plans Standardize admitting service criteria upon ED arrival Standardized patient assessment guidelines/processes Geriatric pain management standardization Anti-coagulation reversal guidelines Operative suite availability Urgency of intervention Delirium diagnosis and treatment Co-ownership of patient throughout process Patient aggregation Osteoporosis assessment and management Setting expectations and communication of plan of care Measure: In the Measure Phase the team worked to further understand the current state of the process and collect sound data on process performance. All key stakeholders were asked to complete a current state survey outlining how each discipline cared for hip fracture patients at UM UCH. The workflow was evaluated, stakeholder surveys were conducted, and the following data was collected: Ed arrival to admission (average in hours) Admission to surgery (average in hours) Length of stay (average in days) Mortality rate (in house) 4

5 % cases complicated by pneumonia % cases with drug induced delirium % cases with UTI not present on admission % cases with hospital acquired injury not present on admission % cases with decubitus ulcer not present on admission % cases with DVT/ PE % cases readmitted in 30 days (all cause) % cases with post-discharge ED utilization (all cause) Average cost per case Current State Process: Survey Results: Lack of Pre-Operative communication Need for ED Order Set Need for better Staff Communication Need shared patient ownership or hospitalist should own PT Patient and Family communication should start earlier Patient urgency to OR is not standard and very fluctuating Standardization of practice inconsistent Need for more established care/coordination Need for weight baring standardization Admission order sets are in place, but not being used Baseline Data: Figure 1: UM UCH FY 2015 Process and Demographic Indicators 5

6 Figure 2: UM UCH FY 2015 Quality of Care 7 Patient Safety Indicators, Discharge Destination, and Financial/ Efficiency Indicators Process: During the Process Phase, the team used the process and performance information from the Measure Phase to assess and analyze process data, perform root cause analysis for potential issues, and identify waste and inefficiency. The team recognized multiple opportunities for improvement. The existing Geriatric Fracture Program was divided into several phases with the average amount of time a patient spent in each of those phases also included from observations and data analysis. The purpose of breaking down the overall process into different phases was to help identify potential areas of focus for improvement. Within each phase of the process, there were several opportunities and root causes identified: ED Floor o Standardize the admission process (attending, orders, pathway) o Early diagnosis & treatment o Patient & family education on hip fractures Floor Surgery o Establish medical ownership of patient o Expedite medical clearance o Establish cardiac evaluation / management recommendation Surgery Discharge o Inconsistent medical / surgical ownership of post-operative care o Delirium awareness / education o Geriatric friendly order sets / clinical pathways o Lack of patient navigation o Inconsistent case management / discharge planning o Gaps in communication with family / patient / providers o Patient & family education 6

7 In addition to opportunities present in each phase of the process, there was an overall gap in coordinating care identified through observations and surveys. Improving the coordination of care was a key guiding principle as the team moved to the Re-think phase. Re-Think: The main objective of Re-Think is to design a safer and more efficient process. During this phase we outlined a full-scale implementation plan of our improvement solutions. Outlined below is a GHF Patient Flow Goal outlined during Re-Think to highlight solutions and the overall impact on a patient s length of stay: Our solutions are as follows: Solution 1: Hire Fragility Fracture Coordinator When UM UCH received approval to move forward with the development of a GHF Program, it was evident that we needed a dedicated coordinator to manage the program and act as a patient care navigator. UM UCH has been successful in other clinical service line programs (joint, spine, bariatric and stroke), with hiring a coordinator / program manager to implement, monitor and sustain all aspects of the clinical program. Prior to implementing the IMPRV process, UM UCH leadership approved the recruitment of a clinical professional with experience in patient navigation, case management, program development and orthopaedics. In the fall of 2016, UM UCH hired Rosemarie Palmere, RN as the Fragility Fracture Coordinator. Solution 2: Standardized Hip FX Order Set and Clinical Pathway (Emergency Dept, Admission and Post-Op) The initial step in the patient process was focused on updating the Emergency Department orders. The current orders were vague and did not clearly delineate the steps to diagnose and prepare a patient for medical evaluation. This led to delays in treatment and inconsistency as to what was done prior to admission. The following solutions were identified to address these issues: 7

8 Possible signs/identifiers were developed to assist the ER nurses in identifying a probable hip fracture, allowing for early x-ray to confirm. Once the hip fracture is confirmed, orders were set in place to begin the pre-op clearance process in the Emergency Department; orders included lab work, EKG, Foley catheter placement and chest x-ray. The Hip Fracture Admission Order Set was developed with an interdisciplinary partnership between medicine, orthopaedic surgery, anesthesiology, cardiology and nursing. The goal was to use medications that would treat pain without creating delirium. Fragility labs were included to identify osteoporosis markers for post-op follow up care. Using best practice, a new policy was established to identify which patients needed cardiac clearance prior to surgery in an effort to decrease unnecessary delays resulting from awaiting clearance. Proper identification of the appropriate attending group allowed for medicine to manage the majority of hip fractures, further expediting clearance and streamlining the preoperative care for hip fractures. In addition, a new order for intraoperative block placement for pain management was added to facilitate multimodal pain management protocols and oral tranexamic acid was added to decrease intra-operative bleeding. Finally the Hip Fracture Post-Op orders were designed to decrease delirium and allow for timely discharge to the appropriate post-acute setting. The nursing department completed mandatory delirium training to differentiate between delirium and dementia. Timely identification of delirium allows for early intervention. A CAM assessment was added to the orders as a nursing intervention to be completed every shift. All medications were reviewed by a Gerontologist trained hospitalists for avoidance of known delirium causing agents. Orders were created to monitor for urinary retention, to further aid in avoiding delirium. And the orthopedic surgeons used a risk stratification protocol to choose appropriate anticoagulation with the goal of not placing the patient in risk of developing an unwanted postoperative hematoma. And during our monthly Steering Committee Meetings, we identified additional areas of focus on delays in discharge for this population secondary to constipation so medications to facilitate bowel movements was added to prevent delay. Solution 3: Develop Navigation Support Model The nurse navigator role was developed to assist in program development and facilitation of protocol roll out. The navigator is the primary point of contact for the patient and family during and after the hospital stay. Their primary responsibilities include conducting initial patient assessments, patient and family education, daily rounding, facilitating communication between the nursing team and providers, discharge planning, and follow up care coordination. Patients receive follow up phone calls 30 days and 90 days after their procedure to ensure post-operative care and osteoporosis follow-up are being completed. Solution 4: Delirium Assessment Protocol and Order Set 8

9 Nurse education and shift evaluation for delirium is essential for early identification and treatment of delirium. Conducting nursing assessments for urinary retention with bladder scan can expedite the removal of Foley catheters. IVF orders provide nursing with guidance to follow I&O s and communicate with medical service for prevention of dehydration and inability to void. The nurse educators developed a Delirium Education Module which defines delirium, identifies symptoms, and explains why recognizing and caring for delirium patients is essential. Education on differentiating delirium verses dementia is mandatory for the orthopedic nurse. Solution 5: Patient/ Family/ Staff Education Materials Early patient and family education is important aspects of care for elderly patients suffering from a hip fracture. Since hip fractures can exacerbate other medical conditions in elderly patients, providing information to patients and family on the benefits of early intervention, mobilization, activity and rehabilitation are critical to ensuring patients return to their pre-injury baseline. Patient education is done through one on one discussion, written handouts and follow-up phone calls. Patients are given written material as early as in the ED to explain hip fracture and discharge needs and planning. Patients are then visited in the hospital by the nurse navigator and receive a phone call for osteoporosis follow up. In addition, the clinical team caring for this patient population is provided the education through monthly departmental staff meetings and at first monthly, now quarterly interdisciplinary meetings. Solution 6: Development of Co-Management Model / Admission Criteria Co-Management was a crucial process for identification of the appropriate provider and resources for the hip fracture patient. By spelling out specific criteria for admission to the hospitalist service verses the orthopaedic surgical service. This structure allowed for only low risk patients to be admitted to the orthopedic service, permitting the hospitalist service to take patients with significant co-morbidities who would require closer monitoring and management. The Co-Management Model requires the development of a document that outlines admission criteria and clear delineation of responsibilities for each service. The agreement is then officially approved and presented to each department and the clinical team. The delineation allowed for earlier clearance and better medical management. In addition, the Co-Management model provided the clinical team with clear guidelines on which service (orthopaedics or medicine) to contact to resolve any acute concerns. This gives nursing a clear pathway to follow for expedited and accurate follow-up in the post-operative period. Based on the delineated responsibilities we saw a reduction in length of stay and readmissions with the implementation of the program. There was a noted improvement in outcomes for the hip fracture patients and communication between the clinical team. Solution 7: Development of Perioperative Cardiac Evaluation and Management Policy Restructuring the current pre-operative clearance enabled more efficient use of physician time, and resulted in appropriate referrals. The new policy was evidence based best practice as recommended by the American College of Cardiology, and the American Heart Association and was developed in conjunction with Cardiology, Anesthesia and Internal Medicine. Through streamlining the process, we saw a decrease in delay of surgery and a decrease in unnecessary 9

10 cardiac testing. Improved physician productivity and efficiency was also noted. By developing a hospital policy, the physicians felt reassured they had hospital support to follow evidence based guidelines for cardiac evaluation and management. This helped to redirect efforts towards patients that truly needed cardiac consultation prior to surgery. Solution 8: Incorporation of GHF Team in Interdisciplinary Rounds Use of interdisciplinary rounds was instituted at UM UCH a year ago to improve communication and care coordination. This new model of care provided a platform that allowed the GHF team be interactive on a daily bases with the clinical team caring for hip fracture patients. Improved communication and decreased errors is essential when more than one discipline cares for a patient and one of the primary components of the GHF program was care coordination for this population. Improved outcomes and decreased readmissions were a direct result of good team work and clear lines of communication. The incorporation of the GHF team into the rounding process provided the framework for adherence to the clinical pathway. Validate: The key objective of the final phase of IMPRV is to complete solution implementation, ensure process accuracy, and provide comprehensive training on the solutions to ensure sustainment. Measurable Outcomes What are the results of implementing the Solution? Provide qualitative and/or quantitative results to data. (Please include graphs, charts, or tools.) In April 2017, UM UCH officially launched the Geriatric Hip Fracture Program at UM Upper Chesapeake Medical Center and UM Harford Memorial Hospital. Initially the program was successful by increasing the collaboration between orthopaedic surgeons and internal medicine providers in caring for hip fracture patients. Additionally, the program heightened the sense of urgency with the clinical team to expedite clearance and surgical intervention, a critical success factor in improving outcomes for hip fractures. The program also helped improve the care coordination between the hospital and post-acute care facilities. The Fragility Fracture Coordinator met with the Director of Nursing s for each local skilled nursing facility to overview the program and expectations associated with caring for a post-op hip fracture. And our ultimate goal is to expand this collaboration by evaluating what services can be safely offered at a skilled nursing facility to decrease the acute hospital length of stay. The Geriatric Hip Fracture program also expanded the clinical teams awareness regarding the impact delirium can have on an elderly post-operative hip fracture. Focusing on appropriate medications and interventions to limit the risk of delirium have been helpful in combating significant delays in recovery associated with delirium. UM UCH is currently working on expanding the delirium screening process for all patients within the health system, highlighting the importance of screening and early intervention. 10

11 The program also provided our team with an opportunity to engage patients and families in postinjury follow-up to ensure the underlying cause of the injury was identified and treated. Most hip fractures are a result of poor bone density and treating the underlying condition can have an impact of future injury. All of the above outlined benefits and solutions helped contribute to the initial impact of the GHF program on key indicators that were outlined in the program justification. Outlined below is a review of pre-program metrics compared with data collected from a newly created UM UCH Hip Fracture Registry. The pre GHF metrics were based on outcome measures captured in Fiscal Year 2016 and the post GHF program results were from April 2017 September 2017 (6 months). As outlined in the original justification, key indicators for program success included time intervals for ER Admission, Admission Surgery and Length of Stay. In addition the program focused on the key quality outcomes of readmissions and one-year all-cause mortality for this particular patient population. Since a component of the program is post discharge follow-up, the program will be able to demonstrate the impact on mortality within 18 months. Apr-Sept ED Arrival - Admission (Hours) Pre GHF Post GHF HMH UCMC Admission - Surgery (Hours) Pre GHF Post GHF HMH UCMC Length of Stay Pre GHF Post GHF HMH UCMC Day Readmission Rate Pre GHF Post GHF HMH 11% 4% UCMC 13% 6% 12% 5% Co-Management 85% 95% As a result of implementing the GHF program, UM UCH demonstrated an immediate decrease in several key metrics. The impact was minimal on the ED-Admission average time (only 18 minutes), however, the revised order sets and the focus on early medical evaluation resulted in a drastic decrease of almost 9 hours from the average admission to surgery metric, resulting in an n=96 11

12 average time from admission to surgery of 24.0 hours. As a result, UM UCH also observed a significant impact on overall length of stay (0.5 day reduction) based on expedited surgical intervention and implementing clinical best practices for recovery. And finally, the navigation program had a significant impact on the 30 day readmission rate for this population, resulting in a 41% decrease in just the first 6 months. Sustainability What measures are being taken to ensure that results can be sustained and spread? The GHF program will be continuously monitored through a quarterly GHF Steering Committee that is composed of key stakeholders caring for hip fractures patients and run by the Fragility Fracture Coordinator. The results of program success will be monitored and reported to the Patient Safety and Quality Council and the Medical Executive Committee to ensure all levels of leadership are focused on the sustainability of the GHF program. UM UCH has also implemented a GHF registry to track all patient both in the hospital and once discharged to ensure navigation support continues to return patients to their pre-injury activity level. The GHF team will continue to participate in Interdisciplinary rounds to ensure adherence to clinical pathways and the GHF Steering committee will continue to evaluate extended lengths of stay or opportunities to improve the GHF program to maintain patient outcomes outlined in the program justification. The Fragility Fracture Coordinator will maintain program oversight of the GHF program and shares the responsibility with two additional program coordinators within the Clinical Service Line program at UM UCH. UM UCH has committed to improving the care provided to patients and families suffering an acute hip fracture at UM UCMC and UM HMH and the program structure outlined will ensure the program continues to improve and provide a consistent and coordinated approach to hip fractures in our community. Role of Collaboration and Leadership What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership support demonstrated? Teamwork was paramount to the success of this program. Due to the complexity of caring for this patient population, the development of this program required collaboration between 5 physician specialties (anesthesia, emergency medicine, internal medicine, cardiology and orthopaedics), spanning 2 acute hospitals and 12 hospital departments (emergency room, operating room, acute nursing, rehabilitation, case management, and performance improvement). The planning and implementation of this program included both front line and management staff for each department, ensuring the program had buy-in and support from all levels. Executive and physician leadership played a critical role in the development of the Geriatric Hip Fracture program. Following the site survey, the consultant s highlighted that UM UCH had strong physician champions and leadership support to change the way we care for this population. Our executive leadership team supported the program by allocating financial resources (FTE, consulting fees, and conference support), performance improvement / 12

13 administrative resident support and expedite committee approval). The physician support was demonstrated through numerous planning meetings for order set development, co-management planning, patient throughput meetings, education development and discharge planning. In addition, two of the physician champions attended a conference on Co-Management of the Elderly Hip Fracture that was funded by UM UCH and the knowledge gained during the conference was used to develop appropriate order sets and clinical pathways to enhance the GHF program. Innovation What makes this Solution innovative? What are its unique attributes? The GHF program included several new and innovative solutions that resulted in improved outcomes. The first innovative solution was the development of a Co-Management Model with Orthopaedics and the Hospitalist Service. For years, the two programs have debated on who is the appropriate admitting service for patients with hip fractures and the current UM UCH Admission policy was vague and open to interpretation. Developing a Co-Management model allowed both specialties to identify criteria for admission to the appropriate service and since implementation we have had complete adoption and eliminated the conflict between these two specialties. In addition, the Co-Management model outlines which provider should be called for specific concerns, i.e. the orthopaedics surgeons are responsible for post-op pain, rehabilitation and wound management and the hospitalist are responsible for delirium, hypertension urinary retention and glucose management. These clear lines of delineation have helped the clinical team with directing phone calls and questions to the appropriate discipline and has drastically decreased the unnecessary calls to both specialists. The GHF program also expanded the use of Experal to hip fracture patients. Experal is a liposomal bupivacaine injection that can provide regional pain control for up to 72 hours, decreasing narcotic usage for patients that have a higher risk of delirium and are potentially opioid naïve. In addition to expanding the use of Experal, the GHF program also adopted a clinical best practice from the Joint Center program and initiated a risk stratification program for VTE prophylaxis. Since the risk of post-operative bleeding is higher in this patient population, low risk patients were placed on a full strength aspirin & sequential compression device (SCD) protocol and moderate to high risk patients are prescribed a stronger anti-coagulation medication to prevent DVTs. Culture of Safety What impact did the solution have on the culture of safety within the organization? UM UCH recognizes the risks to the patients who have delays in surgery and the impact it can have on outcomes. By expediting surgical intervention and providing a coordinated model of care for hip fractures patients, we can directly impact the lives of our community. The most significant figure outlined during the justification of this program was the one year all-cause mortality rate (24%), based on our annual hip fractures volumes (220/year), that translated to 52 13

14 individuals within our community that pass away after suffering a hip fracture. Following the implementation of a GHF program, other GHF programs have seen the mortality rate drop to between 10-16%, impacting a potential people within our community each year. That factor alone was significant justification to both physician and executive leadership in allocating the necessary resources to implement this program and change the culture within our organization to improve care to a small but impactful population. Patient and Family Integration How did the solution include the patient and family? Since hip fractures can have a significant impact not only on the patient s life but also the family, one of our key solutions involved developing a patient/family education handbook. A Hip Fracture flyer is provided in the Emergency Department to any patient diagnosed with a hip fracture, the flyer defines a hip fracture and explains surgery / recovery and prepares families to start planning for discharge to a local sub-acute rehabilitation facility. In addition a Hip Fracture Handbook was developed and provided to patients and family once they are admitted to the nursing unit being prepared for surgery. The handbook outlines general information on what is a hip fracture, how is it repaired, who is your care team, outlines recovery, what is osteoporosis and sample exercises to strengthen muscles after surgery. Conclusion The development of the GHF program at UM UCH has been successful in increasing communication and collaboration within the clinical team, resulting in an immediate impact on key metrics of success. However the program is still developing and the impact on our community is still yet to be seen but the UM UCH clinical and executive team are confident that the implementation of the GHF Program will have an impact of countless families who will continue to share memories with their elderly family members after they suffer from an acute hip fracture. We truly believe that this program will have a drastic impact on our community and we thank you for the opportunity to share our journey with you. Related Tools and Resources [1] The Triple Aim: Care, health, and cost. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs May/June;27(3): [2] Hung, W. W., Egol, K. A., Zuckerman, J. D., & Siu, A. L. (2012). Hip Fracture Management. JAMA, 307(20), Nathaniel Albright, FACHE AVP, Clinical Service Lines Upper Chesapeake Health NAlbright@uchs.org Contacts Tennile Ramsay Patient Safety Officer Upper Chesapeake Health tramsay@uchs.org 14