Role and impact of orthogeriatric service in the hip fracture care pathway: 15-year experience

Transcription

1 Role and impact of orthogeriatric service in the hip fracture care pathway: 15-year experience AA Fisher, MW Davis Department of Geriatric Medicine, The Canberra Hospital, and Australian National University Medical School, ACT, Australia

2 Background In developed countries population ageing is associated with a fracture epidemic, particularly hip fracture (HF), and the outcomes are often disappointing. The number of HFs could increase in Australia 1.6-fold by 2021( Fisher et al 2009).

3 Background Although surgical repair of the fracture is crucial, co-morbidities and perioperative complications are the main factors determining the outcome. In older patients, concomitantly with their hip fracture (HF) generally multiple co-morbid conditions and complicated social problems should be managed, but the involvement and responsibilities of geriatricians in providing care pathway (CP) have not been clarified. The optimal model of orthopaedic-geriatric comanagement is uncertain.

4 Major postoperative complications and in-hospital mortality in patients undergoing noncardiac surgery age (Polanczyk CA et al. Ann Intern Med 2001; 134:637) In-hospital mortality Cardiac complications Noncardiac complications Overall major complications The knowledge base of both surgery and medicine is growing rapidly; no individual practitioner can remain expert in both fields. Although multidisciplinary approach to manage hip fracture (HF) patients is widely accepted and most studies showed that care pathways (CPs) positively affect process management and health resource use, there is still a lot of debate and uncertainty regarding the impact of CPs on clinical outcomes.

5 Background Eur J Orthop Surg Traumatol Sep 25. [Epub ahead of print] The effect of care pathways for hip fractures: a systematic overview of secondary studies. Leigheb F, Vanhaecht K, Sermeus W, Lodewijckx C, Deneckere S, Boonen S, Boto PA, Mendes RV, Panella M. This recent systematic review concluded that available evidence is insufficient for formal recommendations of CP. CPs as complex interventions designed to optimise clinical outcomes and resource utilization are mainly focused on implementation of standardized protocols based on best available evidence. However, the need of individualisation and the role and contribution of different specialities is often poorly addressed.

6 Aims To describe a co-managed (between orthopaedic surgeons and geriatricians) model of CP for HF patients with geriatrician-led integration of medical, rehabilitation and social care; To identify the main areas of need for medical intervention in orthogeriatric patients; To highlight the special role(s) of a geriatrician in solving a wide range of diverse peri-operative problems; To analyse the impact of orthogeriatric service on outcomes.

7 Methods Prospective observational study of more than 3500 older ( 60 years) patients with HF over a 15 year period ( ). The database includes socio-demographic, medical, surgical, laboratory and functional data. Presentation and analysis of the full spectrum of elements of perioperative orthogeriatric service as a part of CP in a tertiary university hospital: evaluation of co-morbidities, peri-operative non-surgical needs and complications, risk factors and predictors of poor outcomes; individualized short- and long-term preventive and treatment strategies; integration and coordination of the multidisciplinary team.

8 Results Proportion (%) of older patients (>60 years) (The Canberra Hospital, 2007) All adult patients Surgical patients Orthopeadic patients Orthopaedic patients (>60 years): Represent 35.5% of all adult patients, Consume 49.9% of all bed-days, Have multiple pre-fracture chronic diseases (4.6 diagnoses per patient on average).

9 The orthogeriatric service In our hospital a geriatric HF clinical CP started in The orthogeriatric service (one full-time geriatrician and registrar) includes: early assessment (often in the emergency department), daily clinical care and optimising medication used, weekly ward rounds shared with the orthopaedic team, nurse, pharmacist, physiotherapist and occupational therapist, coordinated planning of the surgery schedule, post-operative ambulation, time and destination of patient discharge.

10 The Model for Combined Orthogeriatric Management of Older Adults With Hip Fracture at The Canberra Hospital Older patient with hip fracture Emergency Department Unstable, severe acute problems Medical geriatric advice (routinely or on request) Stable Admission to Coronary Care Unit, ICU or Acute Care of the Elderly Unit Admission to orthopaedic ward Pre-operative geriatric and anaesthetist evaluation

11 SURGERY Unstable Stable Admission to ICU or CCU Stable Return to Orthopaedic ward Geriatric daily management Medical problems Complications Functionally oriented rehabilitation Social problems Discharge planning Home Residential care facilities Discharge Follow-up after discharge Transfer to another hospital for rehabilitation Transfer to Geriatric ward Assessment in Falls Clinic Domiciliary nursing and/ or social service (e.g meals on wheels) Domiciliary occupational and physiotherapy

12 Pre-operative care issues Preparing and optimising elderly patients for early surgery (door-totheatre time hours), Adequate analgesia, Maintenance of good hydration but avoiding fluid overload (high rates of congestive cardiac failure in this population!), Identifying comorbidities and risk factors for peri-operative complications (e.g., myocardial injury, acute gastrointestinal haemorrhage,etc) and poorer outcomes, Reversal of antithrombotic therapy, withheld of anti-platelet agents and nonsteroidals and proper anticoagulation when indicated (e.g., metallic heart valve), Pressure ulcers prevention, Prophylactic antibiotics and Reducing unnecessary consultations by other medical specialists.

13 Post-operative care issues Early mobilisation (on the first post-operative day), Prevention and treatment of haemodynamic instability (especially orthostatic and/or postprandial hypotension), Blood transfusion (where appropriate), Maintenance of adequate hydration and nutrition (protein supplements), Further investigation and management of comorbidities (including osteoporosis and causes of falls), Rationalisation of medications (anti-hypertensives, anti-depressants), Adequate anti-osteoporotic therapy (triple: specific anti-osteoporotic agent, vitamin D and calcium supplement), Prophylactic anticoagulation for 6 weeks, Coordination of functionally oriented nursing and paramedical care, Early goal setting and discharge planning and Notification of primary care physicians.

14 Prevention and treatment of post-operative complications Anaemia Infections Delirium Thromboembolic complications Acute coronary and cerebrovascular events Pulmonary complications (atelectasis, pneumonia, fat embolism) New arrhythmias Hyponatraemia Oliguria Urinary retention Renal failure Constipation Gastrointestinal bleeding Pressure sores

15 Risk factors (Independent predictors) Although clinical characteristics and incidence of poorer short-term outcomes in patients with cervical and trochanteric HF are similar, the risk factors for certain outcomes are site-specific reflecting differences in underlying mechanisms and indicating the need for an individualized approach (Fisher et al 2012).

16 Independent risk factors for short-term outcomes in older patients with hip fracture by fracture site. CAD, coronary artery disease; LOS, length of hospital stay; RCF, residential care facility; ctni, cardiac troponin I; CRP, C-reactive protein; (-) negative effect

17 Risk factors (Independent predictors) For peri-operative myocardial injury (with cardiac troponin rise): in patients with cervical HF: dementia, smoking and renal impairment, in patients with trochanteric HF: coronary heart disease (CAD), hyperparathyroidism (serum PTH >6.8 pmol/l) and hypoleptinaemia (<12ng/ml); For prolonged length of stay (> 20 days): in patients with cervical HF: CAD in patients with trochanteric HF: age >75 years and hyperparathyroidism

18 Risk factors (Independent predictors) For institutionalisation: in patients with cervical HF: age >75 years, dementia and vitamin D incufficiency(25(oh) D<50nmol/l), in patients with trochanteric HF: age >75 years, dementia and hyperparathyroidism, For in-hospital death: in both groups hyperparathyroidism in patients with cervical HF also male sex and low leptin levels, For acute upper gastrointestinal haemorrhage: in both groups: prefracture use of aspirin, clopidorgel, nonsteroidals, history of peptic ulcer disease and current smoking

19 Post-operative myocardial injury Elevated cardiac troponin (ctni) and main outcomes in older hip fracture patients (multivariate regression analysis)* ctni (μg/l) Outcome OR 95% CI P value >1.00 In-hospital mortality >0.06 Length of stay>20 days >0.06 Discharge to long term residential care facility *Adjusted for age, sex, history of CAD, stroke, dementia, ASA score 3, current smoking Screening for perioperative myocardial injury Improves outcomes (by minimizing unnecessary delays in surgery and premedication with a beta-blocker) Useful for prognosis

20 Post-operative oliguria (PO) and short - term outcomes Outcome PO No P value PRESET PO Troponin I rise,% LOS>20 days, % In-hospital death, % Post-operative oliguria is associated with higher incidence of postoperative myocardial injury, prolonged LOS and in-hospital death

21 Haemodynamic changes and post-operative oliguria (Multivariate regression analysis) Factors Odds Ratio 95% Confidence interval P Value Decrease in SBP 10 mmhg <0.001 Decrease in DBP 10 mmhg <0.001 Increase in HR 10 b/min A post operative fall in SBP and DBP for each 10mmHg increases the probability of PO by 36% and 127%, respectively - A rise in heart rate by each 10 beats/min increases the probability of PO by 49%

22 Predicting post-operative oliguria (Multivariate regression analysis) Factors Odds Ratio 95% Confidence interval P Value Age Gender Dependent mobility <0.001 Atrial fibrillation ASA class Diuretics Pre-operative Positive fluid balance(500ml/hr) The independent predictors of PO in this model are preoperative positive balance( 500 ml/h) and dependent mobility

23 Predicting post-operative oliguria by combination of selected clinical characteristics Preoperative positive fluid balance ( 500 ml/24 hrs.) and Odds Ratio 95% Confidence interval P Value ASA class Dependent mobility <0.001 ASA class and mobility <0.001 The OR for developing PO increases significantly when preoperative positive fluid balance is combined with higher ASA score (OR=1.65), dependent mobility (OR=6.6) or both (OR=8.3)

24 Sequence of events leading to the development of post-operative oliguria APO Compensatory Heart Rate Organ Hypoperfusion Peripheral Resistance Stroke Volume

25 Risk factors for acute upper gastrointestinal haemorrhage in older hip fracture patients (multivariate analysis) Factor OR (95% CI) P-value History of peptic ulcer 4.3 ( ) Current smoker 3.1 ( ) Blood group ( ) Aspirin 6.9 ( ) Aspirin and/or clopidogrel 6.5 ( ) COX-2 inhibitor 4.9 ( ) *Adjusted also for age, sex, type of hip fracture and number of comorbid conditions.

26 Risk factors for permanent institutionalisation post HF repair (Multivariate logistic regression analysis) Factor OR 95% CI P value Dementia Elevated troponin (>0.06μg/L g/l) Anaemia (pre-operative Hb <120g/L) Age >75 years Trochanteric HF

27 Complication prevention In patients with risk factors for myocardial injury: Preventive use of a beta-blocker. In patients with risk factors acute upper gastrointestinal haemorrhage: Preventive use of a proton pump inhibitor (Fisher et al 2007; Fisher et al 2009).

28 Outcomes Implementation of the integrated CP with comprehensive orthogeriatric service resulted in significant reductions in morbidity and in-hospital mortality, and increases in optimal postoperative care.

29 In-hospital mortality 8% 7% % 6% 5% 4% 3% 7.7% 4.7% 3.9% 2% 1% 0% In-hospital mortality of older HF patients significantly decreased after combined orthogeriatric care was introduced.

30 % Post-operative medical complications Sepsis Delirium Pneumonia DVT/PE GI Bleeding UTI Pressure sores ACS CVA p<0.001 % 80% 60% 40% 20% 0% 70% 49.5% 37.90% Total Incidences (%) of main post-operative medical complications in older patients with hip fracture (*=p<0.05) * * * * * * * * (n=504) (n=447) Joint orthogeriatric care resulted in a significant reduction in postoperative medical complications including sepsis, delirium, pneumonia, urinary tract infection, GI bleeding, thromboembolism, pressure sores, acute coronary and cerebrovascular syndromes.

31 Effect of preventive use of proton pump inhibitors in older patients with hip fracture and risk factors for acute upper gastrointestinal haemorrhage (AGIH) Older patients with hip fracture (n=822) RFs for AGIH present, not treated n=134 (16.3%) RFs for AGIH identified and treated n=139 (16.9%) No RFs for AGIH, not treated n=549 (66.8%) AGIH n=18 (13.4%) AGIH n=1 (0.72%) AGIH n=1 (0.18%)

32 Use of pharmacological thromboprophylaxis 100% 80% % 60% 40% 63% 94% 98.70% 20% 0% The number of patients receiving specific pharmacological thromboprophylaxis with low-molecular-weight heparin or unfractionated heparin increased significantly.

33 Use of anti-osteoporotic therapy NS p= % % 80% 60% 40% 94% 97% 69% % 0% 12% 14% 12% On admission On discharge After establishing the orthogeriatric service anti-osteoporotic treatment for secondary fracture prevention has progressively increased.

34 Rehospitalisation to medical wards % 30% 25% 20% 15% 10% 5% 0% 28.0% 7.0% 5.4% The rate of rehospitalisation within 6 months after hospital discharge for HF decreased significantly.

35 Outcomes (summary) In 2011, compared to the period when medical problems were managed only by consultations medical complications decreased by 34.7%, length of hospital stay by 11%, in-hospital mortality by 3%, acute upper gastrointestinal haemorrhage by 88.8% rehospitalisation (within 6 months) by 21.4%, In 2011: specific thromboprophylaxis received 97% anti-osteoporotic therapy 89%, followed-up in our outpatient clinic 14.6%

36 Conclusions A comprehensive orthogeriatric service should be viewed as an essential and effective component of an integrated CP for older HF patients. Combined orthogeriatric care raises clinical standards and improves outcomes. Such model recognizes the significant diversity of HF patients, helps to overcome difficulties in providing concomitantly both standardized protocols and individualized therapy and results in better outcomes by reducing major postoperative complication and mortality.

37 Take home message: A physician in a surgical ward is not a wolf in sheep s clothing and may be helpful in providing optimal perioperative care.

38 European Care Pathways conference Supporting safe, effective, person centred care, through the use of care pathways Grand Central Hotel, Glasgow 20 th and 21 st June 2013 Follow the conference on twitter at #ecpc13