Evolutions in Geriatric Fracture Care Preparing for the Silver Tsunami

Transcription

1 Evolutions in Geriatric Fracture Care Preparing for the Silver Tsunami James Holstine, DO Medical Director for the Joint Replacement Center, Geriatric Fracture Center, Orthopedic Surgeon PeaceHealth Whatcom Region Medical Director for Orthopedic Quality, PeaceHealth System Shevaun Rudkin, RN, BSN Program Manager Orthopedics and Neurosurgery Joint Replacement Center, Spine Care Center and Geriatric Fracture Program

2 Disclaimer I am a program consultant and board member of Stryker Performance Solutions / Marshall Steele

3 2011 Prior to Fracture Program 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

4 Clinical Appearance of Hip Fracture

5 2011 Prior to Fracture Program ED Triaged as non-urgent Foley catheter placed Narcotics started for pain control X-rays and labs obtained Spends 4-5 hours in ED

6 2011 Prior to Fracture Program 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

7 2011 Prior to Fracture Program 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

8 2011 Prior to Fracture Program Surgery Surgery completed 11 pm next evening after patient was bumped for more urgent cases Fracture stabilized hours after injury Procedure performed by on-call team

9 2011 Prior to Fracture Program 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

10 2011 Prior to Fracture Program 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

11 2011 Prior to Fracture Program 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

12 2011 Prior to Fracture Program 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

13 Epidemiology of Osteoporosis 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

14 Epidemiology of Osteoporosis 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

15 Osteoporosis In The Elderly 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 75 are osteopenic Less than 20% of hip fracture pts are receiving osteoporosis follow up

16 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 ENTIRE U.S. POPULATION (2010) +27% change from 2010 to 2030 Millions

17 Incidence of Fragility Fractures

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

19 Osteoporosis A Chronic Disease Morbidity Hip fracture Colles' fracture Vertebral fracture Added morbidity from fractures No fractures increasing morbidity due to ageing alone Age

20 Risk Factors for Geriatric Hip Fracture Osteoporosis Dementia Unstable Gait Poor muscle strength Poor vision or neurologic disease Poor nutrition

21 Patients arrive with more than fracture... 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

22 All fractures are associated with morbidity Death within one year 24% Permanent disability 30% Unable to walk independently 40% Unable to carry out at least one independent activity of daily living 80% Cooper. Am J Med. 1997; 103(2A):12s-19s

23 The Vision 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.

24 Programmatic Goals 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

25 Programmatic Goals 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

26 Menu for Success 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

27 Menu for Success 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

28 Documented Clinical Benefits 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

29 Nuts and Bolts of Geriatric Care 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

30 System by System Fly 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

31 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

32 Quick thoughts on handling comorbidities 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

33 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

34 COPD DM May need to avoid Beta Blockers Know patients baseline Early return to regular diet Avoid dehydration Maintain glucose levels less than Hold sulfonamides Renal Disease Avoid NSAIDs Avoid BP changes Avoid fluids with diuretics, not a role for both

35 By the numbers 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 % increase in the 55 and over age cohort in the next 10 years Falls are the leading cause of injury related hospitalizations The rate for hospitalization for falls in Whatcom Co is 1700 per 100,000 population

36 By the numbers LOS for Hip fractures is currently 4.56 days! (5.7 Nationally) DC Disposition % Home Skilled Nursing Facility Hospice Rehab South Campus

37 Hip Fracture Volume by Year Program started Dec 2011

38 GFP Rates * 30-day readmit rate is between 5% and 9% depending on definitions in our institution * 30-day mortality rate is between 2% and 5% depending on whose data we use

39 Questions and Comments

40 Thank You!

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