Appendix 1A. Process flow for in-hospital management of COPDexacerbation The in-hospital management of COPD-exacerbation includes three core processes: 1. Diagnostic assessment 2. Pharmacological management 3. Non-Pharmacological management The next pages show the three core processes and an overview of the underlying key interventions.
Diagnostic tests Medical anamnesis
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Appendix 1B. Fracture Process flow for in-hospital management of Proximal Femur The in-hospital management of PFF includes three core processes: 1. Immediate Ambulance and Emergency Department management 2. Routine and hip fracture specific surgical management 3. Post-operative care and management The next pages show the three core processes and an overview of the underlying key interventions. European Pathway Association, ivzw, 2012 5
IMMEDIATE AMBULANCE AND EMERGENCY DEPARTMENT MANAGEMENT Clinical presentation Local physical examination Pain assessment & management Inability to bear weight Fractured leg lies shortened and externally rotated Inability to lift heel from bed whilst lying supine Localization and intensity IV/(IM) opiods (convert to oral analgesia after 2-3 days)/ paracetamol / NSAID (IV,IM,Oral) Medical history & examination Medical history/anamnesis. General physical examination. Examination Functional status and premorbid mobility Premorbid mental and cognitive function Current mental and cognitive function Social status Comorbidity Current medications (some predispose to falls) Previous fall Concomitant bone and soft tissue injuries Pre-existing pressure ulcer assessment Pressure ulcer development risk assessment Screening for respiratory and urinary infection MRSA screening BMI Fluid balance Continence Temperature Pulse Blood pressure Oxygen saturation (oxymetry continued up to 72 hours after operation) of Radiologic investigations & type of surgery. X-rays of affected hip: antero-posterior pelvis/ lateral view Decide on type of surgical intervention* If fracture is not confirmed by X-ray: Repeat X-rays, but delay of 24-48 hrs MRI (if diagnosis is unclear) CT (or Isotope Bone Scan) (if MRI is not available) Intra-capsular o Total arthroplasty o Hemi arthroplasty o Internal fixation Extra-capsular o Extarmedullary fixation o Intramedullary fixation o Arthroplasty o (External fixation) FRACTURE IS CONFIRMED AND OPERATION SHOULD BE PERFORMED WITHIN 24 HOURS AFTER ADMISSION * Except in patients for which conservative management is indicated European Pathway Association, ivzw, 2012 6
ROUTINE AND PFF SPECIFIC SURGICAL MANAGEMENT Routine surgical management Blood examination ECG Chest X-ray Urine sample Full Blood Count Hb-Hct o If severe anaemia, than blood transfusion Blood group and blood crossmatch Prothrombin / INR Urea, electrolytes and creatinine Blood glucose PH, protein, ketones, glucose, blood, (urine culture, when UTI is suspected) Traction is not recommended Analgesia Keep analgesia as before (ensure it is adequate) PFF specific surgical management Antithrombotic prophylaxis Antibiotic prophylaxis Pharmacological, from admission (consider stopping 12 hours before surgery and restarting 6 12 hours after surgery) & continued for at least 4 weeks: LMWH, or UFH (if renal failure), or Factor Xa-inhibitors starting 6 hours after surgery Mechanical, from admission & continued for at least 4 weeks: anti-embolism stockings (except contraindication) (or IPC/FI devices, if available) 30-60 minutes before operation single standard therapeutic dose If surgery takes longer than 3 hours or blood loss > 1500 ml, than a second dose, after fluid replacement If arthroplasty, than consider up to 24 hours of proph. Operation Anaesthesia Urine catheterization is not recommended Lumbar plexus/ femural nerve block Epidural analgesia Start surgical operation with anaesthesia Wound drain not always required European Pathway Association, ivzw, 2012 7
POST-OPERATIVE CARE AND MANAGEMENT Early postoperative care & management Adequate analgesia Oxygen Fluid & electrolyte balance Cognitive status Pressure sores Constipation management Urinary catheterization only if: Epidural analgesia Local analgesic agents nerve blocks Non-narcotic (Paracetamol); NSAID; Narcotic (opioids); Combination preparations (Paracetamol + Codeinefosfate or Narcotic) Regular pain reassessment by VAS score Check for and management of delirium Incontinence Concern about retention Monitoring renal and cardiac function If catheterization, than prophylactic antibiotics (urine culture Mobilization Follow up of possible early complications of arthroplasty or internal fixation Early mobilization o Within 24 hours postoperatively, if medical condition allows o Weight bearing on injured leg should be allowed Ambulation Rehabilitation ADL training Nutrition If necessary, intermittent urine catheterization is preferable High energy and high protein nutritional supplements Consider mineral and vitamin supplements Monitor diet Once patient is mobilizing well and weight bearing, than consider discharge Re-assessment of home situation Arrange appropriate bridging care to help the patient in the community Alert patient s GP Community nurse / Carer Discharge management Education & information Falls prevention Medication Mobility, and against fear of falling Expected progress Pain control Sources of help & advise Ongoing exercise program to improve: strength, flexibility, weight bearing, balance training Home assessment of occupational therapist Reduction of psychotropic medication Modification of identified hazards (bath, toilet, stairs,...) Walking and visual aids, where appropriate Footwear Hip protectors (little evidence of effectiveness) European Pathway Association, Alarm ivzw, systems 2012 8
Referral Referral to osteoporosis clinic/consult Referral to geriatrics Bone Density Scan (DXA) Initiation or adjustment of the osteoporosis medication (e.g. bifosfonates) Comprehensive geriatric assessment Comprehensive fall risk assessment IF patients at risk for recurrent falling European Pathway Association, ivzw, 2012 9
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