Clinical Care Team approach to management of key conditions

Clinical Care Team approach to management of key conditions BJD Ho Chi Minh City Nov 30, 2012 Kristina Åkesson, MD, PhD Dept of Orthopedics Malmö University Hospital Lund University Malmö, Sweden

Multidisciplinary Approach Person with the Musculoskeletal Problem Rheumatologist Specialist Nurse Orthopaedics Occupational Therapy Primary Care THE PROBLEM Physiotherapy Carers Support Group. and many others

Multidisciplinary Approach Policy Makers Person with the Musculoskeletal Problem Rheumatologist Specialist Nurse Orthopaedics Occupational Therapy Primary Care THE PROBLEM Physiotherapy Insurance Carers Support Group Patient organisations. and many others

The Hip Fracture Patient Woman Age 82 years Frail Low body weight Multiple co-morbidities Barely managing in her home = The Fragility Fracture Syndrome

Optimal care of fragility fracture patient: Goals - Challenges - Solutions Keep the patient alive Acute medical management Fix the fracture Surgical challenges Keep patient mobile Multidisciplinary rehab Keep patient from returning to your fracture unit Osteoporosis management and secondary prevention Quality control of process

Fracture patient management and care Pre-operative Peri-operative Pre-hospital Emergency room Pre-op unit Operating room Post-op unit Post-operative Rehabilitation Follow-up Ward In-hospital Out-patient /home Clinic

Fracture patient management and care Pre-operative Peri-operative Post-operative Rehabilitation Follow-up Pre-hospital Emergency room Pre-op unit Operating room Post-op unit Ward In-hospital Out-patient /home Clinic Outcomes Patient perceived Functional Medical

Pathogenesis of Fragility Fractures Neuromuscular function Environmental risks Age Type of fall Energy in the fall Local protection Bone mass Bone structure Bone quality Fall Risk Impact of fall Skeletal strength Fracture risk Co-morbidity Lifestyle

Hip Fracture Care Components Pre-hospital management Emergency room pre-diagnosis Emergency room post-diagnosis Pre-operative management In-hospital - Surgical management In-hospital - Post-operative management Rehabilitation Prevention of new fractures Discharge and post-fracture living SIGN Guidelines 2002, NZGG 2005, Chiliv J Med Au 2003, NBHW 2003

Hip Fracture Care Pre-hospital To diminish pain and discomfort for the patient and by doing the right thing from the beginning also improving the ultimate outcome. At the place of injury During transportation

Hip Fracture Care Emergency room pre-diagnosis To adequately and rapidly assess the patient s background and current health state in order to diminish the risks for deterioration of health from the fracture. History medical and social Examination co-morbidities Radiography Medical management Care

Emergency Room Pre-diagnosis Pain management Oxygen Intravenous fluids Prophylaxis against pressure ulcers Ensure short time to investigation including x-ray

Hip Fracture Care Emergency room post-diagnosis Pre-operative management To optimize the patient for anaesthesia and surgery with the expectation that surgery should be performed within 24 hours. Care Medical management Examination

Emergency Room Post-diagnosis Pain management Oxygen Intravenous fluids Nutritional supplementation Urine monitoring Evaluate and optimize other medical conditions Pre-operative investigations (ECG, lab tests) Prophylaxis against thromboembolism Prophylaxis against infection Prophylaxis against pressure ulcers Ensure short time to surgery

Optimal care of the fragility fracture patient Proper diagnosis of the fracture Identify fragility fracture & underlying disease, incorporate into existing workup Influences treatment plan from the onset Who is best trained to optimize an elderly frail patient pre operatively?

Optimal care of the fragility fracture patient Proper diagnosis of the fracture Identify fragility fracture & underlying disease, incorporate into existing workup Influences treatment plan from the onset General fracture management Stabilize patient, pain relief, fracture care

Each fragility fracture is a challenge because the patient is frail Intra-capsular Cervical Displaced Undisplaced Trochanteric Subtrochanteric Displaced Undisplaced Stable Unstable

Post-operative Care - From surgery to discharge Multi-disciplinary team care Standardized care plans Who is best trained to optimize an elderly frail patient post op?

Immediate Post-operative Care Pain management Oxygen Intravenous fluids Monitor electrolytes Monitor urine Monitor anemia Monitor cognition / delirium Prophylaxis against thromboembolism Prophylaxis against infection Prophylaxis against pressure ulcers Prophylaxis against falls from bed Koval KJ et al. Clin Orhop Rel Res 2004

Post-operative Care Pain management Nutritional supplementation Monitor urine Monitor anemia Monitor cognition / delirium Initiate mobilization Prophylaxis against thromboembolism Prophylaxis against infection Prophylaxis against pressure ulcers Prophylaxis against falls Koval KJ et al. Clin Orhop Rel Res 2004, Hommel et al. Acta Orthop 2007

Optimal care of the fragility fracture patient Proper diagnosis of the fracture Identify fragility fracture & underlying disease, incorporate into existing workup Influences treatment plan from the onset General fracture management Stabilize patient, pain relief, fracture care Rehabilitation Minimize dependence, maximize mobility

Post-operative Care - Discharge from Acute Care Unit Advance planning Consider care options Consider home and family situation Information Patient Family Care-givers Family doctor Ensure that pain and other medications are discontinued when appropriate. Ensure follow-up Multi-disciplinary team

Orthogeriatrics Advantages - Specialized in medical management of the elderly person - Cardivascular diseases - Neurological diseases - Gastro-intestinal conditions - Kognitive impairments - Psychological frailty - Pharmacology and drug interactions in the elderly - (medications reduce!?) - Orthopedic surgeons can increase operating room time - Improved surgical skills among young orthopedics

Fragility Fracture Management Pre-fracture functioning Restored function? FRACURE EVENT Hospital care / fracture management ACTIVITY & PARTICIPATION Quality of life Rehabilitation Post-fracture living

Multidisciplinary Approach Policy Makers Person with the Musculoskeletal Problem Rheumatologist Specialist Nurse Orthopaedics Occupational Therapy Primary Care THE PROBLEM Physiotherapy Insurance Carers Support Group Patient organisations. and many others

Bridging the Care Gap THANK YOU

Optimal care of fragility fracture patient: Keep the patient alive Acute medical management Fix the fracture Surgical challenges Keep patient mobile Multidisciplinary rehab Keep patient from returning to your fracture unit Osteoporosis management and secondary prevention Quality control of process

Multi-targeted fracture prevention Physical activity Balance training Coordination training Vision Eyeglasses External hazards Cognitive impairment Social life Falls Reduce Pain meds External protection Vitamin D Nutrition Body weight Reduce Medications overall Adequate Calcium intake Bone Stop smoking Bone specific medication