Development and Utilization of Standardized Hip Fracture Guidelines Sally Knight RN Clinical Quality Nurse Lori Smith RN Clinical Quality Nurse Deborah Newall RN Orthopedic Program Coordinator Wallace Arneson MD. NSQIP Surgeon Champion Michael Chrissos MD. NSQIP Surgeon Champion Orthopedics Mark Hake MD. Orthopedic Surgeon No Disclosures
Hip Fractures Hip fractures are a national problem impacting over 250,000 people annually over the age of 65, with the greatest percentage being female (CDC, 2016). Hip fracture patients are complex, elderly, fraught with co-morbidities, and are at an increased risk for developing complications. It has been shown that patients treated within 48 hours of admission have significantly improved outcomes (Stitgen, et al, 2015). A standardized coordinated approach leads to early identification and medical optimization to facilitate urgent surgical interventions. The use of standardized protocols have proven to reduce one year mortality, hospital length of stay, and medical complications. Our hip fracture population met with delays in treatment and a decrease in functional outcomes due to a lack of standardized hip fracture guidelines.
Data for Pre-implementation of Standardized Orders Variables Nov 2016-Apr 2017 Standardized Orders 8.11% WBAT on POD#1 67.57% DVT Prophylaxis for 28 day 29.73% Rx bone health medication post discharge 10.81%
Implementation Plan A multi-disciplinary team was formed in 2016, to create and develop pre and postoperative clinical pathways and order sets, utilizing NSQIP variables from the Hip Fracture Pilot Program. Four variables were shown to be deficient. We also decided to follow time to incision as this metric has been shown to have an impact on mortality. Implementation of these guidelines went into effect April, 2017. To risk stratify the fractured hip patients on admission we used PRISM, a mortality risk assessment tool that we use in our health system. This helped us to ensure the sickest patients were admitted to a medicine service. Our goal was for 70% of our fractured hip patients to be admitted to the orthopedic/trauma service.
Management of Fracture Hip Patients Diagnosis Plain AP and lateral X-Ray suffice for diagnosis of a femur fracture. For intertrochanteric fractures, full length femur views are required. Emergency Department 1. Baseline Labs: CBC, BMP, PTT, PT/INR, Type & Screen. 2. Insert urinary catheter in all female patients (may be inserted in male patients if indicated clinically). 3. 12 lead EKG if clinically indicated. 4. Pain management for Fractured Hip Pain Protocol. 5. Ultrasound Guided Femoral Nerve Block if indicated 6. Prism Score Prism 1 & 2 admitted to Medicine Service with Orthopedic Service Consult Prism 3, 4 & 5 admitted to Orthopedic Service with Medicine Service Consult
Preoperative Plan Goal is for operative fixation to take place within 24 hours. Orthopedic PA/Resident to consult for Medical Management. Multimodal pain management. Draw Vit. D25 Hydroxyl level pre-op. Order High Protein diet. Order scheduled laxatives. DVT prophylaxis (begin on admission). Nursing Care Urinary catheter in place. Complete bed rest. Ice to fracture site. Incentive spirometry every hour while awake. Neurovascular checks. Assess for fall risk. Complete Braden assessment. Multimodal pain management. Delirium screening. Ensure patient/family have education materials. SCD s to be used at all times.
Postoperative Plan Discharge Plan Urinary catheter to be removed POD#1. PT consult for mobilization. WBAT-weight bearing as tolerated. Vitamin D supplementation should be ordered for 30days. Counsel on smoking cessation if applicable Consult case manager and social worker on admission. Discuss discharge goals with patient/family. Begin developing a plan for transition to post hospital care. Assess discharge planning.
Fractured Hip Pain Protocol Orders Preoperative Scheduled Tylenol 1000mg stat and 650mg Q6 scheduled PRN Orders Tramadol 50 mg PRN Q6 Oxycodone 5mg PRN Q4 (Oxycodone liquid 2.5mgs available if smaller doses are needed) Dilaudid 0.5mg IVP PRN Q4 Flexaril 5mg Q6 PRN (for muscle spasm) Ketorolac 15mg stat & Q6 until surgery Postoperative Scheduled Tylenol 650mg Q6 PRN Orders Tramadol 50mg PRN Q6 Oxycodone 5 mg PRN Q4 (Oxycodone liquid 2.5mgs available in smaller doses are needed) Dilaudid 0.5mg PRN Q4 Ketorolac 15mg PRN Q6
Variables Weight Bearing Status This was addressed in the guidelines. All fractured hip patients were to be weight bearing as tolerated unless specifically documented by the surgeon. DVT Prophylaxis Guidance was given on DVT prophylaxis. Enoxaparin 40mg once a day for 28 days is our standard order as well as SCD s during hospitalization. Bone Health Prescription on Discharge This was taken on by one of our hospitalists who developed a note template to include this prescription. This helped all providers to ensure it was included in the discharge instructions.
Results
Time to Incision 28 26 24 Hours 22 20 18 16 14 12 10 Baseline (Aug 16- Jan17) Started Protocol May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 Mean 25.82 25.9 25.5 20.8 22.5 19.01 20.57 22.1 21.7 21.65 24.57 17.57 25.05 Median 22.72 23.7 18.4 19.3 19.89 18.23 20.68 22.87 21.2 20.72 21.19 18.72 18.59
References AAOS. (2014). Management of Hip Fractures in the Elderly- Evidence-Based Clinical Practice Guideline. Retrieved from http://www.aaos.org/cc_files/aaosorg/research/guidelines/hipfxguideline.pdf ACS NSQIP/AGS. (2012). Optimal Preoperative Assessment of the Geriatric Surgical Patient. Retrieved from https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guide lines.ashx ACS TQIP. (2015). Best Practices in the management of Orthopeaedic Trauma. Retrieved from https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/tqip%20bpgs%20in%20t he%20management%20of%20orthopaedic%20traumafinal.ashx ACS TQIP. (2013). Geriatric Trauma Management Guidelines. Retrieved from https://www.facs.org/quality-programs/trauma/tqip/best-practice Hadi, S., Itte, V., Bradshaw, B., Pinkney, A., Blomfield, M., & Hahnel, J. (2012). Hip fracture management and NICE guidelines. British Journal of Healthcare Management, 18(8), 406-410