An 82-year-old man with a past medical history of dementia, coronary artery disease, hypertension, and diabetes slipped on a rug at home and fell, fracturing his left hip. In the emergency department, a head CT was negative for any evidence of bleeding. Radiographs and CT scan of the pelvis and hip showed a left intertrochanteric hip fracture. Electrocardiogram showed the patient to be in normal sinus rhythm without any signs of ischemia or infarction. Laboratory results revealed normal electrolytes, kidney function, and complete blood count.
The patient was admitted to the orthopedic surgery service to fix the fracture; the surgery was initially scheduled for the following day. However, surgery was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. The patient was not placed on venous thromboembolism prophylaxis prior to surgery. While in the hospital, he was frequently agitated, disoriented, and combative in the evening hours.
He ultimately underwent surgery and was discharged to home a few days later. However, he was readmitted to the hospital several weeks later with chest pain and shortness of breath and was found to have a pulmonary embolism. Treatment with anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status. After discussion with his family, the patient was ultimately transitioned to hospice and died several months later.
by Stephanie Rogers, MD, and Derek Ward, MD
Hip fractures are common in older patients, with a lifetime estimated risk of 6% for men and 18% for women.(1) A 50-year-old woman has a 2.8% lifetime risk of death from a hip fracture, which is equivalent to the lifetime risk of death from breast cancer.(2) Patients with hip fracture are often frail and medically complex, and they require coordinated interdisciplinary care. Yet, they are frequently admitted to health systems characterized by suboptimal communication and coordination between clinical services. From a surgical standpoint, most hip fractures are treated as fractures of necessity, meaning that surgery is indicated for virtually all patients. Although surgery itself is associated with some risks, these are relatively minor compared with the morbidity and mortality hip fracture patients experience without surgery. However, even with surgery, hip fracture patients have a 1-year mortality of 20%–24% (3,4), and for those that do survive 33% are totally dependent or in nursing home care in the year following the fracture.(4,5)
A preponderance of retrospective and observational evidence supports early surgical fixation, within 24–48 hours. The literature demonstrates that early surgery is associated with lower complication rates and 1-year mortality. In a review of 3517 patients from the Danish Fracture Database, there was a stepwise increase in 30-day mortality with progressive delays in surgery and an increase in 90-day mortality with a delay of more than 24 hours.(6) In addition, a meta-analysis of 28 observational, prospective studies including 31,242 hip fracture patients age 60 and older found that patients operated on within 48 hours had a 20% lower mortality within 12 months and fewer complications (such as pneumonia, urinary tract infections, pressure ulcers, and thromboembolic events) compared with patients operated on after 48 hours.(7) Surgery for the patient in this case was delayed for 3 days; unfortunately, such delays are exceedingly common. A study that examined the American College of Surgeons National Surgical Quality Improvement Program database revealed that 78% of patients experienced a surgical delay of 1 day or longer.(8) Factors attributed to delays in surgery included medical optimization, surgeon and operating room availability, and broad organizational challenges.(8)
The fact that patients often don't die for weeks or months after the initial hospitalization creates an ingrained institutionalized bias against treating hip fractures as urgent. Because of this, hip fracture patients are typically given lower priority with regard to operating room schedules. Additionally, unnecessary medical workup can easily delay a case for a day or more. Surgical specialists or operating room staff are often not available during the evening or weekend hours to treat these patients. In the case described above, surgical delay and immobility, combined with inadequate perioperative management of anticoagulation and delirium, likely contributed to this patient's death.
In conjunction with early surgical intervention, two system-level interventions improve care for patients with hip fractures.(9) First, a standardized hip fracture protocol should be developed with interdisciplinary input. All team members involved in the patient's care (internal medicine and/or geriatrics, orthopedics, emergency medicine, radiology, cardiology, anesthesiology, nursing, case management, social work, and physical and occupational therapy) should be involved in the development of the protocol. This protocol sets expectations, minimizes variability of care, and improves quality through the application of evidence-based guidelines from initial presentation in the emergency department to postdischarge follow-up care. The protocol can set expectations and minimize variability using existing guidelines for many conditions. For example, in the preoperative use of echocardiograms, a retrospective review of hip fracture patients receiving transthoracic echocardiograms demonstrated that adhering to American College of Cardiology/American Heart Association clinical practice guidelines would decrease echocardiogram utilization by 34% without missing any disease that might inform surgical, anesthetic, or medical management.(10)
The protocol should contain comprehensive guidelines for rapid preoperative assessment and operating room time, opioid-sparing pain control regimens using regional analgesia, preventing delirium, preoperative and postoperative anticoagulation management, early mobilization, and postdischarge care to optimize secondary fracture prevention. The interdisciplinary workgroup in charge of the protocol should have measurable process and outcome metrics, with regular evaluation of adherence to the protocol and continuous process improvement. Hospital leadership and data management support of this group are critical to success.
The second crucial system-level intervention is the development of a hip fracture comanagement service with either geriatrics or medicine in which both the medicine/geriatrics and orthopedics teams take equal responsibility when caring for the patient. Often, clear responsibilities are established with geriatrics or medicine managing the medical conditions and orthopedists managing surgery-related issues. Several weeks after surgery, this patient was readmitted with a pulmonary embolism, which was likely preventable. Studies have shown that comanagement reduces the incidence of venous thromboembolism as well as the incidence of pneumonia, sepsis, delirium, and ICU admissions.(11,12) Some studies have shown that comanagement is associated with decreased mortality rates, shorter length of stay, and improved functional independence at 4 and 12 months.(12-14)
Hip fracture is a common and serious injury among older patients that is often the result of existing frailty or contributes to worsening frailty. The associated morbidity is generally related to the initial trauma and the subsequent immobilization, which in turn increases the risk of delirium, thromboembolism, pneumonia, pressure ulcers, and significant functional decline. Rapid surgery and mobilization as well as coordinated, comanaged care can decrease complications and significantly improve clinical and quality-of-life outcomes.
- Early surgical repair of hip fracture improves mortality and functional outcomes and results in fewer medical complications, including pneumonia, urinary tract infections, pressure ulcers, and thromboembolic events.
- Engaging the right interdisciplinary team members is crucial to improving care for hip fracture patients at a systems level.
- Development and implementation of evidence-based clinical care protocols can minimize variability of care, set team expectations, and improve quality.
- Comanagement with either medicine or geriatrics and orthopedics reduces medical complications and improves mortality, function, and quality of life.
- Improved treatment for patients with hip fracture often requires a major cultural change within the hospital system.
Stephanie Rogers, MD, MPH
Division of Geriatrics
Department of Medicine
University of California, San Francisco
Derek Ward, MD
Arthritis and Joint Replacement, Orthopaedic Institute
Department of Orthopaedic Surgery
University of California, San Francisco
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