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Helping hip fracture patients

Is comanagement the answer?

A 92-year-old man with Alzheimer's disease is admitted to the hospital after suffering a hip fracture. Physically robust for his age, the man does well in surgery but at discharge, he is sent to a skilled nursing facility due to increasing confusion over the course of his hospital stay. Soon after entering the facility, he aspirates, develops pneumonia, and dies after hospital readmission.

The scenario is not uncommon among elderly patients with hip fractures, a population with a 20% to 50% mortality rate in the year following hospitalization, said Rachel Thompson, MD, MPH, FACP, executive medical director of the acute care services division for Swedish Health Services in Seattle.

Cognitive impairment is one of the biggest risk factors for mortality but is not always flagged and well managed in the hospital, which can result in patients feeling more confused at discharge than when they arrived. It's one of many issues that hospitalists can tackle to try to improve outcomes from hip fracture, experts say.

“If we just address hip fracture as a surgical intervention, we're not seeing the full picture,” said Dr. Thompson, lead author of a review on hospital medicine and perioperative care published in the April 2017 Journal of Hospital Medicine (JHM). “To make sure we take patients' comorbidities into account, we need a more structured approach with a multidisciplinary team and close cooperation among surgeons and hospitalists.”

Hospitalists as solution?

While closer cooperation between the specialties seems like an intuitive solution to improving care, the evidence on comanagement of hip fracture has been somewhat mixed.

One recent large study raised questions about whether the significant resources required to set up a medical comanagement program necessarily translate into improved outcomes. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQUIP), published in the August JHM, found no evidence that dedicated medical comanagement improved postoperative morbidity and mortality in the hip fracture population.

However, the authors noted that selection bias at the individual-patient level may have affected the results, as sicker patients are more likely to be assigned to the medical service for comanagement. In addition, variables specific to individual institutions may affect the relationship between comanagement and outcomes.

Meanwhile, results from programs at individual hospitals and health systems have shown more promising results. For example, data from Yale New Haven Hospital's Integrated Fragility Hip Fracture Program, also published in the August JHM, showed a drop in 30-day mortality from 8% to 2.8% during the first three years of the program's implementation.

Another retrospective study, at the University of North Carolina (UNC) Medical Center in Chapel Hill, found that patients admitted to the hospitalist service had shorter lengths of stay and a lower risk of 30-day readmission compared with patients admitted to orthopedics or other services. Findings were published Oct. 17, 2018, by Hospital Practice.

Under the UNC program, hip fracture patients are admitted to the hospital medicine service with orthopedic surgeons acting as consultants, said the study's lead author, John R. Stephens, MD, a hospitalist and professor of medicine at UNC School of Medicine. Surgeons—who often lack both the time and training to address comorbidities commonly seen in this patient population—were happy to have hospitalists take on a lead role in care, he added.

Other program leaders have found the same. “My strongest piece of advice is to have hospitalists on staff who are dedicated to perioperative management,” said Jensa C. Morris, MD, lead investigator on the Yale study, a hospitalist, and an assistant clinical professor of medicine at Yale School of Medicine in New Haven, Conn. “Building relationships among a small group of hospitalists and surgeons who work regularly with hip fracture patients and trust each other is essential to improving outcomes.”

Setting up a program

Simply implementing comanagement doesn't necessarily ensure improved outcomes, however. Successful programs tend to invest time upfront in developing standardized protocols, building teams, and tailoring care processes to the specific needs of their hospital, the experts said.

“These programs take time to build and are unique and personal to each institution—there is no one-size-fits-all approach,” said Dr. Morris. “Over time, you can change culture, educate, and hardwire quality improvements into order sets so that there's a level of institutional knowledge about caring for this specific population of patients.”

At Yale, a large program spanning two campuses with more than 100 clinicians on the hospitalist service, medical comanagement was in place prior to the integrated hip fracture program but did not include standardized protocols, according to the study. The current system began with centralizing all patients to one campus and implementing standardized pre- and postoperative order sets to guide care.

A critical step at the beginning was forming an oversight group with broad multispecialty representation, including surgeons, hospitalists, anesthesiologists, advanced practice providers, geriatricians, and other relevant clinicians, such as pharmacy and rehabilitation, said Dr. Morris. The group meets monthly to establish and refine protocols.

“Anyone who theoretically could come into contact with a hip fracture patient is represented on this committee,” she said. “Once policies and protocols are set, our goal is to have patients on a clear pathway requiring as few decision points as possible with all team members knowing their role within the program to minimize overlap or disagreement.”

Similarly, establishing a multidisciplinary steering committee was key to launching a program at four hospitals in the 23-hospital Northwell Health system. Program leaders described how they did it in the August Journal of the American Geriatrics Society (AGS).

The system follows a model developed by AGS that partners geriatric-trained hospitalists with orthopedic surgeons, said the study's senior author Maria Carney, MD, FACP, chief of geriatrics and palliative medicine at Northwell's Long Island Jewish Medical Center in New Hyde Park, N.Y. An important first step was creating the committee that would not only establish standard processes and outcome measures but also respond to ongoing problems and challenges.

For example, orthopedists at one hospital expressed concerns about having adequate coverage at night, when hospitalists were busy with admissions, said Dr. Carney. Hospital leaders conveyed their concerns to the steering committee, which in turn initiated joint midnight rounds of hospitalists and orthopedists.

Training hospitalists in geriatrics-focused care was another important element of the AGS program, she said. Early on, hospitalists completed a set of modules related to caring for elderly hip fracture patients, covering such topics as geriatric syndromes, preoperative pain management, and secondary fracture prevention.

Medication management

Hospitalist involvement in perioperative care addresses what has been a major barrier to improving hip fracture outcomes: inadequate medical management prior to surgery, said Nayla Idriss, MD, FACP, director of hospitalist/surgical comanagement at Long Island Jewish Medical Center. The institution launched a comanagement program in 2015 and incorporated the AGS model in the spring of 2018.

“In the past, many elderly patients got more and more confused throughout their stay due to all the medications they were taking and would end up being discharged to skilled nursing instead of going home,” she said. “No one was doing a thorough review of their medications to see what was really necessary and what could be reduced or eliminated, and communicating that information to their outpatient providers.”

The AGS program integrates the four core competencies of geriatrics—known as the 4 Ms—into routine care for hip fracture patients: mentation, medication, what matters, and mobility, said Dr. Idriss. Hospitalists now screen all hip fracture patients for dementia and delirium and conduct a thorough review of their medications in order to avoid overuse of drugs that could aggravate confusion, such as benzodiazepines, antipsychotics, and anticholinergics.

Communication is paramount throughout the process, she added. Clinicians take time to talk with patients and families about their personal priorities and preferences and educate them about any changes to the medication regimen. Hospitalists also make direct contact with patients' outpatient clinicians before discharge.

The hospital has seen improvements since implementing the AGS system, including a significant drop in average length of stay from seven days to six, she said. Hospital mortality also declined from 3.6% to 2.2%, while the percentage of patients reaching the operating room (OR) within 48 hours has jumped from 75% to 83%. At the same time, the comanagement service has grown from three to more than 20 participating surgeons.

Eliminating unnecessary preoperative testing and specialty consultations is another way to speed time to surgery, according to a study published in the January JHM. Investigators found that the majority of preoperative consults—particularly cardiac—did not influence management and often led to patients arriving in the OR more than 48 hours after admission, a known risk factor for increased morbidity and mortality from hip fracture.

“We found that most cardiac consults did not lead to changes in management and, when they did, the hospitalist already suspected something was wrong,” said the study's senior author, Mandeep Kumar, MD, director of perioperative medicine and a hospitalist at Hartford Healthcare in Hartford, Conn. “We've changed practice as a result. We now encourage our hospitalists to use their best judgment, given that setting up a consult can take hours and could lead to the patient being bumped down the list for the OR.”

Hospitalists now request consults only if there is a clinical concern for one of four active cardiac conditions: acute coronary syndrome, acute congestive heart failure, systematic valvular disease, or uncontrolled arrhythmia.

In addition to avoiding unnecessary consults, hospitalists manage patients' underlying conditions and optimize medications so that they're ready to go to the OR as soon as possible, he said. Clinicians follow population-specific protocols and pathways for venous thromboembolism prophylaxis, pain management, and prevention of aspiration and catheter-associated urinary tract infections.

Other common issues in this population that comanagement can address include diabetes, which increases the risk for wound infection, and chronic obstructive pulmonary disease, which puts patients at higher risk for pulmonary hiccups after surgery, noted Dr. Thompson.

“Ultimately, comanagement is about figuring out how we, as a system, can provide the smoothest care for our patients so they recover with the least amount of additional harm and best possibility of returning to their highest level of function,” she said. “The more we work together, the better chance we have of improving patients' outcomes, which is everyone's goal at the end of the day.”