LOS misleading indicator for hip fracture, some say

LOS not good indicator of how these patients do’

Discharge of hip fracture patients from the acute care setting to subacute and skilled nursing facilities should be based on the patient achieving specific functional milestones rather than on the desire to shorten length of stay, experts say. Unfortunately, current payment methodology has hospitals focused on length of stay as a quality indicator.

"Length of stay is really not a good indicator for how these patients do," argues Kelly McDevitt, RN, MS, ONC, orthopedic clinical case manager at University of Colorado Hospital in Denver. The most effective treatment often is to get these patients relocated to their home environment rather than transferring them in three days to a nursing home where they typically sit for several more days, she says.

According to McDevitt, case managers or quality assurance staff are responsible for tracking length of stay for hip fractures. But the key is to have it coded correctly, she says. "A hip fracture can be logged in as a femur fracture, a hip fracture, or a pelvic fracture. It has to be coded correctly to pull up the data."

The focus on length of stay for these patients actually is counterproductive, says Shirley Kennedy, orthopedic case manager at St. Vincent Hospital in Santa Fe, NM. "This population is truly being underserved," she contends. "They usually have numerous other problems and are not in the best of health."

Because hip surgery for these patients is a trauma and not a scheduled surgery, there needs to be a fair amount of work-up, McDevitt points out. "They usually are not well enough to go right to surgery. The trick is getting them worked up quickly and getting them into surgery quickly so they can get up and out of bed fast." She adds that because these patients typically are older, with comorbidities such as cardiac disease, renal disease, poor circulation, or respiratory disease, sometimes taking them to surgery is not the best option.

"First, we have to make sure they can tolerate the surgery, and once we do the surgery, it is best to get them ambulating as quickly as possible afterward," she explains.

"We try to start our total joint replacements a month in advance of the surgery to gain optimal health status so the surgery goes smoothly," Kennedy says.

According to Joseph Zuckerman, MD, professor and chair of the NYU-Hospital for Joint Disease Department of Orthopedic Surgery in New York City, communication is one of the keys to establishing a true continuum of care. "If I operate on hip facture patients and they get transferred on day five to their home, I have to communicate that information to their doctor; it’s very important that information gets transferred. If they go to the rehab center, then leave and go back to their original doctor, how does he grasp the issues that have arisen in the interim?"

According to McDevitt, this can be particularly challenging in larger organizations where there is sometimes insufficient follow-up with the primary care physician.

Her facility is considered a specialty hospital, and patients with complex medical issues often are transferred there because small community hospitals can’t handle all of the potential complications, she says. If the information does not follow patients back to the community hospital, that can create problems, McDevitt adds.

Evidence-based pathway is needed

Zuckerman also maintains that patients with hip fractures should follow "an evidence-based multidisciplinary critical pathway."

"It definitely needs to be an evidence-based multidisciplinary pathway," concurs McDevitt. "There is no question about it." Physical therapy, occupational therapy, nursing, physicians, orthopedists, primary care physicians, as well as community nurses all should be involved in the care plan, she says.

Zuckerman says that one of the elements should be standardized evaluation when the patient is admitted. "There should be rapid recognition as to whether the patient should get to the OR quickly for the stabilization of any serious factors. Patients who go to the OR two days after admission have a higher mortality rate."

As for the surgery itself, that is difficult to standardize, Zuckerman says. "But we should stress prompt surgery, technically well done, rapidly progressive post-op care, thromboprophylaxis to prevent clots, [and] ambulation."

"If you restrict their weight-bearing status, you may as well leave them in bed," says McDevitt. "That puts them at an incredible risk, because they don’t have good dexterity and balance." However, this area is very difficult to standardize in attempting to develop a pathway, she adds.

It also should be recognized that there is significant malnutrition in this population, Zuckerman says. "If they are admitted with a hip fracture and malnutrition exists, this is considered a comorbidity and a separate DRG, which increases the level of reimbursement. In other words, hospitals should want to identify this condition."

Antiresorptive medication is another key consideration. "If a patient has a heart attack, there is no way he leaves the hospital without having his cholesterol and blood pressure checked, and if need be, being put on meds," says Zuckerman. "There should be an analogy when we admit patients with hip fracture.

"Clearly this is a risk factor for osteoporosis, but probably less than 20% of these patients leave the hospital being treated for osteoporosis," he adds. "Some in the medical profession question whether we could actually prevent osteoporosis, but we could clearly have an impact."

Kennedy says that when she reviews the medications the patients are taking, she often finds that they are on multiple medications that may counteract each other or are duplicates with a generic name on one label and brand name on the other. "They go to numerous doctors and self-medicate," she asserts.

"This truly is a multidimentional problem that desperately needs case and family management." She points out that fracture patients typically are frail and elderly, often demented, undernourished, with low socioeconomic status, little or no social or financial support, and often live in unsafe situation to begin with.

According to Kennedy, the families of these patients often are nearby but unaware of how poorly they function at home. "I am usually told, She lives by herself and does very well on her own, so we had no idea she was so bad off.’"

"We rarely have [members of] our wealthy population fall and break their hips, even if they are in their 80s or 90s," she adds.