ED-based intervention aids outcomes, LOS

Focus on geriatric fracture care patients

Hip fractures are among the most debilitating and expensive diagnoses to treat, but your hospital can significantly improve outcomes and lower costs if it moves hip-fracture patients into surgery quickly, explains Anthony Balsamo, MD, an orthopedic surgeon and head of the Geriatric Fracture Care Program (GFCP) at Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA.

ED personnel can play a crucial role in identifying fragility fractures and linking these patients with appropriate care and education as swiftly as possible, adds Balsamo. "Statistics show that if you operate on someone right away, the results, in terms of morbidity and mortality, are significantly improved when the patient is over the age of 65," he says. "If you can get that hip stabilized, and you get the patient ambulating, there are fewer complications."

Balsamo established the GFCP in August 2010 because he recognized the opportunities to improve care while also reducing length of stay and other costs associated with treating fragility fractures, which are common in older patients. With the baby-boom generation reaching retirement age, Balsamo notes that fragility fractures are expected to be a huge drain on healthcare budgets going forward, particularly in regions such as northeastern Pennsylvania, where baby boomers comprise more than 19% of the population.

However, optimal care involves more than just getting patients to surgery quickly. It also requires patient and family education and appropriate follow-up interventions to lessen the chances of a repeat fracture. These are all components of the GFCP, but Balsamo points out that much of this process begins in the ED.

Get family involved

Central to the GFCP is a geriatric nurse coordinator who works within the orthopedic department but is alerted to the ED via pager whenever an older patient presents with a fragility fracture — a fracture that is primarily the result of low bone density as opposed to trauma.

"We focus mainly on hip fractures, but I will see any geriatric fracture patient who comes into the ED," explains Michele Gingo, RN, the nurse coordinator of the GFCP. "I explain to them what their surgery is going to entail, what their recovery is going to entail, and I evaluate their home situation."

The main purpose of the interaction is to ensure that the patient and family understand what will be required for optimal recovery and that they identify and remove any safety hazards that could complicate recovery and potentially lead to repeat fractures. "I educate the family that they are to go home and remove any throw rugs and make sure there are no extension cords in the way because when the patient comes home, he or she will most likely have an assistive device, and a throw rug or a cord could facilitate a fall," says Gingo.

In addition, Gingo explains that while pain medication will be available, patients should not expect to be pain-free right away. "We need them to be able to participate in therapy," she says. "We don't want them to be sleepy and unable to get out of bed the next day, so I explain that bed rest has many complications including, but not limited to, blood clots in their legs or lungs and pneumonia."

Gingo provides the family with a packet of information they can use as a resource for such questions as how to get in and out of a car after surgery or how to get dressed, she says. It also includes information about osteoporosis, because most of these patients will require follow-up treatment to strengthen their bones and prevent future fractures. "While patients are in the hospital, a rheumatologist will see them for our high-risk osteoporosis clinic, and there will be a follow-up office visit with the rheumatologist in a few weeks," says Gingo. "I explain to them what is going to happen. They will see physical therapy, they will see occupational therapy, and they will see a clinical nutritionist."

While hip fractures are a priority, Gingo sees other geriatric fracture patients as well. In those cases, she might help with splinting or casting, and she will discuss with the ED provider whether the patient should be referred on to the high-risk osteoporosis clinic. In the case of an ankle fracture where there is too much swelling for surgery, for example, the injury might be splinted and the patient sent home until the swelling goes down, explains Gingo.

It took some time to get the ED physicians accustomed to the new program, acknowledges Gingo. In the early stages of the program, she would reach out to the ED physicians when they had geriatric fracture patients and explain her role. "It is key to talk to the providers and let them know that you are eager to be [called in on a case]," she says. "I take the beeper home with me, and while I won't return a call in the middle of the night, they know I will be there first thing in the morning."

Now ED providers are part of the GFCP approach, and they appreciate having a nurse who can come down to the ED and spend more time with their patients than they are able to do. "ED doctors buy into the program because there is all this information for them, someone is organizing it, and care is not delayed," says Balsamo. "Nothing is keeping that patient from surgical intervention."

Sources

For more information on ED-based intervention, contact:

Anothony Balsamo, MD, Director, Geriatric Fracture Care Program, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA. Phone: 570-808-1093 E-mail: ajbalsamo@geisinger.edu.

Michele Gingo, RN, Nurse Coordinator, Geriatric Fracture Care Program, Geisinger Wyoming Valley Medical Center, Wilkes-Barre. Phone: (570) 808-7300.