Fracture program cuts LOS by 2+ days

Multidisciplinary team caters to elderly

Just six months after Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA, began its Geriatric Fracture Care Program, the average length of stay (LOS) for seniors having orthopedic surgery for fractures dropped from 7.2 days to 5.1 days.

Anthony J. Balsamo, MD, orthopedic surgeon and director of the Geriatric Fracture Care Program, attributes the drop in LOS to the proactive approach the geriatric fracture team takes to patient care, including performing the surgery as soon as possible, getting the patients out of bed early in their stay, and gathering information from family members in the emergency department so the care managers and social workers can begin on the discharge plan.

"One key factor in the drop in length of stay is that we focus on performing the surgery within 48 hours, preferably within 24 hours," Balsamo says. "When elderly patients break their hip, they face an additional risk of dying or experiencing complications such as skin breakdown, pneumonia, and deep venous thrombosis if surgery is delayed more than 48 hours."

The program includes orthopedic certified physical therapists that get the patients up and moving as quickly as possible after surgery. All geriatric patients are seen by pain management specialists who try to control the pain with acetaminophen or low doses of morphine, rather than barbiturates or other medications that can contribute to delirium in the elderly.

Every nursing shift conducts a delirium screen by asking patients to answer simple questions such as what hospital they are in, the day and the month, names of their children, and their own home address. If there is a change in the baseline, the nurse notifies the physician. "Delirium is a major postoperative problem in geriatric patients," Balsamo says. "Physical therapy can't work with patients if they have delirium, and if they're not involved with physical therapy, they are at risk for pneumonia. If patients are on bed rest for several days, it takes a long time for them to recover their muscle tone."

The geriatric fracture care team includes emergency physicians, orthopedic surgeons, hospitalists, anesthesiologists, physician assistants, nurses, physical therapists, and care managers. All team members follow standardized order sets and protocols geared to the special needs of older orthopedic patients. "We have developed a full geriatric program where everybody gets involved in how to treat our patients. The wheel doesn't turn if everybody isn't involved," Balsamo says.

The patients are followed by a nutritionist beginning with the first day of the hospital stay to ensure that they are getting sufficient nutrition to help them avoid pressure ulcers. Every patient is also seen by the blood conservation team. The care managers and social workers ensure that the patients are getting the physical therapy and occupational therapy consultations they need and to start on the discharge plan. If a patient falls or there is a question about whether they hit their head, they are seen by a neurologist.

The team looks at core measures every month to ensure that all the patients are getting the recommended care. The team has been 100% compliant on all orthopedic core measures since the program began. The hospital starts to gather information on potential patients before the fractures occur. The geriatric nurse coordinator for the program visits local nursing homes and gives the staff forms with spaces for healthcare history, phone numbers of family members, the patient's legal guardian, and advanced directives. The staff fills out the forms for each resident and puts them in an envelope supplied by the hospital.

When a patient comes into the hospital, the nursing home sends the envelope, giving the emergency department physicians the information they need to begin treatment. When geriatric patients have fractures, the orthopedic team starts early to engage the family and patient in the recovery process. "Getting the family involved from the beginning cuts down on problems," Balsamo says. "They understand why we get the patient out of the bed quickly and why we are not going to over-sedate the patient."

The team has developed a packet with information on the geriatric fracture program and questions about the patient's living situation, participation in activities of daily living, details about the house layout, the family doctor, and medications.

The geriatric fracture team continues its interventions after the patient is discharged by referring them to Geisinger's High Risk Osteoporosis Clinic for follow-up treatment, such as bone density supplements, and therapy that includes exercises and training to help reduce the risk of future fragility fractures. "Patients with a history of any type of fracture have a two- to sixfold increased risk of subsequent fractures, and that puts them at greater risk for disability," Balsamo says. "Optimal patient care for fragility fractures includes diagnosing and treating the underlying causes of the fracture, and educating the patient and family on how to prevent falls in the future."