Co-management of hip fractures among different disciplines can be effective in improving care and outcomes, according to the experience of one healthcare network.
With the support of a grant from The John A. Hartford Foundation, a nonprofit, nonpartisan organization in New York City that works to improve conditions for the care of older adults in the healthcare system, Northwell Health, a healthcare network also based in New York City, has implemented such a program at two hospitals and plans to expand it to two more by 2020.
A 2013 study of hip fracture co-management found that it “resulted in a reduced requirement for patient admission to the ICU, decreased lengths of stay for patients in the hospital and in the ICU, and decreased hospital charges per patient.” (The study is available online at: .)
The first step in implementing the program involved forming a steering committee that met monthly for six months to determine what was needed to execute the co-management best practices, explains Maria Torroella Carney, MD, chief of geriatrics and palliative medicine at Northwell Health. The healthcare network already had put some best practices in place, but the committee developed ways to implement them in a comprehensive way in one hospital.
The first hospital was chosen because it had extensive buy-in from key stakeholders like leadership, nursing, anesthesia, and orthopedics. Also, there was a geriatric specialist present at the hospital.
“We looked at our electronic record order sets and we realized that the order sets for hip fractures were good for orthopedics but they were not good for older patients. We had to adjust them for medications and dosages that were safer because they were not always appropriate for an older adult with a hip fracture who may be more frail than the average adult,” Carney says. “We had a data analyst in place to measure outcomes also. We got all of that in place in the first six months to a year. Then, we had to meet with the hospital leadership to explain what we were doing.”
Committee members also met with frontline clinical leadership, who responded well and were eager to learn about co-management of hip fractures, Carney recalls. The program kicked off with a breakfast for participants, followed by educational modules, monthly meetings to monitor progress, and additional meetings to discuss difficult patients.
Once the first hospital was running the program efficiently, staff helped introduce the process to a second hospital with mostly the same features but allowing some flexibility that works with the unique aspects of each facility.
Co-Management Begins in ED
The co-management of hip fractures begins as soon as the patient arrives in the ED, Carney notes. The ED calls orthopedics, which then notifies hospital medicine. Someone from both departments will see the patient soon.
“The orthopedic department begins the admission and gets them to a floor bed, but what is different is that the patient goes to an orthopedic floor and is co-managed with medicine, with the input of geriatrics as well,” Carney says. “Co-management is not just coming by and giving consultation. It’s actually dividing up who is going to do what, the orthopedist dealing with orthopedic, surgical, and pain management issues, while medicine is involved with everything outside of the orthopedic injury.”
That means medicine deals with issues such as avoiding misuse of medications, minimizing pain medications, bowel motility, getting out of bed as soon as possible, diabetes issues, heart failure, and similar concerns.
“A lot of times people with complex medical issues would not go to the orthopedic floor. They would go on medicine, and the nursing staff on the medicine floor might not have been comfortable dealing with the hip fracture,” Carney explains. “It’s important that they go on the orthopedic floor where the staff is best capable of dealing with that primary issue, but they’re still receiving coordinated care for their other medical concerns by a medical, geriatric provider.”
Provide Education on Differences
Successfully implementing such a program requires educating clinicians and hospital leadership on the unique risks faced by patients with hip fractures, Carney says. They are a vulnerable population with a high rate of complications and mortality as well as a high risk of readmission without a good plan of care.
“Once you educate them that this is a high-risk, vulnerable population, then everyone will fall into place and try to help these patients and their families,” Carney says. “We can intervene, and the protocols that exist to support this population show benefit. Co-management can really improve the quality of care.”
It is important to show clinicians and hospital leaders what is different about the hip fracture protocols and why co-management is necessary, Carney says. No one thinks clinicians are providing inadequate care to these patients, so they must understand what is different about what leaders are asking them to do.
“Whenever we bring this up, people tell us they are already doing this well,” Carney says. “But once they follow the protocol, they realize they thought they were doing it fine, but they’re doing it better now.”
Shorter Times to Surgery
The program has been in place at the first hospital for a year and has lowered the length of stay for hip fracture patients by one day, Carney reports. Metrics also indicate the hospital is managing pain better and shortening time to the operating room. The goal is send hip fracture patients to surgery within 24 hours. The hospital is at almost 100% reaching the operating room within 48 hours. That was achieved partly by prioritizing these cases for surgery, whereas in the past they may have been delayed when operating rooms were busy.
“The program has helped us identify the barriers to getting surgery within the time frame we wanted. A big one was feeling that patients needed cardiac clearance before surgery; that would delay getting to surgery by a day,” Carney explains. “We found that we don’t need an echocardiogram of the heart, for instance, for every patient before surgery. These are mostly older adult patients. Many of them have cardiac histories, but we determined that we can stabilize, do the surgery, and get any further workup we need afterward.”