Universal protocol cuts hip surgery fatalities
Sentinel event leads to innovation solutions
The determination that "good" is not good enough has spurred Staten Island (NY) University’s medical staff to develop a new, universal protocol to reduce the mortality rate for high-risk patients undergoing hip fracture repairs. As a result, mortality rates decreased 80% over three years — from 4.9% to 1%.
Staten Island University Hospital is a 785-bed, tertiary care, teaching hospital and part of the North Shore-Long Island Jewish Health System.
Staten Island’s initiative focused on the frail elderly, who are at high risk for hip fracture. This group comprises more than 15% of Staten Island’s population and is the second fastest-growing segment of the community’s population.
By establishing a defined process for preoperative assessment of high-risk surgical patients, Staten Island’s project reduced process variation, defined performance standards, and focused on outcomes for hip fractures, which account for the largest portion of injury-related hospitalizations nationally.
It began with a sentinel event in 2000. A 78-year-old woman was admitted with a hip fracture, as well as a number of medical/surgical comorbidities.
"The medical clearance was identified as no contraindication for surgery,’ recalls Joseph Conte, MPA, vice president of quality. "The anesthesiologist disagreed because of her history of laryngeal cancer and some pulmonary issues." The disagreement went unresolved, however; the patient went to the surgical suite and, at the time of induction, had a cardiac arrest and died.
A root-cause analysis was conducted, and as part of the research, it was revealed that the hospital’s mortality rates for hip fracture patients were well within the state norm, "and even in terms of the national norm, we were right in the ballpark," he says.
Nevertheless, "We felt a benchmark was just a measurement — not a solid line drawn that said we hit it. Anything else but zero is really experience-driven, and when we looked at the literature, we saw that some people were doing better than 5%, so [a new protocol] was certainly worth developing," Conte notes.
Key issues addressed
Since the hospital maintains a quality database for issues of concern, staff were able to sort data on surgical morbidity mortality typically related to hip fracture.
"We found other similar cases, in that the initial assessment did not give a robust picture," he points out. "Then, we began to look into the whole philosophy of medical management; while the prevailing attitude was if a patient had a fracture and needed surgery, they should have it as soon as possible, that’s not necessarily in the patient’s best interest."
One of the real eye-openers in their research was the discovery that, nationally, within a year of hip fracture, 25% of the patients are dead. "That is higher than most cancer diagnoses," Conte says. "But we also saw they did not die from surgery, but rather from pneumonia, pulmonary complications, underlying comorbidities, urinary tract infections, and blood clots."
Medical management took the reins of the initiative. "The head of the department championed it, and through his own due diligence, found that perioperative medicine was becoming a field in itself," he recalls. The staff soon realized that pre-op patients were not, for example, being put on beta-blockers, and that there were other work-ups that could be done.
Root-cause analysis also revealed that the physicians who were giving pre-op exams were not specifically privileged.
"We decided initially that we needed to identify a cadre of physicians right off the bat who could continue to do this service," Conte adds. That cadre consisted initially of about 15 intensivists (primarily pulmonologists or cardiac or critical care physicians). They were followed shortly by the hospital’s 20 hospitalists.
"The next step was the development of a graduate medical education program four hours in duration, which really took from all the evidence-based information out there," he explains.
"A number of physicians then took that class and immediately got on board with what was required; they then requested privileges, and they were granted," Conte adds.
Through a process of education, physicians were encouraged to focus on the new protocol. One component was beta-blocker usage. "It’s becoming a standard of practice," he notes.
"Another thing we did was to liberally use consults as necessary." The team also developed a new assessment tool. "We got less tuned in to the fact that the patient has to go into the OR within 24 hours," Conte summarizes. "And in fact, this was borne out with a paper in JAMA [the Journal of the American Medical Association] last year on the association of timing of surgery for hip fracture and patient outcomes.
The authors said in their conclusion that Early surgery was not associated with improved function or mortality.’1 This flies in the face of everything we used to think, but now we know that if you have the opportunity to optimize the patient by getting beta-blockers on board, improving their cardiac and pulmonary status, that this is more valuable than racing to surgery."
Time still an issue
One interesting discovery during the process, Conte says, was that even though the staff were no longer wed to timeliness, "One of the important things we realized was that we still needed to be aware of time."
For example, the emergency department was focused on the project from the beginning. "As soon as a patient had been identified with a hip fracture, they immediately got the orthopedic surgeon engaged, and he, in turn, immediately got a medical assessment person on board," he shares.
Another key to success, he continues, was the buy-in of the orthopedic surgeons. "If they felt this [new process] was an impediment, that would have been bad," Conte concedes. "We made sure they were involved as important stakeholders at all stages."
Finally, he says, all the people involved had common training and education.
"We started with a common theme of medical management of these patients, which was extremely important," Conte emphasizes.
"Once you have a lot of variance, you don’t have a process anymore. A common methodology, approach, training, and background create the same mindset," he adds.
Reference
1. Orosz GM, Magaziner J, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004; 291:1,738-1,743.
Need More Information?
For more information, contact:
• Joseph Conte, MPA, Vice President of Quality, Staten Island University Hospital 375/475 Seaview Ave., Staten Island, NY 10305. Phone: (718) 226-1910.]
The determination that good is not good enough has spurred Staten Island (NY) Universitys medical staff to develop a new, universal protocol to reduce the mortality rate for high-risk patients undergoing hip fracture repairs. As a result, mortality rates decreased 80% over three years from 4.9% to 1%.
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