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Feb 04, 2023 •708 likes •1.13k views

Evolutions tions in Geriatr tric ic Fractu ture e Ca Care Preparing ring for th the Silver Tsu sunami mi Jam ames es Holst stine ine, , DO DO Medical Director for the Joint Replacement Center, Geriatric Fracture Center,

  1. Evolutions tions in Geriatr tric ic Fractu ture e Ca Care Preparing ring for th the Silver Tsu sunami mi Jam ames es Holst stine ine, , DO DO Medical Director for the Joint Replacement Center, Geriatric Fracture Center, Orthopedic Surgeon PeaceHealth Whatcom Region Medical Director for Orthopedic Quality, PeaceHealth System Shevaun aun Rudkin, in, RN, , BSN Program Manager Orthopedics and Neurosurgery Joint Replacement Center, Spine Care Center and Geriatric Fracture Program

  2. Dis iscla claime imer • I am a program consultant and board member of Stryker Performance Solutions / Marshall Steele

  3. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • 76 y/o female • Independent ambulator • Lives at home alone • Drives herself to Church • Does her own shopping ---------------------------------------------------------------------- • Falls at home and fractures her hip • Transported by EMS to ED

  4. Cli lini nica cal l Appearan pearance ce of of Hip ip Fr Frac acture ture

  5. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • ED – Triaged as non-urgent – Foley catheter placed – Narcotics started for pain control – X-rays and labs obtained – Spends 4-5 hours in ED

  6. 2011 2011 – Prior to Fracture cture Progra ram • Admission – Admitted by orthopedist by telephone – Transferred to floor (anywhere there is a bed) • Standard room – Buck’s traction sometimes applied – Medical consult sometimes ordered

  7. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Pre-op – Extensive medical work up over next 48 hours – Cleared for surgery at that time – Placed on surgery waiting list as non-urgent – No social work visit until after surgery OR – No medical work up – Put on OR schedule as add on

  8. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Surgery – Surgery completed 11 pm next evening after patient was “bumped” for more urgent cases – Fracture stabilized 48-72 hours after injury – Procedure performed by on-call team

  9. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Post-operative course – Post-op delirium occurs lasting 48 hours • No PT during this time • Foley catheter left in place • Family very anxious over patients altered mental status

  10. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Post-operative course – Slow progress with PT • Therapist with little geriatric experience – UTI requiring antibiotics • Due to extended use of Foley catheter – Family anxious about “where we go next” • Social workers begin to explain options

  11. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Post-operative course – Transferred to SNF post-op day 7-8 – Discharged on Narcotic pain meds – Discharged on Antibiotic for UTI – No meds for osteoporosis

  12. 2011 2011 – Pr Prior to to Fracture acture Pr Program ram • Outcome – Patient transferred to long term care – Expires 4-12 months after surgery having never returned home (mortality rate 20-40%) – Average number of handoffs is 3.5 times OR – Returns to hospital for medical resources

  13. porosis Ep Epidemiol emiology ogy of of Oste teoporosi • 350,000 Hip fractures per year • 650,000 by 2050 • Incidence is increasing • 80% occur in females • Most common when age > 80 years • The peak of the “Baby Boom” will be within next 0 – 10 years • 72 million people projected to be > 65 in next 10 years in US • Responsible for > 2 million fractures in 2005 • By 2050, the worldwide incidence of hip fracture in men is projected to increase by 310% and 240% in women

  14. Epid idemi emiolog logy y of Os Oste teoporo oporosis sis • Women have 1/7 lifetime chance of Hip Fracture! (more than Breast cancer) • 1/2 lifetime fracture of any kind risk for women < than 50 • 25% of Trauma is 65 years and older • Fatal injuries occur at 3 times higher rate in this population • 28% of deaths in this population are associated with trauma

  15. Os Oste teoporosi oporosis s In n The he Eld lderly erly • 2 million bone breaks occur each year due to osteoporosis 5,500 every day, 1 every 15 seconds • 90 % of all women over the age of Less than 20% of hip fracture pts are 75 are receiving osteoporosis follow up osteopenic

  16. Prevalence of Osteoporosis and Low Bone Mass Americans Age 50 and Above Affected by Osteoporosis/Low Bone Mass, 2010 to 2030 (projected) 54 million of 99 million Americans age 50+ (2010) 17% of the +27% change ENTIRE U.S. from 2010 to POPULATION 2030 (2010) Millions

  17. Incid ciden ence ce of Frag agili lity ty Fractures actures

  18. Os Oste teoporosi oporosis Osteoporosis is Normal characterized by a decrease in bone mass and density “Fragility Fracture” – fracture resulting from Osteopenic “ standing height” or less

  19. Os Osteopo teoporosis rosis – A Ch Chronic onic Dis isease ease Morbidity Hip fracture Vertebral fracture Added morbidity from fractures Colles' fracture No fractures – increasing morbidity due to ageing alone 50 60 70 80 90 Age

  20. Risk Fac acto tors rs for Ger eriat atric ric Hip Frac acture ture • Osteoporosis • Dementia • Unstable Gait • Poor muscle strength • Poor vision or neurologic disease • Poor nutrition

  21. Pa Pati tien ents ts ar arrive e wi with th more e th than an frac actu ture... re... • Osteoporosis • Arthritis • Parkinson's Disease • Cancer • Respiratory Disease • Cardiovascular • Pressure ulcers • Strokes • Sleep problems • Dementia • Thyroid Disease • Depression • Urinary Disorders • Diabetes • Sensory impairment • Memory Loss

  22. All l fractures ctures are associa sociated ted wi with th morbidi rbidity ty Unable to carry out at least one independent activity of daily living 80% Unable to walk independently Permanent disability 40% Death within one year 30% 24% Cooper. Am J Med. 1997; 103(2A):12s-19s

  23. The e Vis isio ion • To develop a geriatric fracture center of excellence that enables Peacehealth St Joseph to provide a multi disciplinary, multi specialty team that facilitates quality team care and improved outcomes for this growing population over the next 10 years.

  24. Prog ogram rammatic matic Go Goals ls • Address increasing volume of fracture patients • Transition from ER to Nursing Floor within less than 4 hours • Transition from ER to Surgery within 12 to 24 hours • Reduce pain • Reduce LOS to 3.5 days or less • Enhance functional outcomes • Reduce nursing home placements

  25. Programmatic grammatic Go Goals ls • Reduce mortality in the first year following fracture • Maintain HealthGrades quality ratings • Increase patient and family satisfaction scores • Provide education for bone health and injury prevention • Provide screenings for Osteoporosis • Care for non operative fragility fractures for smooth transfer to home

  26. Me Menu u for r Succ cces ess 1. Medical Director / Physician Champion 2. GFP Coordinator 3. Streamlined Evaluation and admission process 4. Co-Admission by Hospitalist and Orthopedic Surgeon 5. Clinical Pathway and Standardized Orders Physician “Buy In” 6. 7. Reserved O.R. time 5 days/week 8. Multidisciplinary Team from ER through rehabilitation 9. Dedicated Beds

  27. Me Menu u for r Succ cces ess 10. Dedicated / Specially trained OR, Nursing & Therapy staff 11. Aggressive Therapy 12. Early D/C Planning 13. Patient / Family Education 14. Regular Team Meetings 15. Dashboard Development 16. Administrative Support 17. Delirium Prevention Program 18. Continuous process improvement

  28. Doc ocumented umented Cli lini nica cal l Benefits nefits • Streamlined Admissions • Interdisciplinary team cooperation • Daily evaluation/communication • Management of pain/delirium • More timely surgery/lower mortality • Clearer path of communication to the patient/family • Earlier, more effective discharge planning

  29. Nut uts s and nd Bol olts s of of Ge Geria riatri tric c Care re Disclaimer: I am an Orthopedic Surgeon! • Aging is not a disease • Occurs at different rates • Does not cause symptoms • Has common characteristics • Increases vulnerability to disease and decreases the ability to adapt • Normal aging begins at the age of 30

  30. Syste stem m by System tem Fly ly By • Neuro – Decrease step height – Increase reaction time – Decrease vibratory sense – Basil Ganglia atrophy • Renal – GDR Decrease – Decrease tubular function – Decrease Plasma flow – CRCL change to be age specific

  31. • CV – Systolic Hypertension – Maintenance of resting left ventricular function – Decrease ability to compensate for stress – Blunted heart rate response to max heart rate requires compensatory increase in stroke volume to maximize cardiac output – Decrease peripheral vascular compliance

  32. Qu Quic ick k tho houghts ughts on on ha handl ndling ing com omorbi orbidit dities ies • “ No such thing as a healthy geriatric hip fracture ” – 90% of these patients come in with comorbidities – Mortality is 9.2% greater with each comorbidity – Renal failure is highest comorbidity – 50% of patient over 65 have CAD

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