By Jeffrey Frank, MD, MBA; Doug Lange, MD; Rick May, MD; Peter Rowe, MD; Reid Rubsamen, MD; Ryan Green, MD; Eric Fulkerson, MD; Catherine Hurt, MD; Teri DeLaMontanya, RN; and Barbara Harris, RN
Reducing complications (and ultimately morbidity and mortality) among hip fracture patients is a crucial quality goal for many hospitals. Here's how John Muir Medical Center – Walnut Creek (Calif.) achieved excellent outcomes for hip fracture patients using a unique interprofessional approach.
The following post is adapted from a poster presented at CEP America's 2013 conference.
Hip fracture patients often experience delays in getting to the OR, which increases use of narcotics for pain control and LOS resulting in increased complications.
At John Muir Health, a Hip Fracture Team was formed to focus on reducing complications by:
The interprofessional team included representatives from orthopedic surgery, anesthesiology, emergency medicine, hospital medicine, OR, and nursing.
John Muir Medical Center – Walnut Creek is a not-for-profit community hospital and Level 2 trauma center that treated 165 hip fracture patients in 2012.
In 2011, with support from the hospital administration, the team formed and developed a hospital-wide care path to reduce complication rates associated with hip fractures. A major goal of this protocol was to reduce ED-to-OR time to less than 24 hours. To accomplish this, the team developed a standardized hip fracture order set.
To test the new care path, the team launched a prospective observational study in 2012. Outcome measures included rates of delirium, urinary tract infections and respiratory and renal failure among hip fracture patients. The team also tracked patients' ED to OR time, length of stay (LOS) and readmission rates.
The Hip Fracture Team organizes care to expedite surgery, reduce use of narcotics and initiate early ambulation:
The ED team provides rapid diagnosis and activates the Hip Fracture Team. When a patient presents with a suspected hip fracture, both hip and pelvic x-rays are ordered to aid in surgical planning, and pre-surgery labs and tests are performed. When imaging studies confirm a hip fracture, the interdisciplinary team is alerted immediately to begin surgical planning — even if lab studies and other tests are not yet complete.
The anesthesia team works to manage the patient's pain, beginning in the emergency department. To reduce the risk of delirium, use of opioid medications is minimized and a femoral nerve block (FNB) is placed as soon as feasible. About 88 percent of hip fracture patients received an FNB in 2012.
The anesthesiology team also works to control pain with non-narcotic medications. (The hospital approved IV Tylenol specifically for use in the hip fracture care path.) When narcotics are needed, short-acting forms like fentanyl are preferred.
The hospitalist performs a preoperative assessment and proactively addresses potential complications (e.g. administers fluids to prevent renal failure).
The entire team works to move the patient from ED to OR in less than 24 hours.
Post-operative care includes early mobility (within one day) and prompt removal of the Foley catheter (within two days).
The new hip fracture protocol quickly produced significant results:
From 2011 to 2012, the number of patients experiencing complications decreased by 21 percent. What's more, the overall complication rate dropped by 38 percent. Improvement was especially marked in regards to delirium.
ED to OR time also decreased dramatically from nearly 30 hours to 16:
LOS among hip fracture patients dropped by 1.2 days:
Readmission of hip fracture patients declined by 14 percent across the study period:
By all measures, the hip fracture care path was a success. The data show it produced significantly better outcomes for patients. What's more, physicians and staff report that the process improves their efficiency and workflow.
By the conclusion of the study, the new care path had become self-sustaining. As of July 2014, the team continues to follow the protocol and meets regularly to refine and improve it.
John Muir Medical Center-Walnut Creek Campus is an acute care facility that is designated as the only trauma center (Level II) for Contra Costa County and portions of Solano County. Recognized as one of the region's premier healthcare providers, areas of specialty include high- and low-risk obstetrics, orthopedics, neurosciences, cardiac care and cancer care. John Muir Medical Center-Walnut Creek Campus is accredited by The Joint Commission (TJC), a national surveyor of quality patient care, is a STEMI receiving center and an Accredited Stroke Center. They achieved Magnet Status from the American Nurses' Credentialing Center in 2008, which recognizes hospitals where nursing delivers excellent patient outcomes, where nurses have a high level of job satisfaction and where there is a low staff nurse turnover rate and appropriate grievance resolution. To learn more, visit www.JohnMuirHealth.com.