Hip Fracture Treatment in Older Patients

Hip Fracture Treatment in Older Patients1.1 BackgroundHip (neck of femur) dampens are a common, serious and well-defined injury alter mainly one-time(a) people. As global populations age, projections for rose hip break dance numbers over the coming decades will rise. Delays to functioning are associated with increased post-operative complications, prolonged convalescence and distance of stay (LOS), and with increased morbidity and deathrate (Trpeski, Kaftandziev, and Kjaev, 2013). In do-gooder, the cost burden of hip fractures is substantial. The outgrowth of caring for people with hip fractures is complex, long, and involves several diagnostic, therapeutical and administrative activities. These activities occur in AE and orthopaedic departments, operating theatres, and in the community. They involve a range of health professionals and support staff. When this coordination fails, patients may suffer from avoidable delays and suffering. In the united Kingdom (UK), the bed occupancy rove for hip fractures was to a greater extent than 1.5 million days, which represent 20% of the total orthopaedic beds (Compston et al., 2009). The lifetime risk of sustaining a hip fracture in the UK from age 50 is around 11% for women and 3% for men (Van Staa et al., 2001). Many of those who recover suffer a loss in mobility and independence approximately half of those previously independent become partly dependent, while one-third become totally dependent (Myers et al., 1996).1.2 legitimate ProcessWatford full general Hospital (WAT) treat 450 patients for hip fractures every year. Hip fractures are one of the most common complex trauma problems orthopaedic surgeons face. Patients are often earnestly ill, elderly and frail, which can result in poor outcomes.Hip fractures generally result from a fall, patients present at AE where imaging samples are practiced to pretend a diagnosing and offend medication is administered (Appendix A). When possible, patients are moved from the emergency department to a protect.Ideally, patients will call for surgery within 72 hours of arriver at infirmary, put upd they are in a stable condition. A pre-operative assessment is carried out to establish the patients overall health to make sure they are launch for surgery. They also have an anaesthetic assessment. Two main types of anesthesia are used general anaesthetic and spinal or epidural anaesthesia. A aggroup of health wish well professionals will perform the surgery, including an orthopaedic surgeon.The National Hip Fracture Database (NHFD) produce an annual report that includes an analysis of 30-day deathrate grade for hip fracture patients who are over 60 years old within the UK. WAT were alerted by the NHFD that they were an outlier, with 12% mortality over 3 years. In the UK the overall mortality rate within 30 days of hip fracture in 2014 was 7.5% (Johansen, 2016). High mortality rates are a signal to hospitals that they should investigate t o identify and respond fiber issues. soma 1Funnel Plot of Crude and Adjusted Mortality Rates 2014 (Source Johansen, 2016)Effective strategies are needed to reduce the burden on health palm providers and to ameliorate patient quality of life and outcomes aft(prenominal) a hip fracture. Staff at WAT want to develop an action plan to analyse performance and encourage amendment programmes. This included questioning what elements of negociate could have been de exitred better to ensure that racy-quality care is delivered throughout the patients treatment, to improve 30-day mortality rates and operating(a) outcomes for patients.1.3 Perceived Issues with the Current ProcessIn the present study, the incidence and mortality and functional outcomes in hip fracture patients was studied. The relationships between entree and treatment clock, pain dispensement drugs and anaesthesia, and their opinion on the patients length of stay (LOS) in hospital were assessed and the following is sues were foundAdmission time from AE to treatment is highHigh level of opiate usage to manage painRoutine use of general anaesthesia1.4 Value Adding ActivitiesAdmission to surgery times botheration managementDays spent in hospital1.5 ScopeOlder people with hip fractures aged 60 or over are in scope for this project. 1.6 Problem disceptation30-day mortality rates for older hip fracture patients at Watford General Hospital have been 12% for 3 consecutive years, 4.5% higher than the national average (NHFD).1.7 Goal StatementReduce 30-day mortality rates in older hip fracture patients to 8.5% by the end of June 2017.2.1 Process functionFigure 2 Process Map2.2 Process Narrative The person arrives at the AE department by ambulance or car. The triage nurse assesses the patients condition. Patients are classified by severity of injury (red, yellow, or green). Patients presenting with pretend hip fractures are comm that assigned a yellow classification, which indicates an emergency but not of a life-threatening nature. An AE reinstate or nurse checks the patients alert signs, records their pre-fall health condition, and administers pain medication (generally opiates). Subsequently, in consultation with an AE doctor (if available), several basic tests (blood tests) and X-rays (hip and often chest) are ordered and performed. The patient is transferred to the radiology department for x-ray. The AE doctor or nurse then reviews the test results. If a hip fracture is diagnosed, the patient is deemed admissible and an intravenous (IV) drip is started. The patient is transferred to the orthopaedic ward for admission when a bed becomes available. Admission times are currently 13.4 hours.On admittance to the orthopaedic ward an orthopaedic surgeon will review the test results. If the patient is deemed suitable for treatment the medical assessment team will assess if the patient has any existing medical issues that may affect treatment. If exist medical conditions with th e potential to affect treatment are found patients are referred to lenitive care and discharged. If no pre-existing conditions are found patients are assessed by the anaesthesia team. Patients deemed suitable for surgery are placed on the trauma list, surgery generally takes place within 72 hours. Patients deemed unsuitable are referred to palliative care and discharged. Patients go to theatre, they are anesthetised using general anaesthetic and receive surgery. They are subsequently transferred back to the orthopaedic ward for ward-based management. Patients are discharged erst they are mobile.2.3 Identification of Problems, Weaknesses, and Change AreasHigh level of opiate use by AE staff for pain managementAdmission times of 13.4 hoursSurgery wait times of up to 58.6 hoursRoutine use of general anaesthetic in surgery3.1 Key Strategic Elements for ImprovementPatients with hip fractures often require complex and repugn care, this is provided by a number of professionals in severa l departments, crossing a number of service boundaries. These patients are often frail, and their outcomes depend on how in effect their care pathway is managed. Pain management medications, avoidable delays, anaesthesia choices and post-operative care affect functional outcomes and mortality.The key strategic elements towards improving outcomes for older hip fracture patients areReducing morbidity and mortality ratesAchieving better functional outcomes for patientsIncreasing discharge rates to original place of residenceIncreased value from the healthcare budgetThey can be achieved byAltering pain management practicesAltering anaesthetic managementReducing admission and treatment times3.1.1 Pain ManagementDespite recent advances in the care of hip fracture patients, significant morbidity and mortality persists. Some of this is attributable to the pain medication administered in hospital. Opiates are the preferred pain management drug at WAT currently (Appendix A). Opiate use can ca use nausea, constipation, and confusion (delirium) in the older patients (Coruhlu and Pehlivan, 2016).Effective pain management is a primary goal in hip fracture treatment. Research suggests fascia iliaca compartment blocks (FIB) is an alternative for pain management in hip fractures. endovenous opioid therapy is used frequently (Appendix A). However, opioid side effects, such as nausea, vomiting and delirium, are common. Regional analgesic techniques have been shown to provide similar analgesia to opioids. FIB is reported to effectively block cutaneous lateral femoral and femoral nerves in adults (Nie et al., 2015). Studies have suggested superior analgesic effect with pre-operative FIB. They provided superior analgesia to intramuscular morphine in a randomised controlled trial of hip fracture patients (Callear et al., 2016).FIB is a safe and simple technique that can be administered by junior doctors and specialiser nurses with training (Hanna et al., 2014). FIB administered in AE provided significant decreases in pain when compared to opiates. Post block analgesic requirements for patients in the FIB group were minimal. A study conducted by Callear and Shah (2016) concluded that a single dose of FIB given in the pre-operative period significantly reduced the post-operative and total analgesic requirements in the hip fracture patient. Patients also experience lower rates of delirium and were discharged faster. This reduces the cost of providing inpatient hospital beds and improves quality of life for older patients.3.1.2 Anaesthetic ManagementAnaesthetists have an essential role in the preoperative, operative and postoperative management of hip fracture patients. Complications arising from anaesthesia in hip fracture surgery is influenced not only by the type of anaesthetic used, but also by patient comorbidities and the delays between admission and surgery. Approximately 25% of hip fracture patients display at least one episode of cognitive dysfunction duri ng hospitalisation (Heyburn et al., 2012). A systematic review published by SIGN (2009), suggests that the use of spinal anaesthesia may reduce the incidence of postoperative confusion.3.1.3 Time to SurgeryAt present admission times are 13.4 hours (NHFD statistics show the national average is 9.3 hours) and surgery wait times are 58.6 hours. Current guidelines recommend surgery to be carried out within 24 hours of injury (BOA, 2014). Observational studies suggest better functional outcomes, shorter hospital stays, duration of pain, and lower rates of complications and mortality are achieved by performing surgery earlier. Pre-operative delays increase mortality and, in those who survive, prolongs post-operative stay. For every additional 8 h delay to surgery after the initial 48 h, an extra day in hospital results (Colais et al., 2015). Currently WAT fall far short of the ideal to provide optimal care for hip fracture patients.3.1.4 Multidisciplinary ApproachThe management of hip fr actures requires complex, connected care from presentation at AE, through all departments. A study of 116 patients found that dedicated nurse specialists are effective at fast-tracking hip fracture patients to surgery by securing hospital beds, organising care, operating theatre lists and acting as a liaison with all other relevant departments (Larsson and Holgers, 2011).Many published guidelines recommend a multidisciplinary approach to the treatment of hip fractures, in addition to, a good care environment to promote best outcomes. The Scottish Intercollegiate Guidelines Network (SIGN, 2009), the National Institute for Clinical Excellence (NICE, 2013), and the British orthopaedic Association in cooperation with the British Geriatric Society (BOA, 2014), have all produced guidelines supporting a multidisciplinary team approach to deal with hip fractures in older people.Figure 3 Multidisciplinary Team (Source orthopaedics and Trauma)Rieman and Hutichson, (2016) It is recognised t hat a team approach with excellent communication between all the members is essential. The multidisciplinary team looking after hip fracture patients is large (Figure 2), and each role is important in the jigsaw of care.3.1.5 Clinical PathwayClinical pathways should be used to aid the multidisciplinary team. They provide a description of the expected interventions and outcomes throughout the patient journey following a hip fracture. The use of clinical pathways ensures everyone knows the next step in the process and this minimises unnecessary variations in practice (Chudyk et al., 2009). A study of 1193 older hip fracture patients conducted at 6 hospitals in the Limburg trauma region of the Netherlands concluded that the use of a multidisciplinary clinical pathways (MCP) for patients with hip fractures tends to be more effective than usual care (UC). Time to surgery was significantly shorter in the MCP group when compared to the UC group. The mean length of stay was 10 versus 12 day s. In addition, the MCP group had significantly lower rates of postoperative complications (Kalmet et al., 2016).3.2 Proposed StrategyEstablish a designated Hip Fracture Unit within the main orthopaedic unit.Appoint a multi-disciplinary team to be based on the ward comprised ofPhysio /Occupational TherapistOrthopaedic /Orthogeriatric Doctor medical specialist Hip Fracture NurseNursing staffEstablish a Hip Fracture Pathway.Establish a protocol-driven, fast-track admission of patients with hip fractures through AEAE beep specialist hip fracture nurseFIB administered by nurse for pain management and patient centred carePatients are admitted to the hip fracture ward within 6 hoursAppropriate, medically fit patients receive surgery within 24 hoursUse of spinal anaesthesia when appropriateContinuous tracking/live data systems that regularly update patient and logistical data may improve management by identifying patients location, delays in treatment and relevant clinical information.3.3 authorisation Process Improvement Tools3.3.1 Continuous Quality ImprovementContinuous Quality Improvement (CQI) is a quality management tool that encourages all members of the health care team to continuously ask, How are we doing? and Can we do it better? (Edwards et al., 2008). It focuses on proceeds for the patient and the practice by asking questions like, can we do things more efficiently? Can we be more effective? Can we do it faster? CQI uses a structured planning approach to evaluate the current processes and improve those processes to achieve the desired outcomes.Tools commonly used in CQI help team members identify the desired clinical or administrative outcome and the evaluation strategies that change the team to determine if they are achieving that outcome. The team can adjust the CQI plan based on continuous monitoring of progress through an adaptive, real-time feedback tat (NLC, 2013).A CQI approach can help improve patient care. There is a strong link between org anisations with explicit CQI strategies and high performance (Levin, 2016).Figure 4 CQI Framework Model (Adapted from NLC)Structure examines the characteristics of resources, staff and consultants, physical space, and financial resources.Process - the activities, workflows, or tasks carried out to achieve an output/outcome.Output the immediate harbinger to a change in the patients status. Not all outputs are clinical e.g. business or efficiency goals.Outcome the end result of care. Can be change in the patients current and future health status.Feedback Loop represents its cyclical, iterative nature.3.3.2 tiptoe Management flimsy is a process improvement method authentic by Toyota in the 1950s. Lean management principles have been used in manufacturing for many years, however, these principles can be used in healthcare too. According to Womack and Jones, thither are five key lean principles value, value stream, flow, pull, and perfection. Lean drives out waste so that all work adds value from a customer positioning. Lean thinking focuses on how efficiently resources are being used, it looks at each step in the process and asks what value is being produced? Value from a patients perspective can be defined as timeliness of treatment, reduced stress, or better functional outcomes. The NHS defines value as anything that helps treat the patient. Everything else is waste (Jones and Mitchell,2006).Figure 5 Lean Principles severalise customer value in healthcare value is any activity that improves the patients health.Manage the value stream the value stream is the patients journey. Identify process that deliver value to patients.Create Flow align processes to facilitate the smooth flow of patients and informationEstablish Pull provide care on demand and utilising resources effectively.Seek Perfection optimise the process through continued development and adjustment to meet patients needs.Optimal delivery of high-quality care to reduce mortality in hip fract ure patients is an achievable goal. There are numerous opportunities to enhance the quality of care reduced length of stay, reduced institutionalisation, reduced mortality and better functional outcomes for patients. Better quality care minimises treatment delay, promotes recovery and facilitates a speedier discharge. Cost and quality are not in conflict providing high quality hip fracture treatment is a lot cheaper than poor quality treatment. Lean inspired and clinical pathway related process improvement efforts make inconsistent and inefficient practices in health care more visible. The implementation and adherence to evidence based standards will considerably improve the care and management of older patients with hip fractures, this will result in significantly improved outcomes for patients and the healthcare system.5.1 Appendix AReferences BOA (2014) BOA standards for trauma (bOASTs). visible(prenominal) at http//www.boa.ac.uk/publications/boa-standards-trauma-boasts/ (Acce ssed 5 December 2016).Callear, J., Shah, K., Hospital, J.R. and Oxford (2016) Analgesia in hip fractures. Do fascia-iliac blocks make any difference?, BMJ Quality Improvement Reports, 5(1), pp. 210130-4147. doi 10.1136/bmjquality.u210130.w4147.Chudyk, A., Jutai, J., Petrella, R. and Speechley, M. (2009) Systematic review of hip fracture rehabilitation practices in the elderly, Archives of physical medicine and rehabilitation., 90(2), pp. 246-62.Colais, P., Di Martino, M., Fusco, D., Perucci, C.A. and Davoli, M. (2015) The effect of early surgery after hip fracture on 1-year mortality, BMC Geriatrics, 15(1). doi 10.1186/s12877-015-0140-y.Compston, J. (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK, Maturitas., 62(2), pp. 105-8.Coruhlu, O. and Pehlivan, S. (2016) Worst pills. Available at http//www.worstpills.org/includes/page.cfm?op_id=459 (Accessed 5 December 2016).Edwards, P., Huang, D., Metcalfe, L. and Sainfort, F. (2008) Maximizing your enthronement in EHR. Utilizing EHRs to inform continuous quality improvement., JHIM, 22(1), pp. 7-12.Hanna, L., Gulati, A., Graham, A. and Corporation, H.P. (2014) The role of Fascia Iliaca blocks in hip fractures A prospective case-control study and feasibility assessment of a junior-doctor-delivered service, transnational Scholarly Research Notices, 2014. doi 10.1155/2014/191306.Heyburn, J., Holloway, G., Leaper, E., Parker, M., Ridegway, S., White, S., Wiese, M. and Wilson, i (2012) Management of proximal femoral fractures 2011, Association of Anaesthetists of Great Britain and Ireland, 67(1), pp. 85-98.Jones, D. and Mitchell, A. (2006) Lean thinking for the NHS. Available at http//www.nhsconfed.org//media/Confederation/Files/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf (Accessed 11 December 2016).Kalmet, P.S.H., Koc, B.B., Hemmes, B. and ten Broeke, R.H.M. (2016) Effectiveness of a Multidisciplinary Clinical Pathway f or Elderly Patients With Hip Fracture A Multicenter Comparative Cohort Study, Geriatric Orthopaedic Surgery Rehabilitation, 7(2), pp. 81-85.Levin, D. (2016) Using continuous quality improvement to improve patient experience. Available at http//bivarus.com/using-continuous-quality-improvement-improve-patient-experience/ (Accessed 7 December 2016).Myers, A.H., Palmer, M.H., Engel, B.T., Warrenfeltz, D.J. and Parker, J.A. (1996) Mobility in older patients with hip fractures Examining Pre diary of Orthopaedic trauma, Journal of Orthopaedic Trauma, 10(2), pp. 99-107.NICE (2013) Falls in older people Assessing risk and prevention. Available at https//www.nice.org.uk/guidance/cg161 (Accessed 5 December 2016).Nie, H., Yang, Y.-X., Wang, Y., Liu, Y., Zhao, B. and Luan, B. (2015) effectuate of continuous fascia iliaca compartment blocks for postoperative analgesia in patients with hip fracture, 20(4).NLC (2013) Continuous quality improvement (CQI) strategies to optimize your practice Prime r provided by. Available at https//www.healthit.gov/sites/default/files/nlc_continuousqualityimprovementprimer.pdf (Accessed 7 December 2016).Rieman, A.H.K. and Hutichson, J.D. (2016) The multidisciplinary management of hip fractures in older patients. Available at http//www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327(16)30025-2/fulltext (Accessed 5 December 2016).Scottish intercollegiate guidelines network part of NHS quality improvement Scotland SIGN management of hip fracture in older people (2009) Available at http//www.sign.ac.uk/pdf/sign111.pdf (Accessed 5 December 2016).Simunovic, N., Devereaux, P. and Bhandari, M. (2011) Surgery for hip fractures Does running(a) delay affect outcomes?, 45(1).Trpeski, S., Kaftandziev, I. and Kjaev, A. (2013a) Fast-track care for patients with suspected hip fracture. Available at http//www.injuryjournal.com/article/S0020-1383(11)00002-7/fulltext (Accessed 10 December 2016).Trpeski, S., Kaftandziev, I. and Kjaev, A. (2013b) The effec ts of time-to-surgery on mortality in elderly patients following hip fractures, Prilozi (Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski nauki)., 34(2), pp. 115-21.Van Staa, T.P., Dennison, E.M., Leufkens, H. and Cooper, C. (2001) Epidemiology of fractures in England and Wales. Available at http//www.thebonejournal.com/article/S8756-3282(01)00614-7/fulltext (Accessed 5 December 2016).Verhelst, J., Dawson, I., Paul T. P. W. Burgers, Esther M. M. Van Lieshout and Piet A. R. de Rijcke (2013) Implementing a clinical pathway for hip fractures effects on hospital length of stay and complication rates in five hundred and twenty six patients, 38(5).