While hip fracture carries a high risk of associated morbidity and mortality, previous studies of co-management indicate that orthopedic surgeons and internists working side by side, each within their own knowledge base, results in better outcomes than with either working as a consultant to the other, explains Jensa C. Morris, MD. “At Yale, we initiated the co-management model in 2012 with reductions in inpatient mortality and complications,” she notes. “But we found that working together was only the first step in building a comprehensive hip fracture program. We recognized that the medical complexity of these patients requires involvement of a more extensive team, including our emergency department, orthopedic nursing, pharmacy, care management, and rehabilitation colleagues. The focus needed to expand from the co-management surgeon–internist dyad to a comprehensive hip fracture team with standardized protocols and outcome monitoring.”
Guiding Best Practices
With a wealth of research to guide best practices in the care of patients with fragility hip fractures—including literature on pain management, femoral nerve blocks, DVT prophylaxis, pre- and post-operative radiography, blood management, and pneumonia and delirium prevention—Dr. Morris and colleagues sought to determine their Yale Integrated Fragility Hip Fracture standard of care at all decision points, from EMS arrival and emergency department (ED) evaluation to preoperative evaluation, time to the operating room, postoperative care, and transition to home or rehabilitation. After extensive literature review and team consensus, the guidelines (Table) were hardwired into order sets to limit deviation. Results of their efforts are published in the Journal of Hospital Medicine.
“The intent was never specifically to publish a study,” notes Dr. Morris, “but to build a program that best served the patients. The only way to know if we were successful was to monitor the outcomes meticulously. We reviewed inpatient and 30-day mortality, medical and surgical complications, and time to OR quarterly. Interventions were added iteratively as data became available and our groups progressed to consensus. There was never a true before and after, as we continue to assess and modify protocols.”
“It wasn’t until 2 years into the program that we realized that each individual intervention and standardization of process had added up to substantial improvements in outcome and in 30-day mortality,” explains Dr Morris. Indeed, implementation of the Integrated Fragility Hip Fracture Program was associated with a 30-day mortality reduction, from 8.0% in 2015 to 2.8% in 2018. Significant improvements also occurred in blood transfusion use (from 46.6% to 28.1%), adverse effects of drugs (from 4.0% to 0.0%), length of stay (from 5.12 to 4.47 says), unexpected return to the operating room (from 5.1% to 0.0%) and time to the OR of less than 24 hours (from 41.8% to 55.0%).
“There wasn’t one single intervention that made the difference,” Dr. Morris notes. “It was a series of interventions that ultimately impacted the mortality of this patient population. One could also hypothesize that this is simply the effect of a highly reliable team working together with shared goals and clear expectations. Regardless, the entire process of evidence-based protocols introduced in a standardized fashion had the outcome of reducing mortality.”
Helping Others Build Successful Programs
Dr. Morris and colleagues hope that sharing their processes and outcomes can help others build successful programs within their institutions. “The first, most important step is to build a co-management team,” Dr. Morris adds. “Rotating hospitalists through a consult service will not provide the same standardized, high-quality care. The program cannot be built overnight. Even in areas in which the evidence is clear, the individual structure of each hospital will require unique problem solving and solutions. One cannot simply take our order sets and apply them. This principle can be applied to any complex patient care process. And certainly, we are starting to see better inter-departmental partnerships within our academic medical centers to care for other complex patient populations, such as those with stroke, heart failure, and cancer.”