James Holstine, DO Medical Director for the Joint Replacement Center,
Geriatric Fracture Center, Orthopedic Surgeon
PeaceHealth Whatcom Region
Medical Director for Orthopedic Quality,
PeaceHealth System
Shevaun Rudkin, RN, BSN
Program Manager Orthopedics and Neurosurgery
Joint Replacement Center, Spine Care Center
and Geriatric Fracture Program
Evolutions in Geriatric Fracture Care
Preparing for the Silver Tsunami
Disclaimer
• I am a program consultant and board member of Stryker
Performance Solutions / Marshall Steele
2011 – Prior to Fracture Program
• 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
Clinical Appearance of Hip Fracture
2011 – Prior to Fracture Program
• ED
– Triaged as non-urgent
– Foley catheter placed
– Narcotics started for pain control
– X-rays and labs obtained
– Spends 4-5 hours in ED
2011 – Prior to Fracture Program
• 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
2011 – Prior to Fracture Program
• 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
2011 – Prior to Fracture Program
• 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
2011 – Prior to Fracture Program
• 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
2011 – Prior to Fracture Program
• 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
2011 – Prior to Fracture Program
• 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
2011 – Prior to Fracture Program
• 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
Epidemiology of Osteoporosis
• 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
Epidemiology of Osteoporosis
• 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
Osteoporosis In The Elderly
• 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 75 are osteopenic
Less than 20% of hip fracture pts are receiving osteoporosis follow up
Prevalence of Osteoporosis and Low Bone Mass Americans Age 50 and Above Affected
by Osteoporosis/Low Bone Mass, 2010 to 2030 (projected)
Millions
54 million of 99 million
Americans age 50+ (2010)
+27% change
from 2010 to
2030
17% of the
ENTIRE U.S.
POPULATION
(2010)
Incidence of Fragility Fractures
Osteoporosis
Osteoporosis is
characterized by a
decrease in bone mass
and density
“Fragility Fracture” –
fracture resulting from
“standing height” or
less
Normal
Osteopenic
Osteoporosis – A Chronic Disease Morbidity
50 60 70 80 90
Colles' fracture
Vertebral fracture
Hip fracture
No fractures – increasing morbidity due to ageing alone
Added morbidity from fractures
Age
Risk Factors for Geriatric Hip Fracture
• Osteoporosis
• Dementia
• Unstable Gait
• Poor muscle strength
• Poor vision or neurologic disease
• Poor nutrition
Patients arrive with more than fracture...
• Arthritis
• Cancer
• Cardiovascular
• Strokes
• Dementia
• Depression
• Diabetes
• Memory Loss
• Osteoporosis
• Parkinson's Disease
• Respiratory Disease
• Pressure ulcers
• Sleep problems
• Thyroid Disease
• Urinary Disorders
• Sensory impairment
All fractures are associated with morbidity
Cooper. Am J Med. 1997; 103(2A):12s-19s
40%
Unable to walk independently
30%
Permanent disability
24%
Death within one year
80%
Unable to carry out at least one independent activity of daily living
The Vision
• 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.
Programmatic Goals
• 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
Programmatic Goals
• 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
Menu for Success
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
6. Physician “Buy In”
7. Reserved O.R. time 5 days/week
8. Multidisciplinary Team from ER through rehabilitation
9. Dedicated Beds
Menu for Success
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
• 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
Documented Clinical Benefits
Nuts and Bolts of Geriatric Care
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
System by System Fly 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
• 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
Quick thoughts on handling comorbidities
• “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
Co-morbidities…
• CHF
– Daily weights important
– Easier to deal with CHF than a dry patient
– Cardiology consult when not responsive to traditional care
• CAD
– ASA, Beta Blockers, avoid Hypoxemia, maintain HCT, control
pain
– Highest rate of infarctions is 72 hours
• COPD
– May need to avoid Beta Blockers
– Know patients baseline
• DM
– Early return to regular diet
– Avoid dehydration
– Maintain glucose levels less than 170- 180
– Hold sulfonamides
• Renal Disease
– Avoid NSAIDs
– Avoid BP changes
– Avoid fluids with diuretics, not a role for both
By the numbers
• Whatcom Co. has demonstrated a 24% increase in total
population from the year 2000 to 2013 (US Census Bureau)
• Whatcom Co. has projected a:
– 15% increase in the 55 and over age cohort in the next 5 years
2015-2020
– 28% increase in the 55 and over age cohort in the next 10 years
2015-2025
• Falls are the leading cause of injury related hospitalizations
• The rate for hospitalization for falls in Whatcom Co is 1700
per 100,000 population
By the numbers
• LOS for Hip fractures is currently 4.56 days! (5.7 Nationally)
DC Disposition %
2014 2013 2012 2011
Home 10 12 11 14
Skilled Nursing Facility 77 73 69 71
Hospice 2 4 4 3
Rehab – South Campus 6 8 12 3
Hip Fracture Volume by Year
Program started
Dec 2011
GFP Rates
• * 30-day readmit
rate is between 5%
and 9% depending
on definitions in our
institution
• * 30-day mortality
rate is between 2%
and 5% depending
on whose data we
use
Questions and Comments
Thank You!