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!