Geriatric Hip Fracture Program Christina McQuiston M.B.Ch.B. Mission Hospitals, Asheville, NC.
Transcript of Geriatric Hip Fracture Program Christina McQuiston M.B.Ch.B. Mission Hospitals, Asheville, NC.
Geriatric Hip Fracture Program
Christina McQuiston M.B.Ch.B.
Mission Hospitals, Asheville, NC
The Problem
• 300,000 Americans experience a hip fracture annually
• In 2005 fragility fractures cost around $19 billion
• By 2025 it is predicted that these costs will rise to around $25billion.
• Around 24% of such patients over 50 will die in the year following a fracture
Hip Fracture Repair per 1,000 Medicare Enrollees (2003)
Source: Dartmouth Atlas 2003
National Average
7.53
1. Oklahoma 9.06
2. Tennessee 8.87
3. Georgia 8.78
3. North Carolina 8.78
11. South Carolina
8.28
23. Florida 7.46
2005 COUNT
Mission Hospitals 414Duke University Medical Center 389New Hanover Regional 302Moses Cone 283Forsyth Memorial 243Presbyterian 215Carolinas Medical Center 197Pitt County 197The NC Baptist Hospitals 182First Health Moore Regional 167WakeMed 165Gaston Memorial 161UNC Hospitals 161Northeast Medical Center 160Rex Healthcare 157Cape Fear Valley 141High Point Regional 140Rowan Regional 120Alamance Regional 116Cleveland Regional 106Pardee Hospital 102
2006 COUNT
Mission Hospitals 402Duke University Medical Center 342Moses Cone 309Forsyth Memorial 284New Hanover 278Carolinas Medical Center 238Presbyterian 237WakeMed 203The NC Baptist Hospitals 187Pitt County Memorial 186First Health Moore Regionsl 185Gaston Memorial 178Rex Healthcare 173UNC Hospitals 153Cape Fear Valley 141Northeast Medical Center 141High Point Regional 135Rowan Regional 121Durham Regional 118Frye Regional 117Alamance 116Pardee Hospital 112
Hip Fracture Repairs NC Hospitals
Medicare volumes
Mission Hospitals All payers
2006 2007
Total number 586 563
Total number over age 64
492 454
ALOS all pts 5.8 days 6.36 days
Mission Hospitals: Net
income per
Case
Patients with CC and MCC
($2,000)
($1,800)
($1,600)
($1,400)
($1,200)
($1,000)
($800)
($600)
($400)
($200)
$0
FY 06 FY 07 FY 08 Q1
Patients without CC or MCC
($1,000)
($800)
($600)
($400)
($200)
$0
$200
$400
FY 06 FY 07 FY 08 Q1
Environmental Survey
• Reviewed literature on co-management models. Shows decreased LOS and readmissions.
• Reviewed anesthesia literature. Less delirium with spinal anesthesia.
• Reviewed and incorporated CHEST guidelines for VTE prophylaxis.
• Reviewed orthopedic literature regarding post hip fracture weight bearing status.
• Reviewed current recommendations for osteoporosis treatment.
• Site visit to Highland hospital in Rochester NY to review their process. (data published this summer)
Plan Outline
All patients with fragility hip fractures(>65yr)
Orthopedist remains attending physician.All patients co-managed by hospitalist.Elder specific pre and post op order sets.Consistent early weight bearing.Chest guidelines for VTE prophylaxis.Incorporate osteoporosis treatment.
Current Work
• Improve collaboration among ER physicians, orthopedists, hospitalists and anesthesiologists.
• Develop a protocol driven medical co-management process.
• Streamline throughput from admission to discharge.
• Create elder specific computerized power plans.
Medical Co-Management
• Standardize the initial medical consult with attention to geriatric syndromes.
• Accurately document medical co-morbidities.
• Stratify risk.• Coordinate additional consults.• Actively manage the discharge
process.
Everyone Wins
• Door to OR in <24 hrs.• Reduce length of stay.(4 day goal)• Reduce costs.• Reduce complications.• Reduce hospital acquired delirium.• Reduce readmissions.• Increase patient and family
satisfaction.
Door to OR dataED to OR
79% fall under 24 hoursn=101
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100
Volume
Ho
urs
ED to OR
20.79%
6.93%
19.80%
10.89%
18.81%18.81%
3.96%
0
5
10
15
20
25
≤ 4 4-8 8-12 12-16 16-20 20-24 > 24
Hours
Vo
lum
e
Readmission-Reasons 46 Patients
Anemia 1
Aspiration Pneumonia 1
Atrial Fibrillation 3
C Diff Colitis 2
CHF 2
Cholelithiasis 1
Dehydration 3
Dysphagia 1
Fever 1
Gangrene non-operative leg 1
GI bleed 1
Hip dislocation 7
HTN 1
Ileus 1
Lag screw cut femoral head 1
Nausea 2
New fracture 9
Non-union 1
Pain 1
Pancreatitis 1
Pneumonia 6
Septic Shock 2
Thrombus 1
UTI 3
Wound Erythema 2
Wound Infection 6
Readmissions – Timing 46 Patients
Returned within 7 days 16
Returned between 8-14 days 12
Returned between 15-21 days 8
Returned between 22-31 days 10
APR DRG
Cases
APRReadmissi
onRate
Expected APR
Readmission
Rate
Expected APR
Readmission Rate Index
308 418 7.56% 10.45% 0.76
309 51 9.80% 10.93% 0.74
Readmissions
Barriers
• Hospitalists fears over “scope creep”• Surgical outliers regarding delays from
admission to OR• Inter-hospital transfers (we have 2 campuses)• OR availability • Weekend discharges to rehabilitation
facilities• Medicare part A reimbursement for SNF care
and VTE prophylaxis.( Coumadin vs Arixtra/lovenox)
Facilitators
• Administrative advocate• Support from orthopedic service line
leader• Access to data collection and
statistician.• Enthusiastic and supportive nursing
staff.
Time Line
• October 2008 . Turn on geriatric specific pre and post op order sets.
• November . Formalize agreement with hospitalists.
• January. Roll out new discharge process.
• February. Incorporate delirium prevention and management and the HELP program.
Year 2
• Work with SNF’s on post hip fracture care.
• Develop out patient falls prevention program with community partners.
• Develop osteoporosis management strategy for SNF’s.
Delirium Task Force
• Develop standardized tools for documentation (CAM)
• Non pharmacological approaches to prevention and management,
• Streamline medication options for treatment.
• HELP pilot.
Long Term Goals
• To provide a best practice model for the hospitalized older patient .
• The hospitalist as geriatrician.• To heighten visibility of Senior
Services in my institution.• Earn a “place at the table” for
geriatrics
What I’ve Learned
• “A prophet is not without honor except in his or her own country.”
• That and the importance of data to administrative support.