The Effectiveness of a Geriatric Hip Fracture Clinical Pathway in Reducing Hospital and Rehabilitation Length of Stay and Improving Short-Term Mortality Rates

Abstract

Background:

A geriatric hip fracture clinical pathway, led by an orthopedic surgeon, was developed in 2007. This clinical pathway team is multidisciplinary and consists of surgeons, physicians, anesthetists, nurses, physiotherapists, occupational therapists, medical social workers, dieticians as well as voluntary support groups.

Methods:

From early 2007 onward, all patients older than 65 years with acute isolated hip fractures were included. During the whole inpatient treatment, all relevant data were captured prospectively. The data in 2006, before the implementation of the clinical pathway, were collected retrospectively through computer record system. A study of the length of stay in acute and rehabilitation hospital and also the short-term mortality rate was carried out to compare the difference before and after the implementation of the pathway.

Results:

From 2007 onward, more than 1300 hip fractures were treated. After the implementation of the pathway, the preoperative length of stay was markedly shortened by 4 days, from an average of 6.1 days in 2006 to 1.5 days in 2011 (P < .05). The postoperative length of stay and the overall acute hospital length of stay also improved significantly. The length of stay in rehabilitation hospital was also significantly shorter in the 4-year period. Although the number of hip fractures increased annually with increased age and number of comorbidities each year, the inpatient mortality rate showed a gradual decrease from 2.7% in 2006 to 1.25% in 2010. The 30 days mortality rate also showed a decrease from 3.65% in 2006 to 2.75% in 2010.

Conclusion:

Geriatric hip fracture clinical pathway is an excellent approach to the geriatric hip fracture service. The most significant improvement is the dramatic shortening of the length of hospital stay. Our success in the past 5 years has proven its value and sustainability.

Introduction

As the count of the elderly population increases, the annual number of hip fractures is globally expected to exceed 7 million in the next 40 to 50 years.¹ In United Kingdom, the bed occupancy rate for hip fractures was more than 1.5 million days, which represent 20% of the total orthopedic beds.² In Hong Kong, a city with a population of 7 million, over 4500 hip fractures were operated in 2012. The trend is increasing in the past 5 years, which is also reflected in other parts of the world.^3,4 Furthermore, these geriatric hip fractures are associated with a number of comorbidities. Despite the fact that aggressive surgical treatment is commenced during the preoperative, perioperative, and postoperative periods, morbidity and complication rates are still high compared to other common surgeries.⁵ Most important of all, the mortality rate is relatively high. The 30 days mortality is around 10%, and the 1 year mortality rate can be up to 30%.⁶

Geriatric hip fracture presents an increasing burden to our medical system and requires increasing health utilization in the first year after fracture.^7,8 In our medical care system, the patients undergo surgery in the acute hospitals and are then transferred to rehabilitation hospitals before going home. There were literatures supporting the use of clinical pathway to shorten the length of hospital stay and thus improve the clinical outcomes.^9–11 However, many of these clinical pathways only focused on the acute hospital stay and does not take the rehabilitation hospitals into consideration. These clinical pathways may not be able to apply to our local medical system where the patients need to stay in the rehabilitation hospital before discharging back to home. Therefore, we feel that there is a need to develop a unique pathway tailor-made for our local needs.

Model of Care

Since early 2007, we started our geriatric hip fracture critical clinical pathway.¹² Patients with hip fractures are admitted to the orthopedic ward in our hospital, which is a level 1 trauma center having more than 1000 beds. During the stay in admission ward, preoperative workup and anesthetist assessment will be made. After the operation, the patients will be transferred back to the ward for postoperative care. Once the general conditions of the patients are stable, they will be transferred to a rehabilitation hospital, usually 4 to 5 days after the surgery.

The geriatric hip fracture clinical pathway team was first developed by a team of medical staff in the acute hospital led by an orthopedic surgeon named as the clinical champion. He or she is the one who develops and coordinates the running of the pathway. A case manager, who is a nurse, will be responsible for the monitoring of the whole pathway running on a day-to-day basis.

In order to achieve a smoother and shorter preoperative stay, the whole process of preoperative assessment is redefined. It started with the communication with the emergency department. When a patient with geriatric hip fracture is admitted, apart from the hip x-ray, a chest x-ray and a pelvic x-ray should be available before he or she is transferred to the orthopedic admission ward. Once the patient is in the ward, a general preoperative workup will be done immediately on a 24-hour basis so that the patient is ready to be seen by the anesthetist the next day morning. The preoperative workup includes complete blood count, liver and renal function tests, clotting profile, cross-matching of blood group, and 12-lead electrocardiogram.

Our pathway team, led by the clinical champion and the case manager, also includes surgeons and nurses that are responsible for the daily routine in the acute and rehabilitation ward. The other team members include a cardiologist, a respiratory physician, and a senior anesthetist who are responsible for setting the guidelines on the indications of preoperative cardiac, respiratory, and other medical consultations.

Close collaboration with cardiologist is a crucial step in eliminating last minute operation cancelation. After several meetings and discussions with several dedicated cardiologists and anesthetists, a consensus was made. Whenever there is any active cardiac problem, for example, active heart failure, uncontrolled arrhythmias, recent myocardial infarction, and/or previously undiagnosed severe ejection systolic murmur, a consultation will be arranged with the cardiologist the next day morning together with a 12-lead electrocardiogram faxed prior to the consultation. A proper preoperative cardiac assessment, usually including an echocardiogram, will be performed.

Senior representatives from the allied health worker group include physiotherapists, occupational therapists, medical social workers, and community nurse units, and voluntary support groups are also involved in the development and running of the pathway. Besides the usual daily routine of the therapist in taking care of the patients, they also define the assessment scores, Mini-Mental State Examination and Modified Barthel Index, used for the monitoring of the rehabilitation potential and the progress during the hospital stay. Social problem is also one of the difficulties upon patient discharge. The medical social workers redefine their duties in geriatric hip fracture care. All admitted patients will be assessed and a discharge plan will be formulated with the patients and their family. Outpatient therapists and community nurse units also extend their services to the postdischarge period in order to provide a better and comprehensive rehabilitation.

In the rehabilitation hospital, a standard protocol of postoperative management is implemented. During the first week, the patients are encouraged to mobilize or ambulate in the ward. The wounds are inspected once they are transferred to the rehabilitation ward. Stitches are removed on day 14 after operation. Pain control is very important and regular analgesics are usually prescribed. Interim assessment of the functional state of the patients by occupational therapists is done to monitor the speed of recovery.

In the second week, x-ray will be taken to look for early fixation problem. The physiotherapists will focus on muscles strengthening and walking stability. The occupational therapists will look for potential need of home modifications and start planning early.

During the third week, the patients should be ready to be discharged home or nursing home. The care providers or families are educated for home exercise. Any medication that has been changed during the hospital stay will be finalized (Figure 1).

Figure 1.

The model of geriatric hip fracture clinical pathway.

Methodology

The clinical pathway first started running in February 2007. All isolated patients older than 65 years with hip fractures were recruited into the clinical pathway. Pathological fractures, multiple fractures, and hip fractures that were transferred from other specialty were excluded from this pathway. Demographics of the patients, including age, sex, original placement where the patients live before admission, history of previous fractures, premorbid mobility, and walking aids, were prospectively collected. Other data including the number of comorbidities, laterality of fractures, classification of fractures, surgery types, American Society of Anesthesiology (ASA) score, surgeons’ rank, preoperative hemoglobin level, postoperative requirement of blood transfusion, number of days before the patients start walking, number of days when drains are removed, financial assistance requirements, and also rearrangement of placement are all collected from 2007 till the end of 2010.

The comorbidities are defined by the previous diagnoses when the patient is admitted. These comorbidities include 6 main categories, cardiovascular, respiratory, neurological, endocrine, psychiatric problems, and neoplasm. Common cardiovascular problems include ischemic heart disease, history of myocardial infarction, congestive heart failure, and arrhythmias. Respiratory problems include chronic obstructive airway disease, pulmonary tuberculosis, and asthma. Neurological problems include history of cerebral vascular accident, transient ischemic attack, and Parkinsonism. The most common endocrine problems include diabetes and thyroid disease. Psychiatric problems include dementia, schizophrenia, and other forms of psychosis. There are some other problems like renal impairment, chronic renal failure, and liver problems, which are also considered as comorbidities.

The preoperative and postoperative length of acute hospital stay and also the rehabilitation hospital stay were all recorded. Wound complications and medical complications are recorded. Postoperative pneumonia rate is also recorded, which is defined as the patients with clinical signs of chest infection together with positive sputum culture. The inpatient mortality rate and the 30 days mortality rate were used as the clinical outcomes to evaluate the effectiveness of this pathway. The inpatient mortality is defined as the patient’s death occurring either in the acute or in the rehabilitation hospital stay. The 30 days mortality is defined as the patient’s death occurring within 30 days after his or her admission to the acute hospital, regardless of the fact that whether he or she is staying in or discharged from the hospital system. The data from 2006 were then collected retrospectively through the computer medical system. These 2 sets of data were then compared and analyzed by simple linear regression method. The institutional review board approval was obtained for the collection and analysis of the data.

Demographics

From January 1, 2007, to December 31, 2010, a total of 1342 patients with hip fracture entered the study. The female to male ratio was kept relatively constant at around 2.5:1 each year. The average age was from 82 in 2007 increasing to 84 in 2010. The youngest age of the hip fracture was 65. The oldest patient operated was a female patient aged 102. Regarding the number of hip fractures operated each year, there was a steady increase annually, reaching more than 400 cases a year in 2010. There were 672 (50%) femoral neck fractures, 736 (47%) intertrochanteric fractures, and 37 (3%) subtrochanteric fractures. Treatment included 231 (17%) cannulated screw fixations, 362 (27%) hemiarthroplasties, 524 (39%) dynamic hip screw fixations, and 218 (16%) cephalomedullary nail fixations.

Among these 1342 patients, the majority of them has ASA scores 2 and 3, comprising 41% and 56%, respectively (Table 1). The number of comorbidities also increased gradually in the 4 years (Figure 2). Moreover, 52% of them had more than 3 comorbidities when they were admitted. The 3 most common problems were hypertension, diabetes, and dementia. In the community we serve, about 70% of these patients lived in their home and the remaining 30% were already institutionalized before admission.

Table 1.

ASA Score Trend From 2007 to 2010.

	2007	2008	2009	2010
ASA1 (%)	1.43	0.57	2.69	2.38
ASA2 (%)	53.05	40.46	44.91	32.28
ASA3 (%)	45.16	58.69	51.05	64.02
ASA4 (%)	0.36	0.28	0.9	1.32

Abbreviation: ASA, American Society of Anesthesiology.

Figure 2.

The number of comorbidities for patients with hip fracture, in the years 2007 to 2010.

In 2006, before the implementation of the clinical pathway, we have treated 411 patients with hip fracture. The average age was 82 years. All other parameters including male to female ratio, hip fracture types, number of comorbidities, and ASA score were comparable to those of the following 4 years. However, one special point is that there was a 3 times increase in the use of cephalomedullary device for fixing the intertrochanteric fractures from 2006 to 2010, despite the fracture patterns were comparable in these 2 periods.

Results

Length of Hospital Stay

After the implementation of the clinical pathway, there was a decrease in the preoperative length of stay as well as the total length of stay in acute hospital. Besides, the length of stay in rehabilitation hospital also decreased. In 2006, the average preoperative length of stay was 6.1 days. It was decreased to an average of 2.53 days in 2007. Upon the subsequent years with the clinical pathway fully operational, there was a steady and gradual improvement in the preoperative length of stay. Our most recent data showed that the average preoperative length of stay was 1.5 days in 2010. This improvement was significant when compared with that of 2006 (P < .05). The postoperative length of stay also showed a decrease from 6.8 days in 2006 to 5.1 days in 2010. This improvement was also statistically significant (P < .05). Since both preoperative and postoperative stay were significantly shorter, the total length of stay also showed a significant improvement from 12.1 days in 2006 to 6.4 days in 2010 (Figure 3). Although there was an increase in the number of geriatric hip fractures each year, a total of 50% reduction in the total acute hospital stay demonstrated the tremendous effectiveness of the clinical pathway.

Figure 3.

The average preoperative length of stay in terms of days during the period 2006 to 2010.

Our statistics showed that in 2006, the average length of stay in rehabilitation hospital was 40 days. This was reduced to 17.6 days in 2010 (Figure 4). The decrease was statistically significant as well (P < .05). The reduction was more than 50%. Despite this improvement, over 80% of the patients were still able to be discharged back to their original placements during the study period.

Figure 4.

The average length of stay in the rehabilitation hospital in terms of days during the period 2006 to 2010.

Complication Rates

Wound infection rate is one of the clinical outcomes we monitor after the implementation of the clinical pathway. There was no change in the infection rate in both fixation group and hemiarthroplasty group. The fixation group includes cannulated screws fixation, dynamic hip screws, and cephalomedullary devices. The hemiarthroplasty group includes bipolar hemiarthroplasty, cemented and noncemented ones, and also Austin Moore hemiarthroplasty. In fact, there was a slight increase in the infection rate in the data of 2010 (Table 2). Postoperative pneumonia was another parameter we monitored. There was a slight decrease in the rate of pneumonia, but it is not statistically significant (Table 3).

Table 2.

Wound Infection Rate of Hip Fracture Surgeries From 2006 to 2010.

	2006	2007	2008	2009	2010
Infection rate	1.2%	0.3%	1.4%	0.3%	2.6%

Table 3.

Postoperative Pneumonia Rate From 2006 to 2010.

	2006	2007	2008	2009	2010
Postoperative pneumonia	1.2%	0.3%	1.1%	0.6%	0.8%

Mortality Rates

The inpatient mortality rate showed a decrease from 2.7% in 2006 to 1.25% in 2010 (Figure 5). The 30-day mortality rate also showed a decrease from 3.65% in 2006 to 2.75% in 2010 (Figure 6). However, the decrease in both mortality rates did not reach statistical significance, which is likely due to the relatively small number of deceased patients.

Figure 5.

The inpatient mortality rate during the period 2006 to 2010.

Figure 6.

The 30-day mortality rate during the period 2006 to 2010.

Discussion

Geriatric hip fractures used to be less attended in the past because these patients were considered as less urgent when compared to the younger patients. These fractures are also traditionally considered “simple” fractures to treat. Therefore, they were considered to be fractures that were suitable for beginners to learn. However, this “traditional” approach was changing rapidly in the last decade. More and more evidences showed that these osteoporotic fractures should be managed with aggressive medical and surgical support, which achieved excellent results with good clinical outcomes.¹³

One of the uniqueness of our clinical pathway when comparing with the other pathways in the world^9–11,14,15 is that ours starts from the emergency department of the acute hospital when the patient is admitted and continues all the way to another rehabilitation hospital until the patient is discharged home. This ensures a smooth running of the whole chain of care.

Preoperative length of stay is one of the most important factors that affect clinical outcomes. In many clinical studies, the shorter the preoperative waiting time, the fewer the complications and the lower the mortality rate.^6,16 Therefore, the significant reduction in the preoperative waiting time is considered one of the major accomplishments in our clinical pathway. The availability of a dedicated daytime trauma operating room is a big help to the efficient running of the whole management process.¹⁷ This trauma operating room caters for all patients that need fracture care and offers several advantages. First is the flexibility of the trauma cases allocated for operation. The more difficult cases, in terms of anesthesia or surgical technical difficulty, can be allocated to the time when more experienced surgeons or anesthetists are available. Second is the availability of a team of designated operating room nurses for trauma care and fracture fixation. This helps to shorten the operating time and the transit time between cases. Third is the availability of the anesthetists prepared for geriatric patients with trauma and patients approaching extreme age. Finally is the team of the experienced trauma surgeons. Their common goal is to help these patients safely and efficiently manage their hip fractures with the appropriate implants or prosthesis.

In rehabilitation hospital, rehabilitation doctors, nurses, therapists, and medical social workers all work together to speed up the whole rehabilitation process. Early active walking exercise and postdischarge rehabilitation by community nurses and therapists play a great role in shortening the need for inpatient treatment. The regular assessments of the mental and functional state in rehabilitation hospital can help to monitor the speed of recovery of the patients. The medical social workers can identify social or financial problems that may complicate the discharge and try to recruit the available resources to help. The overall shortened rehabilitation hospital stay reflects the effectiveness and cooperation with this multidisciplinary approach.^9,10

Complication rates did not change after the implementation of the pathway. Surgical site infection stayed low despite the shortened preoperative waiting time. This is different from some of the reports from other literatures.^11,15 One of the possible explanations is that the infection rate in our study is relatively low and a statistical significant change cannot be shown. Postoperative pneumonia rate did not show any improvement, which was similar to other studies.^11,14,15

We achieved excellent clinical outcomes in the past 5 years in terms of short-term mortality rate. The 30-day mortality rate in our study was generally much lower than the commonly quoted figures, ranging from 5.1% to 13%.^{6,9,11,15,18–20} Although there is no statistical significance in the mortality rate before and after the clinical pathway, it definitely showed a decreasing trend despite increasing the number of hip fractures with increasing number of comorbidities.

Regular yearly audit of the performance and the clinical outcomes is another important aspect leading to the early success and the sustainability of this clinical pathway for the past 5 years. All the data were analyzed and presented during the half-yearly meeting. Everyone involved can review what has been achieved and what was not done well. Any setback of any clinical outcome is discussed during the meeting, even to the case-by-case level, in order to seek for the solutions and revisions of the clinical pathway if needed.

Conclusion

Our geriatric hip fracture clinical pathway was introduced 5 years ago to improve our fragility fracture service as well as to face the ever growing challenge from the elderly population. This was proven to be successful in terms of both clinical and administrative points of view. The approach of using a clinical pathway to provide multidisciplinary approach to the geriatric fracture problem is also proven to be very effective.