Evidence-based practices can reduce complications and healthcare costs
Hip fractures in the elderly are life-altering orthopaedic events that are often associated with significant morbidity as well as loss of mobility and independence.

More specifically, the one-year mortality has been estimated at 14 percent to 36 percent and patients undergoing successful surgery rarely return to their baseline functional status, according to "Surgical Management of Hip Fractures: An Evidence-based Review of the Literature," published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS, November 2008).

Furthermore, hip fracture patients have a large impact on healthcare dollars spent, with 2010 estimates of 258,000 fractures in the United States resulting in an economic burden estimated at $17 billion to $20 billion, according to the February 2015 JAAOS article "AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in the Elderly."

To reduce complications and healthcare dollars spent in this fragile patient population, organizations must integrate evidence-based practices into the care of hip fracture patients and improve overall outcomes.

A medically complex geriatric hip fracture population presents many challenges. Consistent, timely clinical decision making and efficiency of care can have a significant positive impact on outcomes. On the other hand, if interdisciplinary coordination, standardized care, and defined processes and pathways for hip fracture patients are missing, several problems may result. These challenges can affect patients, providers, staff, and the health system. They may also contribute to increasing mortality, complications such as delirium or aspiration, and future fragility fractures.

Our solution
St. Luke's Health System (SLHS), based in Boise, Idaho, used the 2014 AAOS evidence-based clinical practice guideline (CPG) to develop a standard hip fracture management protocol throughout the region. Collaboration by orthopaedists, internal medicine physicians, anesthesiologists, rheumatologists, and hospital staff was critical for success. This multidisciplinary group developed a standard care map to streamline care in several areas, including:

1. Improving emergency department (ED) to operating room (OR) time
2. Delivering a preoperative fascia iliaca block
3. Utilizing AAOS appropriate use criteria (AUC) to determine the procedural surgical approach
4. Managing osteoporosis postdischarge

The care map was designed to be a simple, easy-to-follow tool that providers could reference to promote a standard, evidence-based approach to hip fracture treatment. SLHS optimized its timeliness in delivery of care and efficiency in management of hip fracture patients by providing the right care, to the right patient, at the right time through interdisciplinary collaboration and reduction in variation of care delivered using the hip fracture care map.

Measuring success
SLHS identified the following four areas in which changes could improve the quality of hip fracture care and designed outcome measures to track success within each segment.

ED to OR time: Data at SLHS showed that there was opportunity to reduce ED to OR time and reduce mortality and complication rates. The following outcome metrics address this issue:

• Expectation was set that the incision time of hip fracture patients should be within 24 hours of arrival to the ED. Collaboration with ED physicians to immediately consult the orthopaedic surgeon and internal medicine physician once a hip fracture is identified expedites consult and clearance for the patient to go to surgery.
• Performance was measured, monitored, and reported monthly.

Fascia iliaca block: SLHS historical data have shown that hip fracture patients may receive high doses of opioids for preoperative pain management, resulting in delirium. Administration of a fascia iliaca block as soon as possible after a patient arrives with a hip fracture reduces delirium rates and improves overall comfort of the patient. The following outcome metrics address this issue:

• Ensure that 100 percent of hip fracture patients, for whom there are no contraindications, receive a fascia iliaca block within 4 hours of the orthopaedic surgeon being consulted by the ED physician or within 4 hours of being directly admitted from an outlying institution.
• Performance was measured, monitored, and reported monthly to the health system.
• SLHS contraindications for this block, set by anesthesia, are an international normalized ratio greater than 3.0, uncontrolled atrial fibrillation, systolic blood pressure less than 90, heart rate greater than 110, and a known stroke, myocardial infarction, head injury, sepsis, uncompensated heart failure, or acute nerve injury.

Utilization of the AUC: In the past, variation was noted in selection of the surgical procedure in hip fracture patients at SLHS. Development of the AUC by AAOS provided an easy way to ensure the most clinically appropriate approach was used.

At SLHS, surgeons primarily provide total hip arthroplasty rather than a hemiarthroplasty for cognitively intact and physiologically younger patients who sustain a displaced femoral neck fracture and have high preoperative mobility and functional status. Cemented unipolar stems are generally chosen for patients receiving a hemiarthroplasty at SLHS. Cephalomedullary nails are the preferred implant for intertrochanteric fractures by SLHS surgeons.

Osteoporosis management: In the past, osteoporosis management was inconsistent at SLHS. Early diagnosis and management of osteoporosis is associated with improved outcomes. The SLHS rheumatology department developed a comprehensive osteoporosis program. The following outcome metrics address this issue:

• Ensure that 100 percent of hip fracture patients are scheduled for an appointment with rheumatology for osteoporosis treatment and management 4 weeks after discharge.
• Order a complete blood count, comprehensive metabolic panel, parathyroid hormone, and 25-hydroxyvitamin D level on all patients during admission for hip fracture, streamlining the patient's subsequent rheumatology follow-up appointment.
• Ensure that 100 percent of hip fracture patients attend the scheduled appointment for osteoporosis. If the appointment is not attended, the surgeon addresses the importance of osteoporosis management at the next appointment, and the follow-up rheumatology appointment is rescheduled.
• Performance is measured, monitored, and reported monthly to the health system.
• To deliver the right care to the right patient at the right time, SLHS determined that patients with severe dementia or a life expectancy of less than 6 months will not receive osteoporosis treatment and management following hospitalization for a hip fracture.

Summary
The SLHS project used the AAOS evidence-based CPG and AUC to improve care, reduce variation, and increase value for patients and families. This evidence-based approach enabled the SLHS to address the complex needs of this patient population, recognize the challenges of providing care in a large health system, and improve patient-centered care.

Britton Wells, MD, is medical director of the Hip Fracture Program at SLHS. Carolann Stanek, RN, is manager of the Hip Fracture Program. Jessica Burlile is a second-year medical student. Kevin G. Shea, MD, is a member of the AAOS Council on Research and Quality.