As the elderly population grows, so does the number of geriatric hip fractures, making appropriate management of such fractures increasingly important. The goal is to maximize patient outcomes without increasing healthcare expenditures. One approach is the development of a clinical pathway.
A clinical pathway is a sequential plan of care that involves a structured multidisciplinary approach to address a specific healthcare problem according to evidence-based guidelines. The resources available to each institution determine the design of a specific clinical pathway. An effective clinical pathway for perioperative treatment of geriatric hip fractures involves the collaboration of many different specialists and services. Delay of surgery greater than four days has been shown to significantly increase the risk of mortality, so early consultation is important. Emergency physicians, orthopaedic surgeons, nurses, anesthesiologists, physiotherapists, occupational therapists, and social workers (Fig. 1) need to work together in an organized and coordinated way. The need for preoperative cardiac testing is an independent factor associated with delays prior to surgery and increased length of stay (LOS). Respiratory conditions also can delay or negatively impact surgery in this age group. Therefore, cardiologists and respiratory therapists should be included in the preoperative rubric.
The clinical pathway for geriatric hip fractures begins in the emergency department. Initial assessment should include evaluation for concomitant injuries (e.g., distal radius fractures, neurovascular injury) with appropriate radiographic studies. Prior to surgery, the following diagnostic tests should be performed: chest radiograph, electrocardiogram (ECG), complete blood count (CBC), basic metabolic panel (BMP), coagulation studies, type and screen, and arterial blood gas for patients with pulmonary or cardiac disease. Abnormal results require follow-up and appropriate consultation. Because dehydration is frequent in the elderly, this must be taken into consideration when the healthcare team evaluates hemoglobin levels.
At admission, internal medicine professionals should be consulted and an anesthesiologist should perform an early preoperative evaluation. Echocardiography and pulmonary function testing may be required for patients with preexisting cardiac or pulmonary disease. Social services should evaluate the patient and family to identify resources and needs upon discharge. All patients should receive appropriate gastrointestinal (GI) and deep-vein thrombosis prophylaxis, along with education on proper use of an incentive spirometer. Contraindications to anticoagulation, such as von Willebrand disease and other bleeding disorders, idiopathic thrombocytopenic purpura, or causes of low platelet counts and low albumin (as an indicator of low clotting factors in the blood), must be carefully considered. If there are no contraindications, low-molecular-weight heparin may be preferred in patients due to lack of required monitoring. It has a reasonably low complication rate and no GI side effects. To assist with mobility, patients should be given a bed with a trapeze frame, which they can continue to use postoperatively. Intravenous (IV) fluids should be started and a urinary catheter placed for adequate measurement of intake and output. Injectable narcotics should be titrated for adequate pain control.
On the day of surgery, preoperative lab work should be repeated if abnormalities were present at admission. Postoperative lab work includes a CBC and BMP, and a repeat ECG should be compared to the previous one. If there are any changes on the repeat ECG, myocardial infarction must be ruled out. Prophylactic antibiotics should be continued and IV fluids maintained while the patient’s diet is advanced. If the patient can use a bedpan, the urinary catheter can be removed. High-risk patients, such as those who cannot be extubated or who are hemodynamically unstable, should be transferred to a monitored unit for close observation.
On postoperative day one, patients begin physical therapy using assistive devices and strength-training exercises to aid with mobilization and ambulation. Use of a urinary catheter should be discontinued; however, if a patient is unable to void within eight hours and more than 300 mL are removed with urinary catheterization, the catheter should be retained and antibiotics continued while the catheter is in place. Laboratory analysis should include a CBC to identify anemia, as well as a BMP for electrolyte abnormalities. Occupational therapy should be consulted to assess needs for activities of daily living.
On postoperative day two, IV lines and drains are discontinued if they are no longer required. Prophylactic IV antibiotics should be completed, and analgesics should be converted to oral preparations. A repeat analysis of CBC and BMP should be obtained. The goal of physical therapy at this time is minimal assistance with ambulation for 20 feet.
By postoperative day three, the multidisciplinary team should be able to identify patients who require inpatient rehabilitation. Nursing or wound-care staff should begin daily dressing changes. A final CBC and BMP should be obtained and repeated only when abnormalities are present. Physical therapy activities should be performed at least twice a day, and the patient can be encouraged to sit in a chair. The discharge plan is outlined with the patient and family. Referrals and arrangements for transport are made for patients who will not be discharged home; home health arrangements with prescriptions for adaptive equipment are made for patients cleared for discharge by physical and occupational therapists. Times and frequencies of follow-up visits should be determined by patient disposition.
A review of the literature comparing clinical pathways for geriatric hip fractures to traditional perioperative care appears to favor the implementation of a clinical pathway. Although conflicting data exist on a pathway’s ability to reduce overall hospital LOS, most studies have reported a significant reduction in postoperative morbidity, which may be the result of earlier recognition and management of potential complications by the multidisciplinary team. Some studies have reported a reduction in mortality rate with a clinical pathway, but the reductions were not statistically significant. One study analyzing the cost of inpatient care determined that there was no difference between the two groups. Overall, the implementation of a clinical pathway for geriatric hip fractures has demonstrated outcomes that are either similar to or better than traditional care.
Ian Broussard, DO, is a PGY-2 emergency medicine resident at Grand Strand Medical Center in Myrtle Beach, S.C., with an interest in orthopaedics. He graduated medical school at William Carey University College of Osteopathic Medicine in Hattiesburg, Miss.
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