Osteoporosis is overshadowed in an era of chronic illnesses, and a care gap exists between physicians and patients. The aim of this study was to determine the effectiveness of implementing an automated system for identifying and sending a letter to patients at high risk for osteoporosis. Patients 50 years of age and older were tagged with an International Classification of Diseases, Ninth Revision, diagnostic code upon initial visit to the emergency department (ED), identifying potential fragility fractures. Automatically generated letters were sent via our osteoporosis database system to each patient 3 months after the initial visit to the ED. The letter indicated that he or she was at risk for osteoporosis and suggested that the patient schedule a follow-up appointment with a physician. Patients were subsequently telephoned 3 months after receiving the letter and asked about their current plan for follow-up. The control group did not receive a letter after departure from the ED. In the control group, 84 (85.71%) individuals of the total 98 did not have any follow-up but the remaining 14 (14.29%) sought a follow-up. In the intervention group, 62 (60.19%) individuals of 103 did schedule a follow-up, while the remaining 41 (39.81%) did not seek a follow-up. Thus, the patient follow-up response rate after fracture treatment improved with intervention (P < .0001). Current literature has demonstrated the low rate of follow-up care addressing osteoporosis in patients experiencing fragility fractures (1%-25% without intervention). Research has shown the effectiveness of various types of intervention programs for improving the continuum of care for these high-risk patients. Nonautomated intervention programs can have a multitude of human-related system failures in identifying these patients. Our study successfully implements an automated system that is able to be applied to most hospitals with minimal cost and resources.

Background: Orthopaedic residency education requires trainees to participate not only in clinical and research endeavors but also in quality improvement (QI) projects. To our knowledge, little has been published on how to implement a structured QI curriculum as part of an orthopaedic residency program. This article describes a single institution’s experience with developing a longitudinal, integrated, and collaborative resident QI curriculum. Methods: The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process was taught to residents as a formal curriculum at our institution beginning in 2014. A structured integrated process was developed for residents to work in teams and meet on a monthly basis. Since then, residents have developed multiple QI projects with measured outcomes. Serial surveys have been administered to the residents to collect feedback. Results: Seven major QI projects have been implemented by residents since the program’s initiation. The resident surveys revealed significant improvement in comfort level with organizing QI projects. Residents also reported being comfortable working in interprofessional teams and incorporating patient safety techniques into clinical practice. Conclusions: There are few guidelines that reflect how to initiate a formal QI curriculum in an orthopaedic residency program to promote a standardized and systematic way to approach QI projects. With a structured DMAIC education plan, an emphasis on graded responsibilities within a team setting, and responsiveness to resident feedback, orthopaedic programs can develop an effective QI program to allow residents to learn valuable patient safety practices, which allows residents to have a meaningful and impactful effect on QI initiatives that will serve them well as they enter clinical practice.

Objective: An interdisciplinary pain team was established at our institution to explore options for improving pain control in patients undergoing orthopedic surgery by identifying traits that put a patient at increased risk for inadequate pain control postoperatively. Materials and Methods: The interdisciplinary pain team identified 7 potential risk factors that may lead to inadequate pain control postoperatively including (1) history of physical, emotional, or sexual abuse; (2) history of anxiety; (3) history of drug or alcohol abuse; (4) preoperative nonsteroidal anti-inflammatory drug, or disease-modifying antirheumatic drug use; (5) current opioid use; (6) psychological conditions other than anxiety; and (7) current smoker. Statistical analysis determined which risk factors were associated with increased preoperative and postoperative pain scores. Results: A total of 1923 patients undergoing elective orthopedic surgery were retrospectively identified. Hip, knee, and shoulder replacements accounted for 76.0% of the procedures. 78.5% of patients had 3 or fewer risk factors and 17.1% had no risk factors. Anxiety, other psychological conditions, current opioid use, and current smoking were significantly associated with higher preoperative and postoperative pain scores. Discussion: We found a significant association between anxiety, current smoking, psychological conditions, and current opioid use with increased preoperative and postoperative reported pain score. We propose that identification of these risk factors should prompt more attention to postoperative pain control plans and will improve communication with patients and providers. We recommend a multimodal approach to postoperative pain control, and developed a pain orderset to help guide providers.

Introduction: In 2014, we implemented a geriatric hip fracture patient care pathway at our institution which was designed to improve outcomes and decrease time to surgery. Materials and Methods: We analyzed retrospective data from 463 patients, aged greater than 50, who had surgical treatment for a closed hip fracture due to a low-energy injury between 2013 and 2016 at an academic institution. Objective outcome measures included time to surgery, mortality rate, and total hospital length of stay. Our primary goal was to decrease the time to surgery for definitive fracture fixation to within 24 hours of admission to the hospital for patients who were medically fit for surgery. Results: We implemented a multidisciplinary, collaborative approach to address the needs of this specific patient population. Prior to implementing the pathway in 2013, our baseline time to surgery within 24 hours was 74.67%. After implementation, we had incremental yearly increases in the percentage of patients operated on within 24 hours, 82.31% in 2014 ( P = .10) and 84.14% in 2015 ( P = .04). During the study period, our overall time to surgery was reduced by 27% with an initial average of 20.22 hours in 2013, decreasing to 15.33 hours in 2014, and 14.63 hours in 2015. Our mortality rate at 1 year was 16% in 2013, 17% in 2014, and 15% in 2015. Conclusion: With implementation of the pathway, we were able to expedite surgical care for our patients and demonstrate a 10% improvement in the percentage of patients able to have surgery within 24 hours over a 3-year period. Our mortality and hospital length of stay, however, remained the same. Through this collaborative process and system standardization, we believe we have significantly improved not only direct patient care but their overall hospital experience. We continue to make improvements in our pathway.

Introduction:The aim of this study was to compare the effectiveness of 2 interventions in prompting patients to obtain osteoporosis follow-up after a fracture. Our hypothesis was that a phone call plus letter would yield greater response toward osteoporosis evaluation versus a letter alone to patients after sustaining a fragility fracture.Materials and Methods:Prospective study randomized 141 patients age 50 years and older with a fragility fracture into 3 groups for comparison. Group 1 (letter only) patients received a letter 3 months after their diagnosis of fracture indicating their risk for osteoporosis and urging them to follow-up for evaluation. Group 2 (phone call plus letter) patients were contacted via phone 3 months after their diagnosis of fracture. A letter followed the phone call. Group 3 (control) patients were neither contacted via phone nor sent a letter. All groups were contacted via phone 6 months after their initial visit to determine if they followed up for evaluation.Results:In group 1, 23 (52.27%) of 44 had follow-up, and 21 (47.73%) of 44 did not follow-up. In group 2, 30 (62.5%) of 48 had follow-up, and 18 (37.50%) of 48 did not follow-up. In group 3, 6 (12.24%) of 49 had some sort of follow-up, and 43 (87.76%) of 49 did not have any follow-up. A statistical significance was achieved between group 3 (control) and both groups 1 and 2 with regard to follow-up (P < .0001). The results did not show a statistically significant difference between Groups 1 and 2, however, there was a trend toward improved response with a phone call plus letter (P = .321).Conclusion:A more personalized approach with a phone call plus follow-up letter to patients increased osteoporosis follow-up care by an additional 10%, however, this was not a statistically significant difference from just sending out a letter alone.