Applying Evidence-Based Medicine Principles to Hip Fracture Management

Bernstein, Joseph; Morshed, Saam; Helfet, David L.; Bhandari, Mohit; Ahn, Jaimo

doi:10.3389/fsurg.2014.00040

Cited by 3 publications

(1 citation statement)

References 22 publications

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“…Furthermore, it may not be sufficient to say that “surgery” is indicated, since the type of operation also needs to be determined as part of a process of shared decision-making [ 38 ]. Specifically, the configuration of the fracture pattern, the needs and goals of the patient, the presence or absence of degenerative joint disease, and other considerations may point to partial joint replacement, total joint replacement or fixation.…”

Section: Urgencymentioning

confidence: 99%

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

et al. 2017

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BackgroundHip fractures are common and serious injuries in the geriatric population. Obtaining informed consent for surgery in geriatric patients can be difficult due to the high prevalence of comorbid cognitive impairment. Given that virtually all patients with hip fractures eventually undergo surgery, and given that delays in surgery are associated with increased mortality, we argue that there are select instances in which it may be ethically permissible, and indeed clinically preferable, to initiate surgical treatment in cognitively impaired patients under the doctrine of presumed consent. In this paper, we examine the boundaries of the license granted by presumed consent and use the example of geriatric hip fracture to build an ethical framework for understanding the doctrine of presumed consent.DiscussionThe license to act under presumed consent requires three factors: patient incapacity, clinical urgency and clarity on the correct course of action. All three can apply to geriatric hip fracture. The typical patient frequently lacks capacity. Delays in initiating surgical treatment are associated with markedly increased mortality rates. Last, there appears to be consensus that surgery is the preferred treatment. Nonetheless, because there is a window of safe delay during which treating physicians can stabilize the patient, address reversible causes of cognitive impairment and identify surrogate decision makers, presumed consent should be invoked only as a method of last resort.ConclusionsA medical situation need not be characterized by risk of imminent and certain death for presumed consent to be relevant. Rather, there are two distinct windows that must be considered: the time interval in which action may be delayed without danger, and the time interval needed to obtain a better form of consent. Presumed consent is appropriate only when the latter exceeds the former.

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Section: Urgencymentioning

confidence: 99%

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

et al. 2017

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Delirium Reduced With Intravenous Acetaminophen in Geriatric Hip Fracture Patients

Connolly

Kleinman²,

Stevenson³

et al. 2020

J Am Acad Orthop Surg

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Introduction: Postoperative delirium is associated with opioid use in the elderly and is a common complication of geriatric hip fractures, with reported incidences from 16% to 70%. Intravenous (IV) acetaminophen is a safe and efficacious medication in elderly patients and has been shown to reduce use of opioids after hip fracture. At our institution, IV acetaminophen was implemented for the first 24 hours postoperatively as part of a multimodal pain control regimen for geriatric hip fracture patients. Methods: A retrospective review of 123 hip fragility fracture patients older than 60 years from January 2016 to December 2016 was performed. Delirium was identified using a validated chart–based review tool. The rate of delirium, as well as length of stay, pain scores, opioid administration, need for one-to-one supervision, and readmissions were analyzed. Results: Sixty-five patients (52.8%) received IV acetaminophen during this period. No notable differences were found in baseline characteristics between groups. Ten of 65 patients receiving IV acetaminophen postoperatively experienced delirium compared with 19 of 58 who did not receive the medication (15.4% versus 32.8%, P = 0.024). The IV acetaminophen group also required fewer doses of IV opioids on postoperative day 1 (0.37 versus 1.19 doses, P = 0.008), were less likely to require one-to-one supervision (9.2% versus 24.1%, P = 0.025), and had shorter lengths of hospital stay (6.37 versus 8.47 days, P = 0.037). Readmission rates and discharge dispositions did not vary with significance between the two groups. Conclusion: The inclusion of IV acetaminophen as part of a multimodal pain regimen led to fewer episodes of delirium in this study. The reduced use of opioids immediately after surgery may have been a large factor in this outcome. Lower delirium rates may reduce the utilization of inpatient resources for direct patient supervision and provide for shorter hospital stays.

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A Geriatric Hip Fracture Care Pathway: An Operational Approach to Quality Improvement

Donegan,

Bonilla,

Kleinman

et al. 2021

Journal of Orthopaedic Experience &Amp; Innovation

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Introduction: Geriatric hip fractures are a devastating injury that decrease patient independence, increase morbidity and mortality, and have a significant economic impact. Although early operative intervention decreases mortality, hospitals often do not meet these benchmarks. The purpose of this study was to use a methodological approach to optimize the care and outcomes of patients sustaining geriatric hip fractures at a single level I trauma center by minimizing time to surgery and length of stay (LOS). Methods: A process map that outlined the paths that a hip fracture patient could take through our system from the time of injury to discharge was created. Classical operations management tactics known as Lean Synchronization and Six Sigma were used to identify bottlenecks in the system that led to delays in time to surgery or discharge. The pathway was systematically revised to address additional inefficiencies. Results: The initial process map revealed that time to surgery was increased by extensive preoperative testing and LOS was increased by admission to a non-orthopaedics service. By creating a standardized protocol for risk stratification and admitting all hip fracture patients to the orthopaedics service, improvements were seen within 6 months, including reductions in time to surgery (32.4 vs 17.5 hours), LOS (7.1 vs 5.6 days), 30-day readmissions (14.29% to 8.33%), and in-hospital mortality (2.79% vs 0%). Additional areas for improvement were later identified to reduce delirium rates and cost of care. Discussion: We conclude that the use of an operational management approach to address the inefficiencies in a clinical care pathway produced substantial and sustainable improvements in relevant outcome measures in patients sustaining geriatric hip fractures. By systematically identifying the bottlenecks in the system, we generated an ideal state pathway, which has allowed us to deliver higher quality care to our patients while simultaneously decreasing cost of care.

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Applying Evidence-Based Medicine Principles to Hip Fracture Management

Cited by 3 publications

References 22 publications

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

Delirium Reduced With Intravenous Acetaminophen in Geriatric Hip Fracture Patients

A Geriatric Hip Fracture Care Pathway: An Operational Approach to Quality Improvement

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