Hip fracture Co-Management

Hip fractures in our older adults population are common and carry a significant increase in mortality and morbidity. Some sources stated 60% mortality at 6 months and many who survived will not recover their baseline independence. It is deadly.

Here, they have an interesting way to manage their hip fracture population based on a few principles:

  • Patient centered
  • Early intervention (target <24h)
  • Active prevention of Delirium
  • Co-management with geriatrician
  • Interdisciplinary team
  • Pre-printed order sets
  • Early discharge planning to rehabilitation
  • And most importantly: COMMUNICATION.

Let’s take a case to illustrate how exactly a patient with a hip fracture navigate throughout this system.

“88 years old male, from home, fell down because of a carpet vs walker tragedy. His son found him 30 minutes later, called the ambulance and arrived at MSH emergency department by 6pm. A diagnosis of a right inter-trochanteric non displaced fracture was made and his fall remained undiagnosed for now (adequate investigation negative).The emergency physician did a femoral nerve block.

The orthopedic surgeon was called, briefly saw the right leg and schedule the surgery. In the meantime,

the GEM nurse flagged this hip fracture case to the geriatric team by e-mail notifications. The morning after, the surgery was done, the geriatrician evaluated the patient, his fall, his delirium risk and prevention plan. He also took care of the osteoporosis management according to the recent guidelines and made some recommendation about home safety.

OT and PT saw the patient in the afternoon, was able to mobilize him a little, repeat the evaluation the day after, considered he was a candidate to rehab. In the meantime, the urinary catheter was discontinued less than 24 hours after the surgery, pain management was adequate, nurses made sure he was well hydrated, ate his lunch, had his glasses and encourage his family to be around.

3 days after the surgery, no evidence of delirium, patient was sent to intensive rehab, went back to his home 4-6 weeks later and remained functional for a while longer.”

This is not a rare story, it is the everyday story of our hip fracture population.

But does it change anything? Let’s review what the literature says about this. Friedman in 2009 showed that this co-management with geriatrician resulted in a shorter time to surgery, fewer postoperative infection (2.3 vs 19,8%), fewer delirium, shorter length of stay in hospital stay (4.6 vs 8.3 days), but no difference in mortality or readmission.

However, Grigoryan in 2015 did a meta-analysis and was able to show a significant decrease in mortality when patients were included in an ortho-geriatric model of care. He failed to show the same decrease in delirium and complications. Finally, in 2013, Ginsberg was able to demonstrate the cost-effectiveness of a co-management program.

If I summarize, a interdisciplinary management of hip fracture is GREAT for the PATIENT AND the health care SYSTEM. Isn’t it wonderful?

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