Over the last 2 decades, there has been an emergence of new models of care including co-management models of hip fracture patient with geriatricians or hospitalist, and dedicated orthogeriatric inpatient units. There is evidence suggesting that co-management may be associated with improved outcomes, such as Length of Stay (LOS), time to surgery, and complications.
Before 2011, care of patients admitted to Mount Sinai Hospital (MSH) with hip fractures was suboptimal. These complex patients were admitted to general orthopedics service who were ill-equipped to manage acute medical issues. Due to this, most patients with hip fracture were waiting for days before access to
surgery. The hip fracture patients were a low priority as per OR scheduling. This resulted in increased LOS (mean of 19 days), complications, delirium, and inadequate pain management. As a result, we decided to re-engineer the model of care for patients with hip fractures. Based on consultations and literature review, an integrated co-management program was developed. The goal of the program was to improve several domains of quality including efficiency, timeliness, effectiveness, and patient centeredness. To accomplish this, integrated hip fracture inpatient program (i-HIP) consisted of several components including 1) active co-management by hospitalists; 2) coordination of care across services; 3) participation in local quality improvement (QI) projects; and 4) standardization of care. Core members of the i-HIP team included a physician (Hospitalist), orthopedic surgeons, consulting geriatricians, nurses, rehabilitation therapist, clinical pharmacists, and a social worker.
Patients, after admission to orthopedic service, are managed by both hospitalist and orthopedic service. The co-management program is geographically based such that hospitalists were physically located on orthopedic units, rounding on patients daily, inputting direct orders in real time, and available to nursing staff and families for impromptu discussions. The key aspects of the model are described in the following 4 sections:
1. Active co-management by hospitalists: During the week, the hospitalist completes preoperative assessments within 24 hours of admission. The hospitalist coordinates care through direct communication with the orthopedic and anesthesia teams. The patients are then placed on priority for surgical on call list (booked as “B” case). In addition, the hospitalist participates in regular interprofessional patient care rounds, family meetings, discharge planning, and creates an electronic discharge summary available on the day of discharge.
2. Coordination of care: The interprofessional i-HIP team coordinates care between the various consulting services involved in the management of patients with hip fractures. This includes anesthesiology, geriatric psychiatry, and geriatric medicine. Geriatric medicine provides a comprehensive geriatric assessment on all patients aged 65 years and older focusing on fall prevention, polypharmacy, functional assessment, and delirium prevention. The teams’ clinical pharmacist completes a best possible medication history, reconciled admission orders, and provide medication optimization recommendations for each patient throughout the hospital course. A dedicated team of rehabilitation therapists and a social worker complete an initial functional assessment and evaluation on the first postoperative day with a focus on early mobility and restoration of function.
3. Local QI projects: Our i-HIP team created an institutional hip fracture steering committee that meet quarterly to review performance metrics and create QI plans. Examples of projects that team has worked on include improving pain management, access to OR, and early mobility.
4. Standardization of care: The i-HIP team led the creation of best practice (preoperative and postoperative) order sets and care pathways. These include early mobility, appropriate analgesia and constipation management, thrombosis prophylaxis, and delirium prevention strategies including minimizing the use of high-risk medications in the elderly. Care is consistently delivered in a standardized fashion with all hip fracture patients undergoing appropriate medical and allied health assessments pre- and post-operatively. We are able to achieve 100% adherence to process measures such as pre-operative optimization, access to the operating room without delay, adherence to order sets, daily care, discharge planning, and creation and dissemination of high-quality templated discharge summaries. Based on our data collection and analysis we found that implementation of i-HIP reduced cost and improved quality of care in a large academic medical center. Our LOS was reduced by 14 days with an associated cost
reduction of $4953 per hospitalization (estimated annual cost avoidance of over $1,000,000). Time from admission to surgery decreased from 46 hours (pre-intervention) to 29 hours (post-intervention). We have reduced the number of peri-operative echocardiograms (from 16% to 9%) and other utilization such as unnecessary urinary catheter use. In addition, there was a statistically significant reduction of mortality rate of hip fracture patients at MSH from 5.1 to 2% following i-HIP implementation. According to Health Quality Ontario (HQO), our patients enjoy one of the lowest mortality rates in the province and is the subject of a recent site visit by HQO. As such, we have been asked to present at Health Quality Ontario’s quality rounds. Our work is in keeping with the quality standards report on hip fracture patients that will be released by HQO.
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