Mending a Fractured System

January 2017

​Geriatrics Hip Project at University of Colorado Hospital

“Grandma’s broken her hip,” is a phrase we hear all too often. However, such is the skill of our physicians that we sometimes respond with blasé reassurances. “Terrible news,” we say. “She’ll get it replaced and will be fine.” (Pictured at right, Mary Anderson, MD and Jason Stoneback, MD)

However, while same-level falls – such as slipping on ice or tripping over the edge of a rug – are everyday hazards for the elderly population, hip fractures are not insignificant events: they carry a mortality rate of up to 30% at one year.

Jason Stoneback, MD​, knows this all too well. He is director of orthopedic trauma and fracture surgery at University of Colorado Hospital, and was recruited by UCH to build their trauma program. During a needs assessment of the existing service he discovered a broken system when it came to geriatric patients with hip fractures.

“There were no clear admission guidelines for this population,” he said. “When they arrived at the hospital they could be admitted by up to 13 different services.”

This meant staff had to make on-the-spot decisions as to who should admit the patient. If the patient was relatively heathy, it might be orthopedics; yet if they had a history of heart attack, it could be cardiology. 

Jen Wiler, MD​, is associate professor of emergency medicine. She explained that the lack of guidelines led to a disjointed system and confusion in the emergency department around admission and follow-up.

“Frail elderly patients who fall and develop a hip fracture often have a number of medical problems,” she said. “This contributed to them being admitted to a number of different services and resulted in variability in care.”

Inevitably, such variability directly affected patient outcomes.

“The literature shows that these patients tend to do worse if we delay surgery unnecessarily,” Dr. Stoneback said. “We need to get them up and about as soon as possible. Bearing weight on the affected limb is shown to have the best outcomes and decrease complications.”

Developing a proposal for better care

To create a solution to this problem, Dr. Stoneback worked with Mary Anderson, MD​, director of the consultative medicine service at UCH, and orthopedic unit manager Kelly McDevitt, RN. Together they assessed the existing care for patients with hip fractures and developed a proposal for the Institute for Healthcare Quality, Safety and Efficiency (IHQSE), which approved the program.

“The IHQSE process was extremely valuable,” Dr. Anderson said. “We gained many different skills, but the most valuable aspect was having a dedicated time for the group to meet regularly. This was vital in accomplishing the project and moving forward.”

The first step toward better care for patients with hip fractures required a multidisciplinary approach to produce process flow maps of the current system. These maps covered the entire process, from when the patient enters the emergency department, to admission, the perioperative period, immediate post-operative period, discharge and follow up.

“Our analysis discovered that patients who were admitted to the orthopedic unit had half the length of stay of patients admitted to other units,” Dr. Stoneback said. “Our data also showed that many items – such as x-rays or lab values – were not ordered for patients, delaying their surgery and affecting their overall care.”

Indeed, the process flow maps revealed that it took 27 mouse clicks and 88 free-text entries to order all the necessary things for hip fracture patients, something Dr. Stoneback believes invited human error.

“It’s only natural that things were missed with such a complicated process,” he said. “The less variability you create in any complex system the better. We created an order set and reduced this process down to just 14 clicks and one free-text entry.”

Creating meaningful change

Now, unless patients are seriously ill and needing the ICU, they are admitted to the orthopedic unit. There is also a clear process from admission through to discharge and follow-up in the community.

“Patients now have a more cohesive, interprofessional team to take care of them,” Dr. Anderson said. “This means we have far fewer problems with patients getting lost to care. For the first time we are also standardizing things like pain control, delirium prevention and osteoporosis work up and prevention, which also improves care for this population.”

Such positive changes are reflected in the metrics for hip fracture care: length of stay for these patients has reduced by one day, 30-day outpatient follow-up rates have improved and the number of patients receiving osteoporosis evaluation and treatment has increased significantly.

The team was also recognized for their work when they received the Permanente Journal Service Quality Award in 2015, after presenting at the 27th Annual National Forum on Quality Improvement in Healthcare.

Planning for the future

Yet although they have achieved strong results in their work with this population, the team remains committed to further progress.

“We’ve been able to sustain a lot of our improvements in the inpatient setting, but there is still a way to go in other areas,” Dr. Anderson said. “We hope to begin looking at longer-term outcomes that are the true tests of whether the initiative has worked, such as one-year mortality and re-fracture rates, and whether our patients are living independently.”

A fracture liaison service may also be on the horizon, where a coordinator could identify hip fracture patients entering the hospital and follow them throughout their care in an effort to improve outcomes. 

In addition, Dr. Stoneback and the team are working with the emergency department to look at using local anesthetic as pain relief for these patients. This type of anesthesia – a point-of-care ultrasound-guided fascia iliaca block – allows the team to decrease the need for elderly patients to receive oral pain medications that carry a variety of side effects such as delirium.

“There are always opportunities to improve anything we do,” Dr. Stoneback said. “But our experience with this program has shown us that we can yield excellent improvements in patient care by addressing any sort of problem in a systematic, collaborative way.”