Admission Pathways for Elderly Patients With Hip Fracture
Admission Pathways for Elderly Patients With Hip Fracture
This retrospective study was approved by the Duke Institutional Review Board. The study population consisted of 389 consecutive patients 65 yr of age and older who were admitted to our institution with the diagnosis of hip fracture between January 2006 and May 2010. Potential study patients were identified by Current Procedure Terminology (CPT) codes 27235, 27236, 27244, 27245, 27125 and International Classification of Disease (ICD-9) code 820. The old pathway (OP) of admission was used in 227 patients and was employed for all patients admitted before October 2008. This OP approach included admission to either a medical service (133 patients) or an orthopedic surgery service (94 patients). The new pathway (NP) was used in 162 patients and was applied to all patients admitted after October 2008. This NP involved direct admission of all hip fractures to a medicine service with preoperative medical evaluation, medical optimization, and postoperative medical management with consultation of the orthopaedic surgery service. Regardless of the admitting service, all patients entered a universal clinical pathway. Patients began working with physical therapy on postoperative day (POD) zero. All patients were placed on pharmacologic and mechanical deep vein thrombosis (DVT) prophylaxis. Moreover, antibiotic prophylaxis and multimodal pain control modalities were used in the perioperative setting. Indwelling catheters were discontinued as soon as possible. Regardless of the primary service, the orthopaedic surgery team placed orders for perioperative antibiotics, pain control, and DVT prophylaxis. Patient data were excluded from this study if the patient had sustained multiple or high-energy injuries, nonorthopaedic trauma-related injuries, or if the hip fracture did not require operative intervention.
A retrospective chart review was performed using the hospital's electronic medical record system to obtain patient characteristics that included age, sex, race, body mass index (BMI), ASA score (American Society of Anesthesiologists), co-morbidities, type of fracture, treatment, prefracture mobility status, date and time of admission, date of discharge, admitting service, readmission to any hospital within 30 days for any reason, rapid response code (\), transfusion, prefracture and postfracture supplementation with vitamin D, and any postoperative complications or death. All patients were assigned an ASA classification as either part of their anesthesia preoperative assessment or calculated based on the typical five-tier system, as follows: (1) healthy person, (2) mild systemic disease, (3) severe systemic disease, (4) severe systemic disease that is a constant threat to life, or (5) moribund person who is not expected to survive without the operation. Types of medical comorbidities that were recorded included the following: cerebral vascular disease, dementia, preoperative urinary tract infection (UTI), renal insufficiency, diabetes mellitus, hypertension (HTN), congestive heart failure (CHF), coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD). Prefracture functional mobility status was defined as being either independent, cane assisted, walker assisted, or wheelchair ambulator.
Fracture type was recorded as either intracapsular, which included femoral neck, or extracapsular, which included basicervical and peritrochanteric fractures. Types of fracture treatment included the following: percutaneous screw fixation (patients with nondisplaced femoral neck fractures, Garden class I or II), hemiarthroplasty (less active, debilitated patients with displaced femoral neck fracture, Garden class III or IV), total hip arthroplasty, (active patients with displaced femoral neck fractures, Garden class III or IV, especially with preexisting osteoarthrosis), hemiarthroplasty (patients with metabolic bone disease), intramedullary nailing (patients with unstable intertrochanteric fractures, including reverse obliquity fracture patterns and those with subtrochanteric extension), dynamic hip screw (patients with stable intertrochanteric fracture patterns), Girdlestone (nonambulatory patients), or nonoperative treatment (patients who were nonambulators or those who carried significant perioperative complication rates).
Complications were recorded for the following: pressure sores, pulmonary embolus (PE), deep vein thrombosis (DVT), COPD exacerbation, new UTI, pneumonia, CHF exacerbation, myocardial infarct (MI), wound complications, renal insufficiency, delirium, or death.
Time of surgery was defined as start of anesthesia. From this information, LOS (length of hospital stay defined as time from admission to discharge) and TTS (time to surgery defined as time from admission to start of anesthesia) were calculated.
Patient characteristics were summarized with the frequency and percentage of patients for each care plan. A chi-square analysis was used to compare these patient characteristics to verify that each sample population was similar in comparison. Subgroup analysis for patients admitted under OP was done to examine each respective group's initial patient characteristics and perioperative complications. A chi-square analysis was used to compare the frequency of perioperative complications, readmission, rates, RRTs, and vitamin D supplementation between NP and OP. A Student's t-test for two independent groups was used to examine the role that each plan of care or subgroup had on mean TTS and LOS. Analysis of variance was used to examine mean differences when three or more means were compared. Significant effects were analyzed using the Duncan multiple range post-hoc test. Findings were defined as statistically significant when P<0.05.
Materials and Methods
This retrospective study was approved by the Duke Institutional Review Board. The study population consisted of 389 consecutive patients 65 yr of age and older who were admitted to our institution with the diagnosis of hip fracture between January 2006 and May 2010. Potential study patients were identified by Current Procedure Terminology (CPT) codes 27235, 27236, 27244, 27245, 27125 and International Classification of Disease (ICD-9) code 820. The old pathway (OP) of admission was used in 227 patients and was employed for all patients admitted before October 2008. This OP approach included admission to either a medical service (133 patients) or an orthopedic surgery service (94 patients). The new pathway (NP) was used in 162 patients and was applied to all patients admitted after October 2008. This NP involved direct admission of all hip fractures to a medicine service with preoperative medical evaluation, medical optimization, and postoperative medical management with consultation of the orthopaedic surgery service. Regardless of the admitting service, all patients entered a universal clinical pathway. Patients began working with physical therapy on postoperative day (POD) zero. All patients were placed on pharmacologic and mechanical deep vein thrombosis (DVT) prophylaxis. Moreover, antibiotic prophylaxis and multimodal pain control modalities were used in the perioperative setting. Indwelling catheters were discontinued as soon as possible. Regardless of the primary service, the orthopaedic surgery team placed orders for perioperative antibiotics, pain control, and DVT prophylaxis. Patient data were excluded from this study if the patient had sustained multiple or high-energy injuries, nonorthopaedic trauma-related injuries, or if the hip fracture did not require operative intervention.
Data Collection
A retrospective chart review was performed using the hospital's electronic medical record system to obtain patient characteristics that included age, sex, race, body mass index (BMI), ASA score (American Society of Anesthesiologists), co-morbidities, type of fracture, treatment, prefracture mobility status, date and time of admission, date of discharge, admitting service, readmission to any hospital within 30 days for any reason, rapid response code (\), transfusion, prefracture and postfracture supplementation with vitamin D, and any postoperative complications or death. All patients were assigned an ASA classification as either part of their anesthesia preoperative assessment or calculated based on the typical five-tier system, as follows: (1) healthy person, (2) mild systemic disease, (3) severe systemic disease, (4) severe systemic disease that is a constant threat to life, or (5) moribund person who is not expected to survive without the operation. Types of medical comorbidities that were recorded included the following: cerebral vascular disease, dementia, preoperative urinary tract infection (UTI), renal insufficiency, diabetes mellitus, hypertension (HTN), congestive heart failure (CHF), coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD). Prefracture functional mobility status was defined as being either independent, cane assisted, walker assisted, or wheelchair ambulator.
Fracture type was recorded as either intracapsular, which included femoral neck, or extracapsular, which included basicervical and peritrochanteric fractures. Types of fracture treatment included the following: percutaneous screw fixation (patients with nondisplaced femoral neck fractures, Garden class I or II), hemiarthroplasty (less active, debilitated patients with displaced femoral neck fracture, Garden class III or IV), total hip arthroplasty, (active patients with displaced femoral neck fractures, Garden class III or IV, especially with preexisting osteoarthrosis), hemiarthroplasty (patients with metabolic bone disease), intramedullary nailing (patients with unstable intertrochanteric fractures, including reverse obliquity fracture patterns and those with subtrochanteric extension), dynamic hip screw (patients with stable intertrochanteric fracture patterns), Girdlestone (nonambulatory patients), or nonoperative treatment (patients who were nonambulators or those who carried significant perioperative complication rates).
Complications were recorded for the following: pressure sores, pulmonary embolus (PE), deep vein thrombosis (DVT), COPD exacerbation, new UTI, pneumonia, CHF exacerbation, myocardial infarct (MI), wound complications, renal insufficiency, delirium, or death.
Time of surgery was defined as start of anesthesia. From this information, LOS (length of hospital stay defined as time from admission to discharge) and TTS (time to surgery defined as time from admission to start of anesthesia) were calculated.
Statistical Analysis
Patient characteristics were summarized with the frequency and percentage of patients for each care plan. A chi-square analysis was used to compare these patient characteristics to verify that each sample population was similar in comparison. Subgroup analysis for patients admitted under OP was done to examine each respective group's initial patient characteristics and perioperative complications. A chi-square analysis was used to compare the frequency of perioperative complications, readmission, rates, RRTs, and vitamin D supplementation between NP and OP. A Student's t-test for two independent groups was used to examine the role that each plan of care or subgroup had on mean TTS and LOS. Analysis of variance was used to examine mean differences when three or more means were compared. Significant effects were analyzed using the Duncan multiple range post-hoc test. Findings were defined as statistically significant when P<0.05.