Hip Fracture Treatment in Older Patients

pelvic arch to(predicate) Fracture Treatment in Older Patients1.1 place setting pelvis (neck of femur) busts be a common, serious and well-defined injury touch mainly quondam(a) people. As global populations historic period, projections for rosearticulatio coxae rift takingss pool everyplace the coming decades exit rise. Delays to mental move atomic number 18 associated with increased post-operative knottinesss, prolonged rec overy and space of ride out (LOS), and with increased morbidity and death rate (Trpeski, Kaftandziev, and Kjaev, 2013). In addition, the cost burden of pelvis to(predicate) displacements is substantial. The process of caring for people with rose pelvis splits is complex, long, and involves several diagnostic, therapeutic and administrative activities. These activities occur in AE and orthopedical surgical incisions, operating(a) theatres, and in the community. They involve a range of wellness professionals and support staff. When thi s coordination fails, patients may suffer from avoidable delays and suffering. In the United Kingdom (UK), the bed occupation rate for hip fractures was more than 1.5 million days, which represent 20% of the descend orthopaedic beds (Compston et al., 2009). The lifetime risk of sustaining a hip fracture in the UK from age 50 is around 11% for women and 3% for men (Van Staa et al., 2001). more of those who recover suffer a loss in mobility and independence well-nigh half of those previously independent become partly dependent, while trinity become sum of moneyly dependent (Myers et al., 1996).1.2 Current transitWatford General infirmary (WAT) treat 450 patients for hip fractures every year. Hip fractures are one of the intimately common complex trauma problems orthopaedic surgeons face. Patients are often ill ill, elderly and frail, which house result in poor outcomes.Hip fractures generally result from a fall, patients present at AE where imaging shields are delectatio n to let a diagnosis and smart medical specialty is administered (Appendix A). When possible, patients are go from the emergency department to a ward.I involvely, patients will nominate water surgery inwardly 72 hours of arrival at infirmary, provided they are in a lasting condition. A pre-operative assessment is carried out to establish the patients overall health to make sure they are ready for surgery. They also collect an anaesthetic assessment. ii main types of anesthesia are utilise general anaesthetic and spinal anaesthesia or epidural anaesthesia. A team of health charge professionals will coiffe the surgery, including an orthopaedic surgeon.The National Hip Fracture Database (NHFD) produce an annual melodic theme that includes an analysis of 30-day mortality rate rank for hip fracture patients who are over 60 years old at bottom the UK. WAT were alerted by the NHFD that they were an outlier, with 12% mortality over 3 years. In the UK the overall mortality rate within 30 days of hip fracture in 2014 was 7.5% (Johansen, 2016). High mortality rate are a signal to hospitals that they should investigate to identify and resolving power feeling issues.Figure 1Funnel Plot of Crude and Adjusted Mortality place 2014 (Source Johansen, 2016)Effective strategies are needed to reduce the burden on health business concern providers and to ameliorate patient gauge of life and outcomes after a hip fracture. Staff at WAT want to develop an action plan to crumple performance and instigate improvement programmes. This included questioning what elements of business organisation could flummox been delivered best(p) to ensure that high- caliber mission is delivered throughout the patients intervention, to improve 30-day mortality rank and structural outcomes for patients.1.3 Perceived Issues with the Current ProcessIn the present report card, the relative incidence and mortality and usable outcomes in hip fracture patients was studied. T he relationships mingled with portal and treatment time, pain prudence drugs and anaesthesia, and their effect on the patients length of stay (LOS) in hospital were assessed and the following issues were engraftAdmission time from AE to treatment is highHigh level of opiate usage to manage pain good turn use of general anaesthesia1.4 Value Adding ActivitiesAdmission to surgery timesPain managementDays spent in hospital1.5 mountOlder people with hip fractures aged 60 or over are in scope for this project. 1.6 Problem Statement30-day mortality rates for sr. hip fracture patients at Watford General Hospital have been 12% for 3 consecutive years, 4.5% higher than the issue average (NHFD).1.7 remainder StatementReduce 30-day mortality rates in older hip fracture patients to 8.5% by the end of June 2017.2.1 Process MapFigure 2 Process Map2.2 Process Narrative The person arrives at the AE department by ambulance or car. The triage restrain assesses the patients condition. Pati ents are classified by severeness of injury (red, yellow, or green). Patients presenting with suspected hip fractures are commonly delegate a yellow classification, which indicates an emergency but not of a life-threatening nature. An AE doctor or nurse checks the patients vital signs, records their pre-fall health condition, and administers pain medication (generally opiates). Subsequently, in consultation with an AE doctor (if available), several basic tests (blood tests) and X-rays (hip and often chest) are ordered and performed. The patient is transferred to the radiology department for x-ray. The AE doctor or nurse then review obliges the test results. If a hip fracture is diagnosed, the patient is deemed admissible and an intravenous (IV) drip is started. The patient is transferred to the orthopaedic ward for portal when a bed becomes available. Admission times are currently 13.4 hours.On gate to the orthopaedic ward an orthopaedic surgeon will review the test results. I f the patient is deemed suitable for treatment the medical assessment team will assess if the patient has any existing medical issues that may meet treatment. If pre-existing medical conditions with the potential to impress treatment are found patients are referred to palliative care and discharged. If no pre-existing conditions are found patients are assessed by the anaesthesia team. Patients deemed suitable for surgery are hardened on the trauma list, surgery generally takes place within 72 hours. Patients deemed unsuitable are referred to palliative care and discharged. Patients go to theatre, they are anesthetised employ general anaesthetic and receive surgery. They are subsequently transferred back to the orthopaedic ward for ward-based management. Patients are discharged once they are mobile.2.3 Identification of Problems, Weaknesses, and remove AreasHigh level of opiate use by AE staff for pain managementAdmission times of 13.4 hours surgical process wait times of up t o 58.6 hours single-valued function use of general anaesthetic in surgery3.1 Key strategical Elements for ImprovementPatients with hip fractures often require complex and challenging care, this is provided by a number of professionals in several departments, crossing a number of service boundaries. These patients are often frail, and their outcomes depend on how efficaciously their care way is managed. Pain management medications, avoidable delays, anaesthesia choices and post-operative care affect functional outcomes and mortality.The key strategic elements towards improving outcomes for older hip fracture patients areReducing morbidity and mortality ratesAchieving better functional outcomes for patientsIncreasing discharge rates to original place of residence change magnitude value from the healthcare budgetThey can be achieved by holdfast pain management practicesAltering anaesthetic managementReducing admission and treatment times3.1.1 Pain ManagementDespite recent advances i n the care of hip fracture patients, significant morbidity and mortality persists. more or less of this is attributable to the pain medication administered in hospital. Opiates are the preferred pain management drug at WAT currently (Appendix A). Opiate use can pass water nausea, constipation, and confusion (delirium) in the older patients (Coruhlu and Pehlivan, 2016).Effective pain management is a primary goal in hip fracture treatment. Research suggests facia iliaca compartment blocks ( write up) is an alternative for pain management in hip fractures. Intravenous opioid therapy is utilize frequently (Appendix A). However, opioid side effects, such as nausea, vomiting and delirium, are common. regional analgesic techniques have been shown to provide similar analgesia to opioids. FIB is reported to in force(p)ly block cutaneous lateral femoral and femoral nerves in adults (Nie et al., 2015). Studies have suggested superior analgesic effect with pre-operative FIB. They provided superior analgesia to intramuscular morphia in a randomised controlled trial of hip fracture patients (Callear et al., 2016).FIB is a safe and simple technique that can be administered by junior doctors and specialist nurses with training (Hanna et al., 2014). FIB administered in AE provided significant decreases in pain when compared to opiates. Post block analgesic requirements for patients in the FIB assemblage were minimal. A engage conducted by Callear and Shah (2016) concluded that a single demigod of FIB given in the pre-operative period significantly reduced the post-operative and total analgesic requirements in the hip fracture patient. Patients also experience disgrace rates of delirium and were discharged faster. This reduces the cost of providing inpatient hospital beds and improves quality of life for older patients.3.1.2 Anaesthetic ManagementAnaesthetists have an essential grapheme in the preoperative, operative and postoperative management of hip fracture patie nts. Complications arising from anaesthesia in hip fracture surgery is influenced not only by the type of anaesthetic used, but also by patient comorbidities and the delays mingled with admission and surgery. Approximately 25% of hip fracture patients display at least one episode of cognitive dysfunction during hospitalisation (Heyburn et al., 2012). A systematic review published by SIGN (2009), suggests that the use of spinal anaesthesia may reduce the incidence of postoperative confusion.3.1.3 Time to operationAt present admission times are 13.4 hours (NHFD statistics show the national average is 9.3 hours) and surgery wait times are 58.6 hours. Current guidelines pep up surgery to be carried out within 24 hours of injury (BOA, 2014). observational studies suggest better functional outcomes, shorter hospital stays, duration of pain, and lower rates of complications and mortality are achieved by performing surgery earlier. Pre-operative delays increase mortality and, in those w ho survive, prolongs post-operative stay. For every additional 8 h delay to surgery after the initial 48 h, an extra day in hospital results (Colais et al., 2015). Currently WAT fall far short of the ideal to provide better(p) care for hip fracture patients.3.1.4 Multidisciplinary ApproachThe management of hip fractures requires complex, affiliated care from presentation at AE, through all departments. A study of 116 patients found that dedicated nurse specialists are effective at fast-tracking hip fracture patients to surgery by securing hospital beds, organising care, operating theatre lists and playacting as a liaison with all other relevant departments (Larsson and Holgers, 2011). more published guidelines recommend a multidisciplinary accession to the treatment of hip fractures, in addition to, a good care environment to promote best outcomes. The Scottish Intercollegiate Guidelines Net work on (SIGN, 2009), the National Institute for Clinical integrity (NICE, 2013), and the British Orthopaedic Association in cooperation with the British Geriatric fellowship (BOA, 2014), have all produced guidelines supporting a multidisciplinary team access to deal with hip fractures in older people.Figure 3 Multidisciplinary Team (Source orthopedics and Trauma)Rieman and Hutichson, (2016) It is recognised that a team approach with excellent communication between all the members is essential. The multidisciplinary team looking after hip fracture patients is big(p) (Figure 2), and each role is important in the jigsaw of care.3.1.5 Clinical roadwayClinical pathways should be used to aid the multidisciplinary team. They provide a definition of the expected interventions and outcomes throughout the patient journey following a hip fracture. The use of clinical pathways ensures everyone knows the next step in the process and this minimises redundant variations in practice (Chudyk et al., 2009). A study of 1193 older hip fracture patients conducted at 6 hospitals in the Limburg trauma region of the Netherlands concluded that the use of a multidisciplinary clinical pathways (MCP) for patients with hip fractures tends to be more effective than ordinary care (UC). Time to surgery was significantly shorter in the MCP group when compared to the UC group. The basal length of stay was 10 versus 12 days. In addition, the MCP group had significantly lower rates of postoperative complications (Kalmet et al., 2016).3.2 Proposed StrategyEstablish a designated Hip Fracture Unit within the main orthopaedic unit.Appoint a multi-disciplinary team to be based on the ward comprised ofPhysio /Occupational therapistOrthopaedic /Orthogeriatric DoctorSpecialist Hip Fracture Nurse nurse staffEstablish a Hip Fracture Pathway.Establish a protocol-driven, fast-track admission of patients with hip fractures through AEAE bleep specialist hip fracture nurseFIB administered by nurse for pain management and patient centred carePatients are admitted to the hip fracture war d within 6 hoursAppropriate, medically fit patients receive surgery within 24 hours utilization of spinal anaesthesia when appropriate sustained tracking/live info systems that regularly update patient and logistical data may improve management by identifying patients location, delays in treatment and relevant clinical information.3.3 potency Process Improvement Tools3.3.1 Continuous character ImprovementContinuous Quality Improvement (CQI) is a quality management tool that encourages all members of the health care team to uninterruptedly ask, How are we insideng? and tail we do it better? (Edwards et al., 2008). It focuses on improvement for the patient and the practice by asking questions like, can we do things more efficiently? Can we be more effective? Can we do it faster? CQI uses a structured planning approach to evaluate the current processes and improve those processes to achieve the desired outcomes.Tools commonly used in CQI help team members identify the desired cli nical or administrative outcome and the evaluation strategies that enable the team to determine if they are achieving that outcome. The team can adjust the CQI plan based on continuous monitoring of progress through an adaptive, real-time feedback loop (NLC, 2013).A CQI approach can help improve patient care. there is a fuddled link between organisations with explicit CQI strategies and high performance (Levin, 2016).Figure 4 CQI Framework Model (Adapted from NLC)Structure examines the characteristics of resources, staff and consultants, physical space, and financial resources.Process - the activities, workflows, or tasks carried out to achieve an output/outcome.Output the immediate precursor to a change in the patients status. Not all outputs are clinical e.g. business or efficiency goals.Outcome the end result of care. Can be change in the patients current and future health status.Feedback loop represents its cyclical, iterative nature.3.3.2 bunk Management angle is a pro cess improvement method developed by Toyota in the 1950s. Lean management principles have been used in manufacturing for many years, however, these principles can be used in healthcare too. According to Womack and Jones, there are five key fly the coop principles value, value stream, flow, pull, and perfection. Lean drives out waste so that all work adds value from a customer perspective. Lean thinking focuses on how efficiently resources are being used, it looks at each step in the process and asks what value is being produced? Value from a patients perspective can be defined as timeliness of treatment, reduced stress, or better functional outcomes. The NHS defines value as anything that helps treat the patient. Everything else is waste (Jones and Mitchell,2006).Figure 5 Lean Principles bring out customer value in healthcare value is any activity that improves the patients health.Manage the value stream the value stream is the patients journey. Identify process that deliver valu e to patients.Create Flow align processes to advance the smooth flow of patients and informationEstablish Pull provide care on demand and utilising resources effectively.Seek Perfection optimise the process through continued development and adjustment to meet patients needs.Optimal delivery of high-quality care to reduce mortality in hip fracture patients is an achievable goal. There are numerous opportunities to enhance the quality of care reduced length of stay, reduced institutionalisation, reduced mortality and better functional outcomes for patients. Better quality care minimises treatment delay, promotes recovery and facilitates a speedier discharge. Cost and quality are not in conflict providing high quality hip fracture treatment is a lot cheaper than poor quality treatment. Lean shake up and clinical pathway related process improvement efforts make uneven and inefficient practices in health care more visible. The implementation and tenderness to evidence based stand ards will considerably improve the care and management of older patients with hip fractures, this will result in significantly amend outcomes for patients and the healthcare system.5.1 Appendix AReferences BOA (2014) BOA standards for trauma (bOASTs). for sale at http//www.boa.ac.uk/publications/boa-standards-trauma-boasts/ (Accessed 5 declination 2016).Callear, J., Shah, K., Hospital, J.R. and Oxford (2016) Analgesia in hip fractures. Do fascia-iliac blocks make any difference?, BMJ Quality Improvement Reports, 5(1), pp. 210130-4147. doi 10.1136/bmjquality.u210130.w4147.Chudyk, A., Jutai, J., Petrella, R. and Speechley, M. (2009) Systematic review of hip fracture rehabilitation practices in the elderly, Archives of physical medicine and rehabilitation., 90(2), pp. 246-62.Colais, P., Di Martino, M., Fusco, D., Perucci, C.A. and Davoli, M. (2015) The effect of early surgery after hip fracture on 1-year mortality, BMC Geriatrics, 15(1). doi 10.1186/s12877-015-0140-y.Compston, J. (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK, Maturitas., 62(2), pp. 105-8.Coruhlu, O. and Pehlivan, S. (2016) Worst pills. on hand(predicate) at http//www.worstpills.org/includes/page.cfm?op_id=459 (Accessed 5 declination 2016).Edwards, P., Huang, D., Metcalfe, L. and Sainfort, F. (2008) Maximizing your investment in EHR. Utilizing EHRs to inform continuous quality improvement., JHIM, 22(1), pp. 7-12.Hanna, L., Gulati, A., Graham, A. and Corporation, H.P. (2014) The role of Fascia Iliaca blocks in hip fractures A prospective case-control study and feasibility assessment of a junior-doctor-delivered service, International Scholarly Research Notices, 2014. doi 10.1155/2014/191306.Heyburn, J., Holloway, G., Leaper, E., Parker, M., Ridegway, S., White, S., Wiese, M. and Wilson, i (2012) Management of proximal femoral fractures 2011, Association of Anaesthetists of Great Britain and Ireland, 67(1) , pp. 85-98.Jones, D. and Mitchell, A. (2006) Lean thinking for the NHS. Available at http//www.nhsconfed.org//media/Confederation/Files/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf (Accessed 11 celestial latitude 2016).Kalmet, P.S.H., Koc, B.B., Hemmes, B. and ten Broeke, R.H.M. (2016) Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture A Multicenter Comparative Cohort Study, Geriatric Orthopaedic Surgery Rehabilitation, 7(2), pp. 81-85.Levin, D. (2016) Using continuous quality improvement to improve patient experience. Available at http//bivarus.com/using-continuous-quality-improvement-improve-patient-experience/ (Accessed 7 December 2016).Myers, A.H., Palmer, M.H., Engel, B.T., Warrenfeltz, D.J. and Parker, J.A. (1996) Mobility in older patients with hip fractures Examining Pre daybook of Orthopaedic trauma, Journal of Orthopaedic Trauma, 10(2), pp. 99-107.NICE (2013) Falls in older people Assessing risk and prevention. A vailable at https//www.nice.org.uk/guidance/cg161 (Accessed 5 December 2016).Nie, H., Yang, Y.-X., Wang, Y., Liu, Y., Zhao, B. and Luan, B. (2015) Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in patients with hip fracture, 20(4).NLC (2013) Continuous quality improvement (CQI) strategies to optimize your practice Primer provided by. Available at https//www.healthit.gov/sites/default/files/nlc_continuousqualityimprovementprimer.pdf (Accessed 7 December 2016).Rieman, A.H.K. and Hutichson, J.D. (2016) The multidisciplinary management of hip fractures in older patients. Available at http//www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327(16)30025-2/fulltext (Accessed 5 December 2016).Scottish extramural guidelines network part of NHS quality improvement Scotland SIGN management of hip fracture in older people (2009) Available at http//www.sign.ac.uk/pdf/sign111.pdf (Accessed 5 December 2016).Simunovic, N., Devereaux, P. and Bhandari, M. (201 1) Surgery for hip fractures Does surgical delay affect outcomes?, 45(1).Trpeski, S., Kaftandziev, I. and Kjaev, A. (2013a) Fast-track care for patients with suspected hip fracture. Available at http//www.injuryjournal.com/article/S0020-1383(11)00002-7/fulltext (Accessed 10 December 2016).Trpeski, S., Kaftandziev, I. and Kjaev, A. (2013b) The effects of time-to-surgery on mortality in elderly patients following hip fractures, Prilozi (Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski nauki)., 34(2), pp. 115-21.Van Staa, T.P., Dennison, E.M., Leufkens, H. and Cooper, C. (2001) Epidemiology of fractures in England and Wales. Available at http//www.thebonejournal.com/article/S8756-3282(01)00614-7/fulltext (Accessed 5 December 2016).Verhelst, J., Dawson, I., Paul T. P. W. Burgers, Esther M. M. Van Lieshout and Piet A. R. de Rijcke (2013) Implementing a clinical pathway for hip fractures effects on hospital length of stay and complication rates in five hundred and tw enty six patients, 38(5).