1. Geriatric Hip Fracture Program Christina McQuiston M.B.Ch.B. Mission Hospitals, Asheville, NC

2. The Problem 300,000 Americans experience a hip fracture annually In 2005 fragility fractures cost around $19 billion By 2025 it is predicted that these costs will rise to around $25billion. Around 24% of such patients over 50 will die in the year following a fracture

3. Hip Fracture Repair per 1,000 Medicare Enrollees (2003) Source: Dartmouth Atlas 2003 National Average 7.53 1. Oklahoma 9.06 2. Tennessee 8.87 3. Georgia 8.78 3. North Carolina 8.78 11. South Carolina 8.28 23. Florida 7.46

4. Hip Fracture Repairs NC Hospitals Medicare volumes

5. Mission Hospitals All payers 20062007 Total number586563 Total number over age 64 492454 ALOS all pts5.8 days6.36 days

6. Mission Hospitals: Net income per Case

7. Environmental Survey Reviewed literature on co-management models. Shows decreased LOS and readmissions. Reviewed anesthesia literature. Less delirium with spinal anesthesia. Reviewed and incorporated CHEST guidelines for VTE prophylaxis. Reviewed orthopedic literature regarding post hip fracture weight bearing status. Reviewed current recommendations for osteoporosis treatment. Site visit to Highland hospital in Rochester NY to review their process. (data published this summer)

8. Plan Outline All patients with fragility hip fractures(>65yr) Orthopedist remains attending physician. All patients co-managed by hospitalist. Elder specific pre and post op order sets. Consistent early weight bearing. Chest guidelines for VTE prophylaxis. Incorporate osteoporosis treatment.

9. Current Work Improve collaboration among ER physicians, orthopedists, hospitalists and anesthesiologists. Develop a protocol driven medical co- management process. Streamline throughput from admission to discharge. Create elder specific computerized power plans.

10. Medical Co-Management Standardize the initial medical consult with attention to geriatric syndromes. Accurately document medical co- morbidities. Stratify risk. Coordinate additional consults. Actively manage the discharge process.

11. Everyone Wins Door to OR in <24 hrs. Reduce length of stay.(4 day goal) Reduce costs. Reduce complications. Reduce hospital acquired delirium. Reduce readmissions. Increase patient and family satisfaction.

12. Door to OR data

13. Readmission-Reasons46 Patients Anemia1 Aspiration Pneumonia1 Atrial Fibrillation3 C Diff Colitis2 CHF2 Cholelithiasis1 Dehydration3 Dysphagia1 Fever1 Gangrene non-operative leg1 GI bleed1 Hip dislocation7 HTN1 Ileus1 Lag screw cut femoral head1 Nausea2 New fracture9 Non-union1 Pain1 Pancreatitis1 Pneumonia6 Septic Shock2 Thrombus1 UTI3 Wound Erythema2 Wound Infection6 Readmissions – Timing46 Patients Returned within 7 days16 Returned between 8-14 days12 Returned between 15-21 days8 Returned between 22-31 days10 APR DRG CasesAPR Readmission Rate Expected APR Readmission Rate Expected APR Readmission Rate Index 3084187.56%10.45%0.76 309519.80%10.93%0.74 Readmissions

14. Barriers Hospitalists fears over “scope creep” Surgical outliers regarding delays from admission to OR Inter-hospital transfers (we have 2 campuses) OR availability Weekend discharges to rehabilitation facilities Medicare part A reimbursement for SNF care and VTE prophylaxis.( Coumadin vs Arixtra/lovenox)

15. Facilitators Administrative advocate Support from orthopedic service line leader Access to data collection and statistician. Enthusiastic and supportive nursing staff.

16. Time Line October 2008. Turn on geriatric specific pre and post op order sets. November. Formalize agreement with hospitalists. January. Roll out new discharge process. February. Incorporate delirium prevention and management and the HELP program.

17. Year 2 Work with SNF’s on post hip fracture care. Develop out patient falls prevention program with community partners. Develop osteoporosis management strategy for SNF’s.

18. Delirium Task Force Develop standardized tools for documentation (CAM) Non pharmacological approaches to prevention and management, Streamline medication options for treatment. HELP pilot.

19. Long Term Goals To provide a best practice model for the hospitalized older patient. The hospitalist as geriatrician. To heighten visibility of Senior Services in my institution. Earn a “place at the table” for geriatrics

20. What I’ve Learned “A prophet is not without honor except in his or her own country.” That and the importance of data to administrative support.