Protocol reduces mortality rates for hip fracture 80%
Administration overcame physician resistance
In 2000, quality professionals at Staten Island (NY) University Hospital reviewed the perioperative death of a 78-year-old woman undergoing hip fracture surgery. During a root-cause analysis of this sentinel event, a key area for improvement was identified: Medical staff lacked specific privileging for preoperative evaluations of high-risk patients.
Even though the organization’s mortality rate of 4.9% was less than the state average of 5.1%, quality leaders set a goal to reduce mortality by developing criteria-driven pre-op assessment privileges requiring specific training and experience.
A defined privilege was developed for medical staff to assess and preoperatively clear high-risk hip fracture patients to ensure competency and reduce variability. A cadre of physicians was identified who could continue doing the pre-op assessments, consisting initially of pulmonary or cardiac intensivists, and later, 20 hospitalists. In addition, emergency department physicians were asked to give earlier notification of hip fracture patients so medical evaluations can be initiated sooner.
"The medical management of the surgical patient is becoming a specialty field unto itself, and we relied on this research to form the basis of our hypothesis," says Joseph Conte, MPA, the organization’s vice president of quality and risk management. "We did not know that it would be validated by the outcomes until they were measured over time."
There was considerable resistance from attending surgeons who didn’t like having to ask a privileged physician to do preoperative assessments for their patients, Conte says. "The JCAHO medical staff standards do call for privileges to be defined in the department the practice is going to be delivered, so this was the underpinning for the authority we needed to go forward," he says.
Resistance was addressed by making it clear that patient safety was at stake and offering all medical staff who previously did preoperative clearance for hip fracture patients the opportunity to apply for preoperative assessment privileges.
"This was contingent on them taking the continuing medical education class, either internally or externally at an approved center, agreeing to proceed with the evaluation within 12 hours, and most importantly, that they continue monitoring the patient postoperatively throughout the stay," Conte adds. A four-hour evidence-based graduate medical education program was developed and offered to the medical staff so they could become privileged, with approximately 55 of 400 eligible physicians choosing to pursue it.
Outcomes data were shared showing marked improvements, which motivated orthopedic surgeons to become advocates for the new process.
"They saw immediate benefits to their patients. They began using the new approach for assessment on all their patients age 65 and older having any kind of surgery, even though it was not required. This was very powerful," Conte says. The dual effect of reduced mortality and improved continuum of care overcame any remaining resistance within months, he adds.
Over the next three years, mortality rates for high-risk patients undergoing hip fracture repairs decreased nearly 80% — from 4.9% down to 1%. "The first year, it was reduced to 2.7% and the second year was the same. But the third year was a breakthrough year, with 1% mortality for over 200 patients, and so far we have held at that same level," Conte explains.
The impressive results resulted in the organization receiving both JCAHO’s Ernest A. Codman Award, which recognizes excellence in the use of outcomes measurement to achieve improvements in the quality and safety of health care, and the New York State Hospital Association’s Pinnacle Award for Quality Improvement.
The project has led to a credentialing revision for all categories of preoperative assessment for in-house surgical patients, Conte reports. "This process is being phased in starting with high-risk procedures in June of this year," he says. Since nearly 25% of patients die within one year of a hip fracture, the organization now is looking at post-op mortality for hip fracture patients following discharge. "We have developed a protocol that will follow patients post-discharge through a home visit program, including medical and physical therapy follow-up," he reports.
The organization’s root-cause analysis was the key factor in identifying areas for improvement, Conte adds. "We were able to dig down into issues related to competency training and variance and what happened in previous cases, which is not something generally done in morbidity and mortality review, when you are looking at an individual practitioner," he explains.
However, root-cause analysis only is effective when there is no preconceived notion at the initiation of the process, Conte notes. "Often, organizations go through the motions and back into a preconceived solution that is not a proximate cause of the event. If you do not make the hard decisions about competency, training, and performance, the process will not be fully effective."
Blaming an individual for inadequate performance does little to prevent recurrence, when in fact the underlying issues are often systematic and rooted in long-held practices that are difficult to change, both operationally and politically, Conte adds. "Using evidence-based medical information often satisfies the physician’s need for a scientific basis for change and improvement," he says.
[For more information, contact:
- Joseph Conte, MPA, Vice President, Quality and Risk Management, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305. Phone: (718) 226-1910. E-mail: [email protected].]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content