By Dorothy Brooks
Hip fractures become increasingly common as people age, particularly among women. More than 300,000 Americans older than age 65 years are hospitalized with hip fractures annually.1 Considering such fractures can lead to significant morbidity, clinicians in Dallas have developed a multidisciplinary approach aimed at accelerating care and boosting outcomes for patients who present to the ED with this injury.
Called Returning Seniors to Orthopedic Excellence (RESTORE), the approach focuses on prioritizing early pain management and shortening the time to surgery for patients with confirmed hip fractures. Early data suggest the approach is working. Launched in February 2021, investigators reporting on 117 patients treated since the RESTORE program began note the time to surgery declined from 44 hours to 18 hours. Attendance at post-discharge follow-up appointments rose from 40% to 70% when compared with the national average. Also, length of stay shortened from 8.72 days to 7.6 days.2
Megan Sorich, DO, an assistant professor of orthopaedic surgery at UT Southwestern Medical Center in Dallas, says her interest in improving outcomes for hip fracture patients began during her orthopedic residency. “I noticed that hip fractures were often the tip of the iceberg when looking at the whole patient,” she says. “I researched additional training and discovered there was only one fellowship in the country that focused on geriatric trauma ... I knew that I wanted to go there to learn how to build a fracture program to help the whole geriatric patient and improve their outcomes.”
Sorich emphasizes the most important part of the program is the multidisciplinary aspect. “All the different service lines need to work together to improve patients’ outcomes, [and] the patients start in the ED,” Sorich says. “The ED is instrumental in quickly identifying the fracture and consulting the correct teams for early intervention.”
For instance, when the patient is triaged in the ED, if there is a high suspicion for hip fracture, the patient is prioritized to go to X-ray. If a hip fracture is identified, orthopedics is consulted, and the patient is admitted to the hospitalist service. “At this point, the patient is risk-stratified or optimized for the OR. Our goal is to [get the patient] to the OR as safely but efficiently as possible,” Sorich says.
RESTORE aims to accomplish this task within 24 hours. For the procedure, anesthesiologists use an Enhanced Recovery After Surgery protocol and regional anesthesia, if possible.
Following surgery, the RESTORE program is integrated with an existing nursing program focused on the care of older adults, Nurses Improving Care for Healthsystem Elders. This program focuses on standardizing early ambulation and using other elder-focused protocols designed to enhance healing.
For example, patients are encouraged to engage in weight-bearing movement as tolerated and to eat all meals in a chair. “Physical and occupational therapists start mobilizing the patients, and geriatric medicine is consulted for the prevention of delirium as well as to emphasize [to patients] the severity of the injury,” Sorich says.
Clinicians start educating patients on bone health while they are in the hospital. A nutritionist meets with patients to help them optimize their calories and diet. “Care coordinators then help patients and their families with safe discharge plans,” she says.
Sorich firmly believes other health systems could benefit from devising similar programs focused on optimizing care for patients with hip fractures. However, she notes it is critical to secure support from hospital administration to ensure a successful launch. “It is also helpful to have an orthopedic champion at your institution spearhead the program,” she says. “Additionally, bring in stakeholders from other specialties, such as geriatric medicine, the ED, anesthesia, hospital medicine, physical and occupational therapy, and care coordination, to further ensure seamless teamwork once the program is launched.”
While the RESTORE program is relatively new, Sorich notes geriatric-certifying the ED will help further bolster the program’s efforts.
REFERENCES
1. Centers for Disease Control and Prevention. Hip fractures among older adults. Page last reviewed Sept. 20, 2016.
2. Sorich M, Yi J, Fletcher D. Building a comprehensive geriatric fracture program and using evidence-based Nurses Improving Care for Healthsystem Elders (NICHE) best care practices. Geriatr Nurs 2022;46:218-221.
Returning Seniors to Orthopedic Excellence focuses on prioritizing early pain management and shortening the time to surgery for patients with confirmed hip fractures. Since implementation in early 2021, lengths of stay are shorter, time to surgery has declined, and attendance rates at follow-up appointments are higher.
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