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Session Details

Implementing a Nurse Managed Geriatric Fracture Program in a Complex Environment

Track: Podium: Clinical Practice

Session Number: S403
Date: Tue, Jun 2nd, 2020
Time: 10:15 AM - 11:15 AM

Description:

Introduction
The burden of geriatric fractures is expected to increase dramatically over the next several decades, with hip fractures alone reaching an estimated 6.26 million by 2050 world-wide.1,2 With a rapidly aging population that is at risk for falls,3 patients with fragility fractures comprise a sizeable portion of orthopaedic practice. In fact, it is estimated that nearly half of all women, and up to 22% of men will suffer an osteoporotic fracture in their lifetime, often with significant morbidity and mortality.4-6 As these patients often have complex medical, surgical, and rehabilitative needs, a multidisciplinary approach is necessary to ensure that these patients have the best possible outcomes.

A combined approach to the care of geriatric fracture patients was first reported in the early 1990s, with a specific emphasis on geriatric and orthopaedic co-management.7,8 These early studies showed significant improvements in postoperative complications, improved function, and lower discharge rates to nursing homes.7 Subsequent studies using an “Orthogeriatric” model have also shown shorter time to surgery (TTS) shorter lengths of stay (LOS), lower readmission rates, reduced in-hospital mortality 9-11, and lower cost of care.12,13 However, these reports are often based at large academic centers whose physicians have largely employed faculty or who have specific geriatric units.14-21 In hospitals staffed with multiple private practice groups or individuals, or in those who do not have an inpatient geriatrics program, the implementation of a protocol-driven approach to patient care may be more challenging because of lack of cohesion, competition, or contrasting care models. Nonetheless, given the scope and breadth of geriatric fracture needs, it is critical that models for geriatric fracture care programs be developed for a variety of settings.

Our institution is a 900 bed, urban, “pluralistic" medical center with multiple simultaneous care models including employed faculty, private practice groups, private practice individuals, and managed care providers. Nursing care is more homogeneous at our facility than physician care, provided under the direction of the Chief Nursing Officer. However, there was a lack of nursing care focus on the specific needs of geriatric patients, particularly those who had suffered a traumatic event such as a fracture. Before our intervention, there was no organized pathway focused on optimizing care for geriatric fracture patients. We introduced the Geriatric Fracture Program (GFP) in July 2018 intending to establish a protocol-driven model to provide evidence-based treatment for geriatric fracture patients. We hypothesized that those enrolled in the GFP would have quicker TTS, shorter LOS, and reduced readmission rates compared to those who were not enrolled.

Methods
The Geriatric Fracture Program uses a combination of multidisciplinary education, evidence-based clinical protocols, documentation tools and geriatric-centered goals of care. This care model provides an opportunity to close gaps in care, ensure quality and safety, and enhance value and improve outcomes for patients. The GFP mission is to provide high-value, geriatric-centered care that manages the injury in the context of the patient as a whole and strives to return the patient to a meaningful life in a timely manner.

Goals for the program include a standardized care model and documentation for geriatric patient care, time to surgery of 24 hours or less, reduced inpatient length of stay of 5 days or less, post-operative delirium rates of less than 20%, and post-discharge comprehensive geriatric assessment to address fall risk and osteoporosis management.

Program Development
Vital to successfully implementing a project in a large hospital environment is building a team of champions and strong supporters. In addition to multiple private practice internists, the hospital hosts three different hospitalists programs. The impetus for the development of the program began with the Department of Orthopaedic Surgery and Chief of Geriatrics in March 2018. Leadership from Orthopaedics and Geriatrics then recruited the help of nursing management and the hospitalist group associated with the medical center’s managed care program—which is also the largest—and geriatric champions were identified from within that hospitalist group. Additionally, this group employed dedicated case managers and, because of their affiliation with the hospital’s managed care program, had more direct contact with outpatient providers and rehabilitation centers for post-discharge care.

Central to this effort was a dedicated Nurse Practitioner with a background in orthopaedics and geriatrics who was designated program manager and served as a liaison between each group. Department and division champions met for several months to define the goals, identify stakeholders, and develop training programs for physicians and nurses. As the medical center does not have an inpatient geriatrics program, hospitalists underwent geriatric-specific training with a special focus on geriatric syndromes, cardiac risk stratification and indications for additional testing,22 polypharmacy, and delirium to provide geriatric-centered care. Nursing staff on the orthopaedic ward underwent training on the physiologic changes in geriatric patients and how to provide team-based care for these complex patients by addressing the needs of the 5-M’s of geriatrics, which include Mind, Mobility, Medications, Multi-Complexity and (what) Matters Most. Additionally, templates for patient intake, delirium assessment, and daily rounding were developed and published in the electronic medical record (EMR) system to assist with standardization of patient care. These templates included specific areas focused on pre-hospital function, prior cognition, and goals of care. Inpatient order sets specific for the GFP were also created and implemented in the EMR.

Additional details addressed in the Program Development include in-depth discussion of the following methods:

Build a strong, multidisciplinary team
- Recruit and engage executive stakeholders, clinical leadership, and data analysis resources
Goals, Scope, Communication
- Team defines the scope and boundaries of the GFP
- The team defines goals and interventions for the GFP
- Monthly clinical leadership working meetings
- Quarterly executive stakeholder meetings
Training by Geriatrician and Geriatric Acute Care NP
- Geriatric focused training of hospitalists, nurses & CNAs
- Lectures
- Case studies & instructional videos
- Reference material
- Bedside teaching and support
Standardized geriatric-centric pre-operative assessments
- Perioperative management (based on ACC/AHA, ACS/ NSQIP AGS guidelines)
- Mini-Cog, Sweet 16, Confusion Assessment Method for delirium
- Baseline functional status, living situation, support
- Geriatric focused medication review
Goals of care
- Standardized geriatric-centric post-operative interventions
- Daily hospitalist and NP co-rounding
- Daily interdisciplinary huddle with MD, NP, nurse, pharmacist, case management, therapy staff
- Delirium assessment, prevention, mitigation every shift by nursing staff
- Geriatric pain protocol
- Osteoporosis patient education
- Care transition appointments: primary care follow-up, surgical follow-up, geriatric falls assessment, osteoporosis follow-up

Data Collection, Statistical Analysis and Results:
Data will be provided for July 1, 2018 to June 30, 2019. Currently, available data (as of 7/21/19) analyzed is available for July 1, 2018 to April 15, 2019 and is as follows:
Patient enrollment began July 1, 2018 and continued through April 15, 2019. All patients over 65 presenting a fracture (other than the spine) were prospectively followed. Patients were divided into 3 cohorts: GFP, Other Hospitalist group (OH), and private primary care physician (PCP). Continuous variables were compared with a one-way analysis of variance. Categorical variables were compared using a chi-squared or Fischer's exact test. For non-parametric data, median values and interquartile (IQR) values were compared using a Kruskal-Wallis test. A p < 0.05 was considered significant.

A total of 432 operative and non-operatively treated geriatric fracture patients were followed, with 126 (29%) enrolled in the GFP, 114 (26%) in the OH group, and 192 (45%) in the PCP group. There were a total of 221 (51%) hip fractures, 61 (14%) other lower extremity fractures, 24 (6%) periprosthetic fractures, and 126 (29%) upper extremity fractures. There was no difference in the distribution of fracture types between the three groups (p=0.726). Similarly, there were no differences in the average age of the patients between the groups (p=0.123).

For non-operatively treated fractures, length of stay was significantly lower in the GFP group with a median of 3-days (IQR 2, 4.5) compared to 4-days (IQR 2.5, 7) in the OH group, and 5 days (IQR 3, 6) in the PCP group (p=o.o34).

For operatively treated fractures, patients enrolled in the GFP had a significantly lower median length of stay of 4 days (IQR 3, 6) compared to 5 days (IQR 3,6) in the OH group and 5 days (IQR 4, 7) in the PCP group (p=0.044). There was a strong trend towards faster median time to surgery in the GFP group as well (21 hours v 22 hours v 25 hours, p=0.061).

30-day readmission rates were available from July - December (and will be available for July 2018 - June 2019 for the conference presentation). There was no difference between the three groups, with 1% in GFP, 3.7% for OH group, and 1% in the PCP group (p=0.691).

Limitations
- The sample size is relatively small.
Even while patients were organized into discrete groups, all patients were admitted to the same orthopaedic unit and were cared for by nurses who had undergone geriatric-specific training. Quite often patients in different groups were seen by the same surgeon or the same inpatient nurse. Additionally, as the GFP NP was frequently on the unit, she often assisted unit nurses with questions, assessments, and occasional consultations. Thus, all geriatric fracture patients on the unit benefited from the nursing education efforts and the availability of the GFP NP.

Strengths
- Close collaboration between team members and the enthusiastic adoption of GFP goals by orthopaedic nursing staff.
- The pluralistic environment of the medical center provided a natural experiment by which we could compare specific interventions related to GFP versus broader cultural changes within the institution.
- The crossover between the surgeon and nursing care between groups, while considered a limitation from a statistical standpoint, can be considered a major strength in terms of clinical care, as the effort to implement the GFP for a subset of patients required training of health care providers who care for many other patients. Thus GFP educational efforts could lead to improved outcomes for patients not just on the orthopaedic ward, but throughout the hospital.
-Another major strength of the program is inherent in the program design and its ability to grow. While hospitalist and nurse training programs must still be monitored and undergo continuing education by geriatric faculty and GFP NP, program expansion does not require additional staff.

Discussion and Conclusions
- The Cedars-Sinai GFP has resulted in improved LOS and TTS, with no change in readmissions.

- Adherence to evidence-based protocols and close multidisciplinary teamwork are critical to improving outcomes.

-The geriatric acute care NP provides daily administrative, programmatic and clinical program oversight to improve program cohesion and promote geriatric-centric care and is critical to the success of the program.

-A multi-disciplinary geriatric fracture program can be implemented successfully using dedicated teams with geriatric training in a complex, pluralistic environment, resulting in improved patient metrics.



Sub-Categorization: Gerontology
Session Type: Podium

Learner Outcome: The learner will adopt relevant strategies and approaches that improve outcomes in a geriatric fracture (or similar) patient populations.
Category: A
Sub-Categorization: Gerontology
Session Type: Podium

Learner Outcome: The learner will adopt relevant strategies and approaches that improve outcomes in a geriatric fracture (or similar) patient populations.
Category: A

Speakers

Lead Presenter
Kathleen Breda, NP, RN, AGACNP-BC, ONP-C
Cedars-Sinai

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