Orthogeriatrics: fragility fractures in the older patient

Orthogeriatrics is a subspecialty developed in response to clinical, social and financial needs in the management of patients with fragility fractures. Fragility fractures carry significant morbidity and mortality-10% will die within one month of the injury and a third within a year.⁴

Half of patients experience a decrease in mobility after the fracture with 10-20% of those patients who were admitted from their own homes being discharged to 24-hour care.

Health and social aftercare costs for the first two years after hip fracture average £13,000.³ Contributing to the poor prognosis is that as well as being a marker of bone fragility, hip fractures indicate a patient’s general frailty and high falls risk. Patients who sustain hip fractures are also very likely to have numerous serious comorbidities.⁵

Orthogeriatrics is defined as the care of elderly orthopaedic inpatients, most often following a fractured hip. Orthogeriatrics was developed as a subspecialty to address the poor outcomes of hip fracture patients by caring for patients alongside orthopaedic surgeons and with the support of a specialist multidisciplinary team.

In 2007, the British Orthopaedic Association published The Care of Patients with Fragility Fracture (the “Blue Book”) in conjunction with a number of other professional organisations including the British Geriatric Society.⁴ This outlines the best practice in care of this patient group. It identifies eight aspects of good care that should be aimed for in every patient:

1. Prompt admission under the care of an orthopaedic consultant
2. Rapid comprehensive assessment with surgical, medical and anaesthetic input
3. Minimal delay to surgery
4. Accurate and well-performed surgery
5. Prompt mobilisation
6. Early MDT rehabilitation
7. Early supported discharge and community rehabilitation
8. Secondary prevention of fractures.

In relation to these aspects of good care, it also set out six more specific standards for best practice care:

1. All hip fracture patients should be admitted to an orthopaedic ward within four hours of presentation
2. All patients medically fit to have surgery should do so within 48 hours of admission and within normal working hours
3. All patients should be assessed and cared for with a view to reducing the risk of developing pressure areas
4. There should be routine access to acute orthogeriatric support
5. All patients should be assessed for anti-resorptive treatment to reduce the risk of future fractures
6. All patients should be offered MDT assessment and intervention to reduce the risk of future falls.

It also gives more guidance as to the best clinical care of patients with fragility fractures. The initial clinical evaluation should include consideration of the causes of the fall with investigation as appropriate; comorbidities and medications and their optimisation for surgery; previous function and support prior to admission; and previous cognitive status. On admission, the patient should be fluid resuscitated appropriately and have basic investigations carried out pre-operatively including an ECG.

Post-operative care should cover a wide range of issues. Achieving adequate analgesia is important, both for patient comfort and to allow early mobilisation as well as to address a preventable cause of delirium.⁶

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report in 2010 that showed that a poor quality of care was being given to elderly patients undergoing surgery in the UK and found that pain was poorly assessed in these patients both pre- and post-operatively.

Any post-operative anaemia should be addressed promptly with transfusion if necessary. Wound and pressure area care should be a priority. Thromboprophylaxis should be considered.

Early mobilisation helps to reduce the risk of venous thromboembolism and current national guidelines from NICE suggest mechanical prophylaxis and low molecular weight heparin for four weeks post-operatively unless there are contraindications.⁷

Nutrition should also be assessed and optimised-this was identified by the NCEPOD report as another particular area of concern. Early mobilisation should be aimed for with most patients being sat out of bed and starting to stand from the first day following surgery.

Most patients with a fragility fracture will have osteoporosis but other causes of such fractures should also be considered including Paget’s disease, haematological malignancies and metastatic bone disease and investigated as indicated.

In April 2010, the best practice tariff (BPT) for hip fracture was introduced in the UK as a financial incentive to improve patient care.⁸ It allows for an extra payment per patient in addition to the standard NHS tariff payment if all criteria are met (figure 1). This is assessed and monitored using the National Hip Fracture Database (NHFD) into which hospital trusts input data that includes patient demographics as well as information pertaining to the BPT. The NHFD can also be used to gather data for audit purposes and allow casemix-adjusted hospital comparisons and comparison of the outcomes of individual units to national standards.⁴

There are two principle models of orthogeriatric care: a liaison service and dedicated hip fracture units.⁴

Orthogeriatric liaison

Patients are admitted under the care of orthopaedics and remain primarily responsible for the patient’s care throughout their admission. An orthogeriatrician provides input to every hip fracture patient during their stay. The first assessment should be within 72 hours of admission to satisfy BPT. During the assessment, pre-existing oracute medical conditions are addressed, as well as falls risk and bone health.

Hip fracture units

Patients are admitted directly to a dedicated hip fracture ward under the joint care of orthopaedics and orthogeriatrics. Patients are usually admitted under orthopaedics, with care being transferred to orthogeriatrics at a locally-defined point post-operatively, although both specialties are expected to provide input where required throughout the  inpatient stay.

There have been a number of significant improvements made to hip fracture services over the last two years. In 2010, hip fracture patients were admitted to general trauma wards or other wards when this was not possible. Operations were carried out on the general acute trauma list, resulting in delays to theatre and inconsistencies in both orthopaedic and anaesthetic expertise. There was a single orthogeriatrician providing input for two sessions per week.

The 36-bedded Hip Fracture Unit at Pinderfields Hospital in Wakefield opened in April 2011, centralising hip fracture care across Mid Yorkshire. Patients over the age of 65 years are admitted under the joint care of a consultant orthopaedic surgeon and consultant geriatrician. Primary responsibility of care lies with orthopaedics pre-operatively to day three post-operatively. Responsibility of care is then transferred to orthogeriatrics from day four post-operatively until discharge. There are two full-time orthogeriatricians serving the unit and patients are seen within 72 hours of admission and pre-operatively where possible. At the weekend patients are seen by an on-call geriatrician.

There is now a dedicated hip fracture theatre list between Monday and Friday, led by senior anaesthetists with an interest and expertise in hip fracture patients.  Nursing staff on the unit offer a mixed background of both medical and surgical expertise. Additional staff includes a hip fracture specialist nurse, dedicated to maintaining standards of care for all of the hip fracture patients throughout their stay. There are also two health care assistants (band 3). They are responsible for ensuring BPT is maintained and enter data onto the NHFD. They perform pre- and post-operative AMTS on all patients and prepare patients for theatre.  They also offer a 30- and 120-day telephone follow-up service for patients to ensure correct aftercare and rehabilitation has been achieved. There is a dedicated physiotherapist and occupational therapist, and the multidisciplinary team meet daily to discuss patients’ progress.

As simple as this transition sounded, it has not been without problems. When the unit first opened, nursing staff came from a mixed background of elderly medical and trauma/orthopaedic. Whilst this may seem a desirable mix of skills, nursing staff needed to be proficient in both elderly care and trauma/orthopaedics and training needs were actually high. Morale amongst staff was low owing to the recent merging of services of Pinderfields Hospital and nearby Pontefract Hospital and extra care and sensitivity was required in supporting and training staff.

Since the unit opened there has been substantial overall improvements made in standards of care, and this is reflected in the rise in numbers of patients meeting all of the criteria for BPT. Whilst further improvements are still being made, particularly in improving time to surgery, moving from a liaison service model to a hip fracture unit has been a positive one for both patients and staff.

Orthogeriatrics is a subspecialty developed in response to clinical, social and financial needs in the management of patients with fragility fractures, and more specifically hip fractures. The current best practice encompasses the patient’s care from arriving at the hospital through to discharge and involves the whole multidisciplinary team. The care provided aims to be holistic and to include secondary prevention of fractures as well as acute care. With the Department of Health creating a financial incentive to provide best practice care for hip fracture patients, it is hoped that care standards for orthogeriatric patients will continue to improve and the speciality will continue to develop, perhaps routinely providing assessment and secondary prevention in other types of fragility fractures.

The experience at the Mid Yorkshire has shown that a dedicated hip fracture unit with its own multidisciplinary team, along with some changes to the hospital’s working systems, can enable high standards of patient care and outcomes to be met, both during the hospital stay and following discharge. The authors hope that other units may be developed using a similar structure to improve the acute care and ongoing quality of life for patients with hip fractures.

Conflict of interest: none declared

References

1. World Health Organization.  Guidelines for preclinical evaluation and clinical trials in osteoporosis.  Geneva: World Health Organization; 1998
2. Torgerson DJ, Iglesias CP, Reid DM. The economics of fracture prevention.  In: Barlow DH, Francis RM, Miles A, editors. The effective management of Osteoporosis. London.  Aesculapius Medical Press; 2001
3. Burge RT, Worley D, Johansen A, Bhattacharya S, Bose U. The cost of osteoporotic fractures in the UK: projections for 2000-2020. J Med Econ 2001;4: 51-62
4. British Orthopaedic Association.  The Care of Patients with Fragility Fractures. London: British Orthopaedic Association; 2007
5. National Clinical Guideline Centre.  The management of hip fracture in adults.  London: National Clinical Guideline Centre; 2011
6. Wilkinson K, Martin IC, Gough MJ, Stewart JAD, Lucas SB, Freeth H, Bull B, Mason M.  An Age Old Problem: a review of the care received by elderly patients undergoing surgery.  London: National Confidential Enquiry into Patient Outcome and Death; 2010
7. National Clinical Guideline Centre – Acute and Chronic Conditions. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital.  London: National Clinical Guideline Centre; 2010
8. Wilson H, Harding K, Sahota O.  Best Practice Tariff: Making Ends Meet. British Geriatric Society Newsletter June 2010 [cited 2012 Nov 12].  Available from: http://www.bgs.org.uk/index.php?option=com_