A program designed to aid elderly patients following hip fractures reduced mortality rates by nearly 5.2 percentage points, according to a new study by Yale researchers.
The study, published in the February issue of the Journal of Hospital Medicine, looks at the Integrated Fragility Hip Fracture Program developed by the Center for Musculoskeletal Care at Yale New Haven Hospital as a collaborative effort between Yale Orthopaedics & Rehabilitation physicians and Yale New Haven Hospital healthcare providers. With a one-year overall mortality rate of 21%, the researchers wanted to improve outcomes in this vulnerable elderly population. The program combines a multidisciplinary approach to care, standardization of practices, and data metrics to improve patient outcomes.
The researcher hypothesized that creating a program that encompassed all aspects of a patient’s in-hospital care and incorporated the latest surgical and medical approaches following a fracture, they could improve health outcomes for patients following the injury.
Through the standardized protocols of the Integrated Fragility Hip Fracture Program, 30-day mortality rates dropped from 8 to 2.8 percent, the use of blood transfusions dropped 18 percent, and length of stay reduced from an average of 5 days to 4.5.
To achieve this required an overhaul of existing programs and streamlining care processes. The issues that the researchers recognized were managerial as well as medical. They reviewed existing processes at both Yale New Haven Health’s York Street campus and the St. Raphael’s site in New Haven. Prior to 2016, patients would be treated for hip fractures at both sites and in multiple nursing units and with varying surgical protocols.
Centralizing all fragility hip fracture patient to one of the two hospital campuses was a major shift and supported a focused effort. “The barriers to implementing coordinated, multidisciplinary care are significant,” the researchers wrote. “In order to achieve consensus, address concerns, and allay fears, we engaged the primary care and surgeon leadership for their support at the onset of the program and held monthly large group meetings and many smaller sessions to advance objectives.”
The program rolled out over time, but researchers used the 2018 calendar year to compare their standardized changes. A critical component for the program was standardizing the time for surgery. Established research shows that surgery is best completed within 24 hours of injury to reduce potential health complications. The team designated a hip fracture operating room where patients in need of treatment could be operated on consistently in the same window each day. Patients were then discharged to the orthopedic nursing unit on their floor in the early evening and mobilized the following day.
“I am so very proud of our team and how we have improved care for these vulnerable patients in our community,” said Professor Mary O’Connor, MD, who is also Director of the Center for Musculoskeletal Care. “No one person or one group could make this type of difference. But all of us come together, from x-ray technicians and social workers, from nurses and physicians across many departments, to dramatically lower the mortality rate. This is the kind of work that I find so personally rewarding. And we are still learning and making further advances.”
The results showing a reduction in length of stay and mortality “cannot be explained by any one intervention,” researchers wrote.
“We propose that the standardization of all processes and protocols, the establishment of clear expectations among all of the medical and nursing personnel, and the shorter time spent waiting for surgery all contributed to the length of stay reduction,” they wrote.
The research team included O’Connor; Professor Michael Baumgaertner, MD, Trauma Section Chief; third-year resident Joseph Kahan, MD; Jinlei Li, MD, Yale New Haven Hospital’s Jensa Moore, MD, Anne Moore, DNP, and Brooke Spadacino, RN and Marc Shapiro, MD, of Massachusetts General Hospital.