Elderly Fracture Care Lowers Patient Risk and Length of Stay

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The American Academy of Orthopaedic Surgeons reports 300,000 annual hospitalizations for hip fractures, and according to research published in The Permanente Journal, the incidence of all adult frailty fractures approaches 500,000 per year. As the population ages, these numbers could increase by 21% over the next five years, as noted by researchers in The Burden of Musculoskeletal Diseases in the United States.

With that in mind, geriatrics specialists at Massachusetts General Hospital have implemented the Geriatric Inpatient Fracture Services (GIFTS) program to address care gaps for older adults with orthopedic fractures. The program works to improve quality of care, treatment protocols and care transitions and is educating a broad set of clinical professionals in geriatric care concepts.

"GIFTS was established when our physicians, focused on decreasing mortality and morbidity associated with geriatric fractures, identified opportunities to mitigate care gaps," says Esteban Franco Garcia, MD, geriatrician in the Division of Palliative Care and Geriatric Medicine at Mass General. "It was clear that these patients needed additional, more careful care. Over the program's lifespan, we've observed a 1-day reduction in acute length of stay for this fragile patient population. Our team has been able to reduce complication rates such as delirium, where our measures are 15% to 20% below benchmarks."

Multidisciplinary Approach to Structure and Alignment

Fracture patients may face a fragmented and age inappropriate care model when they present for treatment. Subsequent surgical delays, complications and extensive hospital stays often compromise outcomes, while failure to diagnose and address underlying osteoporosis frequently leaves patients at risk for future fractures.

The impacts on patients and families are significant. Morbidity, including deficits in activities of daily living (ADLs), forces many into institutional care. Hip fracture patients face a 1-year mortality rate of 30%, according to research published in the Journal of the American Geriatric Society.

As Mass General's geriatric and orthopaedic physicians sought to address care gaps, they focused on the program's foundation, says Dr. Franco Garcia.

"In our co-managed model, physicians across both specialties carry equal responsibility for patient care, driving collaborative development of protocols and strong communications among team members."

Patient care improvements are approached by a team consisting of geriatric, orthopaedic, endocrine and emergency department physicians. Nurses, as well as physical therapy, social work and anesthesia experts, help develop processes that span the acute stay, post-acute transition and transition to home.

Protocols for Rapid Patient Evaluations and Comprehensive Care

When the attending orthopaedic physician identifies a fracture patient older than 65. He or she triggers an automatic, proactive geriatric consult. Geriatrics experts conduct a comprehensive evaluation of the patient, including:

• Functional status
• Cognitive level
• Medication usage
• Complication risks
• Patient preferences

"Because outcomes data suggests that patients who have surgery within 24 to 48 hours have better outcomes, our trauma protocol also requires an expedited initial medical evaluation. This allows us to move patients into surgery quickly, most within 24 hours of admission," says Dr. Franco Garcia.

He notes that most older fracture patients have osteoporosis as an underlying factor in their fracture. If not treated, these patients are at risk for future fractures. To address this, the team initiates a consult with the endocrine team's fracture liaison. The liaison conducts a bone health assessment and engages the patient in development of an action plan.

Additional protocols address common complications, including delirium. Clinicians closely monitor for both hypoactive and hyperactive delirium. Patient orientation protocols supporting normal sleep/wake cycle are closely monitored and medications are carefully prescribed to minimize impacts. The team engages patients and families in prevention activities throughout acute stays.

The geriatric team rounds daily to continue in-depth patient assessment. Orthopaedic and geriatrics physicians also meet with care team members at least daily, and more frequently if an individual patient's condition requires more oversight.

Transition Risks and Follow-up Care

Nearly all GIFTS program patients discharge to a skilled nursing facility (SNF). But each care transition, says Dr. Franco Garcia, carries risks.

Acute to post-acute transition risks are addressed with discharge summaries that are cowritten by geriatrics and orthopaedics providers. These summaries support SNFs in providing continuity in the post-acute setting.

"We built an orthopaedic trauma discharge summary around age-modified care concepts. In our communication to the receiving SNFs, we specifically address mobility, cognitive status, active medical problems and patient preferences," says Dr. Franco Garcia.

The GIFTS program provides additional support for the subsequent transition to home. When needed, social workers interview patients and family, identifying and developing transition and resource plans. An endocrine fracture liaison coordinates with the patient and their primary care physician or outpatient endocrinologist to ensure follow-up is completed. The team provide education on bone health and fall risks and connect patients with community aid and resources.

GIFTS Program Success Leads to Expansion

Quality improvements such as reduced length of stay and reduced incidence of delirium are accompanied by positive impacts that are beginning to be quantified. Surgeons and anesthesiologists have observed:

• Higher surgeon confidence levels based on the comprehensive assessment
• Fewer cancellations due to medical complications
• Consistent adherence to acute care protocols, allowing surgeons to focus on surgical care

In response, Dr. Franco Garcia and his colleagues are expanding the GIFTS program scope, introducing outpatient follow-up in the geriatrics clinics and expanding to include elective orthopaedic services. Other surgical specialties are also under consideration for a future program phase.

"Programs like this are greatly needed as we face an aging population and a declining number of geriatricians," Dr. Franco Garcia says. "Along with improving quality of care, this program gives us the chance to "geriatricize" the residents, fellows and nurse practitioner students who rotate through the program. We're creating the capabilities and culture to provide better care for frail older adults."

Visit the Division of Palliative Care and Geriatric Medicine

Refer a patient to Mass General Geriatric Medicine