Efficiency of the lausanne clinical pathway for proximal femoral fractures

Do we understand each other when we develop and implement hip fracture models of care? A systematic review with narrative synthesis

BACKGROUND

A hip fracture in an older person is a devastating injury. It impacts functional mobility, independence and survival. Models of care may provide a means for delivering integrated hip fracture care in less well-resourced settings. The aim of this review was to determine the elements of hip fracture models of care to inform the development of an adaptable model of care for low and middle-income countries (LMICs).

METHODS

Multiple databases were searched for papers reporting a hip fracture model of care for any part of the patient pathway from injury to rehabilitation. Results were limited to publications from 2000. Titles, abstracts and full texts were screened based on eligibility criteria. Papers were evaluated with an equity lens against eight conceptual criteria adapted from an existing description of a model of care.

RESULTS

82 papers were included, half of which were published since 2015. Only two papers were from middle-income countries and only two papers were evaluated as reporting all conceptual criteria from the existing description. The most identified criterion was an evidence-informed intervention and the least identified was the inclusion of patient stakeholders.

CONCLUSION

Interventions described as models of care for hip fracture are unlikely to include previously described conceptual criteria. They are most likely to be orthogeriatric approaches to service delivery, which is a barrier to their implementation in resource-limited settings. In LMICs, the provision of orthogeriatric competencies by other team members is an area for further investigation.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement

BACKGROUND

Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions.

METHODS

GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci.

RESULTS

In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research.

CONCLUSIONS

Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

Clinical pathway efficiency for elective joint replacement surgeries: a case study

PURPOSE

The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation.

DESIGN/METHODOLOGY/APPROACH

This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory.

FINDINGS

There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps.

RESEARCH LIMITATIONS/IMPLICATIONS

The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged.

PRACTICAL IMPLICATIONS

Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations.

SOCIAL IMPLICATIONS

Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other.

ORIGINALITY/VALUE

Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND

Adherence to guidelines for patients with proximal femur fracture is suboptimal.

OBJECTIVE

To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

DESIGN

The European Quality of Care Pathways study is a cluster randomized controlled trial.

SETTING

26 hospitals in Belgium, Italy and Portugal.

SUBJECTS

Older adults with a proximal femur fracture (n = 514 patients) were included.

METHODS

Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

RESULTS

In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

DISCUSSION

Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00962910.

Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture

As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered.

Internal fixation of intra-capsular proximal femoral fractures in patients older than 80 years: Still relevant? Multivariate analysis of a prospective multicentre cohort

BACKGROUND

Arthroplasty is now widely used to treat intra-capsular proximal femoral fractures (PFFs) in older patients, even when there is little or no displacement. However, whether arthroplasty is associated with lower mortality and complication rates in non-displaced or mildly displaced PFFs is unknown. The objectives of this prospective study were: (1) to evaluate early mortality rates with the two treatment methods, (2) to identify risk factors for complications, (3) and to identify predictors of functional decline.

HYPOTHESIS

Arthroplasty and internal fixation produce similar outcomes in non-displaced fractures of patients older than 80 years with PFFs.

MATERIAL AND METHODS

This multicentre prospective study included consecutive patients older than 80 years who were managed for intra-capsular PFFs at eight centres in 2014. Biometric data and geriatric assessment scores (Parker Mobility Score, Katz Index of Independence, and Mini-Nutritional Assessment [MNA] score) were collected before and 6 months after surgery. Independent risk factors were sought by multivariate analysis. We included 418 females and 124 males with a mean age of 87±4years. The distribution of Garden stages was stage I, n=56; stage II, n=33; stage III, n=130; and stage IV, n=323. Arthroplasty was performed in 494 patients and internal fixation in 48 patients with non-displaced intra-capsular PFFs.

RESULTS

Mortality after 6 months was 16.4% overall, with no significant difference between the two groups. By multivariate analysis, two factors were significantly associated with higher mortality, namely, male gender (odds ratio [OR], 3.24; 95% confidence interval [95% CI], 2.0-5.84; P<0.0001) and high ASA score (OR, 1.56; 95% CI, 1.07-2.26; P=0.019). Two factors were independently associated with lower mortality, with 75% predictive value, namely, high haematocrit (OR, 0.8; 95% CI, 0.7-0.9; P=0.001) and better Parker score (OR, 0.5; 95% CI, 0.3-0.8; P=0.01). The cut-off values associated with a significant risk increase were 2 for the Parker score (OR, 1.8; 95% CI, 1.1-2.3; P=0.001) and 37% for the haematocrit (OR, 3.3; 95% CI, 1.9-5.5; P=0.02). Complications occurred in 5.5% of patients. Surgical site infections were seen in 1.4% of patients, all of whom had had arthroplasty. Blood loss was significantly greater with arthroplasty (311±197mL versus 201±165mL, P<0.0002). Dependency worsened in 39% of patients, and 31% of patients lost self-sufficiency. A higher preoperative Parker score was associated with a lower risk of high postoperative dependency (OR, 0.86; 95% CI, 0.76-0.97; P=0.014).

DISCUSSION

Neither treatment method was associated with decreased mortality or better function after intra-capsular PFFs in patients older than 80 years. Early mortality rates were consistent with previous reports. Among the risk factors identified in this study, age, preoperative self-sufficiency, and gender are not amenable to modification, in contrast to haematocrit and blood loss.

CONCLUSION

Internal fixation remains warranted in patients older than 80 years with non-displaced intra-capsular PFFs.

LEVEL OF EVIDENCE

III, prospective case-control study.