1265 / Improvement approach for hip fracture patient through a multidisciplinary research group

Type of Patient Safety Practice SAFE
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Implementation of Patient Safety initiatives / Activities
Topic of the reported practice
Clinical guidelines or pathways
Aim and the benefit of the Patient Safety Practice
Hip fracture has become a concerning health issue, affecting more often the older adults, a high level of comorbidity and mortality are closely connected to this process. Only in the US around 350.000 hip fractures are registered annually, from which more than 90% occur in population aged 65 years and over. In Spain this segment of the population (?65 years old) will grow from 15.5% in 1980 to 28.6% in 2025, which means an increase of 18405% in 45 years.

A consequence of aging is the high number of patients due to hip fracture, a process that has increased in recent years. In fact, in the Comunidad Valenciana, hip fractures have an incidence of 614 hospitalizations among 100.000 habitants in over 64 years. What’s concerning about this is the high mortality associated with this procedure. It also generates a loss of mobility and function considerably. This leads to increased medical and social costs associated with this disease.

A revolutionary model of joint attention care of geriatricians and orthopedic specialists was developed in UK by the end of the decade of 1950. In 1974, Devas describes the operation of so-called orthogeriatrics units, which aim to guide their care of the elderly who is urgently hospitalized for hip fracture. A significant percentage of the patients treated in these units presents comorbidity, cognitive impairment or meet the criteria for physical frailty.

These hospital units intended to provide care continuity in order to avoid further complications, facilitating functional recovery of these patients. Currently, orthogeriatric units are grouped into different performance models, depending on the degree of involvement by geriatricians, orthopedic and rehabilitation physicians. Despite the disparity of results in terms of effectiveness, the published articles usually agree on reducing the length of hospital stay, complications, readmissions and mortality generated by units orthogeriatric. In addition, it save costs to the National Health System. However, they have present heterogeneous results regarding functional recovery. Of published models, programs that provide an early and intensive geriatric care have demonstrated greater efficacy regarding functional recovery, the average stay and mortality, as demonstrated by the results of some clinical trials.

Given the complexity of the process and the inherent problems in these patients hospitalization, Ribera University Hospital has structured a system of care in order to improve the approach of elderly patients hospitalized in hospitals for hip fracture. This system aims to bring together the measures that have proven efficacy and efficiency improvement in functional recovery, early ambulation, in basic and instrumental activities of daily living and / or attention to comorbidity. All those measures intend to decrease the rate of complications, reduce length of stay and mortality when applied in these patients hospitalized for hip fracture

Description of the Patient Safety Practice
This project’s main goal is to improve the quality of care to elderly patients with hip fracture (CIE 820. *) by a joint system of early care to the senior patients with this disease through interdisciplinary collaboration of geriatric services, orthopedics, rehabilitation, anesthesia and resuscitation and social work, applying techniques “groups improved quality” and “clinical practice guidelines”. The aim is to consolidate a continuum care to improve control of comorbidities, inherent in these patients and increase their clinical safety, reducing the number of complications or facilitating an early approach once they show up. Thus, the offered care may reduce length of stay, improve functional recovery rates, readmissions and readmissions and reduce mortality and hospital complications. The second objective is to initiate the cycle of continuous improvement of care for this condition, regularly reviewing the clinical guidelines developed for the process, through the analysis of adverse prognostic factors for survival and functional recovery one year after discharge, to improve their detection and design strategies to prevent / treat exhaustively and early hospitalization. Secondary objective of this work is to verify / validate the system’s efficiency by comparing the results obtained in our center with the official data published by the Ministry of Health, both for the same diagnosis and the same age range, and the results obtained with patients published in the literature by similar units. METODOLOGY Ribera University Hospital is a third level hospital that covers the population of the region of La Ribera (Valencia, Spain), which is 256.090 habitants, from which 13.5% are over 69 years. The hospital has a Geriatrics Section, formed by 5 doctors, who take part in the internal medicine service that performs activities in the different hospitalization areas (medical and surgical), outpatient visits and medical on-call service. In the surgical area, the medical section of geriatric takes care for all patients over 69 years hospitalized for hip fracture, for other diagnostic services orthopedics, general surgery, vascular surgery, neurosurgery and urology is made risk screening based on previous models (HARP, Yale-New Haven, Studio Toledo) using the pre-anesthetic evaluation, prior comorbidity, functional status and clinical income in the case of planned interventions, making monitoring if you have any risk factor. In the case of emergency admissions, a thorough monitoring is performed to all patients with risk of prognosis worsening due to complications and previous mortality. In the review of results, all patients older than 69 years hospitalized with a diagnosis of hip fracture between January 1, 2004 and December 31, 2008 were included. In the hospital exists since 2002, an improvement multidisciplinary team (consisting of orthopedic surgeons, geriatricians, anesthesiologists, rehabilitation, emergency physicians, hematologists, radiologists, nurses and technical quality) which will, firstly, be in charge of developing the clinical guidelines for Hip Fracture and after, perform various periodic reviews subjecting it to cycles of improvement. The service model defined in the Clinical Guide to the care process is as follows: After the diagnosis of hip fracture and hospitalization, the patient was assigned to an orthopedist, a geriatrician and a team of nurses responsible for it during admission. The geriatrician and orthopedic patients evaluated the patient within the first 24 hours. After surgery, the rehabilitation service examined the patient and started rehabilitation treatment in the first 48 hours postoperatively. In the first evaluation, the orthopedic patient assessed and decided the suitability of surgery and the technique used and the geriatrician conducted a comprehensive geriatric assessment (CGA), including the assessment of the functional, cognitive and social sphere. An assessment of comorbidity and clinical condition at admission was also performed, establishing a treatment plan from the preoperative period. In patients with prior diagnosis of cognitive impairment or those presenting delirium at the time of the interview data they were obtained primary caregiver. The social worker discussed the social network of the patient in the first 48 hours and advised measures to strengthen after discharge. The orthopedic and geriatric specialists monitored the patient evolution daily. The decision to discharge the patient was agreed between orthopedic, geriatric and rehabilitation specialists. In cases where it was deemed necessary, rehabilitation continued after hospital discharge in rehabilitation referral centers. The model designed sought to provide a comprehensive and early care, emphasizing the urgency in the geriatric assessment, surgery and early initiation of rehabilitation therapy to regain mobility in the shortest possible time after surgery. Two guide reviews were conducted in 2004 and 2008, mainly based on literature reviews and ECH reviews looking for improvement areas. The latest revision was made in 2012, during which, a complete scoreboard was designed to ensure adequate identification, monitoring and quantitative monitoring of the process and the different existing prognostic factors in our environment. The defined indicators, as well as those obtained systematically are Emergencies: ? Time between arrival and emergency medical care in <1 hour. ? P3 ? Time between arrival and simple hip RX < 1 hour ? Time between arrival and hospitalization < 4 hours ? % of patients with visual paint indicator scale < 3 when taking hip RX Hospitalization: ? Average stay in patients whose hip is already operated ? % of patients in which the geriatrician or specialist has already checked in < 8 h ? % Patients with presence of delirium: with or without preventive treatment (CIE: 239.0) ? % of patients with appropriate antibiotic prophylaxis ? % of patients with adequate antithrombotic prophylaxis ? % of patients with transfusion performed ? % of patients with RHB Interconsult reported in less than 24 hours ? % Patients With Scale EVA made ? % Patients With Scale NHFS made ? % Patients With Barthel Scale completed ? % Patients With Lawton Scale completed ? % Patients With Norton Scale completed ? % Patients With CAM Scale completed ? % FC%, TA, SAT O2, temperature, diuresis, intestinal habit monitored patients ? % of patients with heels Protection ? % Patients with protection against hypothermia Surgery: ? % of operated patients < 36hours since hospitalization ? Surgery suspensions rate after being programmed in the operating room report ? % of patients with Hb. > 9 before surgery ? % of patients with femoral / iliac fascia lock preoperatively ? % of patients under general / local anesthesia ? % of patients with atrial fibrillation with controlled ventricular rate <100 before surgery Results: ? Hospital mortality rate ? Mortality Rate 1 month ? Mortality Rate 1 year ? Rate of Medical Care Complications (CRAM) ? urgent readmissions rate of hip fracture in less than 30 days ? Analysis of complications by type. Identification and quantification of the most common complications during the process Currently the multidisciplinary group meets quarterly and evaluate the results of the these patients medical care, according to the criteria defined in the guideline and the evolution of indicators. It is planned a new revision of the guidelines for 2016.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Enclosure of a reference or attachment in case of published evaluation’s results
Tarazona-Santabalbina, et al. Early interdisciplinary hospital intervention for elderly patients with hip fracture – functional outcome and mortality. Clinics. 2012;67(6):1-9.
Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation’s level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
Health care assistants
Clinical manager
Quality manager
Risk manager
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives’ involvement takes place
There is no specified text here
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users’ level of involvement
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Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
No data feed back to involved staff
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 100
External consultants: 0
Support staff: 200
Managerial staff: 150
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 30
External consultants: 0
Support staff: 10
Managerial staff: 10
Others: 0
Not relevant: 0
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice