HIP FRACTURE MANAGEMENT PATHWAY:

NEPEAN HOSPITAL CASE STUDY

Prof. Gustavo Duque, MD, PhD, FRACP

Director – Geriatric Medicine Section & Ageing Bone Research Program

Sydney Medical School Nepean

Nepean Hospital, Penrith, NSW

Disclosures

-Consultant for Sanofi, P&G, Novartis.

-Research grants from Merck, Novartis, Amgen, Sanofi, P&G,

Servier, Key Pharmaceuticals

http://www.bbc.co.uk/news/10353642

A case of neck of femur (NOF) fracture at Nepean

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Emergency Department

Orthopaedic Surgeon

-Surgical criteria

-Booking of theatre

Geriatrician

-Multi-disciplinary

assessment

-Clinical stability

A case of NOF fracture at Nepean

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Orthopaedic Ward

Orthopaedic Surgeon

- Follow up

- Preparation for Sx

(within 24 hours)

Geriatrician

- Pre-op assessment

- Other consultants

- Electronic pathway

Liaison Nurse

(Orthopedics)

- Assessment

- Care plan

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A case of NOF at Nepean

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Surgery

A case of NOF fracture at Nepean

Orthopaedic Ward

Orthopaedic Surgeon

- Follow up

- Preparation for

discharge

Geriatrician

- Post-op assessment

- Electronic pathway

- Discharge planning

Liaison Nurse

(Orthopedics)

- Discharge planning

Fracture Care Coordinator

(Geriatrics)

- Comprehensive risk

assessment (falls and

fractures)

- Appointment at F&F Clinic

- Follow up (8 weeks post

discharge) - Research

A case of NOF fracture at Nepean

- Constipation

- Wound care

- Blood transfusion

- Urinary catheterization

- Pressure care area

- Nutrition

- Delirium

- Serum vitamin D/PTH/Ca/P

- Antithrombotic prophylaxis

- Pain relief

- Oxygen therapy

- Fluid and electrolyte balance

- Weight bearing

- Early mobilization

- Physiotherapy

- Hip precautions

After the Surgery

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A case of NOF fracture at Nepean

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Orthopaedic Ward - Discharge

Orthogeriatrics

Rehab Residential Aged Care Rehab Hospital

Falls and Fractures Clinic

Components of our Falls and Fractures Clinic

›Physical examination

›Cognitive assessment

›Nutritional Assessment

›Medications review

›Gait assessment

›Balance Assessment

›Environment assessment

›Evidence-based interventions

Components of our Falls and Fractures risk assessment

›Nutritional assessment

-Mini-nutritional assessment

tool

Components of our Falls and Fractures risk assessment

›Medications review - Indication

-Dosing

-Side effects

- Interactions

Balance assessment

Bone mineral density

Quantification of sarcopenia

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Gait Assessment

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The Orthogeriatrics Model: Testing the effectiveness of an integrated model of care in older patients with neck of femur fracture. M. Martinez-Reig1,2 , N. Vignakaran3, P. Kurusumuthu3, J. Smith3, O. Demontiero1,3, G. Loza-Diaz1,

L. Sardinha3, A. Sharma3, G. Duque1,3

1. Ageing Bone Research Program, Sydney Medical School Nepean – The University of Sydney, Penrith, NSW, Australia.

2. Geriatric Medicine, Complejo Hospitalario Universitario de Albacete, Albacete, Spain.

3. Geriatric Medicine, Nepean Hospital, Penrith, NSW, Australia.

The investigators retained full independence in the conduct of this research.

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METHODS

Two geriatricians run the model with the assistance of a multidisciplinary team. Assessments included surgical risk, physical examination, nutrition, cognition, and blood tests (blood count, biochemistry, electrolytes, and calciotropic hormones).

A comprehensive intervention plan was designed following established guidelines: Agency for Clinical Innovation of NSW

(www.aci.health.nsw.gov.au/).

Two populations of NOF fracture patients admitted before (2006) and after (Jan 2011-June 2012) the implementation of the program were compared.

Uni and multivariate regression analysis models were used to determine association between the groups and the different co-variables.

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Predictors of early adverse events after

NOF fracture

Martinez-Reig et al, Submitted data

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Predictors of early adverse events after

NOF fracture

Martinez-Reig et al, Submitted data

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Martinez-Reig et al, Submitted data

2006 group has increased risk for: 2011-12 group has better results on:

Summary

›Evidence-based interventions work!

›Prevent post-op complications and increase

survival

›Care pathways are highly recommended

›Early rehab and mobilization are essential

›Think about late mortality

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›Close partnership with the orthopaedic

surgeons is pivotal

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Ageing Bone Research Program Nepean – Clinical Section &

Departments of Geriatrics and Orthopaedics – Nepean Hospital

• Luis Sardinha

• Anita Sharma

• Oddom Demontiero

• Piumali Gunawardene

• Pushpa Suriyaarachchi

• Registrars and advanced trainees

• Rami Sorial

• Orthopaedic Surgeons

• Jenny Smith

• Griselda Loza-Diaz

• Bona Treder

• Derek Boersma

• Sanobar Hassan

• Deanna Davies

Acknowledgements

www.boneresearch.edu.au

www.fallsandfractures.com