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Hip Fracture Co-Management Sevice

Page history last edited by gabrielpalley 6 months ago

Hip Fracture Care Pathway 

 

Start Date: 10/1/2019

Revision: 3/9/2020

 

Objectives:

Decrease time between hip fracture diagnosis and surgical intervention to < 24 hours.

Decrease post-operative complication rates and length of stay via planned orthopedic surgery and internal medicine/Family Medicine co-management.

 

Rationale: Prolonged time to surgery is associated with significant increases in morbidity, mortality, and hospital complications.

 

Current State: Average time to surgery for patients with hip fractures at UNM Hospital is ~31.7 hours. Excess time to surgery attributed to (1) delays in determining admitting service and (2) delays in pre-operative risk stratification.

 

Determination of Admitting Service: 

All patients with a hip fracture will be admitted to Orthopedic Surgery, EXCEPT if the patient has ≥ 1 unstable medical conditions (determined by Internal Medicine/Triaging Hospitalist OR Family Medicine) that would be best managed by admission to an Internal Medicine or Family Medicine service.

 

Some examples of unstable medical conditions include, but are not limited to, active myocardial infarction, unstable arrhythmia, decompensated heart failure, acute respiratory distress, gastrointestinal hemorrhage, and severe sepsis.

 

Please apply a low clinical threshold for admission to Internal Medicine or Family Medicine!

 

After July 1, 2020: Triage hospitalist (seven days a week, 24 hours a day) will be responsible for triaging patients appropriately to Orthopedic Surgery OR Internal Medicine.

 

If the triaging hospitalist determines the patient is appropriate for admission to Orthopedic Surgery, then this will be communicated to the ED who will then need to consult Orthopedic Surgery for admission.

 

If a patient is a Family Medicine patient then Family Medicine will be consulted to evaluate for admission versus consultation

 

After initial evaluation, please communicate ASAP with Orthopedic Surgery regarding determination of admitting service.

 

This change supersedes the 10/19/2011 service agreement.

 

See flowchart HERE

 

Initial Consultation For Pre-Operative Risk Stratification:

For ALL hip fracture patients determined stable enough for admission to Orthopedic Surgery, Internal Medicine or Family Medicine will complete an expedited consultation that will include pre-operative risk stratification (ex. RCRI). Grey medicine (or Silver Medicine) will complete this consult during daytime hours and the consult night float resident will complete this consult during the night time hours. All consults should be completed by 0700 the following day in order to proceed to surgery. All consults done by internal medicine are to be handed off to SILVER Medicine for ongoing co-management.

 

SILVER Medicine & Family Medicine Co-Management Responsibilities:

In addition to completing an initial consultation for pre-operative risk stratification, Silver Medicine or Family Medicine will co-manage all hip fracture patients admitted to Orthopedic Surgery through at least POD 3.

On POD 3, the Silver Medicine or Family Medicine team will determine whether continued co-management will meaningfully impact patient care.

 

The Orthopedic Trauma Chief Resident will communicate directly to the Family Medicine or Internal Medicine teams for requests for transfer based on the patients’ clinical post-operative course. 

 

SILVER Medicine/Family Medicine Responsibilities:

-          Pre-operative consultation for risk stratification, daily Progress Notes

-          Code status note and code status order

-          Manage fluids and electrolyte abnormalities

-          De-escalation of pain regimen starting on POD 1

-          Admission and discharge medication reconciliation

-          Management of chronic medical comorbidities

-          Evaluation and management of post-operative complications

 

Orthopedic Surgery Responsibilities:

-          Bed request and admission orders

-          H&P, daily Progress Notes, Discharge Summary

-          Order pre-operative labs, ECG, and CXR (as needed)

-          Post-operative pain management through POD 0, as well as determination if Acute Pain consultation is necessary

-          Rehabilitation orders, including weight bearing status, activity orders, and coordination with PT/OT

-          DVT prophylaxis indication, duration, and discontinuation

-          Foley catheter indication, duration, and discontinuation

-          Nursing Communication orders to direct floor questions to appropriate team

-          Facilitate follow up with outpatient Orthopedic Surgery and Primary Care

 

 

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