A Novel Perioperative Pathway for Acute Geriatric Hip Fracture Patients (Preprint)

BACKGROUND Morbidity and mortality in geriatric hip fracture patients remains high. Despite advances in medical care, the incidence of medical complications, especially delirium, has remained stable in hip fracture patients. Early surgical repair and optimized perioperative care may improve outcomes. OBJECTIVE To evaluate a multidisciplinary perioperative pathway aimed at reducing delirium, time to surgery, length of stay, and mortality among elderly patients with acute hip fractures. Although individual components of hip fracture pathways have been studied, the components together have not. We designed a pathway to specifically address common medical conditions in elderly patients who experience hip fractures. METHODS A novel pathway incorporating regional anesthesia, multimodal analgesia, preoperative anemia correction, and guideline-based cardiac evaluation to expedite time to surgery was implemented at a tertiary care academic center. Data from two 18-month periods before and after implementation were compared . A pre-post design was used for this quality improvement study to examine the effects of nerve block utilization on the rates of delirium and carbohydrate drink administration on acute kidney injury , Results were tracked using statistical process control (SPC) charts to assess for special cause variation. RESULTS A total of 372 patients met inclusion criteria (183 pre- and 189 post-pathway). Implementation led to significant reductions in cardiology consultation time, length of stay, intra- and postoperative blood transfusions, and time to surgery among delayed cases. There was increased use of nerve blocks and preoperative carbohydrate drinks, with no change in delirium rates or 30-day readmissions. Statistical process control methods were used to detect special cause variation after implementation of selected interventions. There was a significant increase of the use of nerve blocks and carbohydrate drink administration after our educational intervention and addition of these orders to a specific order set in our electronic medical record. We then examined the effect of implementation of nerve blocks on delirium and carbohydrate enriched drinks on acute kidney injury. Although there was an improvement in rates of delirium and acute kidney injury with our interventions, special cause variation was not demonstrated. Mortality remained low at 0.5%. CONCLUSIONS Hospitalist-led multidisciplinary care pathways can reduce hospital stay, expedite perioperative care, and improve implementation of evidence-based practices in geriatric hip fracture management. CLINICALTRIAL n/a