Fractured hip: The clock is ticking

It’s a situation that many baby boomers are facing: The phone rings and they find out a parent has fallen, forcing them both into a sudden introduction into the often-confusing world of accessing emergency hip fracture surgery.

If this happens to your family, you can insist that the hospital that admits your mother uses the Canadian-designed National Hip Fracture Toolkit, released in June 2011, as the basis of their orthopaedic treatment. Developed by Bone and Joint Decade Canada in strategic partnership with the Canadian Orthopaedic Care Strategy Group (COCSG), Health Canada and other expert agencies, this toolkit outlines the best practices, as used in leading national and international hospitals, for the treatment of hip fractures. The toolkit ensures patients have the best outcome, which also reduces the associated healthcare costs for that patient. It’s the proverbial win-win situation – the patient does better and healthcare costs reduced, says Jim Wilson, a director of COCSG.

What this hip fracture toolkit emphasizes is the vital importance of getting the necessary surgery within 48 hours of the injury and the appropriate care afterwards. If a patient is forced to wait any longer for surgery, the health outcomes become considerably worse, leading to increased complications and chances of death, says Dr. James Waddell, an orthopaedic surgeon at St. Michael’s Hospital and professor at the University of Toronto, as well as the toolkit’s project lead and editor.

Why the intense focus on hip fractures? Because the problem is much bigger than it looks at first glance and it is a costly burden on an already overstretched healthcare system, says Dr. Hans Kreder, head of the orthopaedic division and program chief of the Holland musculoskeletal program at Sunnybrook Health Sciences Centre. “We [Sunnybrook] were one of the worst in the province for getting patients to the operating room within 48 hours. This was because we are a major trauma centre with life and limb threatening injuries competing for access to the operating room. Hip fractures tended to be bumped down the list because they are lying quietly in bed without looking like there is any urgency about them – compare that to a bleeding patient brought in by paramedics – but we know that the longer the delay, the more likely they are to die and to have other major complications. Once the [hip fracture] guidelines were made public, we were able to convince our senior leadership that hip fracture cases must be made a priority.”

This realignment of priorities paid off. Since implementing the comprehensive strategies and best practices outlined in the National Hip Fracture Toolkit, Sunnybrook went from having the worst record in the province with less than 60% of hip fracture surgeries performed within 48 hours, to one of the best with more than 90% of surgeries completed within 48 hours, says Dr. Kreder.

This massive improvement translates not into not only better patient outcomes, but also saves significant healthcare dollars. While hip fracture patients represent a relatively small number of surgeries (about 11,000 in Ontario each year) the cost of treating these patients over the long term is very high. With healthcare costs averaging $27,000 per patient, and more than 30,000 Canadians fracturing a hip each year, it’s become a significant factor in rising healthcare costs. Since most hip fracture patients are elderly, they often have previous healthcare problems that make recovery more difficult, which can lead to return hospital visits if hip surgery is delayed past the two-day mark. In addition, if they are not given appropriate rehabilitation to help them recover from surgery, whether it is in-hospital or community-based, they lose mobility, which leads to a downward spiral that means the inability to live alone, a loss in quality of life, and very often, the loss of life itself. A fractured hip is in reality a life-threatening injury if it is not treated within the two-day window. Increasing evidence also suggests that patients over the age of 80 require surgery within 24 hours of injury if they are to avoid very serious complications that often have fatal outcomes.

No need to send mom to a nursing home

But that doesn’t need to be the case, says Dr. Waddell. “You won’t need to set your mom up in a nursing home or sell her stuff on Craigslist when she breaks her hip,” if she is able to get timely surgery and access the right rehabilitation services available in her community. The toolkit outlines the various models that hospitals can use to ensure the smooth transition from surgery to recovery and back home. Indeed, much of the success of the document is based on managing the entire patient recovery cycle after the surgery, with almost all of it occurring outside of a hospital setting.

This is important information for the families of hip fracture patients. Having a comprehensive understanding of the entire recovery process is invaluable in planning and helping to relieve stress at every turn. Certainly, adult children of elderly “at-risk” parents, should be aware of the strict 48-hour timeline associated with hip surgery and insist the hospital treating their parent follow the toolkit’s best practices. First and foremost, the toolkit is designed to give patients better outcomes; saving healthcare dollars down the line is a natural consequence of this superior care.

Frees up hospital beds

What the toolkit will also do is help relieve the “alternate level care” problem that exists in many hospitals today. This is where hospital beds are occupied by patients who have no where else to go, despite the fact that they don’t require the high level of care a hospital provides, but are not well enough to go back into their home. By speeding up surgery times to within two days, patients do remarkably better and are able to leave the hospital sooner – and in better shape. They are more easily able to integrate them into community-based rehab that gives them a decent measure of mobility and quality of life back, including avoiding repeated hospital visits and depression.

The model of care for Hip Fracture patients (National Hip Fracture Toolkit, June 2011. Developed by Bone and Joint Decade Canada, Canadian Orthopaedic Care Strategy Group, Osteoporosis Canada, Centre of Hip Health and Mobility, Canadian Orthopaedic Foundation, Alberta Bone and Joint Health Institute (ABJHI), Bone and Joint Health Network – Ontario)

Not all hospitals are using this model of care yet because it does require a reallocation of resources, says Dr. Waddell. To achieve this, hospital administrators and government are sitting down in February 2012 to hash out the details of implementing the National Hip Fracture Toolkit across the nation. The goal is to have every hip fracture patient receiving prompt surgical attention and leaving the hospital with a detailed and achievable community-based rehabilitation plan.

Armed with the knowledge that best practices exist in hip fracture surgery, families of patients should now be able to advocate on behalf of the patient, who is often in shock and unable to make clear-headed decisions. It is your right to insist that surgery takes place within 48 hours to meet the toolkit’s guidelines. Your parent’s life may depend upon it.

Editor: Sara Rafuse, EVP & COO, The Canadian Orthopaedic Care Strategy Group

This article may be republished with permission. Please contact info@mobilizecanada.com.

Photo ©iStockphoto.com/ Beyza Sultan Durna