What Was Done?
Global Problem Addressed
Hip fractures are a major public health concern in the United States with more than 100,000 hip fracture repairs performed annually.1 A large proportion of hip fractures occur in the geriatric population and are often presented with comorbidities.2
The consequences of a hip fracture consist of a one-year mortality rate of more than 30 percent, functional loss, and estimated medical expenses of more than $40,000.3 With an aging population, the incidence of hip fractures will continue to increase. Although there has been an improvement in surgical interventions, the rates of subsequent fractures are high at 30 percent for women and 22 percent for men.4 Of the subsequent fractures, the mortality rates for men and women are 74 percent and 49 percent, respectively.4 One method to improve the outcomes of hip fracture patients is the adoption of an Enhanced Recovery After Surgery (ERAS) program. ERAS is a multidisciplinary approach to perioperative care with the goal of standardizing patient care to reduce the physiological stress of surgery, complications, and mortality. By minimizing the variation in perioperative care and implementing a patient-centered team approach that coordinates all phases of care, the value of care (quality ÷ cost) should improve.5
Identification of Local Problem
Previous semi-annual reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) presented an opportunity for improvement in the care of our hip fracture patients. Namely, risk-adjusted rates of postoperative mortality, delirium, venous thromboembolism (VTE), and surgical site infection (SSI) were consistently in the upper deciles.
Therefore, in 2018, we joined the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery (ISCR) with an emphasis on hip fractures. We focused on patients undergoing the following hip surgeries: open reduction, internal fixation, hemiarthroplasty, and/or total arthroplasty. Our overall goal was to standardize and integrate all phases of care. Our specific aims were to improve postoperative mortality, delirium, SSI, urinary tract infections (UTI), VTE and length of stay (LOS).
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
Good Samaritan Medical Center is a community based, 250-bed level II trauma center and is part of the SCL Health integrated network. As a long- standing member of ACS NSQIP, we formed an ERAS task force to develop and implement ERAS service lines for elective colorectal surgery in 2016, and elective total hip and knee replacement in 2017. These initiatives produced substantial health care value and provided the motivation to implement a care pathway for hip fracture patients, which coincided with the ISCR program’s development of a hip fracture ERAS pathway in 2018. Our hospital admits approximately 200 patients with hip fractures per year.
Planning and Development Process
The ERAS task force directed its efforts to hip fractures in 2018. The urgent, non- elective nature of patients admitted for hip fractures, particularly during “off-hours,” required expansion of our team to include the Emergency Department (ED).
We also recruited physician hospitalists and nursing leadership (Chief Nursing Officer, directors, managers) because some hip fracture patient admissions were transferred directly from outlying health facilities to the hospital floor, and thus bypassed the ED process. The task force was led by the ACS NSQIP physician champion who also serves as the Medical Director of ERAS. The exploratory meeting with all stakeholders began with the question: “In your phase of care, what is an identifiable opportunity gap for improvement?” As every representative expressed key concerns and suggestions, it became obvious that an ERAS pathway for hip fracture was a critical need. Subsequent meetings were held monthly to build a pathway that synergized care within and among the care phases.
Description of the Quality Improvement Activity
The ACS NSQIP surgical clinical reviewer (SCR) served as the ERAS coordinator for hip fracture. This coordinator worked in conjunction with representatives in all phases of care. Because our hospital was the first to develop hip fracture ERAS in the SCL Health system, our Clinical Informatics (CI) specialists assisted in developing subsets of hip fracture ERAS-specific orders nested into pre-existing medical and surgical hospital order sets. One key addition was a dietary order that allowed solid food intake until 10 hours before the anticipated surgery start time, and clear liquids until 4 hours prior to the surgery start time. These stop times added 2 hours to the American Society of Anesthesiologists NPO guidelines to account for the possibility of surgeries being moved to earlier in the day. Another key addition was a delirium prevention protocol ordered for all patients admitted with a hip fracture.
The medical director of ERAS created and disseminated a detailed pathway from admission to post-discharge, and a “pocket guide” highlighting the key steps in each phase of care. These materials were developed from published literature, the ISCR hip fracture resource library, and our task force consensus. The director also presented at the Lunch and Learn, our hospital-wide grand rounds. The SCR/ ERAS coordinator led small-group meetings and provided education materials to representatives from each phase of care.
The physician director of the ED and the ED nursing leaders relayed the education materials to the ED department providers and staff. An informational handout was created to provide education to the patient and family members (Appendix 1).
The ED physicians received training on fascia iliaca compartment (FIC) blocks and adopted the rationale for allowing, at a minimum, water intake. Opioid-sparing multi-modal analgesics were encouraged in addition to the FIC block. The directors of hospital medicine emphasized the need for rapid medical clearance to expedite the time from admission to surgery,6 the importance of allowing solid food and clear liquid intake within ASA guidelines prior to the expected time of surgery, and principles of opioid-sparing analgesics.7 These action items provide a promising strategy to reduce the incidence of perioperative delirium.8 In total, we considered pain, dehydration, opioids, polypharmacy (i.e., benzodiazepines, anticholinergics), environmental factors, urinary retention, and constipation as major precipitating factors for delirium.9
A final element specific to patients admitted for hip fracture was a process checklist to be completed by providers in each phase of care (Appendix 2). This “shared note” was added to the EPIC medical record after an ED administrative assistant sent a text alert to the SCR/ERAS coordinator and the Medical Director of ERAS, notifying of a new admission. This was necessary because hip fracture admissions occurred at all hours and providers needed a “behavioral nudge” to institute the ERAS-specific orders and care processes, including the preoperative diet and delirium prevention strategies. The preoperative diet order was especially challenging for multiple reasons: (1) the anticipated surgery start time was subject to operating room availability and the time required for medical clearance of the patient; (2) although multiple diets were available in the EPIC ordering system (i.e., regular, diabetic, clear liquids, NPO), there was no order option accompanying the appropriate diet with stop times for solids and liquids; and (3) the EPIC ordering system is a different platform than what is utilized in the hospital kitchen. As such, an ordering provider could free-text instructions for solid and liquid stop times, but the kitchen would not see the free text. This means that the patient or the family could phone the kitchen ordering system and receive a meal delivery in discord with the EPIC physician order. An “NPO violation” was considered unacceptable as this could lead to surgical delays despite the effort to minimize time from admission to surgery. To address this barrier, we created a new physician order called “Nurse to Place NPO Order,” which allowed the floor nurse to discontinue the solid order and subsequent clear liquid order 10 and 4 hours prior to surgery, respectively.
Several “soft rollout” ERAS items were adopted in early 2019, such as FIC blocks in the ED and spinal anesthesia in the OR. The official launch with all aspects of the pathway, including the patient education handout, the ERAS checklist upon admission, and preoperative diet, was August 21, 2019. The traditional care approach and the ERAS core principles are listed in Table 1.
Resources Used and Skills Needed
Staff
The ERAS task force and number of participants is listed in Table 2.
Costs
There were no additional costs beyond normal hospital operations to implement and maintain the QI program.
* Indicates two personnel were required in each category, one representing a physician group that serves patients in a Health Maintenance Organization (Kaiser Permanente) and private practice orthopaedic and internal medicine physician groups that serve patients apart from the HMO.
What Were the Results?
Overall Results
The patient characteristics and process measures are listed in Table 3. We excluded patients receiving percutaneous hip pinning from analysis, because this surgery is minimally invasive and can be performed under local anesthesia and sedation. Our control group consisted of all hip fracture patients in 2018 to eliminate the confounding effects of “soft rollout” interventions that were developed in early 2019. The percentage of patients with preoperative dementia was greater in the pre-ERAS group, which may be attributed to a slightly older population. Alternatively, the emphasis of ERAS interventions (FIC blocks, opioid-sparing multimodal analgesics, delirium prevention protocols upon admission, clear liquid diet) may have reduced preoperative mental status changes and decreased the chance of listing dementia in the hospital problem list. The time from admission to surgery was improved in the ERAS group. The use of FIC blocks, regional anesthesia in the OR, and the use of tranexamic acid was greater in the ERAS group. The other process interventions that were novel in the ERAS pathway did increase from pre- ERAS, but there is certainly capacity for improvement in these categories.
Data for ERAS patients derived from ISCR reports from August 21, 2019, to March 31, 2020.
As shown in Table 4 the major finding of our QI program is that the 30-day mortality median length of stay was reduced from 5 days to 4 days after implementation of ERAS. Following ERAS implementation, the rate of delirium was reduced from 32 percent to 19 percent (p < 0.05). Since delirium is the most common complication after surgery in the geriatric population, we were pleased to see a drastic reduction in delirium event rates.10 Postoperative VTE requiring therapy were reduced from 3 percent to 2 percent. Rates of postoperative UTIs unexpectedly increased from 3 percent to 4 percent, despite encouragement of urinary catheter removal on POD 1.
Data for ERAS patients derived from ISCR reports from August 21, 2019, to March 31, 2020, and manual abstraction. Delirium events, blood transfusion events, and discharge placement were tracked during hospitalization. Mortality, surgical site infection, urinary tract infection, and venous thromboembolism were tracked for 30-days post-discharge. *p < 0.05.
Setbacks
Major barriers that we encountered during the QI activity implementation centered on the complexity of coordinating all personnel in every phase of care. Busy EDs and physician groups have many rotating on-call providers which evokes a natural variation in familiarity with the ERAS protocol. These challenges are exacerbated by limitations in the EPIC medical record system for off-hours admissions. For instance, ERAS programs for elective surgeries allow pre-hospital education, health optimization, standardized nutritional support, and carbohydrate fluid administration on the morning of surgery. In contrast, our hip fracture program relied upon around- the-clock notification from the ED administrative assistants via text messaging.
By remote access into EPIC, we manually entered a shared note checklist upon admission and asked representatives from each phase of care to contribute to the shared note. Completion of the shared note was also difficult due to the large volume of nursing personnel during each care phase. Direct communication was required to advise providers on the proper handling of preoperative diet orders, which was not always feasible. A final setback and limitation of this report was the inability to automatically extract opioid administration from the EPIC medical record, which would result in mean morphine equivalent data for each patient.
A solution to these barriers may be addressed by a “Care Pathway” system within EPIC, that conceivably would automatically activate the ERAS pathway for hip fracture patients who are admitted through the ED. The system would then guide providers along each step of the pathway. Moreover, improvements are needed for a simple ordering system to allow clear liquids until 4 hours before surgery, and an electronic method to abstract total opioid use.
We revised our original QI plan regarding the preoperative diet. The “Nurse to Place NPO Order” was an undue burden on the busy floor nurse. Although we did not encounter NPO violations, we soon realized that allowing solid foods until 10 hours before surgery was too cumbersome, and we simplified this strategy by stopping solid foods at midnight. Another opportunity gap we need to address
is ongoing vigilance of delirium risk. While the delirium prevention protocol is helpful, we have less ability to track whether the hospital physician was notified if an ICDSC score was increasing for a given patient, and what action items were instituted to ameliorate delirium.
Cost Savings
- The approximate amount we invested was minimal, aside from meeting times and participation of hospital staff.
- The financial analyst at our hospital system estimated that reducing LOS for hip fracture patients by one day saves $593 per patient. For the present ERAS cohort, this saved approximately $90,000. For a full year of approximately 200 admissions, the savings would be roughly $118,600.
Tips for Others
- The key aspect of our launch was to keep a common and achievable goal in mind while establishing new protocols in the ED. After establishing our goal we focused on educating hospital staff and patients during the process to ensure we were collecting accurate and measurable data. For example, if a FIC block was performed in the ED the procedure notes were included in the ED notes along with any complications. Once we decided to measure percentage of patients receiving a FIC block it was easy to access the data and determine if the FIC block occurred in the ED or after hospital admission.
- Meetings occurred monthly at Good Samaritan Medical Center and were key to meeting our deadlines. During meetings it was helpful to discuss our successes, setbacks, and necessary changes. We used a master excel spreadsheet to keep track of our data. Some data was pulled from ISCR reports and some was manually abstracted.
- A leader is important during the process to ensure the team is keeping on track with the ERAS goals. It can be a complicated and tiring process to launch a new program; therefore, a key stakeholder is necessary to manage all of the milestones during the process.
