Northwell Health has partnered with American Geriatrics Society (AGS) to implement the AGS CoCare: Ortho™ program in four of their hospitals. The program, supported by grant funding from The John A. Hartford Foundation, incorporates geriatric professionals to co-manage an older patient with a fragility hip fracture as soon as he/she enters the hospital. Long Island Jewish Medical Center (LIJMC) was selected to be the first of four hospitals to implement the program.
The overall goal of the Co-management model of care for fragility hip fractures in the geriatric population is to improve the patient care experience for older adults, improve the care provider experience, improve patient centered outcomes and reduce cost.
The five principles of the AGS CoCare: OrthoTM include:
- Most patients benefit from surgical stabilization of their fracture
- The sooner patients have surgery, the less time they have to develop iatrogenic illness
- Co-management with frequent communication avoids iatrogenesis
- Standardized protocols decrease unwarranted variability
- Discharge planning begins at admission1
As LIJMC was selected to be the first site at Northwell, one of the first goals of the Project Committee was to develop a Steering Committee of Stakeholders including Geriatrics, Orthopedic Surgery, Anesthesia, Informatics, Quality and Nursing.
This is a multi-disciplinary effort, using standardized protocols and best practice in geriatric care. The Steering Committee works collaboratively to review order sets and improve clinical care processes. Some key metrics that were identified as priorities for measurement included getting patients to the Operating Room within 24 hours for Surgery, decreasing length of stay and decreasing readmissions.
Relevance/ Significance:
Fragility hip fractures represent more than 300,000 unplanned orthopedic admissions annually in the United States.2Over 90% of hip fracture patients are older than 65 and have pre-existing medical conditions. Additionally, one out of five will have a significant adverse postoperative event. Long term outcomes are poor and because our population is aging, fragility fractures are an increased financial burden on our healthcare system.3
In order to achieve the most optimal outcomes for these patients, a comanagement model, with a geriatrician expert and Orthopedics has been shown to decrease the risk of harmful events, as well as to decrease length of stay and readmissions.4
Historically, patients that would come to the Emergency Room with fragility hip fractures would be admitted by the Medicine team with a Surgery Consult. Because many of these patients have comorbidities, they may need optimization before being cleared for surgical repair of their hip. Hence, preoperative and postoperative management was done by two different teams. Geriatricians did not necessarily follow the patient postoperatively and Orthopedic Surgeons did not routinely round on the patient preoperatively. Additionally, patients would be not be placed on a specific Unit preoperatively. LIJ has an Orthopedic Nursing Unit. The Unit has equipment that specifically accommodates the patient with hip fractures. Additionally, the Interdisciplinary Care team on the Orthopedic Unit is well versed in the care coordination of the patient from admission to discharge. One of the initial goals of the Steering Committee was to establish that fragility hips fracture would be identified on admission and cohorted on the Orthopedic Surgical Unit from admission to discharge.
To develop the program, the AGS CoCare: Ortho™ provides resources including ongoing education and an implementation toolkit.
The LIJMC Steering Committee worked to develop:
- standardized order sets,
- an educational roll-out strategy
- a dashboard to track progress, success and challenges of program
The program was launched in March 2018. Some key processes were put into place to improve the care of the patient upon arrival to the Emergence Department (ED). The Orthopedic team is the first to be paged when patient arrives. If the patient needs to be admitted, the Orthopedic Hospitalist is notified and the patient is admitted to the Orthopedic Nursing Unit. The goal of the team is to provide preoperative consultation and optimization for a timely surgical repair. Postoperatively, the orthopedic hospitalist, Orthopedic Surgical team, Nursing and Case Management round and discuss the plan of case several times a day during the patients stay. Key nursing assessments that have been incorporated into the care of the fragility hip fracture patient includes delirium and mobility assessments. The Case Management team initiates discharge planning as soon as possible upon admission.
Year to date, there have been many key successes to the initiation of this program at LIJMC. Order sets were developed and instituted via our electronic medical record. Included in this order set are medications. The set avoids high risk medications for the geriatric population including anti-histamines, benzodiazepines and high dose and/or long acting opiates. Initial education regarding the program was completed and there is a bi-weekly newsletter with updates to the program and direct links to education modules related to topics of interest.
Some outcomes that have demonstrated improvement include improvement of patient from the ED to Operating Room within 48 hours from 70% to 75% since implementation. The 24- hour goal to surgery is facing some challenges. The Committee will be meeting to try to identify the barriers by reviewing cases. The average length of stay has gone from 8.0 days pre-implementation to 7.8 days post and the readmission rate has decreased to 0% from 3.8%.
The second site for AGS CoCare: OrthoTM has been identified and planning is already underway.
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