Integrated care cuts time to surgery, length of stay in geriatric patients with hip fracture

The Integrated Hip Fracture Care Pathway (IHFCP), a standardized care path for older patients with hip fractures implemented at Tan Tock Seng Hospital in Singapore for 5 years, effectively reduces time to surgery, the number of patients treated conservatively, and the average length of stay, reports a study.

“It is distinct from other orthogeriatric care models, with its ability to provide optimal care coordination, early transfer to community hospitals, and postdischarge day rehabilitation services,” the researchers said. “Consequently, [the IHFCP] helped to optimize patients’ functional status and improved their overall outcome.”

This study was conducted over a 5-year period on patients with acute fragility hip fracture who were managed on IHFCP. The researchers assessed outcomes using a descriptive design, analysing the results separately for each of the 5 years of the programme. First-year outcomes were treated as baseline.

Compared to baseline, the major improvements in process and outcome measures over 5 years were as follows: increase in surgeries performed within 48 hours of admission from 32.5 percent to 80.1 percent; reduced nonoperated patients from 19.6 percent to 11.9 percent; reduced average length of stay at acute hospital among surgically (from 14.0±12.3 to 9.9±1.0 days) and conservatively managed patients (19.1±22.9 to 11.0±2.5 days); reduced 30-day readmission rate from 3.2 percent to 1.6 percent; and improved Modified Functional Assessment Classification of VI to VII at 6 months from 48.0 percent to 78.2 percent. [Singapore Med J 2021;doi:10.11622/smedj.2021041]

“Through collaborating with anaesthetists to develop a criterion for fitness for operation, we were able to reduce the time to surgery,” the researchers said. “[These] criteria [are] based on the McLaughlin criteria, which showed that, while major clinical abnormalities should be corrected prior to surgery, patients with minor abnormalities may proceed with surgery while undergoing correction.” [J Gen Intern Med 2006;21:219-225]

Moreover, earlier studies found that higher Charlson Comorbidity Index and American Society of Anesthesiologists scores significantly correlated with delay in surgery. [J Orthop Surg (Hong Kong) 2018;26:2309499018783909]

Of note, working with dieticians at community hospitals brought about improvements in nutritional assessment rates in the inpatient rehabilitation facility. Previous research revealed that nutritional supplementation in the form of oral protein and energy feeds reduces unfavourable outcomes after surgery for hip fracture. [Cochrane Database Syst Rev 2016;11:CD001880]

In a 2014 study, Grigoryan and colleagues reported that a combined orthogeriatric care service could enhance the functional status of patients. [J Orthop Trauma 2014;28:e49-e55]

Improvements in the Modified Functional Ambulatory Classification (MFAC) at 6 and 12 months also showed that more patients were able to ambulate independently outdoors after community hospital rehabilitation and continued community rehabilitation following discharge. This outcome further stressed the importance of continued rehabilitation beyond discharge for mobility and functional improvements, according to the researchers. [Arch Phys Med Rehabil 2017;98:981-988]

“The effects and advantages associated with IHFCP, when compared with other orthogeriatric care models, could be a focus for future research,” they said.