Hip Fracture Management Pathways in Older Adults

r2d2 hipHip fractures are a common injury among older adults and have a staggering one-year mortality of 20-30%. In this episode we discuss a multi-disciplinary pathway to improve the acute care of patients with hip fractures. It can help standardize care, improve pain control, decrease pain-related delirium, reduce the time from the ED to the operating room, and decrease the hospital length of stay. Also, if you have never heard of the fascia iliaca compartment block for pain management in patients with hip fractures, this could be practice-changing for you!

References and Resources:

Femoral Nerve Block podcast from the ultrasound podcast.

Fascia Iliaca block Video

Femoral Nerve Block video

This is a description of guidelines from the UK on recommendations for hip fracture management.

Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA 1995;273(3):1348–1353. PMID 7715059

Godoy Monzon, D., et al. (2007). “Single fascia iliaca compartment block for post-hip fracture pain relief.” Journal of Emergency Medicine 32(3): 257-262. PMID 17394987

Gottschalk, A., et al. (2015). “The Impact of Incident Postoperative Delirium on Survival of Elderly Patients After Surgery for Hip Fracture Repair.” Anesthesia and Analgesia. PMID 25590791

Hogh, A., et al. (2008). “Fascia iliaca compartment block performed by junior registrars as a supplement to pre-operative analgesia for patients with hip fracture.” Strategies Trauma Limb Reconstr 3(2): 65-70. PMID 18762870

Kates, S. L., et al. (2015). “Financial Implications of Hospital Readmission After Hip Fracture.” Geriatr Orthop Surg Rehabil 6(3): 140-146. PMID 26328226 http://www.ncbi.nlm.nih.gov/pubmed/26328226

Lees, D., et al. (2014). “Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.” European Journal of Emergency Medicine. PMID 24949565

Marcantonio, E. R., et al. (2000). “Delirium is independently associated with poor functional recovery after hip fracture.” Journal of the American Geriatrics Society 48(6): 618-624. PMID 10855596

Mouzopoulos, G., et al. (2009). “Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study.” Journal of Orthopaedics and Traumatology 10(3): 127-133. PMID: 19690943

Mundi, S., et al. (2014). “Similar mortality rates in hip fracture patients over the past 31 years.” Acta Orthopaedica 85(1): 54-59. PMID 24397744

Stoneham, M., et al. (2014). “Emergency surgery: the big three–abdominal aortic aneurysm, laparotomy and hip fracture.” Anaesthesia 69 Suppl 1: 70-80. PMID 24303863

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4 Responses to Hip Fracture Management Pathways in Older Adults

  1. Falls are the leading cause of trauma-related mortality and a daily challenge in any ED providing care for older adults. This podcast explores the UC Davis experience developing hospital protocols to more efficiently and compassionately provide acute care for hip fracture patients by working collaboratively with Anesthesiology, Hospitalist-Geriatricians, Trauma and Orthopedic Surgery. Michael Stern and I described a multidisciplinary approach to falls and geriatric orthopedic injuries in http://pmid.us/20971398, including the role of regional anesthesia which was also recently reviewed by Skeptics Guide to Emergency Medicine (be sure to check out the helpful video clips http://thesgem.com/2015/11/sgem138-hip-to-be-blocked-regional-nerve-blocks-for-hip-and-femoral-neck-fractures/). There is also a wonderful module on ED falls management by University of Toronto’s Don Melady (with free CME!) available at http://geri-em.com/.

    The one qualm that I have with the current GEMCast is the outdated, non-EM centric literature referenced. Lack of awareness and acceptance of the scant research exploring fall epidemiology, risk stratification, and interventions in ED settings is a significant barrier to knowledge translation when developing protocols in conjunction with other specialties. For example, most Geriatricians believe that accurate and reliable risk stratification of fall victims (to predict future falls) is possible using instruments derived and validated in non-ED settings like hospital wards and nursing homes. Not true! See http://pmid.us/19281493 and http://pmid.us/25293956. In addition, viable ED interventions to prevent falls are largely untested or ineffective http://pmid.us/19615786 leaving many research opportunities to improve acute management for fall victims, whether they break their hip or not (see http://pmid.us/21498881). We’ve also explored pre-hospital fall prevention interventions for the subset who never reach the ED, but again very challenging research and thus far disappointing results http://pmid.us/26755748. Bottom Line: We’ve got much work to do to improve outcomes for geriatric fall victims so it is no wonder that patients often fail to get guideline-directed fall care (see http://pmid.us/25773899 and http://pmid.us/25773739). Let’s get to work!

    Chris Carpenter, MD, MSc, FACEP, AGSF


  2. First, I’d like to say this is a great podcast, and I’m sure there are other sites with geriatric fracture programs that have similar, though slightly different experiences. At Northwestern, the greatest success of our program has been 1) eliminating the discussion between who admits the patient (ortho takes them unless they have an active medical issue that prevents them from going to OR immediately), and 2) getting patients to the OR and to rehab faster, which ultimately should decrease complications.

    I agree with Chris that the lack of evidence regarding fall risk stratification and fall prevention after an ED visit is concerning. We use the TUG Test with our patients, but find that 83% of our patients are positive. http://pmid.us/26759651 Clearly we can’t consult physical therapy for all of those patients, so our Geriatric Nurse Liaisons tend to go with their gut on who is struggling to walk during their TUG Test. If anyone has any better options for screening for fall risk in the ED I’d love to hear them.


    • Christina Shenvi says:

      Thanks for the comment! That’s great that you have had success at your site. I agree predicting falls risk robustly and intervening to prevent future falls is still a huge problem without great, practical options.


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