Don't waste time on excessive risk stratification by Deborah Gesensway
Published in the September 2011 issue of Today's Hospitalist
While caring for hip fracture patients is a common area of comanagement for hospitalists, it is fraught with challenges. Of the 300,000 Americans hospitalized for hip fracture surgery every year, about 3.5% die during hospitalization, while 14% to 35% die in the following year. Morbidity and re-fracture rates tend to be even higher.
What can hospitalists do to help improve the odds that a patient undergoing hip fracture surgery survives the experience? Several sessions at this year's Society of Hospital Medicine's annual meeting in Texas offered some guidance.
Timing of surgery
One of the keys
"Hip fractures should be repaired within 48 hours to maximize the medical benefit to the patient."
ĖPaul Grant, MD University of Michigan Health System
to treating patients with a broken hip is getting them to surgery quickly. This is urgent surgery," explained Paul Grant, MD, a hospitalist and director of perioperative and consultative medicine at the University of Michigan Health System, who was co-director of a pre- course on perioperative medicine. "The longer you wait, the more challenges you face."
According to Dr. Grant, the sense of urgency surround- ing hip fracture surgery means that the preoperative workup has to be "minimal," even for a patient with a lot of cardiac risk factors.
He did note that physicians need to assess the reasons why a patient fell and sustained a fracture. "If they were down for a while, you need to consider rhabdomyolysis and renal failure," he said. "And because the patient is likely to be elderly, there may be many comorbidities to watch."
But while you want to consider those factors, Dr. Grant emphasized that speed is still of the essence. "Hip fractures should be repaired within 48 hours to maximize the medical benefit to the patient," he said. He cautioned that medical consultants arenít serving their patients well if they delay surgery in the name of more risk stratification or excessive medical optimization before surgery.
"When I was in training, the guidelines said to get these patients to surgery in 48 to 72 hours," explained Michael Huo, MD, an orthopedic surgeon at the University of Texas Southwestern Medical Center at Dallas, who spoke at a session on managing hip fracture patients. "That gave us time to get the patient optimized and stabilized. But the studies now show decreased mortality when patients are taken to the OR within 48 hours."
Dr. Huo noted that research has also shown that taking patients to surgery even earlier not only reduces pain scores and the incidence of pressure ulcers, but lowers length of stay and overall costs.
"The orthopedic surgeons are fully aware that this is not elective surgery," Dr. Huo said. "It should not be delayed to fit into their lifestyle or the anesthesiologistís lifestyle."
Amir K. Jaffer, MD, chief of the division of hospital medicine at the University of Miami Miller School of Medicine, who spoke at the same session as Dr. Huo, urged hospitalists to act with that same sense of urgency.
"If you are called as a hospitalist to see hip fracture patients at 5 p.m. on Friday," he explained, "itís important to see them now rather than leave them for a few hours or let the patient be seen by the team coming on in two hours. You can end up creating delays."
Several speakers noted that there is no reason to stress test most hip surgery patients before sending them to the OR. Dr. Grant said that because of the urgency of the situation, you wonít have time to do anything with the results. "That patient will not be going to the cath lab before his hip repair," he said.
Dr. Grant did say that he might order a stress test if further risk stratification might help him decide whether the patient is a candidate for surgery at all. "This might be the patient with a high degree of dementia who wasnít ambulating prior to the fracture and isnít in pain," he said. "The decision to forgo surgery may be appropriate." He noted that this applies to a very small number of hip fracture patients.
Dr. Jaffer pointed out that hip fracture patients are also not good candidates for initiating perioperative beta-blockers. While the current recommendation is to start patients on beta-blockers a week before surgery, there is simply no time to do so with hip surgery patients. If the patient is already taking a beta-blocker, however, the consensus is to continue that therapy.
Dr. Jaffer also noted that the limited preoperative time youíll have with hip surgery patients is best spent on a good history and physical. "Take the extra five or 10 minutes to communicate" with the surgeon and anesthesiologist, Dr. Jaffer added, but donít tell them how to do their jobs.
"Itís not our job to make any recommendations about anesthesia," Dr. Jaffer explained. "And do not Ďclearí patients for surgery."
In terms of strategies to optimize patients in the little time that is available, Dr. Grant suggested targeting the following issues:
hematologic issues and coagulopathies;
electrolyte disturbances; and
Without prophylaxis, Dr. Grant said, hip fracture patients make up the third highest risk group to suffer a venous thromboembolism. (Spinal cord and trauma patients top that list.) Risk starts at the time of the fracture, not at the time of the surgery.
Thatís why Dr. Grant urged physicians to avoid any delays in beginning VTE prophylaxis. Studies have found that 55% to 62% of patients who come to the hospital more than 48 hours after their fracture occurred have a DVT preoperatively. And when hip fracture patients receive no prophylaxis at all, Dr. Jaffer pointed out, up to 11% go on to have a pulmonary embolism.
Evidence also shows that chemical prophylaxis needs to continue after discharge, and that longer is better. The most recent guidelines from the American College of Chest Physicians (ACCP) on antithrombotic therapy strongly recommend that VTE prophylaxis continue beyond 10 days and up to 35 days following discharge after a hip fracture. The guidelines also call for fondaparinux, but note that low molecular weight heparin or warfarin is acceptable. The guidelines do not recommend aspirin.
While extended prophylaxis does result in more bleeding, Dr. Grant said that studies have found no additional "clinically relevant bleeding," which researchers defined as bleeding that leads to death, re-operation or damage to critical organs.
Delirium is the most common complication of hospitalization for hip fracture patients, said Dr. Jaffer. The incidence ranges from 10% to 60%, and delirium most often occurs between postop days two and five.
According to Dr. Jaffer, the precipitating factors are usually a combination of many things, including the following:
patient characteristics such as age, comorbidities, low BMI and dependence in daily activities;
polypharmacy, particularly when the patient is taking more than six medications, more than three of which have been started in the hospital;
long preop waiting time;
fasting for more than 12 hours or dehydration;
medications like opiods, anticholinergics, benzodiazepines, cardiac drugs like digoxin and drugs that affect the central nervous system.
There are a number of recommendations aimed at preventing delirium after hip fracture surgery. Strategies range from making sure patients have adequate oxygen, fluids and nutrition and optimal pain management to balancing electrolytes and ensuring appropriate environmental stimuli. But Dr. Grant said that one study found that the most effective strategy is to order a geriatric consultation after hip fracture surgery.
Another study found some benefit to giving low-dose haloperidol (1.5 mg/day) preoperatively and continuing the therapy for three days following hip surgery. While a study of low-dose haloperidol didnít show any effect on the incidence of delirium, it did find that patients taking the drug had reduced delirium severity and duration.
Preventing future fractures
Not only does a hip fracture increase the odds that a patient will die in the next year, it also greatly increases the chance of a second fracture, according to Silvina Levis, MD, a professor of clinical medicine, endocrinologist and osteoporosis expert at the University of Miami, who also spoke at the session on managing hip fracture patients. About 45% of women with a hip fracture will sustain at least one subsequent fracture, Dr. Levis said.
"We can do something about this," she said, noting that calcium, vitamin D and bisphosphonates have been shown to significantly reduce the chance of a second fracture. But Dr. Levis added that those therapies are greatly underused. According to an April 2010 study in the Journal of the American Geriatrics Society, only 2% of hip fracture patients received the therapies.
Physicians are often wary about giving hip fracture patients bisphosphonates following surgery because of concerns that the drugs will impede healing. But Dr. Levis noted that a recent study concluded that giving 5 mg of intravenous zoledronic acid had "no clinically evident effect on fracture healing, even when the drug is infused in the immediate postoperative period."
In addition to trying to prevent a second fracture, Dr. Levis urged hospitalists to do a better job identifying inpatients with other medical conditions who are at greater risk of having a first hip fracture after discharge. Those include patients on chronic corticosteroids and those on hormonal treatment for breast or prostate cancer. One strategy is to make sure these patients are given osteoporosis treatment at discharge.
Deborah Gesensway is a freelance writer covering U.S. health care from Toronto.