Zeitschrift für Gerontologie und Geriatrie

, Volume 44, Issue 6, pp 363–367

The Tyrolean Geriatric Fracture Center

An orthogeriatric co-management model

Authors

    • Department of Trauma Surgery and SportsmedicineMedical University of Innsbruck
  • M. Gosch
    • Department of Internal Medicine and Acute GeriatricsHochzirl State Hospital, Anna Dengel-Haus
  • M. Blauth
    • Department of Trauma Surgery and SportsmedicineMedical University of Innsbruck
  • M. Lechleitner
    • Department of Internal Medicine and Acute GeriatricsHochzirl State Hospital, Anna Dengel-Haus
  • T.J. Luger
    • Department of Anesthesiology and Critical Care MedicineInnsbruck Medical University
  • T. Roth
    • Department of Trauma Surgery and SportsmedicineMedical University of Innsbruck
Beiträge zum Themenschwerpunkt

DOI: 10.1007/s00391-011-0253-7

Cite this article as:
Kammerlander, C., Gosch, M., Blauth, M. et al. Z Gerontol Geriat (2011) 44: 363. doi:10.1007/s00391-011-0253-7

Abstract

Background

The aging population is growing rapidly and this change results in an increase in the number of fragility fracture patients. Several reports describe their poor outcome. Integrated models of care have been published in order to improve quality of patient care. We established an orthogeriatric model of care at the Department of Trauma Surgery in Innsbruck in cooperation with the Department of Geriatric Medicine (Hochzirl) and the Department for Anesthesiology. This report describes our concept as well as initial experience.

Patients and methods

We included all geriatric patients according to the definition of the German Geriatric Society. In all patients, basic demographic data, Charlson Comorbidity Index, and type of fracture were recorded. Main principles of the newly implemented system are the integration of a geriatrician in our team of trauma surgeons and anesthesiologists, prioritization of patients, development of our own clinical treatment guidelines, regular interdisciplinary and interprofessional meetings, a special outpatient clinic for these patients, and the better cooperation with the nearby Department of Geriatric Medicine.

Results

A total of 529 patients met our inclusion criteria during 2010; 77.4% were female and the mean age was 84.1 years. The overall medical complication rate was 20.4%. Of the patients, 36.1% had hip fractures and 70.5% could be operated mainly using spinal anesthesia within 24 h and their mean length of stay was significantly shorter than operations performed 5 years previously. At 3 months, 86.7% of the patients had returned home and, thus, had reached their prefracture residency.

Conclusion

A coordinated, multidisciplinary model for the treatment of fragility fractures has the potential to improve the quality of patient care. Several international studies report superior outcome and our own findings are promising as well. We could show that our major goals, e.g., reduction of complications, shortening the length of stay, and restoration of the prefracture residency, can be improved by implementing such a model.

Keywords

Hip fractureInterdisciplinary healthcare teamTreatment outcomeIndependent livingInhospital mortality

Das Tiroler Zentrum für Altersfrakturen

Ein alterstraumatologisches multidisziplinäres Modell

Zusammenfassung

Hintergrund

Der demographische Wandel mit zunehmender Überalterung der Bevölkerung führt auch zu einer deutlichen Zunahme an Patienten mit Fragilitätsfrakturen. Einige Studien zeigten das schlechte Outcome nach solchen Frakturen. In den letzten Jahren haben daher Modelle zur interdisziplinären Primärbehandlung dieser Patienten zugenommen und auch bereits deutliche Verbesserungen im Outcome dieser Patienten erbracht. An der Universitätsklinik für Unfallchirurgie wurde im April 2009 ein „Tiroler Zentrum für Altersfrakturen“ in Zusammenarbeit mit der Akutgeriatrie des Krankenhauses in Hochzirl und der Universitätsklinik für Anästhesie gegründet. Diese Arbeit stellt unser Konzept und erste Ergebnisse vor.

Patienten und Methoden

Alle geriatrische Patienten mit einer Fraktur wurden eingeschlossen. Neben demographischen Daten wurden auch die Nebenerkrankungen und Daten zur Fraktur erhoben. Die Grundprinzipien sind die Integration eines Geriaters in unser unfallchirurgisches Team, die Priorisierung der geriatrischen Patienten, die Entwicklung eigener Guidelines, regelmässige Meetings, eine spezielle Altersfrakturambulanz und ein besseres Nahtstellenmanagement.

Ergebnisse

In die Studie wurden alle geriatrische Patienten mit einer Fraktur eingeschlossen. Neben demographischen Daten wurden auch die Nebenerkrankungen und Daten zur Fraktur erhoben. Die Grundprinzipien des Modells sind die Integration eines Geriaters in unser unfallchirurgisches Team, die Priorisierung der geriatrischen Patienten, die Entwicklung eigener Guidelines, regelmäßige Meetings, eine spezielle Altersfrakturambulanz und ein besseres Nahtstellenmanagement.

Schlussfolgerung

Ein koordiniertes, multidisziplinäres Modell zur Behandlung von Patienten mit Fragilitätsfrakturen verbessert deren Behandlungsqualität. Zahlreiche internationale Studien und eigene Daten belegen dies. Die Hauptvorteile sind eine signifikante Reduktion von internistischen Komplikationen und stationärer Aufenthaltsdauer sowie die bessere Wiederherstellung der Funktion, sodass ein großer Teil der Patienten wieder nach Hause entlassen werden kann.

Schlüsselwörter

HüftfrakturInterdisziplinäre VersorgungBehandlungsergebnisUnabhängiges WohnenKrankenhausmortalität

The aging population is growing rapidly. In the Tyrol, the portion of people aged 65 and older is expected to double within the next 20 years and will then represent 24.2% of the entire population [1]. At our department, this development has already begun: within the last few years there has been an increase of 63% for our inhospital patients aged 65 and older and an increase of 54% for operations within the same age group [9]. This increase regards not only trauma patients—all inpatients aged 70 and above are expected to double within the next 5 years [2].

As a result of demographic changes, an increase in the number of patients with geriatric fractures and, consequently, increasing health care costs are expected [12, 16]. Geriatric fracture patients are predisposed by cardiovascular diseases, neurological disorders, amblyopia, and multiple other indispositions for a fall, which is at high risk to lead to a fracture even if it is from standing height. Roche found at least one relevant comorbid condition in 35% of hip fracture patients aged 65 years and older, whereas 17% had two and 7% three or more comorbidities with cardiovascular diseases (24%), apoplectic stroke (13%), and pulmonary diseases (14%) being most common [17]. A multitude of studies showed that these comorbidities lead to higher perioperative complication rates and poor outcome [7, 10, 11].

Furthermore, there are frequent reports on treatment deficits in this group of patients. The main problems are regarding perioperative time management, pain treatment, avoidance of medical complications, and secondary fracture prevention [15, 17, 19].

The British Orthopedic Association published a Blue Book on comanaged geriatric fracture care in 2003 which points out the importance of this topic [3]. The first Geriatric Fracture Center was begun in Rochester, NY, in 2004 where an improvement of patient care and outcome could be shown [7, 8].

The critical analysis of the situation in our hospital and the previously published reports led us to initiate the Tyrolean Geriatric Fracture Center.

Patients and methods

The center was opened 1 April 2009. All fragility fracture patients aged above 70 with more than two relevant comorbidities and all patients above the age of 80 were included as this is the definition of a geriatric patient according the German Geriatric Society. From all of these patients, basic demographic data, the Charlson Comorbidity Index (CCI) [4] and the type of fracture as a quality assurance were recorded. Data were collected by one of our study nurses in cooperation with our specialists.

The following key issues are the cornerstones of the Tyrolean Geriatric Fracture Center:

1. Integration of a geriatrician in the team of trauma surgeons

A geriatrician is integrated within the trauma team on a full time basis. The exclusive charge is care of the geriatric fracture patients, whereas this is performed in a “co-ownership”-type manner together with the trauma surgeon. The geriatrician takes part in the daily conferences. A shared round is performed weekly. The first patient contact is in the emergency department and from this time the geriatrician sees the patient daily, which ensures the treatment consistency.Besides the geriatrician, anesthesiologists, nurses, physiotherapists, social workers, and study nurses are also part of the multiprofessional team.

2. Prioritization of the patient

The geriatric fracture patients are chronologically favored regarding their operative treatment. This starts in the emergency department, where the postoperative intensive care unit is informed about the patient to allocate capacities. All patients with rehabilitation potential are transferred as soon as possible to the acute geriatric department postoperatively.

3. Guidelines

Guidelines were developed interdisciplinary and interprofessionally for the following issues: organizational course, preoperative assessment, timing of operation, antibiotic treatment, antithromoembolic treatment, workflow in case of preexisting anticoagulation therapy, pain therapy, prevention and treatment of delirium, bone therapy, and nutrition management. All issues were codeveloped and extensively discussed by our professionals. The guidelines are available through our intranet.

4. Meetings

Interdisciplinary and interprofessional meetings are held twice weekly discussing cases, workflows, and other actual themes.

5. Outpatient clinic

All hip fracture patients are seen in the outpatient clinic at 3 months, 6 months, and 1 year after fracture. In addition to trauma aftercare, the bone therapy and other urgent issues are checked and the geriatrician is involved upon request, if the functional status of the patient shows a relevant decline.

6. Acute geriatric ward

All patients with a potential for rehabilitation are discharged to the nearby acute geriatric ward. The geriatric assessment is performed there and the individual therapy of comorbidities is started. Furthermore, other relevant points as polypharmacy, nutritional status, and falls prevention are addressed.

Results

A total of 529 patients (77.4% women, the mean age 84.1 years) met the inclusion criteria during 2010. The geriatrician saw 17 patients daily, which resulted in a total of 4,288 patient contacts. The time frame for the patient contact varied dramatically, e.g., new admissions take up to 2 h. The mean time for a postoperative ward round on the trauma ward is about 15 min/patient.

We used the Charlson Comorbidity Index (CCI) for quantification of the multimorbid conditions, which allows estimation of the 1-year mortality. The mean CCI was 2.5 and selected comorbidities are shown in Fig. 1. The overall medical complication rate was 20.4%, whereby 18.4% suffered from a urinary tract infection (Fig. 2). Thus, 61.7% of our patients had no complications, while 10.1% suffered from two medical complications.

https://static-content.springer.com/image/art%3A10.1007%2Fs00391-011-0253-7/MediaObjects/391_2011_253_Fig1_HTML.gif
Fig. 1

Selected comorbidities (%)

https://static-content.springer.com/image/art%3A10.1007%2Fs00391-011-0253-7/MediaObjects/391_2011_253_Fig2_HTML.gif
Fig. 2

Complications (%). PE pulmonary embolism

Of our patients, 36.9% sustained a hip fracture, 11.9% a vertebral fracture, 10% rib fractures, 10.6% a pelvic ring fracture, and 9.8% a proximal humerus fracture. Spinal anesthesia was used during the operation in 56.8% of the patients; hip fracture surgery was most common (62.1%) operation as illustrated in Fig. 3. The mean length of stay was 10.9 days, whereas patients with vertebral fractures and patients with a lower Barthel Index (BI) had a significant longer hospital stay (p < 0.01).

https://static-content.springer.com/image/art%3A10.1007%2Fs00391-011-0253-7/MediaObjects/391_2011_253_Fig3_HTML.gif
Fig. 3

Operations (%)

Of the patients, 36.3% were discharged to the acute geriatric department, 31.6% went directly home, and 20.7% were transferred to the nursing care home. The inhospital mortality rate was 1.4%. If the mortality rate is examined in more detail, it was determined that most of these patients came from home and had a low BI but tried to manage their life without further help.

As pointed out, the hip fractures were most common. For these patients, the median time to surgery was 18 h (mean 24 h), whereas 70.5% could be operated on within 24 h. The mean length of stay was 11.3 days; the inhospital mortality rate was 3.1%. Data indicated that 24% had any medical complication and 1% needed reoperation. After operation, 50.5% were transferred to the acute geriatric unit, 23% to a nursing care home, and 12.3% were discharged home directly. From the acute geriatric ward, 66.4% of the patients were transferred back home and 21.2% to the nursing home. At 3 months, 86.7% of patients had returned home (Tab. 1).

Tab. 1

Shows the prefracture residency and the 3 month residency for the subpopulation of hip fracture patients

Residency at 3 months

At home

Nursing care home

Other/dead

Residency before admission

At home (%)

86.7

4.5

8.8

Nursing home (%)

0

95.7

4.3

Discussion

The overall goal of our Tyrolean Geriatric Fracture Center is to improve the quality of care of our fragility fracture patients in order to restore their prefracture functional level. A number of different systems are described in the literature reporting lower complication rates and better outcome values for these patients [7, 8, 11]. Each of these reports describes slight differences which makes clear that a co-management system has to be developed individually at each site according to the preexisting conditions and possibilities.

The mean age of 84.1 years and the comorbid conditions with a mean CCI of 2.5 indicates the typical geriatric fracture population [5]. Our medical complication rate of 20.4% for the whole population is low compared to the literature, where a mean rate of 53.2% was calculated for usual care models and 35.1% for integrated care models [11]. In this context, it has to be mentioned that the included complications in the different studies vary widely, and furthermore a clear definition for these is lacking [11, 14]. The high rate of urinary tract infections in our population is probably associated with a prolonged use of catheters until the patient is mobilized postoperatively [8, 18].

The distribution of fractures in our population is quite interesting, whereby hip fractures account for 36.9%, pelvic ring fractures for 10.5%, and proximal humerus fractures for 9.8%. In a British population, hip fractures account for 43.2%, pelvic ring fractures for 5%, and proximal humerus fractures for 10.9% of all admitted fragility fracture patients [5]. This means that the overall rate of fractures around the pelvis and proximal femur is comparable, but hip fractures are more common in the British population. Interestingly, 4% of hip fractures were treated conservatively in Clemet’s population, whereas in our center all hip fractures receive operative treatment. This is necessary in order to mobilize the patient as quickly as possible to avoid bed rest-related complications.

The length of stay for our entire population was 10.9 days and 11.3 days for the subpopulation of hip fractures. Compared to 2005 and 2006 where we had a rate of 12.6 days, this is a significant reduction [10]. Explanations are the better interface with the nearby acute geriatric hospital where our patients are prioritized and the improved communication within the multidisciplinary team.

The inhospital mortality rates of our center are 1.4% for the entire population and 3.1% for the subpopulation of hip fractures. Clement et al. [5] published much higher values for their entire study population. For the subpopulation of hip fractures, there are rates of up to 8% [6] and weighted means of up to 10% [11] reported for usual care models. Nevertheless, for integrated care models much lower rates are reported from Friedman et al. (1.5% [8]) and Vidán et al. (0.6% [20]). A possible cause for our rate is our management of palliative patients. Interdisciplinary conferences together with relatives and nurses take place if a patient is terminally ill. Due to our policy, we discuss the patient’s case and in some cases decide to keep the patient in our ward in order to ensure a high quality of life until death. This approach increases our inhospital mortality rates but improves the quality of patient care.

In our patient population, 86.7% of our hip fracture patients could return to their prefracture residency within 3 months. Naglie et al. [13] reported a change in residency of 23.7% after hip fracture at 3 months in an integrated care model. Other authors reported that only 69.8% of all fragility fracture patients reached their prefracture residency within the same time span [5]. These reports compared to our findings support the superiority of our integrated care model.

Conclusion

A coordinated, multidisciplinary model for the treatment of fragility fractures has the potential to improve the quality of patient care. Several international studies report superior outcome and our own findings are also promising. We could show that the major goals, i.e., reduction of complications, shortening the length of stay, and restoration of the prefracture residency, can be improved by implementing such a model.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

Funding

The Tyrolean Geriatric Fracture Center receives funding from the Tyrolean Government through the “Tiroler Gesundheitsförderungsfonds.”

Copyright information

© Springer-Verlag 2011