Geriatric hip fractures are a major cost driver for the nation’s healthcare system in general and for hospitals in particular.
The burdens hospitals experience from such events are exacerbated by frequent delays from the time patients present to the emergency department (ED) to the time they receive surgery and by potential postoperative complications. These delays, involving middle-aged to geriatric patients, may be a consequence of more frequent (or more comprehensive) evaluations of the diseases of aging, such as cancer, diabetes and cardiovascular disease. To address this challenge, hospitals should revisit care processes to identify inefficiencies and opportunities for process improvement.
Marshalling the precepts of an emerging area of specialized medicine, perioperative medicine, the perioperative surgical home (PSH) is a possible answer to this challenge. Hospitals and health systems are increasingly adopting this approach to enhance outcome measures in various surgical populations that have been shown to benefit from it, including geriatric patients who have suffered hip fractures. University Medical Center (UMC) of El Paso, in El Paso, Texas, is a case example. UMC’s experience with establishing a PSH provides insight into the potential benefits of such an evidence-based approach for improving care for geriatric hip fractures and into the strategy and tactics required to re-engineer perioperative processes. (see the sidebar, "Defining characteristics of PSHs," below.)
UMC launched the PSH as a pilot program called the El Paso Hospital Hip Fracture Pilot. It resulted in improved patient access and clinical outcomes while reducing perioperative costs for the hospital. Here we discuss the planning and implementation stages from the initiative as well as key results and takeaways.
UMC's 2015 baseline
UMC is both an American College of Surgeons (ACS) Level 1 Trauma Center and a safety-net hospital that delivers care to a high percentage of vulnerable Medicaid and uninsured people on the U.S.-Mexico border in West Texas. Before the pilot, the hospital suffered bottlenecks related to imperfect care coordination among the emergency and admitting departments, surgeons, primary care clinicians and anesthesia personnel, and to operating room (OR) availability. At baseline in 2015, prior to the pilot, the average time a patient with a hip fracture waited to have surgery was 47 hours, compared with the average International Geriatric Fracture Society (IGFS) goal of 36 hours. Patient flow was unstandardized, imperfectly coordinated, untimely and inefficient, leading to runaway increases in hospital costs.
PSH goals and objectives
Implementing precepts of evidence-based perioperative medicine, a team of academic orthopedic surgeons from Texas Tech University of Health Sciences, and private anesthesiologists/CRNAs collectively embarked on developing the PSH for a cohort of geriatric patients who had hip fractures. The effort was prompted by a PSH initiative advanced by the American Society of Anesthesiologists, a multidisciplinary collaborative involving a variety of organizations, including the American Academy of Orthopedic Surgeons (AAOS).a UMC’s executive team quickly stepped in to support the initiative, given the opportunity to optimize perioperative outcomes, reduce complications and improve healthcare delivery to the community. Indeed, the UMC COO attended a national PSH meeting to ensure the organization understood and could strongly support the perioperative care model.
To meet the imperatives of the PSH regarding improved patient health outcomes, experiences, access, and to coordinate care delivery models with lower episode-of-care costs, UMC re-engineered the perioperative care process for pilot patients. Process re-engineering led to institutional changes, outlined in the discussion below, to achieve three objectives:
- Streamlined/standardized protocols based on evidence-based perioperative medicine tenets
- Enhanced patient care outcomes (clinical and experiential) and access
- Conserved resources
These three objectives, which are based on the Institute for Healthcare Improvement Triple Aim principles, are organically interrelated. Results have shown that squeezing out inefficiency and waste and refocusing resources on targeted activities to optimize modifiable risk factors can improve patient outcomes, with fewer and less severe postoperative complications. Complications such as delirium, post-operative cognitive disfunction, acute renal disease, pulmonary disorders and surgical-site infections can be relatively inexpensive to preempt, but they are costly to treat. UMC recognized that achieving these aims would not only be beneficial in geriatric hip fracture repair but also and could markedly improve Medicare DRG performance.
Collaborating to build a standard process
One of the first actions of the PSH team was to engage with hospital executives to gain their support in prioritizing the project and in mobilizing health services to organize and participate in the project. Securing this backing paved the way for El Paso clinicians to more readily access essential data and attract willing participants from multiple departments. Key steps in the effort included the following.
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