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as rheumatoid arthritis, or who are taking a medication associated with low bone mass or bone loss, such as glucocorticoids >5mg/day for >3 months 114 Osteoporosis, the Silent Disease in the inception and development of the program. Stacey Youcis, who at that time was vice president of operations, participated, encouraged, and provided LGH institutional support. Richard W. Reese M.D., medical director of the LGH Orthopedic Center and senior rheumatologist at LGH Physicians Arthritis and Rheumatology Specialists, has been involved with the GFP from the outset. As a local champion of osteoporosis awareness, he continues to help the GFP focus on primary and secondary fracture prevention. This initial team of dedicated individuals found many complex challenges that were impeding optimal care of these fragile patients. To identify and work through these challenges, the team meticulously inspected the path of hip fracture patients from their entry into the Emergency Department to their eventual discharge from the hospital. The team then developed order sets and treatment protocols that improved efficiency at every stage. Not surprisingly, though their primary goal was improved care of these patients, it became rapidly apparent that there were secondary benefits in decreased length of stay and cost of care. THE GERIATRIC FRACTURE PROGRAM Initial Evaluation A patient with a hip fracture usually has a characteristic physical appearance, with a shortened and externally rotated leg.11 Given the reliability of the initial physical exam by an experienced emergency medicine physician, timely treatment of a hip fracture begins at that moment, even prior to any confirmatory imaging. To eliminate any step-wise delay, an emergency department set of orders for all appropriate imaging and laboratory studies, pain management, and consultations was developed. The vast majority of these patients are admitted to the orthopedic service with an internal medicine consultation prior to surgery. The orthopedic and internal medicine physicians agreed to expedite their evaluations with the goal of reducing the amount of time a hip fracture patient remains in the Emergency Department. Anticoagulant Reversal Many of the patients with hip fractures are chronically anticoagulated. The various anticoagulants used require different “reversal” regimens, and can delay surgery. Though warfarin, the most common long-term anticoagulant, can be safely and effectively reversed with oral or intravenous vitamin K,12 one early finding of the GFP was that physicians were slow or reluctant to order this medication. As a result, a conditional order for the prompt administration of vitamin K based on the initial PT/INR results was built into the orthopedic admission order set. This routine avoided the need for blood coagulation products or waiting for the passive normalization of the coagulation profile. Timing and Surgical Delay Improved communication between the inpatient charge nurse and the orthopedic operating room coordinator facilitated the physical transport of the patients to the operating room suite and helped clarify any pending or completed preoperative workup. Indeed, sometimes the patient would go directly from the Emergency Department to the preoperative holding area. Whereas only 54% of hip fracture patients had their surgery within 24 hours of presentation to the ED in 2009, that number had risen to 73% by 2014. Due to improvements in both preoperative and postoperative patient management, the average length of stay for a hip fracture patient at LGH decreased by 36%: from 6.7 days in 2009 to 4.3 days in 2014. Preoperative Echocardiograms The GFP found a strong association between the ordering of a preoperative echocardiogram and a delay in surgery of as much as 66 hours. With emerging literature supporting the need to perform hip fracture surgery as soon as medically reasonable, a dedicated collaborative team from cardiology, anesthesia, medicine and orthopedics developed a stringent algorithm to decide exactly which patients must have a preoperative echocardiogram.13 Implementing this algorithm brought the use of preoperative echocardiograms down from 19% in 2009 to 9% in 2012 without an increase in complications, including in-hospital mortality. Blood Transfusions Blood transfusions have been shown to increase the risk of perioperative infections, length of stay, and overall cost of care. Multiple studies of different transfusion protocols have shown that stricter criteria for transfusion do not increase complications.14,15 A restrictive transfusion protocol (hemoglobin 7 gm/dL absolute threshold; 8 gm/dL for those with unstable angina, myocardial infarction, or cardiogenic shock) was adopted based on recommendations by the American Academy of Orthopedic Surgeons Clinical Practice Guidelines.16 Transfusion rates at LGH in hip fracture patients subsequently dropped from 55% in The Journal of Lancaster General Hospital • Winter 2016 • Vol. 11 – No. 4 114 115 2010 to 25% in 2016 without a rise in readmissions for anemia. Nursing Unit and Delirium A major logistical tactic was to consolidate all patients with hip fractures in one nursing unit (4 North). The nursing staff became dedicated to the nuances of this fragile population, particularly with regard to recognizing the
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