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subtle but important impact that delirium can have on a hip fracture patient. Delirium, defined as temporary confusion and disorientation distinct from dementia, has a reported incidence in hip fracture patients of 35-65% nationally. It can lead to an additional seven days of hospitalization and a proportionate increase in cost.17 The Confusion Assessment Method is a verified delirium assessment tool that was adopted to screen for delirium, along with the development of standardized order sets for treatment to shorten the duration of delirium.18 The real work in this arena is in the prevention of delirium, and the nursing staff is increasingly engaging family members to help recognize the warning signs and to prevent or detect delirium early. The rate of delirium in LGH hip fracture patients has dropped from 21% in 2011 to 9.7% in 2016. The nursing staff from 4 North has been teaching other nursing units about the impact, prevention, detection, and treatment of delirium. Pain Management Pain management is a unique challenge in the hip fracture patient for several reasons: a) a hip fracture is sudden so neither the patient nor the family has any chance to prepare; b) schedules and plans are immediately disrupted; c) the patient may feel that s/he is now even more of a burden on family and loved ones, which compounds the patient’s own physical and psychological suffering. Elderly patients often under report pain, whether from a true increase in pain threshold, cognitive impairment, or the feeling of personal burden. Uncontrolled pain can in turn lead to delirium, increased length of stay, and unwillingness to participate in therapy. On the other hand, elderly patients often have increased cerebral sensitivity to narcotics, which can in turn induce delirium. Notwithstanding its cost, intravenous acetaminophen can reduce length of stay, pain scores, and narcotic usage, and can increase participation in therapy, all of which increase rates of discharge to home.19,20 Scheduled IV acetaminophen was therefore introduced into preoperative and postoperative order sets and the ordering of narcotics was highly discouraged unless pain levels required it. The reporting of pain management has been a challenge to document, with the current methodology showing approximately 50-60% effectiveness in meeting the patient’s expected level of manageable pain. Physical Therapy Participation in therapy is a key element in postoperative management of hip fractures. The immediate benefits of mobilization out of bed are a reduction in atelectasis (which can lead to pneumonia), decreased risk of skin compromise from pressure necrosis, and simplification of personal care. Weight-bearing status can have a profound effect on overall mobilization, since most hip fracture patients are unable to accomplish limited weight bearing. While the characteristics of their fracture and subsequent treatment are unique to each patient, the goal after surgery is to achieve weight bearing as tolerated. The long-term focus of postoperative therapy is on gait, balance, and strengthening – with intention of preventing future falls.11,20 In the last few years, 80% of the LGH hip fracture patients have been getting out of bed the day after surgery. To encourage early mobilization, a recent initiative has been to have them sitting on the side of their bed the evening of surgery. Nutrition The nutritional status of many hip fracture patients is less than ideal, which may have itself contributed to the level of osteoporosis or even to the event that precipitated the fracture. Cognitive impairment, poor dentition, lack of appetite, delirium and dementia can all have a negative impact on postoperative nutrition. Adequate caloric intake and proper blood glucose control are imperative for good wound healing, which is inversely correlated with postoperative wound infection.11,20 Nutritionists and nurses together have spearheaded an initiative through the GFP called PRONS – Promoting Recovery through Oral Nutritional Supplements. Through creative techniques, oral supplements have become standard both in the diet and with medication, sometimes representing the majority of caloric intake. The success of this program has been presented at a recent national nursing convention, and is also now being implemented throughout LGH. The Journal of Lancaster General Hospital • Winter 2016 • Vol. 11 – No. 4 Osteoporosis, the Silent Disease 116 The Journal of Lancaster General Hospital • Winter 2016 • Vol. 11 – No. 4 Post-acute Care and Prevention Discharge destinations of LGH hip fracture patients has varied somewhat over the last few years, with 70% currently going to Skilled Nursing Facilities (SNFs), 23% to inpatient rehab, and 6% to independent living. Recently the LGH GFP has been part of a collaborative initiative to improve the care of hip fracture patients after they are discharged from the hospital. LGH has partnered with 10 area SNFs to develop a Hip Fracture Clinical Plan including a standardized approach for wound management, physician follow-up visits, medication management, nutrition, therapy, and pain control. One goal is to reduce the length of stay at the SNF in an effort to reduce the overall cost of post-acute care. Recent reports show that only 27% of hip fracture costs are associated with the acute inpatient hospitalization, while the remainder comes from
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