Are hip fracture patients treated quickly enough?
Hip fractures are an all too common experience for elderly patients, affecting more than 300,000 seniors in this country each year. But, the outcome is often grim. One in five hip fracture patients die within a year of their injury, according to the Centers for Disease Control and Prevention (CDC). And a return to pre-injury quality of life is nearly impossible.
Orthopedic trauma surgeon Michael O’Boyle, MD, decided it doesn’t have to be that way. He pioneered a new approach while working at St. Francis Hospital in Greenville, SC, which has reduced nearly every risk associated with hip fractures, including mortality.
“We looked at the ways we were treating these cases, starting with the moment they came through our doors,” he said. “We discovered that we were really slow in getting people into the operating room, and that fact alone increased their morbidity and mortality. And then we were very slow in getting them out of the hospital and on to the next step, which was rehabilitation at a rehab facility.”
The new protocol put hip fractures on a faster track, which was the difference maker in outcomes.
Dr. O’Boyle is now bringing his program and his skills to the new Geriatric Fracture Center at Cape Cod Hospital in Hyannis this spring.
He pioneered the new fast-track approach because of the discouraging statistics around hip fractures.
“As one of the only on-call surgeons at St. Francis Hospital, I was doing hundreds of hip fracture cases each year. And it allowed me to take a focused look and say, ‘is this really the best that we can do?' We just can’t accept this,” he said.
“When I started in private practice 20 years ago, no one specialized in hip fractures. So there were no standards for care. It was left to the orthopedic surgeons on call to handle these cases. So, as a trauma guy, I started taking a lot of call. And suddenly I was doing up to 400 hip fracture cases per year.”
The volume gave him a unique window into understanding how to make things better. At that time, the average length of stay for hip fractures in the elderly was about eight and a half days. And the one-year mortality was about 40 percent, making it a sentinel event in an older person’s life.
Dr. O’Boyle convinced the heads of the hospital that rethinking how hip fracture cases were handled would be prudent, both ethically as well as financially. At that point, they were losing $1,000 per case.
“There was little interest in investing in something that lost money. I reminded them that the only demographic growing in this country is the elderly and, because of that, it behooves us to try to do better. Not just to improve the costs, but also the outcomes,” he said.
A New Approach
In 2006, Dr. O’Boyle created the Osteoporotic Fracture Program at St. Francis Hospital, which has become the premier fragility fracture program in the nation. He created a new set of standards, based on a careful study of how hip fractures in the elderly were being treated.
At the heart of the problem was the low expectation for improvement or survival, he said. Consequently, hip fractures were assigned a low priority and not treated as true emergencies. Long waits in the emergency department (ED) and for a surgical slot ensued as higher priority cases took precedent.
“It took an average of eight hours for patients to be moved out of the ED,” he said. “ And even then they could wait another few days for surgery.”
All the while, heavy narcotics were often given for pain relief, and long exposure to these powerful medications had a downside. “In 80 percent of these cases, post-operative delirium, or temporary dementia, would develop and could last for days. Not only was this traumatic for the patient, but it is also really hard for the patient’s family to witness,” said Dr. O’Boyle.
The most important factor in recovering from a hip fracture is starting rehabilitation therapy.
“What we found was, if someone is delirious, they can’t get out of bed. And if they can’t get out of bed, then they can’t participate in therapy,” he said. “It was a serious issue in the patient’s recovery and really impacted their chances of surviving.”
In a 2016 interview with the Wall Street Journal, Dr. O’Boyle explained that changing the outcomes started with a cultural shift that fast-tracked these patients through the system. And it involved everyone, starting with emergency first responders through discharge to rehabilitation.
Since inception of the program, the outcomes for geriatric hip fractures at St. Francis Hospital have improved dramatically:
- Average length of stay in the hospital has been reduced from 7.3 days to 3.7 days
- Average length of time between ER and surgery has been reduced from 69 to 17 hours
- Delirium rate is less than 10 percent, as compared to the national average of 80 percent
- 80 percent of patients return to independent living, as compared to a national average of 55 percent
- Mortality rate for one year post-op decreased from 40 percent to less than 18 percent
Dr. O’Boyle concedes that when they started the program, they did not know if they could actually change the mortality rate.
“We thought maybe that was just written in stone. We did think that we could achieve, for lack of a better term, a better experience for the patient and their family,” he said. But they were pleasantly surprised.
And as a result of the success of this program, other organizations are looking to improve their patients’ outcomes, including Cape Cod Healthcare. Dr. O’Boyle’s practice will be located at Cape Cod Hospital, where he will work closely with the Emergency Center teams.
Dr. O’Boyle is relocating from Greenville, bringing him closer to Long Island, where he was born and raised.
“Cape Cod is obviously a tourist destination, as well as a retirement community, with aging folks who are looking to be active. They are going there to enjoy their golden years. And I’m most excited about bringing this program to a place where this a lot of need,” he said.