Yale New Haven Hospital program changes the game for hip fracture patients

April 06--NEW HAVEN -- Elderly patients who fall and break their fragile hips traditionally have had to wait until a surgeon is available, lying on a stretcher with their pain numbed by opioid medication.

Now, however, at Yale New Haven Hospital'sCenter for Musculoskeletal Care, they are cared for more quickly, with less pain and better follow-up once they leave the hospital.

The center at Yale New Haven's St. Raphael Campus is a unit dedicated to those frail patients who otherwise would have had to fit into surgeons' already full schedules.

Rather than hip fracture patients, whose accidental falls cause them to come to the emergency department without warning, forcing them to wait until other scheduled surgeries are completed, "We've reversed that. We look at these patients as patients who need priority surgical care," said Dr. Mary O'Connor, director of the center since its opening in February 2016.

"I call it a vulnerable population," O'Connor said. "There has been a lack of focus on caring for our elderly in a coordinated, targeted manner."

Before the newly renovated center opened, patients would be brought to either St. Raphael or Yale New Haven's York Street campus. Now, "the ambulance crews know to bring patients that they know have a hip fracture to the St. Raphael's emergency room," O'Connor said.

"It made sense for us to concentrate those patients on one campus and allow us to align resources to drive improvement in the quality of care," O'Connor said.

At the St. Raphael campus on Chapel Street, "We have an operating room that we hold in the afternoon as dedicated time for hip fracture patients, and we do that on this campus so we can make sure that those patients have timely surgical care," O'Connor said. "We don't want to be holding time on two campuses in two ORs."

Scheduling dedicated operating room time means that patients -- who more often than not are brought to the hospital at night -- usually wait no more than 24 hours for surgery. According to O'Connor's statistics, only 41.1 percent of hip fracture patients were operated on within 24 hours in 2015. While complete data for 2016 were not available, O'Connor said, "With the advent of the program we have progressively improved that number," above 80 percent in most months.

In January, 97.8 percent of patients were operated on within 24 hours, although O'Connor said that level may be unusually high. "My target is 95 [percent]," she said. "I'll be very happy at 95. ... If we're in the 90-plus percent I'll claim victory."

Getting patients into the operating room quickly is vital. "We know if patients sit in the hospital with a hip fracture for three or four days, the likelihood of them developing a serious complication and dying is higher," O'Connor said.

Dedicating operating room time also has meant putting surgeons on call if there is a procedure that needs to be done. That means a trade-off in that patients may be operated on by a surgeon they or their primary doctors don't know. Cooperation from those doctors "was very important when we started the program," O'Connor said.

"In the old days, you, the primary care doctor, would say, 'I want my orthopedic surgeon.' We said we need to get the patients to the operating room in a timely manner. What we want is your support for the patient to get surgical care from the surgeon on call."

O'Connor said the compromise is worthwhile. "In the old way, our hip fracture patients were considered add-on [surgeries]" and the patients would face waiting until the end of the day "or maybe even a whole other day of delay because there wasn't time on the surgical schedule to fit them in," she said.

The surgeries are divided equally between doctors affiliated with the Yale School of Medicine and independent surgeons. "We've had excellent support from both our community orthopedic surgeons and the Yale faculty surgeons," O'Connor said. "We have a call schedule and people sign up for it ... and they know they have to block off that afternoon."

The staff at the center has also changed the way it relieves patients' pain. Instead of potentially addictive opioid drugs, patients are given an injectable nerve block. "The patients will get a shot of numbing medication in the front of their hip to deaden the nerve and it decreases the pain before surgery," O'Connor said. "We're giving the patient less narcotic because of the nerve block, so we're not getting them all confused."

The nerve-blocking procedure is done by anesthesiologists. "It decreases the pain the patient is having, minimizing the need for the nurse to give that patient [intravenous] narcotics or oral narcotics," O'Connor said. Besides being addictive, opioids can cause confusion and decrease the ability to breathe deeply, which can lead to pneumonia and other life-threatening respiratory issues.

Once a patient is admitted to the center, a hospitalist addresses any other medical issues that might delay surgery, such as fluid in a lung.

"All these things that we've done has allowed us to drive the quality outcome data," O'Connor said.

Those numbers, comparing 2015 with February to December 2016, include improvements in the rate of return to the operating room, from 5 percent to 0.7 percent; in adverse reaction to drugs, from 4 percent to zero; and in rates of pulmonary embolism or deep vein thrombosis (which usually occurs in the leg), from 2.3 percent to 0.9 percent.

Other statistics include a drop in the length of stay in the hospital from 5.1 days to 4.5 days, a readmission rate within 30 days declining from 12.2 percent to 10.8 percent and lower mortality within 30 days, dropping from 6.6 percent to 5.8 percent. Many patients are discharged to their home. Others may go to a skilled-nursing facility, "but that's still a step closer to recovery," O'Connor said.

The number of patients has risen, from 303 in 2015 to 433 in the last 11 months of 2016. "Our overall volume has increased, so we're seeing more patients transferred here from neighboring hospitals," O'Connor said.

John Tarutis, executive director of physical medicine and rehabilitation services for Yale New Haven, said, "I think the program itself is very timely because ... the aging population in our area is going to increase."

Lorraine Novella, a registered nurse and the patient service manager, said the center has vastly improved patients' experiences. "Before we implemented this program, patients would have to wait on a hard stretcher downstairs ... on pain medications every three or four hours. We put the [nerve] block in and within minutes they're able to move, they're pain-free and we're able to continue with a little positioning to make them comfortable so they're not flat on their back.

"I've been in orthopedics now for 38 years and the changes and the strides that we've made over the years are just outstanding," Novella said. Patients who spent two weeks in the hospital in the 1970s now are on their feet the night after their surgery and usually are discharged within three days.

Donita Aruny, 66, of Guilford, broke her hip on a Sunday in January and was home by Tuesday.

"It was during the day and caught me totally by surprise," said Aruny, who is the program and marketing director for the Shoreline Arts Alliance. "It was kind of like one of those cartoon characters where you see somebody up in the air and crashed on the ground, and that was me."

"They did everything for me the right way at St. Rae's because I've had a rather successful recovery," Aruny said. Dr. Lee Rubin performed her hip replacement the next day and she was walking down the hall and up steps that afternoon, "which was kind of unbelievable to me at that time," she said. "It was pretty amazing. I can remember my mom having it and spending weeks in a rehab facility. ... I consider myself very fortunate."

She said she was able to walk upstairs to her bedroom the day she returned home.

O'Connor and Tarutis said the program at St. Raphael is a starting point, but that they are also concerned with how patients fare once they leave the hospital. "We need to have a more holistic approach to the care of these vulnerable, elderly patients," O'Connor said. "This is our community. So what we're working on now is ... focused on that continuum of care ... working with the primary care doctors to improve treatment for these patients in terms of their bone health."

The goal is to ensure that patients who have had surgery for a hip fracture are given medications and physical therapy to improve the strength of their bones so they don't return to the hospital with another broken hip. "We just hired what we call a fracture liaison nurse" to connect with the primary care doctor so the doctor "knows what happened to the patient here in the hospital and [can make] suggestions regarding treatments to improve bone health," O'Connor said.

The hospital is also planning to join the National Osteoporosis Foundation's hip fracture registry, in order to compare results with other hospitals nationwide.

"An advantage we have besides these best practices and improving outcomes is we have an inpatient acute-rehabilitation facility at Milford Hospital, a skilled-nursing facility [the Grimes Center] and also 16 outpatient rehabilitation sites in a large geographic area surrounding New Haven," Tarutis said.

"It's a village that brought this together," he said. "So many people, from the time a patient arrives at the doorstep to discharge, it's a multidisciplinary team effort."

O'Connor said when an elderly person breaks a hip it affects the entire family, who must decide on post-hospital care. "These are really difficult issues for patients and their families when you think about quality of life," she said.

Call Ed Stannard at 203-680-9382.

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