Hip fracture patients recover from operations faster with enhanced care recovery program

The use of an Enhanced Recovery After Surgery (ERAS) approach for hip fracture operations allows patients to return home faster and get back to normal activities sooner, according to new findings presented today by researchers at the American College of Surgeons 2018 Quality and Safety Conference.

Upon reviewing a site report from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), researchers at Langley Memorial Hospital, Langley, B.C., Canada, discovered that patients who underwent hip fracture operations had higher morbidity and mortality rates and a higher prevalence of delirium than the national average. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals.

The research was led by Lila Gottenbos, RN, BScN, a Surgical Clinical Reviewer at the hospital. "We knew we could do better, because we had already successfully applied the principles of ERAS to our colorectal patient population." ERAS is a patient-focused approach that uses evidence-based practices to improve outcomes from surgery.

To address these challenges, a multidisciplinary team of nurses, surgeons, and clinicians adapted an enhanced recovery approach to meet the specific needs of their patients with hip fractures. For example, this population is at greater risk for delirium, a condition which often prolongs hospital stays and results in higher complication rates. Thus, an intervention was implemented to assess these patients for delirium preoperatively and on a regular basis for five days after their operations.

"With enhanced recovery, mobility is one of the foundational process measures, but with our intervention, we were even more aggressive with mobility, specifically making sure that our patients were getting up within 24 hours of surgery and to a chair to eat at least two meals within two days after surgery," said Ms. Gottenbos.

These practices were applied to every patient who had hip fracture operations from January 2016 to the present. The hospital averages 110 of these procedures per year.

Study findings showed that this new care approach cut nearly two days off the average hospital stay, without increasing the readmission rate. "We are not just sending people home and then seeing them return because we sent them home too early. They are going home and staying home to recover," said Ms. Gottenbos. "Eighty-five percent of our fractured hip patients are mobilizing within 24 hours of surgery and we are sending 60 percent of these patients home within 30 days of surgery."

Additionally, over a two-year span the mortality rate dropped by more than 50 percent—from 9.7 to 4.2 percent. The rate of pneumonia, a common complication in high risk patients after an operation, fell nearly 50 percent. Furthermore, the morbidity rate decreased by 33 percent.

Patients and families also received preoperative counseling about what they should expect as part of the operative and recovery experience. Study results also showed that patients were less likely to require a transfer to a nursing facility. "If you came to Langley Memorial before ERAS was implemented, you would return home from acute care about 20 percent of the time, and now we are discharging patients to their homes about 43 percent of the time, so that's a huge increase in getting patients back to their homes rather than sending them to convalescence care or residential care," said Ms.Gottenbos.

Overall, this new enhanced recovery approach has raised awareness about caring for a vulnerable adult population. "The processes we instituted for our fractured hip patients have had a huge positive ripple effect," said Ms. Gottenbos. "We have seen a great shift in the way staff think about patients, caring for them with a more holistic focus, and thinking about the path to discharge as soon as the patient walks in the front door. The focus is on getting patients home safely, quickly and in better condition than when they came to us."

Langley Memorial is now looking to expand this ERAS approach to other patient populations.

"It's very rewarding to see that these high-risk patients can be successfully treated and sent home earlier," said Ms. Gottenbos. "We are very confident that the work we are doing gives people a better chance to return to baseline functioning and get back to their normal lives."