Which Strategy to Europe? Hip Fractures Which Strategy to Europe? Paulo Felicíssimo

Topics 1- Introduction 2- Why is important? 3- Incidence 3- Challenges 4- Clinical Pathway 5- Discharge Program 6- Conclusions

Nota para conversão: _____ng/ml • 2.5 = ______nmol/L _____µg/dia • 40 = UI/dia

Hip Fractures

Why is Important? … de forma a padronizar a nossa actuação!

4ª feira – 20.1.2010

This is a picture of my department…I spend most of time is with these girls!!!

Hip Fractures World Prevision 1,6 Millions in 2000 2,6 Millions in 2025 it is supposed1,6 millions of fractures in 2000…..And it is expected 2,6 millions in 2025 , and probably 4,5 millions ! 4,5 Millions In 2050 Johnell O, Kanis JA, Osteoporos Int. 2006;17:1726-1733.

…and gonna be worse!!!! … de forma a padronizar a nossa actuação!

Growth of population

Growth of life expectancy

Population aging

Hip Fracture Challenges Medical Challenge Orthopedic Challenge Social / Familiar Challenge Economic Challenge Organizational Challenge Como em muitas outras áreas da Medicina as fracturas da extremidade proximal do fémur são um verdadeiro desafio….pluridisciplinar!

The fracture is the drop of water in a full glass

The Patient with a Fracture that has Diseases The Patient with a Fracture that has Diseases???? or The Patient with Diseases that have a fracture???? …nós somos habitualmente o fim da linha! Quando recebemos um doente

Are Orthopedic Departments prepared to Treat these Patients? … de forma a padronizar a nossa actuação!

No!!! Internal Medecine We try to know the opinion of the partners in this war

No!!! We try to know the opinion of the partners in this war Anesthesiology

No!!! Orthopedic Nurses

…Yes!!!! and No!!!…and it's their fault!!!

…No!!!!…

No!!!

Organizational Model Insufficient Not adjust ... Clinically Bad! ... Economically Bad! Diagnostic delay Therapeutic delay Higher mortality …existe pois uma opinião quase consensual… More Diagnosis Tests Discharge Delay

Solution? …nós somos habitualmente o fim da linha! Quando recebemos um doente

Multidisciplinar Team Orthopedic Surgeon Internal Medicine Anesthesiology Physical Medicine and Rehabilitation Physiotherapy Nurse Social support Nutritionist Pharmaceutics

Organizational Model Multidisciplinary Teams!!!!! Clinical Pathway with Therapeutics Protocols!!!

«Clinical pathway» Hip Fractures Dia Emergence Room Analgesic Protocol VTE prophylaxis Geriatrics/Internal Medicine Medical evaluation 0- 2 Surgery Analgesic Protocol Timing of Surgery! Surgical Decision? Fracture Personality Parker and Parker scale Charlson comorbidity Scale VTE prophylaxis AB prophylaxis Anemia Protocol Avaliação Physiotherapy Protocolo Exames Complementares Nutrition Protocol 5- 7 Delirium Protocol Discharge

Is this enough? … de forma a padronizar a nossa actuação!

Previous Physical Function Hip Fractures 15% of patients recover Previous Physical Function Mortality 20% to 30% In the first year 40% of patients severe disability

After a Hip Fracture 10,4 / 100 Patients/ year 1 Incidence of new Osteoporotic Fracture is: 10,4 / 100 Patients/ year 1 2,5 X Superior to population with similar characteristics, without previous fracture 1 1 – Colón-Emeric C et al. The contribution of hip fractureto risk of subsequent fracture:data from two longitudinal studies. Osteoporos Int. 2003;14:879-83.

What to do?

We can try not to see

We can hope that the obvious do not happen.

Nothing to do because is a superior punish

…or just give a little help

Discharge Program!!! … de forma a padronizar a nossa actuação!

Discharge Program - Hip Fractures Dia Emergence Room Movement Medicine Fall Prevention 0- 2 Surgery Fracture Prevention Program Osteoporosis treatment Nutritional Protocol Physiotherapy GP Anemia Protocol Avaliação VTE prophylaxis Schedule Next appointment and X-ray 5- 7 Discharge Schedule Surgical Dressing

Conclusions A Clinical Hospital Team organized in turn of a «Clinical Pathway» is the right answer for a success and management of resources It have to be a Multidisciplinary Team «speaking the same language» Discharge Program with GP in close participation Podem estar muito bem operados … mas se morrerem pouca vantagem existe!!!

...all of this for a good physical and mental health of our old ladies.