Orthogeriatric Assessment and Rehabilitation Dr Kathryn Anderson Royal Victoria Hospital, Edinburgh

Introduction Definition Scale of the problem e.g. hip fracture Assessment Rehabilitation challenges Outcomes (SHFA) Models of Care - review the evidence Recommendations 24/11/2018 Dr Kathryn Anderson

Definition 24/11/2018 Dr Kathryn Anderson

Definition Falls and fractures in the elderly are increasing Orthogeriatrics generally reflects hip fractures but there are a variety of other conditions to consider Assessment and rehabilitation for the majority is complex 24/11/2018 Dr Kathryn Anderson

Scale of Problem Hip Fracture Accounts for 40% of admissions and 60% of bed days from trauma in NHS >75 Incidence rising annually In Scotland over 6000 hip fractures reported in 2005 24/11/2018 Dr Kathryn Anderson

Scale of Problem Hip Fracture Well researched and audited especially in Scotland Cost to NHS £5,000-£20,000 each (£1.7 billion p.a.) Morbidity/Mortality: 20% die at 12 months 30% institutional care 50% reduction in independence 24/11/2018 Dr Kathryn Anderson

Scale of the Problem Other fractures Colles fracture Humeral Neck Clavicle 24/11/2018 Dr Kathryn Anderson

Scale of the problem Other fractures Pubic rami Malleolar 24/11/2018 Dr Kathryn Anderson

Scale of the Problem Other fractures Vertebral: Osteoporosis/trauma 24/11/2018 Dr Kathryn Anderson

Scale of the Problem Elective total hip/knee replacements for osteoarthritis or Rheumatoid Arthritis Hip and shoulder dislocations Renewal or replacement of infected prostheses 24/11/2018 Dr Kathryn Anderson

Assessment Hip Fracture 24/11/2018 Dr Kathryn Anderson

Assessment Hip Fracture Immediate assessment in A/E Pain relief and X-ray as soon as possible Pressure sore risk Hydration and nutrition Core body temp 24/11/2018 Dr Kathryn Anderson

Assessment Hip Fracture Conscious level and AMT Continence Pre-morbid function and social circumstances Consider cause of index fall 24/11/2018 Dr Kathryn Anderson

Assessment Hip Fracture - Pre-operative Management Antibiotic prophylaxis Aspirin 150mgs for 35 days Heparin for “high risk” patients Consider repeat x-rays, MRI or bone scan in symptomatic patient with normal X-ray. 24/11/2018 Dr Kathryn Anderson

Assessment Hip Fracture - Surgical Management Experienced surgical and anaesthetic staff “24 hour rule” between 8am-8pm Delay only for treatment of severe sepsis, anaemia, shock, cardiac/respiratory failure, arrhythmia Exclusion of severe aortic stenosis especially for spinal anaesthesia. 24/11/2018 Dr Kathryn Anderson

Assessment Hip Fracture - Post operative Complications Delirium Pain Constipation Pneumonia/Urinary tact infection PE/DVT Wound infection/dehiscence MRSA/C.Difficile Iatrogenic 24/11/2018 Dr Kathryn Anderson

Rehabilitation When? As soon as possible- discharge planning should start at admission Where? Depends on patient frailty and residence How ? Multidisciplinary team 24/11/2018 Dr Kathryn Anderson

Rehabilitation Challenges Poor nutrition (nutritional supplementation) Anxiety and fear of falling Gait problems prior to fall Depression Dementia Medical co morbidity Social and functional challenges 24/11/2018 Dr Kathryn Anderson

Rehabilitation Challenges Bone health - consider osteoporosis and whether investigation and/treatment is indicated, possible or relevant. 24/11/2018 Dr Kathryn Anderson

Rehabilitation Challenges Falls Risk Assessment How and when? 24/11/2018 Dr Kathryn Anderson

Rehabilitation Challenges Patient/carer expectations Unresolved medical problems Inadequate information about orthopaedic plans Poor documentation/inadequate use of care pathways Staff education in rehabilitation units with specialist needs Delayed discharges 24/11/2018 Dr Kathryn Anderson

Outcomes Difficult to measure Subject of audit SHFA (Scottish Hip Fracture Audit) Compare case mix /process and outcome, includes pre and post op progress, surgical procedures, rehabilitation outcomes up to 4 months and mortality. 24/11/2018 Dr Kathryn Anderson

Outcomes Scottish Hip Fracture Audit Began in 1993 Data collection patchy due to variation in funding Involved 21 hospitals across Scotland Data collected now informs practice and development of guidelines Hip fracture is now a tracer condition for research into care for older people 24/11/2018 Dr Kathryn Anderson

Outcomes 24/11/2018 Dr Kathryn Anderson

Outcomes 24/11/2018 Dr Kathryn Anderson

Outcomes 24/11/2018 Dr Kathryn Anderson

Outcomes National database: www.networks.nhs.uk/nhfdn Standardisation of Audit of Hip fracture in Europe (SAHFE PROGRAMME) 24/11/2018 Dr Kathryn Anderson

Models of Care Reduced LOS and institutionalisation rates in systems with “formal geriatric liaison”…….. Which model works best and why? 24/11/2018 Dr Kathryn Anderson

Models of Care Geriatric Orthopaedic Units (GORU’S) Geriatric Hip Fracture Programmes (GHFP’S) Early Supported discharge schemes (ESD) 24/11/2018 Dr Kathryn Anderson

Models of Care GORU’s Developed in the 1970’s Vary between hospitals Geriatrician–led multidisciplinary inpatient rehabilitation usually separate from acute hospital Frailer patients 24/11/2018 Dr Kathryn Anderson

Models of Care Early Supported Discharge Schemes Developed in the 1990’s Vary between hospitals and schemes Generally therapist led, may have geriatrician input Patients generally less frail Rehabilitation in the home environment with increased social support at this time 24/11/2018 Dr Kathryn Anderson

Models of Care Geriatric Hip Fracture Programmes ‘Liaison’ Geriatric team input starts in orthopaedic unit Frail patients go to rehabilitation unit Less disabled patients remain in the orthopaedic wards for rehabilitation 24/11/2018 Dr Kathryn Anderson

Models of Care Comparison of Models 41 studies- 14 Randomised controlled trials 10 Specific therapy/nursing/medical intervention 7 GORU 6 ESD 6 PPS 5 GHF programmes 4 Miscellaneous 3 ICP for hip fracture 24/11/2018 Dr Kathryn Anderson

Models of Care Comparison of Models Length of stay Readmission Morbidity Mortality Functional outcome Quality of life Cost 24/11/2018 Dr Kathryn Anderson

Models of Care Comparison of Models Median LOS for hip fracture is 20 days (15-23) Length of stay reduced in ESD and GHFP. Slight trend for readmission in ESD GORU’S no benefit on overall LOS but 10-56% of all patients end up in GORU Better rate of return to previous residence in all 3 24/11/2018 Dr Kathryn Anderson

Models of Care Comparison of Models Inpatient mortality 7.5% No evidence of reduced morbidity in any of the programmes but some i.e. GORU and ESD showed reduction in mortality 24/11/2018 Dr Kathryn Anderson

Models of Care Comparison of models No model superior (or inferior) in terms of functional outcomes Quality of life data disappointing 24/11/2018 Dr Kathryn Anderson

Models of Care Comparison of Models GHFP’s and ESD likely to be cost-saving due to reduced length of stay GORU less clear but may save up to £2,200 per patient or net cost of nearly £600 each Care at home for £1600 per year versus care in a nursing home £19,000 per year 24/11/2018 Dr Kathryn Anderson

Models of Care Ideal Model ? Shared care from point of admission. Early Supported Discharge schemes for fitter patients Early step-down to rehab unit may be general or specialist orthopaedic Innovative schemes for care at home (social work) 24/11/2018 Dr Kathryn Anderson

Recommendations Audit outcomes More research into individual elements of programmes Include quality of life and cost, carer burden and societal costs Invest in robust schemes for falls prevention 24/11/2018 Dr Kathryn Anderson

References www.shfa.scot.nhs.uk Cameron I, Crotty M,Currie C, Finnegan T, Gillespie L, Gillespie W, et al. Geriatric rehabilitation following fractures in older people: a systematic review. Health Technol Assess 2000;4(2) Prevention and Management of Hip Fracture in Older People SIGN Guideline 56 (2002) 24/11/2018 Dr Kathryn Anderson