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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. Definition.

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orthogeriatric assessment and rehabilitation
Orthogeriatric Assessment and Rehabilitation

Dr Kathryn Anderson

Royal Victoria Hospital, Edinburgh

introduction
Introduction
  • Definition
  • Scale of the problem e.g. hip fracture
  • Assessment
  • Rehabilitation challenges
  • Outcomes (SHFA)
  • Models of Care - review the evidence
  • Recommendations

Dr Kathryn Anderson

definition
Definition

Dr Kathryn Anderson

definition1
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

Dr Kathryn Anderson

scale of problem
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

Dr Kathryn Anderson

scale of problem1
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

Dr Kathryn Anderson

scale of the problem
Scale of the Problem

Other fractures

  • Colles fracture
  • Humeral Neck
  • Clavicle

Dr Kathryn Anderson

scale of the problem1
Scale of the problem

Other fractures

  • Pubic rami
  • Malleolar

Dr Kathryn Anderson

scale of the problem2
Scale of the Problem

Other fractures

  • Vertebral: Osteoporosis/trauma

Dr Kathryn Anderson

scale of the problem3
Scale of the Problem
  • Elective total hip/knee replacements for osteoarthritis or Rheumatoid Arthritis
  • Hip and shoulder dislocations
  • Renewal or replacement of infected prostheses

Dr Kathryn Anderson

assessment
Assessment
  • Hip Fracture

Dr Kathryn Anderson

assessment1
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

Dr Kathryn Anderson

assessment2
Assessment

Hip Fracture

  • Conscious level and AMT
  • Continence
  • Pre-morbid function and social circumstances
  • Consider cause of index fall

Dr Kathryn Anderson

assessment3
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.

Dr Kathryn Anderson

assessment4
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.

Dr Kathryn Anderson

assessment5
Assessment

Hip Fracture - Post operative Complications

  • Delirium
  • Pain
  • Constipation
  • Pneumonia/Urinary tact infection
  • PE/DVT
  • Wound infection/dehiscence
  • MRSA/C.Difficile
  • Iatrogenic

Dr Kathryn Anderson

rehabilitation
Rehabilitation
  • When?As soon as possible- discharge planning should start at admission
  • Where? Depends on patient frailty and residence
  • How ? Multidisciplinary team

Dr Kathryn Anderson

rehabilitation challenges
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

Dr Kathryn Anderson

rehabilitation challenges1
Rehabilitation Challenges
  • Bone health - consider osteoporosis and whether investigation and/treatment is indicated, possible or relevant.

Dr Kathryn Anderson

rehabilitation challenges2
Rehabilitation Challenges
  • Falls Risk Assessment
  • How and when?

Dr Kathryn Anderson

rehabilitation challenges3
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

Dr Kathryn Anderson

outcomes
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.

Dr Kathryn Anderson

outcomes1
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

Dr Kathryn Anderson

outcomes2
Outcomes

Dr Kathryn Anderson

outcomes3
Outcomes

Dr Kathryn Anderson

outcomes4
Outcomes

Dr Kathryn Anderson

outcomes5
Outcomes

National database:

  • www.networks.nhs.uk/nhfdn
  • Standardisation of Audit of Hip fracture inEurope (SAHFE PROGRAMME)

Dr Kathryn Anderson

models of care
Models of Care
  • Reduced LOS and institutionalisation rates in systems with “formal geriatric liaison”……..
  • Which model works best and why?

Dr Kathryn Anderson

models of care1
Models of Care
  • Geriatric Orthopaedic Units (GORU’S)
  • Geriatric Hip Fracture Programmes (GHFP’S)
  • Early Supported discharge schemes (ESD)

Dr Kathryn Anderson

models of care2
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

Dr Kathryn Anderson

models of care3
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

Dr Kathryn Anderson

models of care4
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

Dr Kathryn Anderson

models of care5
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

Dr Kathryn Anderson

models of care6
Models of Care

Comparison of Models

  • Length of stay
  • Readmission
  • Morbidity
  • Mortality
  • Functional outcome
  • Quality of life
  • Cost

Dr Kathryn Anderson

models of care7
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

Dr Kathryn Anderson

models of care8
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

Dr Kathryn Anderson

models of care9
Models of Care

Comparison of models

  • No model superior (or inferior) in terms of functional outcomes
  • Quality of life data disappointing

Dr Kathryn Anderson

models of care10
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

Dr Kathryn Anderson

models of care11
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)

Dr Kathryn Anderson

recommendations
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

Dr Kathryn Anderson

references
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 Assess2000;4(2)
  • Prevention and Management of Hip Fracture in Older People SIGN Guideline 56 (2002)

Dr Kathryn Anderson