Perioperative Surgical Home Reduces ER Visits and Death in Elderly Hip Fracture Patients

By Sondra Forsyth

Elderly patients who had emergency repair of a fractured hip were much less likely to die or make a return visit to the emergency room (ER) after discharge if they received care under the Perioperative Surgical Home (PSH) model of care, suggests research presented at the ANESTHESIOLOGY® 2017 annual meeting in October in San Francisco.

A release from the American Society of Anesthesiologists notes that PSH patients were also far more likely to go home, rather than to a rehabilitation facility, after discharge from the hospital, according to the study. The PSH is a patient-centric, physician-led, team-based system of coordinated care that guides patients through the entire surgical experience, from the decision to undergo surgery to discharge and beyond.

The release quotes Chunyuan Qiu, M.D., lead author of the study and physician anesthesiologist at Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California, as saying, “The PSH has fundamentally changed the outcomes that matter to patients, which is particularly impressive in this extremely high-risk population. Our research suggests the PSH is beneficial not just for patients having planned procedures, but also for those having high-risk emergency surgeries.”

Because bones tend to weaken with age, elderly people are at greater risk of falling and fractures – with hip fractures being particularly common. More than 300,000 people 65 and older are hospitalized for hip fractures every year. Treatment typically involves surgery, including replacement of the entire hip, or stabilizing it with metal rods, screws and plates so the bone can heal.

The author’s institution created a PSH protocol that is activated when a patient is admitted to the ER with a likely hip fracture. The operator contacts and loops in the various teams, including the ER, anesthesiology, orthopedics, internal medicine and operating-room scheduling so they can begin readying the patient for surgery within 24 hours. The various teams coordinate as they manage preparations for surgery, including pain control, blood tests, imaging and optimizing medical problems and medications prior to surgery.

The single-center study compared outcomes of 222 hip fracture patients treated prior to the implementation of the PSH, to 118 patients who were treated afterward. Researchers reported:

– Death rates for the PSH group were reduced by half or more: 1.7 percent of non-PSH patients died in the hospital, compared to less than 1 percent of PSH patients. Thirty days after discharge 3.2 percent of non-PSH patients died vs. none of the PSH patients, and after 90 days, 6.3 percent of non-PSH vs. 2.5 percent of PSH patients died.

– PSH patients were less likely to visit the ER after they were discharged from the hospital after surgery: 9.5 percent of non-PSH patients vs. 5.1 percent of PSH patients visited the ER within 30 days after discharge, while 23.4 percent of non-PSH patients vs. 14.4 percent of PSH patients went to the ER within 90 days of discharge.

– PSH patients were much more likely to be discharged to their homes instead of a nursing home or other rehabilitation facility: 16.2 percent of non-PSH patients went directly home, compared to 40.7 percent of PSH patients.

Additionally, while 30-day hospital readmissions were slightly higher in the PSH group (13.6 percent) than in the non-PSH group (12.6 percent), the difference was statistically insignificant, and 90-day readmissions were significantly lower in the PSH group (17.8 percent) than the non-PSH group (23.9 percent).

“Hip fractures are extremely expensive, and we found the PSH significantly reduces those costs,” said Dr. Qiu. “The model has been so successful, it is now spreading to 13 medical centers within our system.”