Predicting Discharge Location among Low-Energy Hip Fracture Patients Using the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA)

Patterns of discharge location may be evident based on the “sickness” profile of the patient. This study sought to evaluate the ability of the STTGMA tool, a validated mortality risk index for middle-aged and geriatric trauma patients, to predict discharge location in a cohort of low-energy elderly hip fracture patients, with successful discharge planning measured by readmission rates. Low-energy hip fracture patients aged 55 years and older were prospectively followed throughout their hospitalization. On initial evaluation in the Emergency Department, each patient’s age, comorbidities, injury severity, and functional status were utilized to calculate a STTGMA score. Discharge location was recorded with the primary outcome measure of an unsuccessful discharge being readmission within 30 days. Patients were risk stratified into minimal-, low-, moderate-, and high-risk STTGMA cohorts. A p-value of <0.05 was considered significant for all statistical tests. 408 low-energy hip fractures were enrolled in the study with a mean age of 81.3±10.6 years. There were 214 (52.5%) intertrochanteric fractures, 167 (40.9%) femoral neck fractures, and 27 (6.6%) subtrochanteric femur fractures. There was no difference in readmission rates within STTGMA risk cohorts with respect to discharge location; however, among individual discharge locations there was significant variation in readmission rates when patients were risk stratified. Overall, STTGMA risk cohorts appeared to adequately risk-stratify readmission with 3.5% of minimal-risk patients experiencing readmission compared to 24.5% of moderate-risk patients. Specific cohorts deemed high-risk for readmission were adequately identified. The STTGMA tool allows for prediction of unfavorable discharge location in hip fracture patients. Based on observations made via the STTGMA tool, improvements in discharge planning can be undertaken to increase home discharge and to more closely track “high-risk” discharges to help prevent readmissions.

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Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery?

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459320946021 ◽

2020 ◽

Vol 11 ◽

pp. 215145932094602

Author(s):

Sanjit R. Konda ◽

Joseph R. Johnson ◽

Erin A. Kelly ◽

Jeffrey Chan ◽

Thomas Lyon ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Negative Binomial ◽

Minimal Risk ◽

Middle Aged ◽

Moderate Risk ◽

Time To Surgery ◽

High Risk Patients ◽

Risk Patients ◽

Trauma Triage

Introduction: This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery. Materials and Methods: Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk. Results: Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification ( P = .002). Moderate-risk patients had 33% longer ( P = .019) and high-risk patients had 28% longer time to surgery ( P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification ( P = .015). Low-risk patients had 2.14× higher odds ( P = .009), moderate-risk patients had 2.70× higher odds ( P = .001), and high-risk patients had 2.18× higher odds of delay to surgery ( P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal ( P < .001), low ( P = .046), and moderate-risk patients ( P = .046). Discussion: Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality. Conclusion: Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients. Level of Evidence: Prognostic Level III.

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Can We Stratify Quality and Cost for Older Patients With Proximal and Midshaft Humerus Fractures?

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321992742 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199274

Author(s):

Sanjit R. Konda ◽

Joseph R. Johnson ◽

Nicket Dedhia ◽

Erin A. Kelly ◽

Kenneth A. Egol

Keyword(s):

High Risk ◽

Length Of Stay ◽

Quality Measures ◽

Risk Groups ◽

Hospital Quality ◽

Minimal Risk ◽

Middle Aged ◽

Risk Patients ◽

Humerus Fractures ◽

Trauma Triage

Introduction: This study sought to investigate whether a validated trauma triage tool can stratify hospital quality measures and inpatient cost for middle-aged and geriatric trauma patients with isolated proximal and midshaft humerus fractures. Materials and Methods: Patients aged 55 and older who sustained a proximal or midshaft humerus fracture and required inpatient treatment were included. Patient demographic, comorbidity, and injury severity information was used to calculate each patient’s Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). Based on scores, patients were stratified to create minimal, low, moderate, and high risk groups. Outcomes included length of stay, complications, operative management, ICU/SDU-level care, discharge disposition, unplanned readmission, and index admission costs. Results: Seventy-four patients with 74 humerus fractures met final inclusion criteria. Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%) with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with a significant difference among risk groups (P = 0.029). Lower risk patients were more likely to undergo surgical management (P = 0.015) while higher risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six (70.3%) minimal risk patients were discharged home compared to zero high risk patients (P = 0.001). Higher risk patients experienced higher total inpatient costs across operative and nonoperative treatment groups. Conclusion: The STTGMA tool is able to reliably predict hospital quality measures and cost outcomes that may allow hospitals and providers to improve value-based care and clinical decision-making for patients presenting with proximal and midshaft humerus fractures. Level of Evidence: Prognostic Level III.

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0.25% ropivacaine vs. 0.25% bupivacaine for lumbar plexus and sciatic nerve block in high risk patients with femur or hip fracture

European Journal of Anaesthesiology ◽

10.1097/00003643-200606001-00464 ◽

2006 ◽

Vol 23 (Supplement 37) ◽

pp. 130

Author(s):

A. Kocum ◽

A. Turkoz ◽

H. Ulger ◽

G. Arslan

Keyword(s):

Hip Fracture ◽

High Risk ◽

Sciatic Nerve ◽

Nerve Block ◽

Sciatic Nerve Block ◽

Lumbar Plexus ◽

High Risk Patients ◽

Risk Patients

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Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-011204 ◽

2020 ◽

pp. bmjqs-2020-011204

Author(s):

Kirstin A Manges ◽

Roman Ayele ◽

Chelsea Leonard ◽

Marcie Lee ◽

Emily Galenbeck ◽

...

Keyword(s):

High Risk ◽

Best Practices ◽

Transitional Care ◽

Readmission Rates ◽

High Performing ◽

High Risk Patients ◽

Ethnographic Approach ◽

Care Processes ◽

Risk Patients ◽

Postacute Care

BackgroundDespite the increased focus on improving patient’s postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates.DesignWe used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals.Setting and participantsHospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5).FindingsWe identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes.ConclusionIdentifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.

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Does Comanagement of Patients With Hip Fracture Influence 30-Day Outcomes

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459320901997 ◽

2020 ◽

Vol 11 ◽

pp. 215145932090199 ◽

Cited By ~ 2

Author(s):

Nirav K. Patel ◽

Clifford Y. Ko ◽

Xiangju Meng ◽

Mark E. Cohen ◽

Bruce L. Hall ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Hip Fractures ◽

High Risk Group ◽

Improvement Program ◽

Surgical Quality ◽

Orthopedic Surgeons ◽

Orthogeriatric Comanagement ◽

American College Of Surgeons ◽

Risk Patients

Introduction: Comanagement of hip fractures is thought to optimize outcomes for these high-risk patients, but this practice is not universal. We aimed to determine whether comanagement of patients with hip fracture affects 30-day outcomes. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all hip fractures between January 2015 and January 2017, totaling 15 461 patients (144 hospitals). Patients were divided into 3 cohorts: 11 233 comanaged throughout stay (CM), 2537 partially comanaged during stay (PCM), or 1691 not comanaged (NCM), by orthopedic surgeons with medicine physicians or geriatricians. Data collected included demographics, hip fracture type, postoperative outcomes, and length of stay (LOS). Logistic regression and linear regression analyses were performed. Results: Both CM and PCM patients were older, with more dementia, poorer mobility, and more comorbidities than NCM patients. Mortality rates were 4.55%, 0.81%, and 0.33% for CM, PCM, and NCM, respectively, and risk-adjusted odds ratios (ORs) were 1.63 (95% confidence interval = 1.22-2.23) and 1.22 (0.87-1.74) for CM and PCM, respectively, compared to NCM. Morbidity rates were 11.06%, 15.45%, and 7.63% for CM, PCM, and NCM, respectively, and ORs were 1.74 (1.41-2.16) and 1.94 (1.57-2.41) for CM and PCM, respectively, compared to NCM. Risk-adjusted mean square LOS was 6.38, 8.80, and 7.23 for CM, PCM, and NC, respectively (P < .01). Conclusions: Comanaged patients with hip fracture had poorer cognition, function, and general health, with the shortest LOS. Surprisingly, NCM was associated with reduced morbidity and mortality, which may relate to them being the healthiest patients. Overall, our findings still support orthogeriatric comanagement in this high-risk group to maximize outcomes.

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