Geriatric Fracture Program Protocol
The Cedars-Sinai Orthopaedic Fracture Protocol is an interdisciplinary effort among orthopaedic surgery, anesthesiology, emergency medicine, internal medicine, cardiology, and geriatric medicine. The purpose of this document is to summarize the care pathway for geriatric patients 65 years or older with a fragility fracture with a goal time to OR <24 hours. Patients admitted to the Acute Care Surgery team are excluded from this pathway. Fracture repair within 24 hours is associated with improved health outcomes including decreased postoperative complications (pneumonia, hypoxia, arrhythmias, UTIs, PE), lowered mortality, improved pain, decreased rates of delirium, and shortened length of stay. This protocol establishes evidence based best practices to optimize care. It has been reviewed and approved by the departments of each service.
Points of Service
Emergency Room • Preoperative Optimization • Indications for Preoperative TTE • Preoperative Anticoagulation Management • Pain Management • Intraoperative Management • Surgical Staffing • Delirium Prevention and Management • Postoperative Management • Osteoporosis Management • Discharge Planning and Follow-up • After Visit Summary
EMERGENCY DEPARTMENT CARE
1 Radiographs
Of the affected bones
Focused MRI indicated if high suspicion of hip fracture but no clear fracture on x ray (order is MRI PELVIS WO CONTRAST MSK)
2 Labs
CBC, CMP, Coags, Vitamin D
Type and screen for 2 units PRBCs
Type and cross for 2 units PRBCs if known anemic or significant blood loss
Type and cross for 2 units FFP if on warfarin
3 Chest x-ray indications: active cardiac or pulmonary problem, or new symptoms
4 EKG indications: active cardiac or lung problems, new symptoms, no EKG within 6 months
5 Bilateral lower extremity duplex to screen for DVT if time of injury is unknown or > 24 hours from arrival to emergency department
6 Anticoagulation Management (see section below)
7 Pain Management: Patients should be started on a multimodal analgesic regimen per Geriatric Fracture Program guidelines and should be considered for regional anesthesia (if unsure, consult for an evaluation)
If the patient is a candidate for a regional anesthesia evaluation, the orthopaedic resident will place a consult order “Evaluation for Regional Anesthesia Services” and note the fracture(s) to be addressed and their location in the comments
i. Order should be placed immediately after evaluation by the orthopaedic surgical team to expedite placement of peripheral nerve block (PNB)
1. Consult orders automatically notify the regional anesthesia consult phone
The nerve block should be performed as soon as possible after orthopaedic evaluation, before transfer from the ED, and within 8 hours (https://pubmed.ncbi.nlm.nih.gov/32195685/)
i. During the weekday (7 AM-7 PM) or weekends (7 AM-3 PM), PNB should be performed prior to patient transfer to 7N
ii. If a regional anesthesia consult order is received after hours, evaluation will be performed the next morning after 7 AM
All geriatric fracture patients evaluated by the orthopaedic trauma team will be entered into the Geriatric Fracture Program REDCap by a GFP staff member
8 Consults to be requested in the Emergency Department
Orthopaedic Surgery
Regional Anesthesia
APEC
9 Admission
Patients who are trauma activations are not subject to this protocol and their care will be deferred to the Acute Care Surgical Service
Bed request for 7N bed
Admit to Hospitalist service or primary care provider per ED guidelines
If patient does not have a previously assigned primary MD or hospitalist service, hospital admission will be to the hospitalist service who is On Call for the Geriatric Fracture Program which will be provided by the Orthopaedic Resident
PREOPERATIVE OPTIMIZATION
1 Goal time to OR is < 24 hours
2 Orthopaedic On Call resident discusses with the on-call chief resident and adds the patient to the OR schedule
3 Orthopaedic resident requests preoperative anesthesia consults from APEC
4 Additional specialty consults will be considered and requested at the discretion of the anesthesia preop service
5 Patients will be evaluated by Anesthesia preoperative services and internal medicine within 8 hours and optimized, if possible, by 7 AM the following day for surgery within 24 hours
6 Orthopaedic on-call chief notifies the orthopaedic surgery attending about all cases admitted overnight by 5am the next morning
Medical Optimization – General Orders
1 For patients admitted in evening, keep NPO after midnight. Patients admitted in the morning keep NPO for possible same day surgical repair
2 Start early aggressive hydration of Lactated Ringer’s at 100-150 cc/hour
3 Hold ACE Inhibitors to prevent intraoperative hypotension and AKI. Restart on POD#1
4 Continue beta blockers and other rate control medications
5 Pain management (see section below)
6 Anticoagulation management and reversal, if indicated (see section below)
7 Delirium precautions and interventions as needed (see section below)
8 Patient admitted to 7N
9 Incentive Spirometer
10 PMD contacted on admission by admitting team to confirm medication list and co morbidities.
Medical Optimization – Special Circumstances
1 Cardiac: only unstable conditions should delay surgery
Unstable Coronary Syndrome (unstable angina, MI within 30 days, ischemic EKG changes, or elevated troponin)
Unstable Arrythmia (hypotension or significantly uncontrolled)
Decompensated CHF – severe decompensation with new oxygen requirement or severe symptoms
Known moderate/severe valvular disease with no TTE in past 12 months
TTE orders can delay surgery. Order only for patients with decompensated CHF, new oxygen requirements, known moderate or severe valvular abnormalities, and no recent TTE. Expedite by calling cardiology early with the plan for completion and interpretation of TTE by within 12 hours. Click here to learn more about Indications for Preoperative TTE
2 Pulmonary:
COPD/Asthma- Continue inhaled bronchodilators and steroids
Acute, serious exacerbations may require steroid treatment and possibly delay surgery
Acute bronchitis/pneumonia – Assess for sepsis and treat as necessary
3 Anemia:
Transfusion trigger is Hgb ≤ 7
4 Diabetes/ Elevated blood glucose:
Goal blood sugar < 200 mg/dL
A blood glucose above 200 mg/dL may delay anesthesia/surgery
5 DVT/PE:
If patient has known DVT consider filter placement with IR prior to surgery
Screening bilateral lower extremity duplex for DVT the day before surgery if patient has been in the hospital for > 48 hours or transferring from outside facility
6 Consults: please use the following chart to guide medical service consult requests
Swart E, Kates S, McGee S. The Case for Comanagement and Care Pathways for Osteoporotic Patients with Hip Fracture. J Bone Joint Surg. 2018; 100(15):1343-1350.
PREOPERATIVE TRANSTHORACIC ECHOCARDIOGRAM GUIDELINES
Based on 2011 JACC AUC
PREOPERATIVE ANTICOAGULATION MANAGEMENT
1 For patient on anticoagulants follow ASRA guidelines (Refer to ASRA Coags 2.1 app)
2 Heparin (See Bridging below)
Hold Heparin gtt 4-6 hours before transfer to preop/OR
3 Lovenox
Hold Lovenox 12 hours (24 hours for therapeutic dosing) before transfer to preop/OR
Hold AM dose before surgery
4 Continue all anti-platelet agents (Aspirin, Clopidogrel, Prasugrel, Ticagrelor, Cilostazol) at patient’s current dose
Do not delay surgery for anti-platelet medications
5 Warfarin
Hold Warfarin, give Vitamin K 5mg PO x 1, Type and cross for 2 units FFP
Re-check in 12 hours, give addition 2 mg PO if still elevated
Re-check INR 12 hours after vitamin K dose
Goal INR for OR is ≤1.5 for surgery
Goal INR for neuraxial block anesthesia is normalized INR
Can proceed with surgery if INR≤ 1.8 and patient can get FFP on the way to the OR
6 Direct Oral Anticoagulants (Dabigatran, Rivaroxaban, Apixaban, Edoxaban)
Record time of last dose taken clearly. Refer to CSMC Policy (See Guideline: Time to Surgery for Orthopaedic Trauma Patients on Apixaban (Eliquis®), Rivaroxaban (Xarelto®) or Dabigatran (Pradaxa®) NOT admitted to Trauma Service)
BRIDGING
Bridging therapy with heparin indicated if any of the very high-risk conditions below:
1 Mechanical heart valve
2 Mitral prosthesis
Caged ball/tilting aortic prosthesis
Stroke/TIA within 6 months
3 Atrial Fibrillation
CHADS-VASC score 7-9 + absence of additional bleeding risk (see below)
Stroke/TIA or systolic embolism within 3 months
4 Venous Thromboembolism (VTE)
VTE within 3 months
Severe thrombophilia
History of VTE during discontinuation of anticoagulation
PAIN MANAGEMENT
1 Medications
For chronic pain patients, continue maintenance regimen and consult Inpatient Pain Service
Multimodal pain management strategy will be implemented per Geriatric Fracture Program guidelines and order set:
i. Scheduled NSAID (Mobic 15 daily or Celebrex 100 BID if prior GI intolerance) if not medically contraindicated
ii. Scheduled Tylenol 1000mg Q8
iii. For mild pain: scheduled medications a above with additional nonpharmacologic modalities as outlined in the geriatric fracture program (i.e.: reorientation, repositioning, ice, mindfulness exercises)
iv. For moderate pain: Tramadol 50 Q4 PO PRN or oxycodone 2.5 Q4 PO PRN if tramadol is contraindicated
v. For severe pain: Oxycodone 5mg Q4 PO PRN
vi. For breakthrough pain: Additional oxycodone 5mg PO Q4 or dilaudid 0.4mg IV Q4 if unable to take PO
Non-pharmacologic interventions should be emphasized
Avoid fentanyl (short-acting) or topical agents such as cold packs or lidocaine patches near incision to avoid surgical site skin compromise
2 Regional anesthesia
The orthopaedic resident will consult the regional anesthesia team following the initial orthopaedic evaluation and specify known traumatic injuries to be addressed
i. Based on fracture(s) involved, the appropriate peripheral nerve block(s) or neuraxial anesthesia will be determined by the Regional Anesthesia Consult Service
Refer to the Regional Anesthesia Orthopaedic Fracture protocol
Obtain consent after evaluation and discussion of risks and benefits
Assess block efficacy
3 Local Anesthetic Systemic Toxicity (LAST) Management
Based on the American Society of Regional Anesthesia and Pain Medicine: Checklist for Treatment of LAST
i.https://www.asra.com/news-publications/asra-updates/blog-landing/guidelines/2020/11/01/checklist-for-treatment-of-local-anesthetic-systemic-toxicity
ii. Clinolipid can be accessed in every core main OR Pyxis and in both core and pre-op Pyxis in AHSP under “Lipid”
INTRAOPERATIVE ANESTHETIC MANAGEMENT
1 Neuraxial anesthesia is strongly preferred in all patients if not contraindicated
INR goal < 1.4 or normalized if on coumadin
Adherence to ASRA guidelines for neuraxial procedures in patients taking antithrombotic agents (see above “Preoperative Anticoagulation Management”)
Must provide adequate muscle relaxation for fracture reduction
2 When neuraxial anesthesia is contraindicated (e.g.: coagulopathy, anticoagulation status, patient refusal):
Consider PNB(s) with sedation or general anesthesia
3 Preoperative antibiotics
Cefazolin at a weight-based dose
Alternative prophylaxis in cases of allergy per institutional guidelines
4 Tranexamic acid (TXA; 10 mg/kg IV up to 1 g) given prior to incision and again during closure
Any specific concerns for contraindications to be discussed between attendings
Absolute contraindication: active thromboembolic disease
Topical TXA may be considered for open procedures
5 For INR> 1.5 give two units FFP on call to OR
6 Final anesthetic plan will be determined by the responsible anesthesiologist with review and consideration of multidisciplinary medicine service recommendations
SURGERY
1 At least 2 dedicated Ortho Trauma Block rooms are staffed each day
2 Operative fractures will be prioritized for surgery within 24 hours of ED arrival
DELIRIUM PREVENTION AND MANAGEMENT
1 Assess underlying causes
2 Discontinue precipitating medications
3 Initiate delirium order set IP DELIRIUM
4 Emphasize non-pharmacologic treatment. Medications have not been shown to treat or prevent delirium
antipsychotic use reserved for rare cases when a patient poses a threat to self or staff
POSTOPERATIVE MANAGEMENT
1 Delirium prevention and order set as above
2 Pain management
3 DVT prophylaxis start on POD #1
For CrCl > 31: Enoxaparin 40mg SQ Qday at 8pm
For CrCl ≤ 30: Lovenox SQ nightly at 8pm per pharmacy adjustment
4 Patient seen by PT/OT in morning of POD #1
5 Foley out on POD #1
For urinary retention get bladder scan and straight catheterization
6 Goal is discharge to home or facility in < 48 hours
OSTEOPOROSIS MANAGEMENT
1 Start Calcium Carbonate 1250 mg daily on discharge (alternatively can order extra strength Tums twice daily
2 Check Vitamin D level. If level is:
15 ng/ml then 50,000 IU weekly x 8 weeks then 2000 IU daily
15-30 ng/ml, then start 2000 IU daily
31-40 ng/ml, then start 1000 IU daily
> 40 ng/ml, then no supplementation is needed
3 Patient will be followed by an inpatient Geriatric Fracture Program NP to discuss bone health, fall prevention, and begin referral process for outpatient bone health follow-up
4 Patient also seen by Transitional Care coordinator while an inpatient to provide continuity after discharge
5 Add osteoporosis to the patient’s problem list in CS Link
6 Educate patient on decreasing caffeine and alcohol intake, and smoking cessation
DISCHARGE PLANNING AND FOLLOW UP
Three appointments need to be made on discharge:
1 Orthopaedics
Schedule 2-week wound check visit (can be video or telephone visit with clinical photos)
Schedule 6-week in-person visit with x-rays
2 Bone Health
Schedule 1-2 months after discharge
For nonlocal patients, contact the patient’s PCP with recommendations for bone health optimization
Outpatient Bone Health Coordinator will facilitate referral for bone health follow-up at the first follow-up visit in the Orthopaedic Center
Transitional Care Coordinator will call patient at 7, 30, 60, 90 days to facilitate transition of care to outpatient
3 Primary Care
Primary team makes appointment with PCP within 2-4 weeks
Inpatient care manager
AFTER VISIT SUMMARY
Primary and Orthopaedic Teams ensure detailed instructions
Cedars-Sinai follow-up visits are scheduled and listed with clinic addresses and phone numbers
i. PCP appointment
ii. Orthopaedic Surgery appointment
iii. Bone Health appointment or plan
Postoperative instructions
Wound care and dressing changes
Weight bearing status
DME
Home Health orders
Return precautions
Specific instructions on when to call the doctor (PCP vs. orthopaedic surgeon)
Updated medication list
DVT prophylaxis plan