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.


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

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

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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.

 

JAMA. 2001; 285(22):2864-2870. Doi:10.1001/jama.285.22.2864

 

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 

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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

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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

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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

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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

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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

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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

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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

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