Fast-track pathways can improve outcomes in older hip fracture patients

  • Fast-tracking the Elderly Hip Fracture Patient in the Setting of ERAS and the PSH
  • 9:30-11:30 a.m. Monday
  • West, Room 2004

Conventional care for hip fractures in older patients leaves much to be desired. Fast-tracking older hip fracture patients using enhanced recovery protocols and Perioperative Surgical Home care models may enable improvement in morbidity, mortality, quality of life and other outcomes.

“Significant morbidity and mortality can occur postoperatively with these patients,” said Jaime L. Baratta, M.D., Clinical Assistant Professor of Anesthesia and Director of Regional Anesthesia at Thomas Jefferson University. “Implementing enhanced recovery or fast-track protocols may lead to improved outcomes in significant ways.”

Jaime L. Baratta, M.D., discusses fast-tracking recovery in older hip fracture patients.

Dr. Baratta will moderate Monday’s “Fast-tracking the Elderly Hip Fracture Patient in the Setting of ERAS and the PSH,” where new research suggests that fast-tracking hip fracture patients via enhanced recovery protocols may offer many of the benefits demonstrated by fast-tracking patients undergoing elective surgery.

The problem, Dr. Baratta said, is that it is often assumed that we cannot apply fast-track principles to urgent or emergent surgeries. More than 500,000 hip fractures are treated each year in the U.S., and more than 1.5 million are treated worldwide. In most cases, these patients receive standard care, starting with opioids in the emergency department.

“There are things we can do from the time they hit the ER, starting with reducing the amount of opioids they get,” she said. “We can use regional anesthesia, things like femoral nerve blocks or fascia-iliaca blocks preoperatively when they first arrive at the hospital. That can both decrease pain and decrease opioid use, which reduces side effects. The opioids these patients get often result in confusion, respiratory depression and other side effects. By standardizing non-opioid multimodals, we have seen improvement in analgesia with a number of surgical procedures. It is better to give opioids only when absolutely necessary and not as the standard analgesic.”

Other preoperative steps include a focus on nutrition and preservation of cognitive function. Many older patients are already malnourished because of age or their living situation when they are admitted. Keeping family members with the patient whenever possible can orient them to time and place and improve cognition.

Surgical anesthesia is still an open question. Some surgeons prefer regional anesthesia, while others prefer general anesthesia. Current literature supports both. The ongoing REGAIN trial at the University of Pennsylvania compares regional versus general anesthesia, its effect on morbidity and mortality, as well as functional outcomes and independent living after surgery.

“Postoperatively, the focus is on nutrition, cognitive function and minimizing opioids, and getting patients mobilized as quickly as you can after surgery,” Dr. Baratta said. “Conventional care leaves about a third of these patients unable to walk independently after two months — a real quality of life issue.”

Accelerated recovery pathways are not the standard of care for older hip fracture patients, but things are moving in that direction, she said. Success in elective surgeries and successful implementation at Temple University and other centers is changing expectations.

“Given the reality that the frequency of these injuries is increasing as the population ages and the significant morbidity and mortality, we can do better,” she said.

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