A novel perioperative pathway for hip fractures in the older adult: a pre-post quality improvement study using statistical process control

Despite advances in medical care, the incidence of medical complications, especially delirium, remains high in patients with hip fracture. Although individual components of hip fracture pathways have been studied, the components together have not. At a tertiary academic medical center, an internal review identified a high rate of unnecessary preoperative cardiac testing and postoperative delirium among patients with hip fracture admitted to the hospital medicine service. We designed a multidisciplinary perioperative pathway aimed at reducing delirium, time to surgery, and length of stay by addressing common medical conditions in older adult patients with hip fractures. A novel pathway incorporating regional anesthesia, multimodal analgesia, preoperative anemia correction, and guideline-based cardiac evaluation was implemented at a tertiary care academic center. Led by hospitalists, this pathway was introduced in two sequential phases: Period 1 – educational initiative on evidence-based cardiac testing, regional anesthesia, and opioid-sparing analgesia, beginning July 1, 2018; Period 2 – expanded interventions targeting blood utilization, nerve blocks, carbohydrate loading, and physical therapy staffing, beginning July 1, 2023. Cardiology co-management guidelines aligned with American College of Cardiology/American Heart Association (ACC/AHA) recommendations; an order set for multimodal, opioid-sparing analgesia including a femoral nerve block within 2 h of admission; clear carbohydrate drinks; expedited operative repair targets; and preoperative anemia management with intravenous iron and epoetin alfa. Outcomes for patients admitted July 2021–December 2022 (Period 1, n = 183) were compared with those admitted January 2023–July 2024 (Period 2, n = 189). Statistical process control (SPC) charts were used to assess special-cause variation in nerve block use, carbohydrate drink consumption, delirium, and acute kidney injury (AKI). Implementation led to significant reductions in cardiology consultation time, length of stay, intra- and postoperative blood transfusions, and time to surgery. There was increased use of nerve blocks and preoperative carbohydrate drinks, with no change in delirium rates or 30-day readmissions. Statistical process control methods were used to detect special cause variation after implementation of selected interventions. Mortality remained low at 0.5%. Hospitalist-led multidisciplinary care pathways can reduce hospital stay, expedite perioperative care, and improve implementation of evidence-based practices in geriatric hip fracture management. 12/2021 (Control ##21E.1180).