Perioperative Medical Management


12 Perioperative Medical Management


Jennifer Muniak MD, Susan M. Friedman MD MPH, Joseph A. Nicholas MD MPH, and Daniel A. Mendelson MD MSc


University of Rochester School of Medicine and Dentistry, Rochester, NY, USA


Top three questions



  1. In patients presenting with a fragility hip fracture, does routine preoperative echocardiography, compared to no echocardiography, improve survival?
  2. In fragility fracture patients, does orthopedic and medical co‐management, compared to usual care, improve outcomes such as length of stay, mortality, and readmission?
  3. In fragility fracture patients undergoing surgery, does early surgery, when compared to delayed surgery, have an effect on mortality risk?

Question 1: In patients presenting with a fragility hip fracture, does routine preoperative echocardiography, compared to no echocardiography, improve survival?


Rationale


Wide practice variations exist with regard to obtaining preoperative echocardiograms for the purposes of cardiac risk stratification. It is necessary to establish whether patients undergoing fragility hip fracture surgery benefit from this test as part of a standard preoperative evaluation.


Clinical comment


Preoperative testing, if appropriately utilized, has the potential to improve patient outcomes. However, in some contexts, echocardiography and other tests can cause iatrogenic harm. In cases when surgical intervention is considered urgent, testing can lead to surgical delay. Additionally, many fragility fracture patients are medically complicated by chronic cardiovascular conditions, and abnormal test results may trigger intensive perioperative monitoring (raising risk of delirium, limiting mobility) and medication prescribing that can be harmful in the acute fracture setting.


Available literature and quality of the evidence


There are three retrospective cohorts deemed relevant and of acceptable quality to answer this question (level III).


Findings


A retrospective review of patients treated surgically for hip fracture found transthoracic echocardiography (TTE) prior to hip fracture was not associated with improvements in hospital mortality (3.8% vs 1.8%, p = 0.18), 30‐day mortality (6.9% vs 6.6%, p = 0.90), or one‐year mortality (20.6% vs 20.1%, p = 0.89).1 Similarly, another retrospective review of fragility fracture patients (>65 years old) found that inpatient mortality was not statistically different between patients who did or did not undergo TTE prior to surgical repair (2.4% vs 3%, p = 0.493).2 A third retrospective trial found that one‐year mortality was not significantly affected by perioperative TTE (p = 0.137) in older adults with similar cardiac risk profiles undergoing hip fracture repair.3 Notably, all these trials also measured surgical timing, and echocardiography was associatxed with delay to surgical intervention.


Resolution of clinical scenario



  • Echocardiogram prior to hip fracture surgery rarely changes management but often will result in delay of surgery.
  • Short‐ and long‐term mortality are not improved by routine echocardiography prior to hip fracture surgery.

Question 2: In fragility fracture patients, does orthopedic and medical co‐management, compared to usual care, improve outcomes such as length of stay, mortality, and readmission?


Rationale


In an effort to improve clinical outcomes for patients who experience a fragility hip fracture, there is a growing trend for geriatricians or hospitalists to co‐manage the patient alongside orthopedic surgeons. This unique model of care has yielded promising results in several centers.


Clinical comment


Patients with fragility fractures often have multiple medical comorbidities that warrant careful management by care teams well versed in perioperative geriatric medicine. The expertise of the medical doctor (usually a hospitalist or geriatrician) and their relationship with the orthopedic surgeon has the potential to positively impact clinical outcomes in this frail patient population. Co‐management is a distinct relationship between two physicians in which there is shared responsibility for patient care and outcomes. Both teams perform daily rounds, contribute to the plan of care, document, and write orders. Frequent, respectful communication between teams is expected. Most co‐management programs include close collaboration and aligning of practice patterns with emergency medicine and anesthesia physicians in addition to the disciplines of nursing, social work, occupational therapists, and physical therapists. Additional features of many high‐performing co‐management programs include proactive hospital discharge planning, standardized order sets, and ongoing quality improvement.


Available literature and quality of the evidence


Eight studies, all prospective (level II) and retrospective (level III) cohort studies, were deemed to be the highest‐quality evidence on this topic.


Findings


A sentinel study in 2008 found that, compared to usual care, co‐management of fragility fractures by geriatricians and orthopedists significantly improved length of stay (4.6 vs 8.3 days, p <0.001), rates of postoperative infection (2.3% vs 19.8%, p <0.01), complications (30.6% vs 46.3%, p = 0.005) and use of restraints (0% vs 14.1%, p <0.001).4,5 In‐hospital mortality and 30‐day readmission rates were also improved (1.6% vs 2.5%, p = 0.68, and 9.8% vs 13.2%, p = 0.35, respectively), though neither was statistically significant.


Several medical centers have subsequently instituted comprehensive co‐management programs for fragility hip fractures and compared outcomes before and after program implementation (i.e. utilizing prospective observation with retrospective, historical controls). Results from five programs are outlined below:



  1. A significant reduction in hospital length of stay (6.4–5.5 days, p = 0.0004) with stable 30‐day readmission rate and time to surgery. Increase in number of patients receiving osteoporosis evaluation and receiving outpatient follow‐up in the metabolic bone clinic (p <0.001) and orthopedics clinic (p = 0.005).6

Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Perioperative Medical Management
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