New program aims to help seniors with hip fractures

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Upstate has implemented a new model of care for older patients with hip fractures, designed to help them heal more quickly. Here to explain the American Geriatric Society's Ortho CoCare Program is Dr. Sharon Brangman and nurse Lia Fischi. Dr. Brangman is chair of Upstate's department of geriatrics and a past president of the American Geriatric Society, and Ms. Fischi is the interim orthopedic program manager. Welcome to "The Informed Patient," both of you.

Sharon Brangman, MD: Thanks for inviting us.

Host Amber Smith: Ms. Fischi, can you first explain how common hip fractures are in people over age 65?

Nurse Lia Fischi: According to the CDC (Centers for Disease Control and Prevention), about 300,000 adults aged 65 and older are hospitalized for hip fractures.

More than 95% of hip fractures are caused by falling, so this is pretty common, and the most serious fall injury is a broken hip. Actually women experience three quarters of the hip fractures. Women fall more often than men, and women more often have osteoporosis, a disease that weakens bones and makes them more likely to break. So the chances of breaking your hip go up as you get older.

Host Amber Smith: And Dr. Brangman: Older people being more susceptible, does that mean that fractures in someone who is older than 65 are inherently different and have to be managed differently than a fracture in a younger person?

Sharon Brangman, MD: So the fracture itself needs to be managed based on their amount of osteoporosis and how the break occurred, where it broke. There's all different areas of the hipbone that could actually break.

But in general, what we try to do is look at the other medical problems that might be going on with the person. So after the age of 65 and into our 70s and 80s, we generally have other chronic medical problems that are going on, and we're often taking a lot of medications.

And all of these can have an impact when you're in the hospital, and you're getting pain medicines or other treatments. So we want to make sure that when people start to have a long list of medical problems and medications, and they have a hip fracture, that we keep all of this in mind while we're taking care of them.

Host Amber Smith: So is recovery necessarily going to take longer for someone who's older because maybe they do have other medical things going on?

Sharon Brangman, MD: Well, it can vary, depending on the person. So if they have severe thinning of their bones, if they have problems with their memory like dementia and maybe can't follow instructions, they may have a different recovery than someone who is healthier and has a simple fracture. So our team is trained to take care of people, whether their fracture is simple or more complex.

Host Amber Smith: Ms. Fischi, I was going to ask: With seniors with fractured hips, do they require surgeons that have expertise in handling more complicated fractures?

Nurse Lia Fischi: Well, our surgeons here at Upstate are fellowship trained. So that means that they received extra training to take care of these types of fractures in dealing with the older adult. So, yes, I would say that our surgeons here at Upstate Hospital have the expertise to deal with these fractures, and combined with our multidisciplinary team, with the Ortho CoCare Program, it makes a great program to take the best care of our older adult population.

Sharon Brangman, MD: So what we've really done is combined geriatric care with excellent orthopedic care so that we can get the best outcome for our patients.

Host Amber Smith: And so that's where the name co-care comes from, because you're cooperating. But what can you tell us about when this program was developed and what the overall goal is?

Sharon Brangman, MD: Well, the program was started by some of my colleagues at the University of Rochester many years ago. And it was so successful that in about 2017 or so, the American Geriatric Society stepped in and helped to make it a national model.

So there are now many hospitals across the country that have used the American Geriatric Society's template, so to speak, to help set up this system in various hospitals across the country. And what they found is that when you have a team working together, each with their own expertise, we can take better care of the patient.

So we get them to the operating room quicker, we control their pain better, we get them out of bed and into rehab quicker, because our goal is to get them back to their previous level of functioning.

Host Amber Smith: And you said it's been implemented in other hospitals, in other cities and states, it must be going well, or it wouldn't have been replicated in so many places.

Sharon Brangman, MD: So it has been shown to be an excellent program. It's based on evidence and data, so we have the information to back it up, to know that it helps to reduce the amount of time a person stays in the hospital. It reduces their likelihood of coming back to the hospital with a complication, and it reduces the potential complications that can occur when you have somebody come in, and they're on many medications, we can reduce their delirium.

Delirium is an acute confusional state that an older person can get when they're under stress in the hospital. And our team has special expertise to help reduce that risk of delirium because when you have delirium, you end up staying in the hospital longer.

So we have an expert team that can look at all aspects of this person's care, so that we're not just fixing their hip.

We're also trying to optimize their health and get them back to where they were as soon as possible.

Host Amber Smith: A lot of people who have fractured a hip have other injuries from that fall, right? You've got to deal with concussion or whatever the other things are.

Sharon Brangman, MD: We're not going to take care of people who have the more complicated traumas. So if they've had a head injury or, say, a spinal fracture and a hip fracture, they're going to go to the trauma service because that's a different kind of care. But if you have a simple fall with a hip fracture, then we're going to take care of you.

Host Amber Smith: Do seniors with other kinds of fractures qualify for this program?

Sharon Brangman, MD: Not at this time, although in models across the country, they have looked at other fractures, but right now we're starting out with hips because hips are the ones that can change an older person's lifestyle so significantly. Other programs have expanded their co-care to all levels of surgical support, for general surgery, for vascular surgery, for trauma surgery. That could be something that we look at down the line, but right now we're focusing on hip fractures. We want to get this program going and help older people who have hip fractures in Central New York have the best outcome possible.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with nurse Lia Fischi and Dr. Sharon Brangman. Ms. Fischi is the interim orthopedic program manager at Upstate, and Dr. Brangman is the chief of geriatrics. And we're talking about a new program from the American Geriatric Society that's designed for seniors with hip fractures, called Ortho CoCare.

Ms. Fischi, how does Ortho CoCare work from the patient's point of view? I want to ask if you can walk us through what happens if someone falls and fractures their hip.

Nurse Lia Fischi: So when they do come to our hospital, like Dr. Brangman was mentioning, our key goal is standardized care for the older adult. So we provide very patient-centered care, taking the patient as a whole. We use evidence-based practice and the current clinical practice guidelines so that the patient has the best outcome. So with that, our work included standardizing order sets, our notes, staff education to allow us to provide standardized, high-quality care for the patient when they come in through the emergency room or direct admission.

Sharon Brangman, MD: What we really did was look at them from the minute they hit the emergency department, so our emergency department team is aware of them. The operating room is aware of their needs, the hospitalists, which are the doctors that manage care in the hospital, are part of our team, our physical therapists, our pharmacists, we have pain experts who are going to be involved, so that every piece of care that's needed when you have a hip fracture is being addressed.

Host Amber Smith: Now, can they come to either emergency department, either at the Community campus or downtown? Is that right?

Nurse Lia Fischi: Yes. Both downtown and Community.

Host Amber Smith: And is this the type of injury that's going to require X-rays for a diagnosis?

Nurse Lia Fischi: Yes.

Host Amber Smith: And are there any other tests that would be done, and is surgery always recommended for a hip fracture?

Nurse Lia Fischi: No, not always. It's dependent, so the orthopedic surgeons will look at the X-rays and make a determination and also speak with the family and go from there, make a treatment plan.

Host Amber Smith: Now, without getting too involved in this, in terms of the surgery, is it a replacement of the hip or are they able to insert pins, or how is it done, typically?

Nurse Lia Fischi: Both. It could be a replacement. It could be pins. So it just depends on where the break is in the hip.

Host Amber Smith: Well, can you talk to me about what recovery is typically like and what you would hope to see in patients after the surgery is finished?

Sharon Brangman, MD: Normally, recovery is, somebody is watched to see how their pain is and then they may be walked around the unit if they can bear weight, so we can see how they move. And then a physical therapist would evaluate them at that point. And then a decision would be made. Do they need to go to a rehabilitation center or can they go home?

It really depends on the person,

Host Amber Smith: But it sounds like they're out of bed relatively soon after the surgery. And that's got to be a huge change from what it used to be.

Sharon Brangman, MD: We found out that bed rest is really not as good for us as we think. So our goal is to get people out of bed. There's an old saying: "Bed rest is good if you're dying." But you really want to get out of bed if you're older because staying in bed and not moving actually causes more harm than good. And not just to your hip, but to your lungs and your heart and the way your blood pressure responds.

So we want to make sure that people are getting out of bed. We want to make sure they don't have any catheters or IV (intravenous) lines and that they're eating a good diet. And that we have a physical therapist who evaluates them to see how well they're moving and what would be the next best step for them in their recovery.

Host Amber Smith: Are there things in particular that need to be looked out for during the healing, after a hip fracture, things that might warrant a return to the hospital or a call to the doctor, at least?

Nurse Lia Fischi: There would be signs of infection, fevers, chills, bleeding, new pain, new extreme pain, loss of feeling or numbness, swelling. Anything else, Dr. Brangman, to add?

Sharon Brangman, MD: Shortness of breath.

After a hip fracture, you may have an increased risk of getting a blood clot, so we want to make sure that you're on the right medications to reduce that risk.

But if anybody was to get any chest pain or problems breathing, we would certainly want them to come back to the hospital.

Host Amber Smith: What advice do you have for family and friends, if a loved one has had a hip fracture? I'm wondering what they can do to help while the person's in the hospital?

Sharon Brangman, MD: Well, I think it's just good support to make sure that their needs are being met in the hospital and to give input on the best place for them to get their rehabilitation. I think it would be important to know the reason for the fall so that we could look back and prevent any future falls.

There's a lot of reasons why people fall as they get older. There are normal changes that happen with our gait and balance as we get older, and then you can add medications and certain medical problems, but most of the time falls are due to accidents that can often be prevented. So we want to make sure that if somebody had a fall, that we talk about future fall prevention, make sure there's no clutter in the house and that no one's climbing on a ladder and they're wearing the right footwear so that they get the right support on their feet.

And we do a medication review to see if there's any medications that can make someone more prone to falls, so the next step is, after the fall and somebody has recovered, we want to reduce the chances of them falling again.

Host Amber Smith: If someone over the age of 65 arrives with a broken hip, are they automatically enrolled in this Ortho CoCare Program, or do they have to ask about it?

Nurse Lia Fischi: They're automatically enrolled into the program.

Host Amber Smith: That makes it easy. Well, I want to thank both of you for taking time to explain this to us.

Sharon Brangman, MD: We're really excited about this program, and we're so glad to be offering it to older adults in our area.

Nurse Lia Fischi: Very happy.

Host Amber Smith: My guests have been Lia Fischi, she's a nurse and clinical lead for the Ortho CoCare Program and the interim orthopedic program manager, and Dr. Sharon Brangman. She's the chief of geriatrics at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.