Anyone do pre-op optimization for hip fractures in the ED?

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TheTruckGuy

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EM bound 4th year on my anesthesia elective. I've been tasked with coming up with a presentation of how the ED could help streamline getting elderly patients with hip fractures into the OR faster. I'm going through papers and stuff, but most of it seems to focus on what anesthesia can do differently, and I can extrapolate some of that out to things that could get started/ordered in the ED (either by the ER doc or the co-admitting internist). I was told the big name academic centers are doing some really fancy stuff and figure out what their recommendation on "best practice" was.

So do any of y'all do anything, or know if wherever you did residency (for recent grads), does anything to speed things up?

Thanks

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I work in the land of senior citizens (Gulf coast of Florida). This is my all day, every day.

CBC, BMP, CXR, EKG, INR, NPO, D5 NS w/20K+ @ (125 or so/hour... less if they're a frail old granny, more if they're a fatty boom-bah). Foley. I&O. Call to hospitalist. AMF.

That's it.
 
 
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Have y'all heard of anyone doing, or done yourself, orders for a pre-emptive echo to possibly shave a few hours off the time to OR? And I suppose this wouldn't fly outside of academic centers, but do your hospitals have the internists come in at whatever time at night to get started on any other tests?
 
our orthos are swamped. they usually dont go to the OR for a day or 2 anyways because no surgeon available.

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Same here, except hip fracture isn't enough to buy a Foley here. Concerns for catheter associated UTI have meant it is pretty much limited to acute urinary retention or intubated ICU patients that need strict urine output measurements. Which, in my opinion, kinda sucks.

I would think a patient with a hip fracture would qualify for a foley, with the indication of 'comfort care near the end of life".

OP, medical optimization for the OR is generally outside our scope of practice, as well as competely irrelevant to ED care. One suggestion, though, would be to have strict criteria for cardiology consultation (i.e. recent ASC or stent placement, decompensated CHF, a fib w/ rvr or other active arrhythmia, etc) to prevent unnecessary consultations and delays. You could also look into IV iron for preexisting anemia, I believe there's some emerging literature on this topic.
 
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I work in the land of senior citizens (Gulf coast of Florida). This is my all day, every day.

CBC, BMP, CXR, EKG, INR, NPO, D5 NS w/20K+ @ (125 or so/hour... less if they're a frail old granny, more if they're a fatty boom-bah). Foley. I&O. Call to hospitalist. AMF.

That's it.

We do the exact same except call goes to ortho as they take these admissions. Usually don't get surgery for 24 hours. Very rarely will they be an add-on for the end of the day if they roll in the early AM.

I do like the idea above about looking at IV iron. Could be an interesting thing to look at those with baseline anemia and potential prevention of transfusion (I have no clue how efficacious IV iron is for this)
 
I do like the idea above about looking at IV iron. Could be an interesting thing to look at those with baseline anemia and potential prevention of transfusion (I have no clue how efficacious IV iron is for this)
Very efficacious if they're going to sit on the floor for a week or so waiting for their surgery.
 
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Very efficacious if they're going to sit on the floor for a week or so waiting for their surgery.
Is that to say it takes a week to work?

I would guess it works better in those with microcytic anemia, does it work for all comers?
 
Thats not the purpose of the ED. Whatsoever. That is the entire reason they are getting admitted...so a hospitalist can evaluate them and determine what test they pre-op.

That being said I will often seen coags to prevent the patient from needing to be stuck again. Beyond that my job is not to provide inpatient care. If they want to go to the OR faster they can come see the patient faster.

I am more concerned with the chest pain people in the waiting room than ordering a preop echo on some dude at 2am.
 
Is that to say it takes a week to work?

I would guess it works better in those with microcytic anemia, does it work for all comers?
To get any appreciable bump in their Hgb, enough to keep them from getting blood (unless they're borderline already), yes. And obviously, giving iron for IDA works. But it typically helps everyone a little bit.

Our bloodless medicine program (very large JW population around here) typically does a 6-12 week pre-op optimization program including B12, iron and Aranesp for non-emergent patients. At a minimum, they like 3 weeks (enough for a full iron load, a B12 shot and 2 or 3 Aranesp doses) and we'll hold colon and other GI cancer surgeries for this.
 
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Thats not the purpose of the ED. Whatsoever. That is the entire reason they are getting admitted...so a hospitalist can evaluate them and determine what test they pre-op.

I would say that ED optimization would begin and end with "don't ask questions for which you cannot stand the answer." However, preventing others from doing that is one of the "Holy Grails" of EM in general.
 
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That being said I will often seen coags to prevent the patient from needing to be stuck again. Beyond that my job is not to provide inpatient care. If they want to go to the OR faster they can come see the patient faster.
I was thinking make "time to ortho eval in the ED" a metric for your ortho group (yes, I'm aware that if it's a private group they'll just move to another hospital) or part of the RRC core competencies for residency.

Nothing else, besides a financial incentive that no hospital can afford, is going to make that happen.

Also (and I'm very clearly showing my complete ignorance on the subject), is there any data to suggest that pinning a hip fracture at hour 4 is better than doing so at hour 48 (aside from the obvious issues of old people being immobilized for too long)? This isn't a STEMI or a stroke. I understand getting them out of the ED, but that should be a slam dunk.

When I used to moonlight on a hospitalist service, roughly 50% of the admits I took overnight were, "82F, HTN, DM2, COPD, FDGB, L hip Fx, Ortho consulted, admit to IM, formal ortho eval in AM". Took longer to move them upstairs than it did to do the H&P and put in admit orders. The Med Rec form is what kept me up all night.

Likewise, where I am now, the inpatient Geriatrics service is physically located on the Ortho floor...saves everyone a lot of time and energy.
 
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I was thinking make "time to ortho eval in the ED" a metric for your ortho group (yes, I'm aware that if it's a private group they'll just move to another hospital) or part of the RRC core competencies for residency.

Nothing else, besides a financial incentive that no hospital can afford, is going to make that happen.

Also (and I'm very clearly showing my complete ignorance on the subject), is there any data to suggest that pinning a hip fracture at hour 4 is better than doing so at hour 48 (aside from the obvious issues of old people being immobilized for too long)? This isn't a STEMI or a stroke. I understand getting them out of the ED, but that should be a slam dunk.

When I used to moonlight on a hospitalist service, roughly 50% of the admits I took overnight were, "82F, HTN, DM2, COPD, FDGB, L hip Fx, Ortho consulted, admit to IM, formal ortho eval in AM". Took longer to move them upstairs than it did to do the H&P and put in admit orders. The Med Rec form is what kept me up all night.

Likewise, where I am now, the inpatient Geriatrics service is physically located on the Ortho floor...saves everyone a lot of time and energy.

Excuse me, we're discussing metrics. Why are you asking for evidence?
 
EM bound 4th year on my anesthesia elective. I've been tasked with coming up with a presentation of how the ED could help streamline getting elderly patients with hip fractures into the OR faster. I'm going through papers and stuff, but most of it seems to focus on what anesthesia can do differently, and I can extrapolate some of that out to things that could get started/ordered in the ED (either by the ER doc or the co-admitting internist). I was told the big name academic centers are doing some really fancy stuff and figure out what their recommendation on "best practice" was.
I do love that you're on an anesthesia rotation and your research project, from Anesthesia, is basically how to best pass the buck for not meeting some ridiculous and irrelevant metric, to another department entirely.

Whoever assigned you that project is worthy of all of today's internet points.
 
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I have a great way to get hip fxs to the OR faster.
As soon as I identify a fracture, they are wheeled directly to the pre-op area.
Ortho, anesthesia, medicine and whomever else can see them there.
 
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