More seniors recover from hip fractures if they're treated as emergencies

There are good reasons that older people fear hip fractures. They can remember the days when a broken hip was often the beginning of the end. Even today, up to 30 percent of seniors who break a hip are dead in a year. Many others never get around quite as well as they did before, which could make the difference between living at home or in assisted living, or even a nursing home.

Yet until recently, doctors often took a fairly leisurely approach to fixing broken hips. Patients would wait in bed for two or three days for surgery while doctors carefully evaluated their other medical problems. Now, spurred by research that found better results with shorter delays, hospitals are creating special programs to get more hip-fracture patients into the operating room within 24 hours or less of entering the hospital. A clinical trial in Canada is testing whether surgery within six hours should be the goal. Run by a cardiologist, this trial, known by the acronym HIP ATTACK, is treating hip-fracture victims with the kind of urgency that is now the norm for heart attack and stroke patients.

Hospitals in the Philadelphia region haven't gone that far yet, but several have created special programs to expedite care for older patients with fragile bones, whose frailty makes prolonged bed rest especially dangerous. Among them are Penn Presbyterian Medical Center, Temple University Hospital, Einstein Medical Center, and Bryn Mawr Hospital. The multidisciplinary programs also work with patients before they leave the hospital to discuss how to strengthen bones or prevent more falls.

Almost everyone who breaks a hip will get some kind of surgical repair, surgeons said. The question is when.

The pressure to speed up hip-fracture treatment grew after an August 2015 study of more than 2 million patients found higher in-hospital death rates for patients who got surgery more than two days after admission. Complication rates rose with each day.

Joseph Zuckerman, an orthopedic surgeon at NYU Langone Medical Center who led the study, thinks it's impractical to talk about 24-hour or 48-hour periods because of the logistical challenges of doing surgery in the middle of the night. He said doctors have long known that it is better to repair broken hips quickly but  they also want to thoroughly evaluate patients' other medical problems, and that adds time.

Until the 1950s and 1960s, Zuckerman said, hip fractures were treated with long periods of bed rest. "People were dying left and right," he said.

Modern repair methods have changed that. "The basic principle has always been to take them to the operating room as expeditiously as possible," Zuckerman said.
But busy ORs and lack of coordination between specialists who need to evaluate patients can slow the process, doctors said.

The Canadian trial is testing whether patients do better when the times are reduced even more. It is enrolling patients admitted between 6 a.m. and 5 to 8 p.m. Philip Devereaux, the study leader and a cardiologist at McMaster University in Hamilton, Ontario,  is particularly interested in truncating the body-wide inflammatory response that a broken hip sets off. It can lead to blood clotting problems that make patients more prone to heart attacks and strokes.

"The quickest way to resolve that," Devereaux said, "is to get the surgery done as soon as you can." That allows the bone to start healing faster.

It also isn't good, he said, for patients to spend days in pain. Many aren't eating while they await surgery.

About a quarter million elderly Americans fracture a hip each year, a number that is expected to rise as the giant baby boom generation ages.

The breaks are considered a sentinel event — a wake-up call that a patient has been declining. Doctors say it's hard to know sometimes whether the hip is what leads to death or whether it's one of many things heading in that direction. While the goal is for patients to return to their previous function after hip repair, surgeons said many never quite do.

Penn Presybterian started its geriatric hip-fracture program last February. Its focus is on prioritizing older hip-fracture patients — the program's average patient is a 78- to 82-year-old woman — in a coordinated way. Before, said Samir Mehta, chief of orthopedic trauma, "everyone would do their job and [they] were ships passing in the night."

Now, the minute a hip-fracture patient enters the hospital about a dozen people — surgeons, nurse managers, researchers, hospitalists, geriatricians, therapists,  social workers — get a hip-fracture alert text similar to what they receive for stroke patients. The group has streamlined processes and made sure that elderly patients, who don't tolerate medications as well as younger people, get painkillers and other medicines that won't make their problems worse.

Mehta said that patients are more likely to suffer from complications like heart and lung problems or pressure sores if they wait a long time for surgery. The new approach aims to get the bone repaired and have patients up and moving around as soon as possible.

There's much more communication between staff members now, which "by far improves the efficacy and quality of care," Mehta said.

The average length of stay in the program dropped by two days for hip patients between 2014 and 2016. Complications held steady at 7 percent. The average number of hours to the OR dropped from 23 in 2015 to 17 this year, according to Penn data.

Alysa Krain, a geriatrician who sees all of Presbyterian's hip-fracture patients 70 and older, said she tries to get patients off of medications that might make them more likely to fall. Some may be prescribed drugs for after they leave to make their bones stronger. They also discuss other factors that might make a patient prone to falling — shoes that don't fit, poor lighting, a lack of hand rails on stairs.

Susan Bush, 67, who lives 100 miles north, in Pocono Pines, Pa., wound up at Penn Presbyterian on Sept. 25 after her 60-pound dog, Piper, spotted a bear in their neighborhood. Bush was already on one crutch because of an earlier problem with her right hip. The dog, which has a "reputation as a bear bully," was on a long leash that wrapped around Bush's ankle. She fell and heard a snap.

Because she had previously been treated at Penn, Bush took a very painful ambulance ride to Philadelphia. Mehta had her in the OR in 13.6 hours. In the meantime, she signed up for a research study.

By December, she was back to work and driving, but still using a crutch she wasn't sure she needed. Her confidence had taken a hit. "I am so thankful that I can move," Bush said.

She also appreciated that the Presbyterian team wanted to find out why she had broken four bones — there was also an elbow and foot — in the last 16 months. That's still a mystery.

Other hospitals have similar initiatives.

Bryn Mawr Hospital, which treats about 200 hip fractures a year, began piloting its hip-fracture program in 2014. It has reduced time to the operating room from 31 hours to 23. Complications are down by 6 percent. That effort is now expanding to other parts of the Main Line Health system.

Unlike Penn, Bryn Mawr does not use orthopedists to manage its hip patients. "This is really a medical patient who happens to break their hip," said Marianne Harkin, vice president of patient care. Bryn Mawr's team looks at environmental factors that might have led to the fall. And, for patients in their late 80s and early 90s who may not recover well, the hospital brings in palliative-care specialists to talk with families about "life planning."

Christopher Haydel, an orthopedic surgeon who is codirector of Temple's  geriatric hip-fracture program, said Temple University Hospital is shooting for getting patients to surgery within 24 hours, down from two to three days a couple of years ago.

Doctors there discovered that unnecessary heart tests were slowing things down. "If there was any suggestion of a heart condition, that would delay the case probably two to three days," Haydel said.

Daniel Goldstein, an orthopedic surgeon at Einstein Medical Center Montgomery, said his hospital gets 10 to 15 "fragility" hip fractures a month. Up to 95 percent of them are now in the OR within a day.

In the past, Goldstein said, doctors were sometimes ordering tests whose results wouldn't change what surgeons would do. Doctors can successfully operate on even very old patients.

Still, they would have been better off if they had never needed surgery. "We've gotten really good at fixing broken hips," Goldstein said. "We haven't gotten really good at preventing them."