Elderly Care: The Hip Fracture Journey Flashcards
12 standards of hip fracture care pathway?
- Transferred from the ED (emergency dept) to the orthopaedic ward within 4 hours
- Have the ‘Big Six’ interventions in the ED
- Receive the ‘Inpatient Bundle of Care’ within 24 hours
- Undergo surgery with 36 hours of admission
- Not to be fasted repeatedly and should be given fluids up to 2 hours before surgery
- Not to be pre-operatively catheterised without medical reason
- Have a cemented hemiarthoplasty unless otherwise indicated
- Receive geriatric assessment within 3 days of admission, if frail
- Receive early mobilisation by end of 1st day after surgery; have physiotherapy assessment by end of day 2
- Receive OT assessment by end of day 3 post-operatively
- Receive assessment of bone health prior to leaving acute orthopaedic ward
- Have recovery optimised by MDT, so they can be discharged within 30 days of admission
Why should long, uncomfortable periods on trolleys in A&E be avoided?
Pressure sores can develop
What are the ““big six” interventions that should be done in ED, when there is clinical suspicion/confirmation of hip fracture?
- Analgesia (esp. for X-ray)
- Early warning score
- Pressure area inspection
- Blood tests
- Fluid therapy
- Delirium screening
What is the inpatient bundle of care?
- Cognitive
- Nutritional
- Pressure area
- Falls
What does the geriatric assessment of a frail patient involve?
- Ongoing analgesia
- Fluid and electrolyte management, inc. blood transfusion
- Co-morbidity management, inc. medication review
- Prevention, identification and management of delirium
- Prevention of complications (infection, DVT, pressure ulcers)
- Early identification and treatment of complications
- Falls assessment
How to recognise delirium (acute confusion) using the confusion assessment method (CAM)?
Acute changes/fluctuating cognitive levels
Inattention
Altered conscious level or disorganised thinking
4AT tool helps identify delirium (scoring system)
Mx for delirium (acute confusion)?
Predisposing factors:
• Age, dementia
Precipitating factors:
• Pain, drugs and constipation
Propagating factors:
• Change in environment, constipation and infection
Treat underlying cause
Non-pharmacological methods:
• Ensure orientation, use the same nursing team and inv. family
Describe fluid Mx
This is critical peri-operatively and the appropriate fluids must be chosen (resuscitation vs maintenance)
There is a danger of fluid overloading
Describe pressure ulcers
Can start to develop within 30 minutes of lying on a hard surface, e.g: A&E trolley or floor at home
Cause pain and immobility, limiting rehab
More likely when:
• Delays to sugery
• Frail/ malnourished patients
• Failure to mobilise early
WHO pain ladder?
- Non-opioid +/- adjuvant, e.g: aspirin, paracetamol or an NSAID
- Opioid for mild-moderate pain +/- non-opioid +/- adjuvant, e.g: codeine
- Opioid for moderate-severe pain +/e non-opioid +/- adjuvant, e.g: morphine, oxycodone, fentanyl
Other types of pre-operatively analgesia?
Local nerve blocks
Types of post-operative analgesia?
- Paracetamol regularly oral or intravenously
- Codeine starting small dose (15mg) but can increased
- Morphine as required/ regular; oxycodone, if confused on morphine
Side effects of opiate analgesics?
Drowsiness, confusion, constipation, dizziness
How to assess falls?
Falls history
Examination • Visual assessment • Cardio Ax • Neurology Ax • MSK/gait Ax
Medication review
ECG +/- further Ix
How to assess bone health?
Basic assessment should be done whilst inpatient (with follow up arrangements)
Calcium/ Vitamin D intake should be assessed (most get supplemented)
Dual X-ray Bone Densitometry (DeXA) is required as outpatient
