Patient Admitted

1. Patient admitted to Orthopedics unless age > 90, multiple medical co-morbidities requiring active management, or significant active medical issue per current protocol.
2. Geriatrics co-follows/consults on all patients 65 and older and all patients in the ortho-bundled payment program no matter which service they are admitted to
3. Orthopedic On-call chief notifies attending on-call and covering trauma attending as well as University Service Chief and Intern (Attending covering case will depend on when case can go to the OR, if case goes from 1PM to 7PM then ortho trauma attending of the day will cover. If the case goes after 7PM or on weekends then general on-call attending will cover).
4. Orthopedic chief discusses all hip fractures admitted overnight or planned for surgery each day with E1 in the morning at approximately 7AM at the surgery board. This discussion will include any relevant co-morbidities that may affect surgical planning as well as any concerns raised by geriatric/medicine service.
5. Daily Hip Fracture Rounds at 1:30PM in Location 754L, attended by on-service geriatrician, orthopedic surgery intern, arthroplasty NP, case management, bedside nurse PT/OT, & primary team (if not on Med or Ortho). Email will be sent each morning to team members that should attend.
6. For patients admitted in the evening keep NPO after Midnight in anticipation of OR next day, for patients admitted in the morning keep NPO for possibility of OR the same day.
7. 100-150cc/hr  normal saline maintenance fluids started early (monitor fluid status carefully)
8. Hold ACE inhibitors to prevent intraoperative hypotension and AKI, restart POD #1
9. Continue beta-blockers/rate control medications
10. Pain Control

                                i.Tylenol 1000mg TID PO ATC, use IV only if unable to take PO

                                ii.Call pain service for pre-op fascia iliaca block if not done in ED

                                iii.If age>70, start Oxycodone 2.5mg po Q 3 hours prn, Dilaudid 0.4mg Q2 hour prn severe pain

                                iv.If age<70, start Oxycodone 5mg po Q 3 hours prn, Dilaudid 0.6 mg Q2 hours prn severe pain

11. Delirium Order Set
12. PT/OT ordered pre-emptively to service aware of impending need
13. Patient admitted to 7 Long if possible
14. Order Vitamin D if not already done in ED
15. PMD contacted on admission to confirm medication list and co-morbidities (Geri/Med)

Postoperative Course

1. Daily Hip Fracture Rounds at 1:30PM in Location 754L, attended by on-service geriatrician, orthopedic surgery intern, arthroplasty NP, case management, bedside nurse PT/OT, & primary team (if not on Med or Ortho). Email will be sent each morning to team members that should attend.
2. Standard postoperative antibiotics x 1 dose (orthopedics orders)
3. Postop CBC, Chem 10 x 1, other labs as needed or based on medical co-morbidities
4. Lovenox for VTE prophylaxis x 4 weeks to start POD#1
5. Bone Health Labs ordered: f/u Vitamin D level or order if not done earlier

i.If level is:

20-30 ---> start 2000IU daily

                                    31-40 ---> start 1000IU daily

                                    < 20 ---à start 50,000IU weekly x 8 weeks then 2000IU daily

ii.Start Calcium Carbonate at 1250mg po daily

6. Delirium order set
7. Patient seen by PT/OT the morning after surgery
8. Foley out POD #1, straight cath if retention
9. Goal discharge to home or facility is < 48 hours

Discharge:  (3 appointments need to be made: bone health, orthopedics, primary care)

a. BONE HEALTH:  Primary team schedules bone health appointment for 1-2 months after discharge: Place UCSF Skeletal Health Referral or contact initiated with patient’s PMD for bone health care if patient not local

b. ORTHOPEDICS FOLLOW UP:  Orthopedics team schedules Orthopedic Surgery Follow up (based on surgical type):

i.ORIF:  follow-up in Trauma Clinic with Advanced Health Provider for first visit

1. Referral and Orthopedic Intern emails Orthopedic Institute Scheduling Desk for Trauma Clinic follow-up in 2 weeks with radiographs

ii.Hemiarthroplasty or total hip arthroplasty: follow-up with Arthroplasty Fellow for first visit

1. Referral and Orthopedic Intern emails Orthopedic Institute Scheduling Desk for Arthroplasty Fellow Clinic follow-up in 2 weeks with radiographs

                                iii.Non-Local patient: follow-up with a local orthopedic surgeon in 2 weeks with radiographs

c. PRIMARY CARE: Primary team makes appointment with PCP within 2-4 weeks

d. Ortho Bundled Payment (OBP) program:  If patient meets criteria for the OBP, a Care Support Program Nurse Practitioner will connect with patient before discharge to ensure continuity 

                                i. Inpatient Case Manager & OBP Program Coordinator will be in communication to ensure collaboration with the UCSF complex care                                                               management team

                               ii. NP from Care Support will often meet patient in house before discharge

e. Primary service ensures detailed instructions for patient and family in the AVS:

                              iv.UCSF follow-up visits scheduled & listed with clinic addresses and phone numbers

1. Orthopedic Surgery
2. Skeletal Health
3. PCP

v.Post-op instructions

1. Wound care/dressing
2. PT/Activity

                                vi. Follow up anticipatory guidance

1.  Specific instructions on when to call the doctor (PCP vs Orthopedic Surgeon)

                                vi.Updated medication list

1. Neuraxial strongly preferred in all patients

                                i.INR < 1.3

ii.Must provide adequate paralysis for fracture reduction

2. Contraindications or neuraxial + regional anesthesia: Refer to: http://medctrpharm.ucsf.edu/system/files/documents/UCSF%20Antithrombotics%20%20Neuraxial%20Intervention%20July%202015.pdf

1. GETA for patients with INR > 1.3 but able to go to surgery otherwise
2. Basic Preoperative Workup

                                i.CBC, Chem 10, Coags

                                ii.Chest radiograph if clinically indicated (hx of heart or lung problems or sx)

                                iii.ECG if clinically indicated (hx of heart problems or new sxs)

d.Standard Preoperative antibiotics as a weight based dose of Cefazolin

                                i.Vancomycin for Cephalosporin allergic patients

                                ii.Vancomycin for penicillin allergic patients if the allergy was anaphylaxis

e.Tranexemic Acid 10mg/kg IV at the beginning and end of the case

                                i.Any specific concerns for contraindications to be discussed between attendings

Anticoagulation

1. Continue Aspirin at all doses
2. Warfarin

                                i.Hold Warfarin, give Vitamin K 5mg PO x 1 ASAP

                                ii.Type and cross for 2 units FFP

                               iii.Goal INR for OR is 1.5 or less for surgery, Goal INR for neuraxial anesthesia is 1.3 or less

                              iv.Re-check INR 12 hours after vitamin K dose

                              v.Can proceed with surgery if INR 1.8 or less and patient can get FFP on the way to the OR (patient will receive GETA)

3. Clopidogrel, prasugrel, ticagrelor, cilostazol

                                i.Continue any Acute Coronary Syndrome (treated medically or with stent) within last 12 months

                                ii.Continue if drug-eluding stent in last 6 months (in non-ACS)

                               iii.Continue if bare metal stent within last 1 month (in non-ACS)

                               iv.No need to delay surgery (patient will receive GETA)

4. NOACs (dibigatran, rivaroxaban, apixiban, edoxaban)

                                i.Hold, record time of last dose taken clearly. Clearance dependent on renal function.

                               ii.Generally hip fracture surgery with general anesthesia only can be undertaken 24 hours after last dose for all medications and normal renal                                           function (48 hours for Dabigatran and Apixiban and high risk of bleeding). Risks and benefits should be weighed by teams (ortho, medicine,                                       geriatrics, and anesthesia) for delaying surgery more than 24 hours.

5. Bridging

                               i.Bridging therapy with heparin indicated if any of the very high risk conditions below:

                               ii.Very high risk conditions

1. Mechanical heart valve
   1. Mitral prosthesis
   2. Caged ball/tilting aortic prosthesis
   3. Stroke/TIA within 6 months
2. Atrial Fibrillation
   1. CHADS-VASC score 7-9  + absence of additional bleeding risk
   2. Stroke/TIA or systolic embolism within 3 months
3. VTE
   1. VTE within 3 months
   2. Severe thrombophilia
   3. History of VTE during discontinuation of anticoagulation

Co-morbidities:  Only unstable conditions should delay going to the  OR (Active ACS, Unstable Arrhythmia, Decompensated CHF and Known Moderate/Severe Aortic or Mitral stenosis [a-d]) below:

1. Active Acute Coronary Syndrome (ischemic EKG changes or elevated troponin)

                               i.Cardiology consult and OR delay until optimized

2. Unstable Arrhythmia (hypotension or significantly uncontrolled)

                               i.Cardiology consult and OR delay until optimized

3. Decompensated CHF with new symptoms:  see “Patients requiring an echo”

                               i.New symptoms or severe decompensation needs an echo before OR

4. Known Mod/Severe AS or Mod/Severe MS with no echo in the past 12 months

5. Pulmonary Compromise

               a. COPD/Asthma- continue inhaled bronchodilators/steroids. If acute, serious exacerbation--consider delaying surgery 24-48 hours with steroid treatment

               b. Acute bronchitis/PNA: Assess for sepsis/SIRS/bactermia and treat as necessary

    6. Anemia

                                i.Transfusion trigger is Hgb < 8

7. Diabetes/Elevated blood sugar

                                i.Goal  blood sugar 100-180 (too low increases falls, too high impedes repair)

Patients Requiring an Echo

1. A recent Echo is defined as in the last 12 months
2. Only patients with the following conditions require a new echo

                                i.CHF with new symptoms/signs of decompensation

ii.Mod/severe aortic stenosis or mitral stenosis

     3. With new severe symptoms or new oxygen requirement

     4. If no echo in last 12 months

     5. Coordinate with cardiology to have echo done within 12 hours of admission (before 11 am next day)

Cardiac Anesthesia

a.Only a requirement at the discretion of the anesthesia service (Medicine, Cardiology, or Geriatrics should NOT recommend)