Utilization of a Standardized Care Pathway to Decrease Costs of Ankle Fracture Management.

INTRODUCTION: Ankle fractures are the most common fracture of the foot and ankle treated at trauma hospitals in the United States, costing millions of dollars yearly. The purpose of this study was to determine whether a standardized care pathway led to a difference in the direct and indirect costs of surgical fixation of ankle fractures at one Level I Trauma Center and tertiary care medical center. METHODS: We analyzed cost, volume, length of stay, and collections for surgical treatment of ankle fractures in inpatient and outpatient settings by the orthopaedics and podiatry departments during fiscal years 2016 to 2018. Based on these data, we compared projected costs and collections across a 5-year period with the procedure being done by a single department (orthopaedics only and podiatry only). RESULTS: Total costs per case fell by 18% in the orthopaedics department and 8% in the podiatry department over the 3-year period. The podiatry department spent an average of $1,296 (46%) more per case than the orthopaedics department, driven by increased average supply costs. Both departments had significantly decreased direct costs (P = 0.0039 orthopaedics and P = 0.033 podiatry) in the outpatient setting. The orthopaedics department also had significantly lower average supply costs than the podiatry department (P = 0.045) and significantly decreased total costs in the outpatient setting (P = 0.0084). DISCUSSION: The orthopaedics department performed a higher volume of cases at a lower cost per case than the podiatry department. These savings were driven by a standardized ankle fracture treatment pathway that we propose decreased direct and supply costs. Our results suggest that surgical treatment of ankle fracture cases using a standardized care pathway is economically advantageous because of limiting variations in care and creating manageable workflows.

Delirium Reduced With Intravenous Acetaminophen in Geriatric Hip Fracture Patients.

INTRODUCTION: Postoperative delirium is associated with opioid use in the elderly and is a common complication of geriatric hip fractures, with reported incidences from 16% to 70%. Intravenous (IV) acetaminophen is a safe and efficacious medication in elderly patients and has been shown to reduce use of opioids after hip fracture. At our institution, IV acetaminophen was implemented for the first 24 hours postoperatively as part of a multimodal pain control regimen for geriatric hip fracture patients. METHODS: A retrospective review of 123 hip fragility fracture patients older than 60 years from January 2016 to December 2016 was performed. Delirium was identified using a validated chart-based review tool. The rate of delirium, as well as length of stay, pain scores, opioid administration, need for one-to-one supervision, and readmissions were analyzed. RESULTS: Sixty-five patients (52.8%) received IV acetaminophen during this period. No notable differences were found in baseline characteristics between groups. Ten of 65 patients receiving IV acetaminophen postoperatively experienced delirium compared with 19 of 58 who did not receive the medication (15.4% versus 32.8%, P = 0.024). The IV acetaminophen group also required fewer doses of IV opioids on postoperative day 1 (0.37 versus 1.19 doses, P = 0.008), were less likely to require one-to-one supervision (9.2% versus 24.1%, P = 0.025), and had shorter lengths of hospital stay (6.37 versus 8.47 days, P = 0.037). Readmission rates and discharge dispositions did not vary with significance between the two groups. CONCLUSION: The inclusion of IV acetaminophen as part of a multimodal pain regimen led to fewer episodes of delirium in this study. The reduced use of opioids immediately after surgery may have been a large factor in this outcome. Lower delirium rates may reduce the utilization of inpatient resources for direct patient supervision and provide for shorter hospital stays.