Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome.

OBJECTIVE: The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management. METHODS: Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated. RESULTS: In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate. CONCLUSION: We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients. LEVEL OF EVIDENCE: III, prospective non-randomised cohort study.

Continuous improvement process: ortho-geriatric co-management of proximal femoral fractures.

OBJECTIVE: The objective of the current study was to evaluate the effect of a quality management system on treatment and care delivery of proximal femoral fractures. Specifically, our hypothesis was that the "plan-do-check-act (PDCA)" philosophy of the ISO 9001 quality management system results in a continuous improvement process. METHODS: 1015 proximal femoral fractures were prospectively included into a hip fracture database over a 5-year period, after a restructuring process with implementation of clinical pathways and standard operation procedures. A close and structured ortho-geriatric co-management (certified ortho-geriatric center) was the basis for treatment. ISO 9001 certification was granted for the first time in 2012. Procedural and patient outcome parameters were analyzed by year and evaluated statistically using SPSS 25.0. RESULTS: In both categories (procedural and outcome) significant changes could be detected during the 5-year period, e.g., significant reduction of time to surgery for the first 2 years, improvement in discharge management, and reduction of surgical complications. However, no significant changes could be demonstrated for mortality or internal complications such as pneumonia, urinary tract infections, or postoperative delirium. However, the incidence of the latter was already on a very low level at the onset of the quality improvement process. CONCLUSION: We could show a relevant and continuous improvement of several quality indicators during a 5-year period after implementation of a quality management system based on the PDCA philosophy for the treatment of proximal femoral fractures in elderly patients. However, other parameters (internal complications, cost-effectiveness, etc.) need our close attention in the future.