Hip Fracture Consult
For the assessment, be sure to assess and document the person’s prior functional and cognitive status, living
arrangements, need for home supports and for the presence of geriatric syndromes. See the ortho-geriatric
hip fracture template for further details.
This will help you come up with your plan that should focus on amongst other things:
1.
Delirium Prevention or Management
This usually emphasizes aggressive mobilization – up in chair for all meals and D/C Foley 48Hrs
after Surgery. Optimizing Pain and Nausea Management that emphasizes less deliriumgenic
medications and screening for B12 and Thyroid Issues helps as well.
1.
Pain and Nausea Medication Optimization.
Pain Management - D/C PAIN Meds Ordered and Reorder the Following Regimen:
a) Tylenol 1g PO TID and
b) Hydromorphone 1mg PO Q2H PRN and 0.5mg IV Q1H PRN (PRE-OP) and
Hydromorphone 1mg PO and 0.5mg IV Q4H PRN (POST-OP)
The thinking here is to reduce the use of opiates with round the clock Tylenol which is
underutilized in these patients. When using Opiates in these patients – the goal is to use the best
metabolized and most effective narcotics. T3s, Percocets, and Morphine are not as good as the
regimen that we are standardizing above.
Nausea Management – D/C the GRAVOL that is often Ordered and Reorder the Following
Regimen:
a) Zofran 4mg PO or IV Q8H PRN for Nausea/Vomiting or
b) Maxeran 5mg PO or IV QID PRN for Nausea/Vomiting
The thinking here is to reduce the patient’s exposure to high anti-cholinergic (and this
deliriumgenic) and less effective nausea medications like Gravol. If the patient has Parkinson’s or
is antipsychotic medications – then best to use Zofran instead of Maxeran which can cause some
EPS Symptoms in high doses.
2.
Constipation Prevention or Management
If patients are getting a narcotic – they should be on something for constipation.
3.
Osteoporosis W/U or Management and
4.
Geriatric Screening – for B12 Deficiency and Thyroid Issues
Every patient should get a B12, 25-Hydroxy Vitamin D and a TSH Level Done.
All patients can be started Pre-Op on Calcium Carbonate 1250mg bid and Vitamin D 1000 iu
Daily.
When their Vitamin D Level Comes back at less than 30 nmol/L we usually replete the patient
with a Vitamin D replacement protocol, usually Vitamin D 50,000 units weekly x 8 weeks, then
maintain on 2,000 units daily.
Chris our Geriatrics Pharmacist helps to follow-up on these results and will work with you to
advise on how we can initiate further treatment based on the results that are generated.
Last Revised: 7 February 2016
5.
Disposition Planning
The key here is to indicate the best plan of post-op care. Patients who had a good level of function
and are not severely cognitively limited should be recommended a Rehab Stay. Even patients
with mild-moderate dementia should be considered for a Rehab Stay as they can often benefit
from therapy.
We are currently working with the Orthopedics Group to revise the Hip Fracture Order Sets to
indicate the above. While the ORTHO Group is getting better about following the above regimen
- they are happy to give us permission to refine their orders directly to ensure their patients get the
best care and derive the best outcomes possible.
Last Revised: 7 February 2016