The International Collaboration of Orthopaedic Nursing (ICON): Best practice nursing care standards for older adults with fragility hip fracture

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Introduction

The purpose of this document is to provide nurses who care for older adults with fragility hip fracture with a framework to promote safe and optimal care for this vulnerable population. The successful application of the standards of care contained in this document requires clinical expertise and evidence-supported decision-making in order to maximize patient outcomes. In 2012, 2013 a two part consensus document published in the International Journal of Orthopaedic and Trauma Nursing entitled “Acute nursing care of the older adult with fragility hip fracture: an international perspective” was developed by nursing leaders from seven countries across 3 continents who delineated the recommended care standards for this group of patients (Maher et al., 2012; Maher et al., 2013).

Several years after publication of the original work, an audit tool was developed to explore the extent to which those recommended care standards were reflected in nursing policies and protocols in acute care settings (MacDonald et al., 2018). Distribution to 35 acute care sites around the world revealed a continued gap between what is known to be best practice and the care standards reflected in nursing policies and protocols. Those sites that participated in the audit indicated the audit process served as a gap analysis, raising awareness of opportunities for improvement.

Over five years have passed since the initial document was published. The present paper reflects a review of the literature and updating of the previously published standards to keep abreast of the latest knowledge, evidence and science. The section on mobility has been expanded and introductory material about frailty and sarcopenia has been added. The contributors are internationally recognized clinicians, educators and academicians experienced in care of the older adult with fragility hip fracture. They represent eleven countries across four continents. The focus remains on nurse-sensitive quality indicators specific to older adults with hip fracture, including:

  • Pain

  • Delirium

  • Pressure Ulcers/Injuries

  • Fluid Balance/Nutrition

  • Elimination: Constipation/Catheter Associated Urinary Tract Infection

  • Prevention of secondary fracture

This update coincides with the release of a global Call to Action issued by the Fragility Fracture Network (Dreinhöfer et al., 2018). This call to action serves to raise awareness of the global health crisis that will result from the rising number of fragility fractures. By 2010, the global incidence of one of the most common and debilitating fragility fractures, hip fracture, was estimated to be 2.7 million cases per year (Gullberg et al., 1997). Conservative projections suggest that this will increase to 4.5 million cases per year by 2050. While all countries will be impacted, in absolute terms, Asia will bear the brunt of this growing burden of disease, with approximately 50% of hip fractures occurring in this region by the middle of the century (Cooper et al., 1992). The associated costs are staggering: in Europe, in 2010, costs related to osteoporosis were 37 billion, while in the United States estimates for fracture costs for 2020 are estimated to be $22 billion (Hofheinz, 2018).

In order for global health care systems to survive this impending challenge, evidence-based care strategies must be adopted. For those who sustain a fracture, care for this vulnerable population must be prioritized and based on best practices. Clinicians must possess a heightened awareness that the first fragility fracture is a signal to address underlying bone health and prevent the cycle of recurring fractures. This paper provides clinicians who care for older adults with fragility hip fracture with a resource that contains current best practice evidence-based care standards.

Section snippets

Frailty & sarcopenia

Frailty and sarcopenia are complex geriatric syndromes, often overlapping in older individuals, that are recognized as important contributors to falls and fragility fracture (see Box 1).

Frailty is decline across multiple organ systems, placing the frail elderly at risk for functional deficits and comorbid disorders (Gielen et al., 2012). In a recent study of community dwelling adults aged 65 and older, frail older people were more likely to experience recurrent falls when compared to both

Mobility

The primary goal of nursing care for the older adult with fragility hip fracture remains to maximize functional independence. Up to 50% of people recover their pre-fracture function following hip fracture while the remainder experience ongoing limitations in mobility, activities of daily living, and quality of life (Dyer et al., 2016; Magaziner et al., 2003). These limitations may contribute to the observed increase in falls, long-term care admissions, and mortality after hip fracture (

Pain

Pain following a fall, hip fracture and surgical repair is distressing for the older person with the potential for serious adverse consequences. Older people with hip fractures are at high risk of under-managed acute pain after surgery. Poorly managed pain can result in impeded mobility, functional impairment and prolonged hospital stay with resultant increased healthcare costs (Chou et al., 2016; Björkelund et al., 2009). Pain may also contribute to the development of delirium, depression,

Delirium

Delirium is a cognitive disturbance prevalent in older adults with hip fracture with rates ranging between 16% and 62% (Bitsch et al., 2004; Edelstein et al., 2004). Defined as a sudden alteration in baseline cognition, delirium is characterized by rapid development of fluctuating disturbances of consciousness, attention and perception (American Psychiatric Association, 2013). It is well known that delirium is independently associated with a variety of adverse outcomes including; pressure

Pressure ulcers/injuries

Pressure ulcers/injuries (PU/PI) are common and present a major challenge for patients with hip fracture. Despite the fact that prevention strategies have been disseminated widely, the prevalence of pressure ulcer/injury remains high (Vanderwee et al., 2011; Bååth et al., 2014). Pressure related skin breakdown following hip fracture surgery is estimated to occur in 12% of patients (Magny et al., 2017). These largely preventable wounds cause suffering for the patient (Gorecki et al., 2009),

Fluid balance/nutrition/elimination

Following hip fracture surgery, older adults may experience one or more common post-operative complications including; delirium, heart failure or myocardial ischemia, deep vein thrombosis (DVT), pneumonia, pulmonary embolism (PE), anemia, urinary retention, and urinary infections - all of which increase length of stay and perioperative mortality (Carpintero et al., 2014). These “common” complications can affect the fluid balance, nutrition, and elimination status of the older adult with hip

Fluid Balance

Age related changes in homeostatic mechanisms and underlying co-morbidities increase the vulnerability of older people to the physiological stresses associated with hip fracture and subsequent surgery. Frail, older hospitalized patients are at risk of; dehydration, fluid overload, heart failure and electrolyte disturbances. Perioperative anemia prevalence ranges from 24% to 44% (Bateman et al., 2012) and acute kidney injury occurred in 24% of hip fracture patients in a study of over 2000

Nutrition

Nutrition plays a key role in recovery after hip fracture surgery. Often associated with aging, malnutrition is defined by the European Society of Parenteral and Enteral Nutrition (ESPEN) as: “a state resulting from a lack of intake or uptake of nutrients leading to diminished physical and mental function and impaired clinical outcome from disease” (Cederholm et al., 2017, p 51). Studies suggest that malnutrition is common in hospitalized older adults, with rates as high as 70% in those with

Elimination

An assessment of elimination habits/issues should be made on admission as part of the comprehensive assessment. Early resumption of baseline bowel and bladder habits must remain the priority following hip fracture. This section addresses two common complications related to elimination: constipation and catheter-associated urinary tract infection (CAUTI).

Transitioning care

From the moment a hip fracture occurs, the patient experiences multiple transfers between care providers and care settings. Research highlights that these transitions are perilous times for older hospitalized adults due to incomplete and inconsistent sharing of vital information (Kripalani et al., 2007a, 2007b). Problems with hand offs (or hand overs) are an international concern. Breakdown in communication was a leading cause of sentinel events reported to the Joint Commission in the United

Secondary fracture prevention

Osteoporotic, or ‘fragility,’ fractures represent a significant worldwide health threat. According to the National Osteoporosis Foundation, a fragility fractures usually result from a fall from a standing height or less. The World Health Organization and the International Osteoporosis Foundation report that 40% of women and 15–30% of men will sustain one or more fragility fractures during their lifetime (Melton et al., 1992a,b; Nguyen, 2007) and, globally, it is estimated that hip fractures

Orthogeriatric model

The orthogeriatric service model (OGS) is primarily used in the acute care setting and is focused on patients aged 60–65 years and over who present with a fracture from a low trauma incident, typically a hip fracture. The OGS model is an interdisciplinary collaboration between orthopaedic surgeons, orthopaedic nurses, and the geriatric team. The goal is to work collaboratively to optimize the patients' medical comorbidities and manage complications before and after fixation of the fracture.

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