Innovation

Quick fix

Winnipeg hip surgery turnaround times among the fastest in Canada

Brenda Unfried and her husband Charlie
Brenda Unfried and her husband Charlie
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Orthopedic care in the
Winnipeg Health Region

About hip fractures

Repairing a fractured femur

Hip fracture prevention tips

BY ROBIN SUMMERFIELD
Winnipeg Health Region
Wave, November / December 2011

Brenda Unfried hadn't felt well in weeks, even months.

She wasn't in pain. She didn't have fevers, chills, coughing or any suspicious lumps or bumps. Instead, she was gripped by a general malaise, along with a niggling feeling that something wasn't quite right.

"I'm the type that never went to the doctor. I probably should have," she says.

Then, one day last May, while standing in line at a restaurant, Unfried collapsed.

Everything went white, then black. She woke up on the floor with a crowd of people hovering over her. The 61-year-old could barely move. "I was in such pain."

She managed to crawl on her hands and knees to a nearby table and two young men, who she later found out were studying to become paramedics, helped her sit up as they waited for the ambulance to take her to Concordia Hospital.

Once there, Unfried was wheeled into the Emergency Department for an X-ray. When technicians adjusted her leg to get the pictures they needed, she felt a sharp pain. "I thought I was going to die," Unfried says. "I had never had pain like that. It was awful." No wonder. Unfried's left hip was broken.

A hip fracture is the common term used to describe to a break in the femur, or thigh bone, which connects to the hip. It is one of the most serious - and painful - injuries a person can suffer. Not only does it effectively prevent a person from moving, it's also associated with a relatively high mortality rate. As a result, quick access to surgical care is essential. Studies show that delays complicate recovery and increase mortality rates. Timely care, on the other hand, means better quality of life, less pain, a shorter stay in hospital and faster rehabilitation.

Fortunately for Unfried, Manitoba has one of the fastest hip surgery turnaround times in Canada. Every year, an estimated 700 people break their hip in this province, and an estimated 81.2 per cent of them can expect to have their hip surgically repaired within 48 hours of their injury. Indeed, Unfried underwent surgery to repair her hip a mere 26 hours after she suffered her injury. At 82.9 per cent, only New Brunswick performed better.

Of course, the quick turnaround times didn't happen by accident.

In 2007, Manitoba was the worst in the country for timely hip fracture care, according to Health Indicators, a Canada-wide analysis and comparison of provincial health-care systems, patient care and access to care produced by the Canadian Institute for Health Information and Statistics Canada.

Provincially, just over half of hip fracture patients (53 per cent) were getting their hip surgery within the 48-hour benchmark, while the remaining 47 per cent of patients waited longer, ultimately setting back long-term recovery and increasing the risk of death.

But then things started to change.

Led by Dr. Eric Bohm, the Winnipeg Health Region's Orthopedic Standards Committee started developing an innovative plan to overhaul the hip surgery program.

The 2007 Health Indicators "provided the catalyst for change," says Bohm, who is also Director of Research for the Concordia Joint Replacement Group at Concordia Hip and Knee Institute. The result has been a dramatic improvement in care. "We've gone from being at the bottom of the pile to the top of the pile in Canada."

The key was to change the way hip fractures were viewed within the system. Bohm, who has co-chaired the Region's Orthopedic Standards Committee since 2005, had been concerned about timely care since the beginning of his tenure. So, with the support of the Region's surgical leadership, the group started its own audit of care.

Along with Laurie Walus, standards committee co-chair, and Linda MacDonald, the Region's orthopedic wait list coordinator, Bohm enlisted the surgery program directors at Grace Hospital, Seven Oaks General Hospital, Concordia Hospital, Victoria General Hospital and the Health Sciences Centre to collect data on hip fracture surgery and patient care. Their goal was to identify the common causes of delays in hip fracture surgery. They discovered patients faced five major barriers to getting timely surgery for their hip fractures, including:

  • Lack of beds at hospitals and a perceived inability to take outof- region transfer patients;
  • Delays waiting for pre-existing blood thinner medications to wear off before surgery;
  • A mandatory but sometimes unnecessary pre-surgery consultation with an internal medicine physician;
  • A classification system for emergent surgeries that sometimes bumped hip fracture surgeries over the 48-hour mark; and
  • Lack of education within the system about the need for timeliness in hip fracture surgeries.

With recommendations from Bohm and company in hand, the Region made wide-ranging changes to the existing system.

These changes included:

  • A rotation calendar that explicitly outlined which Region hospital was responsible for accepting hip fracture patients from rural hospitals. As Bohm says, "It was as if they were in your own emergency department."
  • After a review of the most recent data of patients on the blood thinner Plavix and the effects of using spinal anesthetics, doctors recognized that the "risks in stopping the drugs - in particular strokes - outweighed the possible slight reduction in bleeding," Bohm says. Today, hip fracture patients on blood thinners are put under with a general anesthetic, allowing surgeons to perform surgery in a "timely fashion."
  • The mandatory pre-operation consultation process has been streamlined to include just the orthopedic surgeon and the anesthetist, unless the patient has a pre-existing medical condition like congestive heart failure or a poorly controlled irregular heart beat. In those special cases, an internal medicine consult still occurs.
  • The classification system of urgency for surgery now bumps up hip-fracture patients whose surgery has been delayed overnight into the second highest ranking. The higher classification means those patients get their surgery sooner.
  • An educational program amongst health professionals in the Region outlined the importance of timely hip fracture surgeries, risks of increased mortality, issues related to unnecessary delays because of blood thinners, and the need to eliminate needless consultations with internal medicine physicians before surgery.

"There's been a lot of work but we've had some great improvements," Bohm says of the changes introduced over the last few years.

Dr. Peter MacDonald, Medical Director of Orthopedics for the Winnipeg Health Region agrees, adding that the committee's changes have been implemented at all Region facilities carrying out surgical hip repairs, including Concordia Hospital, Seven Oaks General Hospital and Health Sciences Centre. "All the hip fractures done in the city follow the same guidelines," he says.

Unfried has been the happy beneficiary of those changes. Moments after she was wheeled into the Emergency Department at Concordia, the medical team went to work. The doctor on call conducted an initial assessment of Unfried's injury and ordered an X-ray. The injury was diagnosed as an intertrochanteric fracture, which means the break occurred below the neck of the femur, which is also known as the thigh bone and connects the hip to the knee.

The medical team at Concordia also discovered why Unfried fell in the first place. Turns out Unfried had Type 2 diabetes. Her blood sugar had spiked perilously high while she was at the restaurant, which is why she fell. So in addition to dealing with a fractured hip, Unfried would also have to learn how to manage her diabetes.

Following the diagnosis, the Emergency Department doctor consulted with Bohm. He then assessed the patient, conducted a physical examination and reviewed the X-rays.

Generally speaking, a surgeon will recommend a treatment plan for the patient following the consultation and taking into account many factors, including type of fracture, patient age and mobility level. This can range from nonoperative pain control in patients who are very ill (for example receiving palliative care for cancer) to fixing the fracture with plates, screws and/or rods, to doing a partial or complete hip replacement.

As one might expect, the technology used in hip repairs has improved over the years. At Concordia, and throughout the Region, the hardware used in hip repairs now allows for patients to be up and around sooner than was the case 10 years ago. In addition, Region hospitals have started using complete hip replacements for certain types of fractures, says Bohm. "This seems to provide a better long-term functional result."

In Unfried's case, Bohm opted to stabilize her broken hip with a plate and screws. Once inserted, the screws hold the fractured bone in place and the healing process, which can take three to six months, begins. With generous painkillers and expert care, Unfried was in no pain prior to her surgery, but she was a bit uneasy about what lay ahead. She wondered when she would be back on her feet and able to go back to her job as an insurance broker.

Fortunately, she had a few things going for her. After 20 years of faithfully taking a calcium supplement, her bones were in pretty good shape. The break was clean and genetics were on her side. Unfried's 92-year-old mother had two hips replaced and recovered very well. "It never crossed my mind that I wouldn't heal," Unfried says. Her biggest fear was "not waking up" from surgery.

She did wake up, hip repaired. Other than the 20 staples and a five-inch-long scar on her upper thigh, Unfried felt fine, relieved and thankful. "They did a fantastic job," she says. Pain medication ensured Unfried "felt nothing." With the help of a walker, nurses got her up and walking the day after surgery. She took about 10 steps to the threshold of her hospital room and back to her bed using a walker.

"Because I could weight-bear, I knew the recovery would be fine."

Back at home in her East Kildonan bungalow, Unfried struggled with the emotional trauma of her experience. "I had crying fits because I felt sorry for myself."

She used the walker for two weeks before graduating to a cane for another four weeks. Her surgical staples were removed after just 10 days.

By choice, she stayed primarily at home for a month after her accident and surgery. A few bouts of muscle spasms and sharp pains in her hip were knocked out with extra-strength acetaminophen. Other than one standard follow-up appointment with Bohm at the end of May, Unfried hasn't needed any rehabilitation.

"It's what I expected and I did it on my time. I wanted to do it my way," she says.

Now, Unfried is back at work. Her hip and her life are almost back to normal, thanks to the speedy work of her medical team at Concordia Hospital.

Robin Summerfield is a Winnipeg writer.

Wave: November / December 2011

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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