Comanage orthopedics like a pro

An expert offers her top 10 pearls.

The patient had been admitted for a hip fracture, but his history and comorbidities were extensive: coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation, and, just a month before, a type 2 non-ST-segment elevation myocardial infarction (NSTEMI) after a lower-extremity revascularization.

Dr Wallace Photo by Kevin Berne
Dr. Wallace. Photo by Kevin Berne

“He was admitted to the orthopedic surgery service with hospitalist comanagement,” said hospitalist Mary Anderson Wallace, MD, FACP, who offered the anecdote during her Internal Medicine Meeting 2018 session on orthopedic comanagement.

The patient reported worsening dyspnea, and his electrocardiogram, troponin, and echocardiogram were concerning for a type 1 MI, so a cardiologist was consulted. Since it was the start of the weekend, a stress test to determine whether the patient could benefit from a cardiac catheterization was scheduled for Monday. In the meantime, the cardiologist counseled the orthopedists that it would be reasonable to proceed with surgery if they deemed it emergent.

But on Sunday, the patient underwent hip fracture repair, which is “by definition, an urgent procedure, not an emergent surgery,” noted Dr. Wallace. Shortly after surgery, he died, most likely of an anterior STEMI.

This case highlights one of Dr. Wallace's top 10 pearls for comanagement: the importance of speaking a common language. “Having that shared understanding of perioperative terms—what is emergent and what is urgent—could really have an impact on people and could potentially have led to a different outcome in this case,” she said.

Ten tips

Dr. Wallace, who is an assistant professor of hospital medicine and directs the medicine consult service at the University of Colorado in Aurora, offered all 10 pearls, and the latest data on debated topics in orthopedic comanagement, during her session.

Her next tip was pretty simple: “This probably seems very obvious, but I did want to include it: It's the importance of introducing yourself and explaining your role to the patient,” said Dr. Wallace. “You've probably experienced that patients have a hard time sometimes telling us apart from the orthopedic surgeons and the infectious disease team, etcetera, so it can go a long way if you can explain what part of their care you're responsible for.”

Communication was the focus of many of her tips, and it begins in the medical record. “It's no secret that we tend to write longer notes than the orthopedist.... If there's something that you want to be sure really gets communicated to the orthopedic team, try to put it up on top in your note, bold it, bullet point it, whatever it takes, just so it's really clear and obvious,” she said.

And even better than a clear note is a conversation. “Try to communicate your recommendations in person, every day, either that or over the phone,” Dr. Wallace said.

At discharge, that communication focus should shift to the patient's primary care physician. “This probably varies from institution to institution, but at our hospital, it's primarily the orthopedic [physician assistants] and sometimes the residents who do discharge summaries. There can be some variation in terms of the level of detail about [the patients'] medical course,” said Dr. Wallace. “If something major happens during the hospital stay, try to pick up the phone and call the primary care doctor, or forward your note at the time of discharge.”

One topic of interspecialty communication should be clear assignment of responsibilities. “If a heparin drip needs to be restarted after surgery, who is putting in that order? Helping to delineate those things, I believe, is really important to trying to prevent things from falling through the cracks or preventing duplication of work,” said Dr. Wallace.

Sometimes a little duplication is necessary, however, as her next tip indicates. “Trust but verify the med rec,” she said. “We certainly go through the med list with a fine-toothed comb on those patients that we're comanaging, particularly around high-risk medications, like anticoagulation or insulin or other meds that tend to get mistimed around surgery.”

Medication regimens are individual, but other aspects of care don't have to be. “Use protocols, order sets, and pathways,” Dr. Wallace advised. “I was talking to some of my colleagues recently who work at another hospital in our division.... They actually comanage three to four independent orthopedic groups, and all of those groups use different pain management pathways, different VTE [venous thromboembolism] prophylaxis precautions, etcetera.”

At her hospital, a pathway was created to place all geriatric hip fracture patients on one unit with a single orthopedic surgery service. Hospitalists manage their pain and prophylactic needs according to standardized order sets. “Just with those relatively simple interventions, we were able to reduce length of stay by about a day and show significant improvements in osteoporosis treatment at the time of discharge and even achieve a long-term mortality benefit,” said Dr. Wallace.

Her next-to-last tip was a very specific one: Have the incentive spirometer within the patient's reach. “Sometimes I feel like this is what I spend most of rounds doing. You come in. You can't find the incentive spirometer anywhere. You eventually find it over by the sink. You bring it back over to the bed and talk the patient through its use,” she said.

The last piece of advice could make all of the other ones easier to execute. “Finally, I'll just call out the importance of building relationships with your orthopedic colleagues,” Dr. Wallace said. “I found that this has happened most naturally when I worked together with them on a project or developing a pathway together, and I think if you can establish that genuine sense of trust and respect and mutual appreciation for each other's strengths and weaknesses, it'll go really well.”

Hot topics

From her own personal advice, Dr. Wallace moved on to the best comanagement practices identified by recent research.

First, she tackled the question of how soon patients need to undergo hip fracture repair. The goal should be less than 24 hours, based on a study published in the Nov. 28, 2017, JAMA. It found higher complications and mortality among patients operated on after that cutoff. The one caveat is for patients who need treatment of a decompensated medical issue before surgery, she noted.

Next up, how worried should you be about a fever in a patient who has just had a hip or knee replaced? “Fever early after total joint replacements is usually due to cytokine release,” said Dr. Wallace, noting that fevers lasting multiple days or starting on the third day are more likely to signal infection. “We can use the time course of postop complications to inform our pretest probability and guide our testing.”

Also on the subject of timing, it could be OK to wait a little longer to catheterize patients with postoperative urinary retention. A study in the June 2016 Anesthesiology found that patients who were catheterized at a threshold of 800 mL in their bladders had similar outcomes to those treated with a 500-mL threshold.

“It's something to consider doing for your patients with postop urinary retention,” said Dr. Wallace. “The one caveat being that you wouldn't want the duration of distention to last more than two or three hours, because that's theoretically when you start having some bladder damage.”

Other recent news in the field includes the 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline on managing immunosuppressive medications in patients having hip or knee replacements, published by Arthritis & Rheumatology on June 16, 2017.

“There still aren't very many randomized controlled trials out there, but at least there's a starting point for us to standardize our care,” said Dr. Wallace.

The use of aspirin after hip or knee replacement has also been far from standardized. “It seems like nothing has been such an enduring controversy in the comanagement literature,” said Dr. Wallace, noting that a 2008 CHEST guideline recommended against aspirin but the organization came out in favor in 2012. “Over the course of about four years, we had a nearly 180-degree reversal in what we should be doing.”

Researchers continue trying to determine whether some lower-risk patients can take aspirin instead of anticoagulants. “That generally seems to be the case, that patients who get aspirin seem to have no worse rates of VTE than those patients who are getting the standard anticoagulants and perhaps even lower risk of bleeding,” she said. “The question remains, ‘What is the optimal aspirin dose that we should be giving to patients?’ ... There's a lot of interest in figuring out if we can get by with low-dose aspirin for this population.”

Shifting to the cognitive consequences of surgery, Dr. Wallace reviewed a recent study in which the Mini-Cog assessment was given to patients scheduled for an elective hip or knee replacement who were age 65 years or older and didn't have a diagnosis of dementia. According to results published in the November 2017 Anesthesiology, 24% tested positive for probable cognitive impairment.

“That actually predicted how patients did after surgery,” said Dr. Wallace, so hospitalists might want to consider using the test to calculate patients' perioperative risks.

Risk of postoperative delirium will not be affected by whether you prescribe gabapentin, however, according to an article in the October 2017 Anesthesiology. “Think twice about adding gabapentin to the pain regimen for these patients for the sole purpose of preventing postop delirium. There could still potentially be a role for adding it for the purposes of helping with pain,” Dr. Wallace said.

Finally, she noted that reducing the overall costs of orthopedic surgery has become a particular concern for hospitals, thanks to bundled payment programs. Hospitalists can help with this by focusing on where their patients go after discharge.

“You can see that there would be a benefit to establishing a relationship with a few select [rehab] facilities where you really trust that they're going to have an efficient rehab protocol and move the patient through the system,” Dr. Wallace said. “Perhaps counterintuitively, it could even be cheaper for the hospital to keep the patient a day or two longer in the hospital for more rehab, if then they could go home with home health care rather than to a skilled nursing facility.”