Assessing Preinjury Frailty in the Elderly Hip Fracture Patient to Promote Palliative Care Referral in Those at Risk for High Morbidity and Mortality

Abstract

Objective: To assess preinjury frailty in elderly hip fracture patients as a predictor for postsurgical morbidity and mortality, prompting early referral to palliative care services in patients deemed high-risk for postoperative complications. Including palliative care in the multidisciplinary care of the highrisk patient has been shown to improve quality of life (QOL), increase patient and caregiver satisfaction, and reduce healthcare costs. Design:The design is a quality improvement initiative. Setting:The setting is an academic medical center, serving as the region's Level 1 Trauma Center. There is no current process for measuring frailty as a predictor of postsurgical morbidity and mortality.Participants: The project's participants are elderly adults aged 65 and older presenting to the emergency room for treatment following a hip fracture. Interventions/Measurements:A frailty measurement tool using PDSA (plan-do-study-act) cycles was selected. Next, a clinical decision-making algorithm for risk assessment and palliative care referral was designed and implemented for the project participants. Pre-and post-implementation referral rates and post-implementation risk identification and compliance with the utilization of the risk assessment tool were measured. This initiative aimed to begin preoperative frailty assessment with 50% compliance in the target population, with palliative care referral occurring per recommendations based on an algorithm.Results: Patients in the post-implementation group were more likely to have their frailty risk evaluated and to receive a palliative care referral than the pre-implementation group. Rates of risk identification and palliative care referral increased by 68% and 85%, respectively, which surpassed the goals of this initiative. Conclusion:Identifying patients with higher preinjury frailty can predict those at risk for mortality and morbidity, thus indicating those patients for whom palliative care referral may be beneficial. Using a standardized process for preinjury frailty screening and referral increased risk assessment and palliative care referral for elderly hip fracture patients.