Much akin to Charles Dickens’ famous tale of two cities, the orthopaedic bastille has been stormed with the publications of the Blue book and BOAST 1 guidelines. Supported by heavy artillery in the form of the new HRG tariff for hip fractures, the revolution has well and truly begun. Ortho-geriatric services across UK have been transformed and this has catapulted this emerging sub-speciality onto the map. As a trainee, the changes have been marked, radical and at times near miraculous. Orthopaedic junior doctors are actually taking time to document AMTS scores (Abbreviated Mini-Mental Test Score) in the admission clerk-in whilst Ortho-geriatricians are culturing a knack of looking at post-op wounds and prescribing post-op venous thrombo-prophylaxis.
Different hospitals seem to structure ortho-geriatric services diversely. Some run a ‘liaison’ service – where geriatricians or specialist nurses visit the ward intermittently, others take the ‘nuclear option’ of having an ortho-geriatric team based on the orthopaedic wards and looking after the patient from admission to discharge. There are a variety of hybrid models in-between. This of course raises the question as to which approach is ‘better’. This would be an interesting research topic to tackle and the national hip fracture database may prove to be a future gold-mine of data. The service changes (egged on by the new tariff) seem to go a long way towards improving outcomes and care of older hip fracture patients. Issues such as Falls, Bone Health, Delirium, thrombo-prophylaxis and discharge planning are addressed from the outset.
As I complete this attachment, I am aware I have learnt a lot but am conscious of further unanswered questions and issues:
- Will the tariff be expanded to cover all older patents who are admitted with fractures? [At present due to the focus of the tariff on hip fractures, the ‘plight’ of older patients with other types of fractures is generally overlooked]
- In deciding Bone-protection, there are the usual questions of how long? When to switch? And what to do for the oldest old or near centurions?
- What is the place for dexa scans and myeloma screens? Should all patients be screened or just on a case-by-case basis?
- Who takes ultimate legal responsibility for the patient? Who is the primary consultant? Is it the Ortho-geriatrician or the Orthopaedic Consultant? [eg in terms of death/Complications or complaints]
- Which is the best way of running an ortho-geriatric service?
How does Ortho-geriatric services operate at your Hospital? Please blog your thoughts and comments here?