Emergency Department



Geriatric Hip Fracture Care PathwayEmergency DepartmentH&P directed diagnostics and management. If hip fracture (Patient age 50 and over) suspected:AP pelvisIf hip fracture (Patient age 50 and over) confirmed:LabsComprehensive metabolic panel Complete blood count with auto-differentialType and screenPT/INR ImagingAP/Lateral hipAP/Lateral femurCXREKGConsultsIf PCP on staff, notify of admission for hip fracture.Contact and place order for consult: Faculty Medicine (MAR)Contact and place order for consult: Orthopedic Surgery Resident and orthopedic surgeon as specified by PCP, patient, family, or prior relationship with orthopedic surgeon (On call surgeon if no preference indicated)Bed Request: 6W unless higher level indicatedPre-operative (Medicine Team)H&P, Pre-operative medical evaluationAcutely decompensated medical problemsSurgical risk assessment using Gupta, RCRI, or NSQIP calculator Other co-morbids that may affect timing of surgery including, but not limited to, volume status, use of and indication for anticoagulation/antiplatelets and possible need for reversal, timing of hemodialysis, recent re vascularization procedures, recent MI, CVANotify OR when medically optimized and documented in chart by attending (41-5760)Medication Reconciliation and OrdersStop oral hypoglycemicStop/avoid unnecessary medications with high likelihood to cause deliriumAvoid abrupt cessation of medications likely to cause withdrawalOther H&P directed diagnostic and management ordersSymptom directed medicationsAnalgesiaPatient Controlled Analgesia, Adult Protocol- see PCA Order Form – No other opioids to be administered during PCA therapyAcetaminophen 500, Two tablets PO q6 hours if patient is not NPO -AND- Oxycodone IR 5 mg tablet, 0.5 tablet q4 hours as needed for pain if pain >3, <7 and patient is not NPO -OR- Oxycodone IR 5 mg tablet, 1 tablet q4 hours as needed for pain if pain >=7 and patient is not NPO –OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Hydrocodone-acetaminophen 5mg/325mg (Norco 5) 1 tab PO every 4 hr as needed for pain if pain >3, <7 and patient is not NPO -OR- Hydrocodone-acetaminophen 10mg/325mg (Norco 10) 1 tab PO every 4 hrs as needed for pain if pain >=7 and patient is not NPO -OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Oxycodone-acetaminophen 5mg/325mg (Percocet) 1 tab PO every 4 hr as needed for pain if pain >3, <7 and patient is not NPO -OR- Oxycodone-acetaminophen 5mg/325mg (Percocet) 2 tabs PO every 4 hrs as needed for pain if pain >=7 and patient is not NPO -OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Tramadol (Ultram) 50mg 1 tab PO every 4 hr as needed for pain if pain >3, <7 and patient is not NPO -OR- Tramadol (Ultram) 50mg 2 tabs PO every 4 hrs as needed for pain if pain >=7 and patient is not NPO -OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.NauseaOndansetron 4mg, one tablet PO q6 hours as needed for nausea and able to take PO –OR-Ondansetron 4 mg IV q6 hours as needed for nausea and unable to take POBowel RegimenSenna-docusate, 1 tablet each evening. Hold if patient having loose, frequent stools.Bisocadyl suppository daily as needed for constipation not relieved with senna-docusate or patient NPO.InsomniaTemazepam, 7.5 mg qhs as needed for insomniaDeliriumZyprexa zydis 2.5 mg sublingual x1 for CAM+. Notify MD –OR-Haldol 0.5 mg IM x1 for CAM+. Notify MD.IV Fluids (Select one and adjust rate if indicated):LR IV at 100mL/hrD5-LR IV at 100mL/hr0.9 NS IV at 100 mL/hrPerioperative AntibioticsCefazolin (Ancef) 1gm IVPB every 8 hr x 3 doses. Last dose to be completed within 24 hrs of anesthesia end time. (Patient weighing less than 80kg).Cefazolin (Ancef) 2gm IVPB every 8 hr x 3 doses. Last dose to be completed within 24 hrs of anesthesia end time. (Patient weighing greater than or equal to 80kg).If patient is Penicillin allergic give:Clindamycin (Cleocin) 600mg IVPB every 8 hr x 3 doses. Last dose to be completed within 24 hrs of anesthesia end time. (Patient weighing less than 80kg).Clindamycin (Cleocin) 900mg IVPB every 8 hr x 3 doses. Last dose to be completed within 24 hrs of anesthesia end time. (Patient weighing greater than or equal to 80kg).If patient is MRSA positive give:Vancomycin IVPB x 24 hours, pharmacist to dose. Last dose to be completed within 24 hours of anesthesia end time.Anticoagulation (Only if surgery will be delayed >24 hours after presentation to ED)Heparin 5000 units subcutaneous every 8 hours. Do not give within 12 hours prior to planned surgery. Labs (If not already completed in ED)25-OH Vitamin DTSHOther ancillary tests for osteoporosis as indicated by existing dataH&P directed ancillary testingNursingNotify primary physician if temperature greater than 38.5 ° C, HR less than 60bpm or greater than 110bpm, BP less than 90/60mmHg or greater than 160/100mmHg, or SpO2 <90%Vital signs per unit routineIntake & Output every 8 hours. Notify primary physician for urine output less than 30mL/hr.CMS checks every 4 hours on affected extremities. Call surgeon if exam changesPain assessment every 4 hrsHeel care every 8 hrs and apply heel protectors if indicatedCAM assessment every 8 hours, call primary MD if CAM+Insert foley catheter if indicated per unit foley catheter guidelines. DC on POD#1Hibiclens wipes to surgical siteIncentive spirometer to bedside, train patient on use, patient to use 10 times each hour while awake.Obtain surgical, anesthesia, blood product consentSCD to lower extremitiesHold all antiplatelet and anticoagulant medications within 12 hours of planned surgeryProvide and insure proper use of eye glasses and hearing aids if neededProvision of clock and calendarTurn out lights in room and minimize interruptions between 9PM and 6AMActivityBedrestDietNPO after midnightClear liquid dietHeart healthy dietMedium Carbohydrate Consistent (1800-2400 calories)medium carbohydrate consistent dietFaculty medicine team to notify primary MD of admission and transition care to them, or preferred hospitalist, POD #1. Primary MD may defer care to faculty medicine if desired. Post Op (Ortho Team)Activity (Select as indicated)Day of Surgery: Progressive mobility protocolDay of Surgery: complete bed rest. First post op day: Progressive mobility protocolAbductor wedge on when in bed; instruct on hip precautions Pillow between legs when turning patientDiet/Nutrition (Select One):Clear Liquid Diet; advance to pre-procedure diet as toleratedGeneral DietMedium Carbohydrate Consistent (1800-2400 calories)Heart HealthyAnalgesia (If not already ordered):Patient Controlled Analgesia, Adult Protocol- see PCA Order Form – No other opioids to be administered during PCA therapyAcetaminophen 500, Two tablets PO q6 hours if patient is not NPO -AND- Oxycodone IR 5 mg tablet, 0.5 tablet q4 hours as needed for pain if pain >3, <7 and patient is not NPO -OR- Oxycodone IR 5 mg tablet, 1 tablet q4 hours as needed for pain if pain >=7 and patient is not NPO –OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Hydrocodone-acetaminophen 5mg/325mg (Norco 5) 1 tab PO every 4 hr as needed for pain if pain >3, <7 and patient is not NPO -OR- Hydrocodone-acetaminophen 10mg/325mg (Norco 10) 1 tab PO every 4 hrs as needed for pain if pain >=7 and patient is not NPO -OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Oxycodone-acetaminophen 5mg/325mg (Percocet) 1 tab PO every 4 hr as needed for pain if pain >3, <7 and patient is not NPO -OR- Oxycodone-acetaminophen 5mg/325mg (Percocet) 2 tabs PO every 4 hrs as needed for pain if pain >=7 and patient is not NPO -OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Tramadol (Ultram) 50mg 1 tab PO every 4 hr as needed for pain if pain >3, <7 and patient is not NPO -OR- Tramadol (Ultram) 50mg 2 tabs PO every 4 hrs as needed for pain if pain >=7 and patient is not NPO -OR- Morphine 1 mg IV q4 hours as needed for pain if pain >3, <7 and patient is NPO –OR- Morphine 2 mg IV q2 hours as needed for pain >=7, notify MD if pain not <7 after 2 dosages.Celecoxib (Celebrex) 200mg PO BID to start day of surgeryKetorolac (Toradol) 15mg IV-Push every 6 hrs for 24 hrs. For patients greater than or equal to 65 years of age. (Pharmacist to adjust initial dose for renal function)Ketorolac (Toradol) 30mg IV-Push every 6 hrs for 24 hrs. For patients less than 65 years of age. (Pharmacist to adjust initial dose for renal function)VTE Prevention (Select one or more as indicated)Apixaban (Eliquis) 2.5mg PO BID (for 28 days for VTE prophylaxis) (Administer first dose between 11 and 23 hours after the end of surgery) Rivaroxaban (Xarelto) 10mg PO daily (for 28 days for VTE prophylaxis) (Administer first dose between 11 and 23 hours after the end of surgery) Enoxaparin (Lovenox) 30mg subcutaneous every 12 hrs (for 28 days for VTE prophylaxis) (Administer first dose between 11 and 23 hours after the end of surgery). Discontinue enoxaparin (Lovenox) when INR greater than 2 if bridging to warfarin. (Pharmacist to adjust initial dose for renal function)Warfarin (Coumadin) _____mg PO x 1 dose tonight @ 1700 (for 28 days for VTE prophylaxis) Warfarin protocol daily per physician communication (select this when ordering warfarin)Warfarin orthopedic protocol (for 28 days for VTE prophylaxis)Warfarin protocol daily per physician communication (select this when ordering warfarin)Aspirin 325mg PO BID (for 28 days for VTE prophylaxis) (Administer first dose between 11 and 23 hours after the end of surgery) IV Fluids (Select one if indicated):LR IV at 100mL/hrD5-LR IV at 100mL/hr0.9 NS IV at 100 mL/hrOther medicationsNauseaOndansetron 4mg, one tablet PO q8 hours as needed for nausea and able to take PO –OR-Ondansetron 4 mg IV q8 hours as needed for nausea and unable to take POBowel RegimenSenna-docusate, 1 tablet each evening. Hold if patient having loose, frequent stools.Bisocadyl suppository daily as needed for constipation not relieved with senna-docusate or patient NPO.InsomniaTemazepam, 7.5 mg qhs as needed for insomniaDeliriumZyprexa zydis 2.5 mg sublingual x1 for CAM+. Notify MD –OR-Haldol 0.5 mg IM x1 for CAM+. Notify MD.Nutritional50000 IU ergocalciferol x1 for all patients50000 IU ergocalciferol weekly x 6 weeks if 25-OH Vit D <30 and >1550000 IU ergocalciferol weekly x 12 weeks if 25-OH Vit D <15Calcium-Vitamin D, 500 mg – 200 IU, One tablet oral twice dailyRespiratory:Incentive Spirometer 10 times every1 hour while awakeOxygen ProtocolLabs (Select as indicated):BUN/Creatinine every 24 hrs for 3 days starting POD#1Hemoglobin and Hematocrit q 24 hrs for 3 days starting POD#1Hemoglobin and Hematocrit STAT in recovery roomProthrombin Time/INR q 24 hrs for 4 days starting POD#0 if receiving warfarinRadiology:X-ray of Pelvis 1V Stat, Portable in Recovery Room; Reason: post op repair hip/femur fracture; Include entire prosthesisHip Xray Right 1 view portable in PACU - Reason: Post Op repair hip/femur; Include entire prosthesisHip Xray Left 1 view portable in PACU - Reason: Post Op repair hip/femur; Include entire prosthesisRehab:Physical Therapy Adult Eval & Treat Occupational Therapy Adult Eval & Treat Weight bearing status (Select one as indicated and document in note):Full weight bearing on operative leg, as tolerated Partial weight bearing on operative leg – (_____ pounds)Toe touch weight bearing on operative legNon-weight bearing on operative legNursing:Notify primary physician if temperature greater than 38.5 ° C, HR less than 60bpm or greater than 110bpm, BP less than 90/60mmHg or greater than 160/100mmHg, or SpO2 <90%Vital signs per unit routineIntake & Output every 8 hours. Notify primary physician for urine output less than 30mL/hr.CMS checks every 4 hours on affected extremities. Call surgeon if exam changesPain assessment every 4 hrsHeel care every 8 hrs and apply heel protectors if indicated CAM assessment every 8 hoursIf drain present, keep compressed and closed. Drain to self-suction. Notify surgeon if output is greater than 200 mL in 8 hours.Remove scopolamine patch, if present, on arrival to floorConvert to saline lock and stop IV fluids when tolerating PO wellIntermittent compression device/SCD to bilateral lower extremitiesIf urinary catheter inserted, discontinue on POD#1 AT 0600 unless contraindicated. If urinary catheter is not discontinued, document indication for continued use. If patient has not voided by 8 hours post op, perform bladder scan prior and straight cath patient if residual is greater than 400 mL. If less than 400mL, notify physician for possible fluid orders. If patient has not voided 8 hours post straight cath, perform bladder scan, and initiate prompted voids if residual is less than 250mL. If bladder scan is greater than 400mL, straight cath and notify physician for further orders. Change dressing daily & prn starting 2nd post op day using dry gauze dressing. No soaps, lotions, or ointments to incision sitePolar Ice unit or Ice packs to operative siteProvide and insure proper use of eye glasses and hearing aids if neededProvide and insure proper fit and function of dentures if neededProvision of clock and calendarTurn out lights in room and minimize interruptions between 9PM and 6AMAdditional consults:Consult social worker for discharge planningConsult acute inpatient rehab (if indicated)DieticianDischarge Planning ................
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