{"id":{"repo_id":"utswmed","oai_identifier":"oai:utswmed-ir.tdl.org:2152.5/10838"},"canonical_url":"https://search.dev.ndltd.org/etd/utswmed/oai:utswmed-ir.tdl.org:2152.5/10838","repository":{"repo_id":"utswmed","name":"University of Texas Southwestern Medical Center","base_url":"https://utswmed-ir.tdl.org/server/oai/request"},"display":{"title":"Addressing Delirium in Hip Fracture Patients to Reduce Post-Operative Length of Stay","abstract":"Pages iv-vi are misnumbered as pages vi-viii.","abstract_html":"Pages iv-vi are misnumbered as pages vi-viii.","abstract_has_math":false,"creators":["Flindt, Grant Herbert"],"institution":null,"degree_name":null,"degree_level":null,"degree_discipline":null,"degree_department":null,"school":null,"contributors":["Reed, W. Gary","Wingfield, Sarah A.","Phelps, Eleanor"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2026,"date_issued":"2026-06-15T19:55:27Z","date_published":"2026-06-15T19:55:27Z","updated_at":"2026-07-24T05:52:22Z","subjects":["Delirium","Hip Fractures","Length of Stay","Orthopedic Procedures","Postoperative Complications","Quality Improvement"],"languages":["en"],"rights":[],"rights_urls":[],"identifier_entries":[{"key":"dc:identifier","label":"Identifier","values":["1596185264"],"render_values":[{"text":"1596185264","href":null,"code":true}]}]},"links":{"outbound_url":"https://hdl.handle.net/2152.5/10838","outbound_label":"Handle","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["Reed, W. Gary","Wingfield, Sarah A.","Phelps, Eleanor"]},{"key":"dc:creator","label":"Author","values":["Flindt, Grant Herbert"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date","label":"Dc Date","values":["2026-06-15T19:55:27Z","2026-05","May 2026","2026-06-15T19:55:28Z"]},{"key":"dc:type","label":"Dc Type","values":["Thesis","text"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Delirium","Hip Fractures","Length of Stay","Orthopedic Procedures","Postoperative Complications","Quality Improvement"]}]},{"id":"language_rights","label":"Language and Rights","entries":[{"key":"dc:language","label":"Dc Language","values":["en"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://hdl.handle.net/2152.5/10838","1596185264"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description","label":"Description","values":["Pages iv-vi are misnumbered as pages vi-viii.","BACKGROUND: Hip fractures are common and costly conditions that represent a significant financial burden to both patients and healthcare systems. Treatment for a hip fracture is approximately USD 50,508 per patient, totaling an estimated USD 5.96 billion annually across the United States. In addition to increased cost, prolonged length of stay (LOS) in the hospital increases the risk of medical complications such as hospital associated infections, pressure sores, depression, anxiety, and functional decline. Shorter LOS after total hip arthroplasty (THA) has been associated with lower readmission rates without an increase in major complications. Recent efforts to improve efficiency and quality have reduced average LOS for THA from approximately three weeks historically to 4-6 days. LOCAL PROBLEM: The Returning Seniors to Orthopaedic Excellence (RESTORE) program at Clements University Hospital (CUH) provides care for patients receiving emergency hip fracture treatment. Recently, the program observed an increase in average LOS from 7.3 days in FY2021 to 10.2 days in FY2022. This is higher than the published standard LOS of 4-6 days. METHODS: A QI initiative was started at CUH to reduce postoperative LOS among RESTORE patients. The project was structured using the "Define, Measure, Analyze, Improve, and Control" (DMAIC) framework. The problem was defined via demographic and process analysis of RESTORE patients. Potential interventions were identified via literature review of hip fracture management, orthogeriatric care pathways, and the Hospital Elder Life Program (HELP). QI tools including process mapping, an Ishikawa diagram, and a driver diagram were used to identify potential interventions to reduce LOS. Baseline demographic and clinical data were collected via retrospective chart review of the RESTORE database (2021-2024). Based on this analysis and feasibility considerations, delirium reduction was selected as the focus of the first intervention. INTERVENTIONS: This QI initiative aimed to reduce LOS by decreasing postoperative delirium rates. The primary intervention focused on increasing HELP volunteer visits for RESTORE patients. Beginning June 1, 2024, patients on the RESTORE pathway were added to and prioritized on the HELP volunteer list. HELP volunteers provide evidence-based delirium prevention strategies such as reorientation, cognitive stimulation, hydration encouragement, and promoting natural light exposure. RESULTS: Define: Among 276 baseline RESTORE patients, 64% (176) were female and 83% (228) were older than 65 years. A validated process map from admission to discharge for RESTORE patients identified key delay points during admission, post-operative recovery, and discharge planning. Stakeholder input highlighted delays related to Medicare Advantage authorizations and postoperative delirium. Measure: Of 146 patients experiencing prolonged LOS (>6 days),44% (64) had Medicare Advantage insurance, 38% (55) developed post-operative delirium, and 16% (22) were older than 80 without a geriatrics consultation. All three variables were significantly associated with prolonged LOS. Analyze: Factors associated with increased LOS included Black race (p<0.0001), age >80 years (p<0.05), Medicare advantage insurance (p<0.05), delirium (p<0.0005), and age >80 years without a geriatrics consultation (p<0.05). Baseline delirium rates were 28% overall and 44% among adults ≥80 years. Root cause analysis supported targeting delirium as potential contributor to increased LOS. Improve: Following implementation, the proportion of RESTORE patients receiving HELP visits increased from 27% to 50% (p<0.05). However, no statistically significant changes were observed in overall delirium rates or average LOS. Average LOS among patients with delirium and among adults ≥ 80 years both demonstrated a nonsignificant downward trend. Control: RESTORE patients will continue to be prioritized for HELP volunteer visits. Additional interventions will be explored including reducing deliriogenic medication usage (BEERS criteria) and optimizing discharge planning for patients with Medicare Advantage insurance plans. CONCLUSION: Implementation of a structured QI initiative using the DMAIC framework identified postoperative delirium as a key contributor to prolonged LOS in hip fracture patients on the RESTORE pathway at CUH. Although prioritization of RESTORE patients significantly increased HELP volunteer visits, there was no significant reduction in delirium rates or average LOS. These findings suggest that multifactorial contributors to LOS require broader system-level interventions. Ongoing efforts will focus on medication optimization for RESTORE patients as well as addressing discharge planning barriers to further reduce LOS and improve outcomes for RESTORE patients at CUH."]},{"key":"dc:format","label":"Dc Format","values":["application/pdf"]},{"key":"dc:title","label":"Title","values":["Addressing Delirium in Hip Fracture Patients to Reduce Post-Operative Length of Stay"]}]}],"canonical_facts":{"dc:contributor":["Reed, W. Gary","Wingfield, Sarah A.","Phelps, Eleanor"],"dc:creator":["Flindt, Grant Herbert"],"dc:date":["2026-06-15T19:55:27Z","2026-05","May 2026","2026-06-15T19:55:28Z"],"dc:description":["Pages iv-vi are misnumbered as pages vi-viii.","BACKGROUND: Hip fractures are common and costly conditions that represent a significant financial burden to both patients and healthcare systems. Treatment for a hip fracture is approximately USD 50,508 per patient, totaling an estimated USD 5.96 billion annually across the United States. In addition to increased cost, prolonged length of stay (LOS) in the hospital increases the risk of medical complications such as hospital associated infections, pressure sores, depression, anxiety, and functional decline. Shorter LOS after total hip arthroplasty (THA) has been associated with lower readmission rates without an increase in major complications. Recent efforts to improve efficiency and quality have reduced average LOS for THA from approximately three weeks historically to 4-6 days. LOCAL PROBLEM: The Returning Seniors to Orthopaedic Excellence (RESTORE) program at Clements University Hospital (CUH) provides care for patients receiving emergency hip fracture treatment. Recently, the program observed an increase in average LOS from 7.3 days in FY2021 to 10.2 days in FY2022. This is higher than the published standard LOS of 4-6 days. METHODS: A QI initiative was started at CUH to reduce postoperative LOS among RESTORE patients. The project was structured using the "Define, Measure, Analyze, Improve, and Control" (DMAIC) framework. The problem was defined via demographic and process analysis of RESTORE patients. Potential interventions were identified via literature review of hip fracture management, orthogeriatric care pathways, and the Hospital Elder Life Program (HELP). QI tools including process mapping, an Ishikawa diagram, and a driver diagram were used to identify potential interventions to reduce LOS. Baseline demographic and clinical data were collected via retrospective chart review of the RESTORE database (2021-2024). Based on this analysis and feasibility considerations, delirium reduction was selected as the focus of the first intervention. INTERVENTIONS: This QI initiative aimed to reduce LOS by decreasing postoperative delirium rates. The primary intervention focused on increasing HELP volunteer visits for RESTORE patients. Beginning June 1, 2024, patients on the RESTORE pathway were added to and prioritized on the HELP volunteer list. HELP volunteers provide evidence-based delirium prevention strategies such as reorientation, cognitive stimulation, hydration encouragement, and promoting natural light exposure. RESULTS: Define: Among 276 baseline RESTORE patients, 64% (176) were female and 83% (228) were older than 65 years. A validated process map from admission to discharge for RESTORE patients identified key delay points during admission, post-operative recovery, and discharge planning. Stakeholder input highlighted delays related to Medicare Advantage authorizations and postoperative delirium. Measure: Of 146 patients experiencing prolonged LOS (>6 days),44% (64) had Medicare Advantage insurance, 38% (55) developed post-operative delirium, and 16% (22) were older than 80 without a geriatrics consultation. All three variables were significantly associated with prolonged LOS. Analyze: Factors associated with increased LOS included Black race (p<0.0001), age >80 years (p<0.05), Medicare advantage insurance (p<0.05), delirium (p<0.0005), and age >80 years without a geriatrics consultation (p<0.05). Baseline delirium rates were 28% overall and 44% among adults ≥80 years. Root cause analysis supported targeting delirium as potential contributor to increased LOS. Improve: Following implementation, the proportion of RESTORE patients receiving HELP visits increased from 27% to 50% (p<0.05). However, no statistically significant changes were observed in overall delirium rates or average LOS. Average LOS among patients with delirium and among adults ≥ 80 years both demonstrated a nonsignificant downward trend. Control: RESTORE patients will continue to be prioritized for HELP volunteer visits. Additional interventions will be explored including reducing deliriogenic medication usage (BEERS criteria) and optimizing discharge planning for patients with Medicare Advantage insurance plans. CONCLUSION: Implementation of a structured QI initiative using the DMAIC framework identified postoperative delirium as a key contributor to prolonged LOS in hip fracture patients on the RESTORE pathway at CUH. Although prioritization of RESTORE patients significantly increased HELP volunteer visits, there was no significant reduction in delirium rates or average LOS. These findings suggest that multifactorial contributors to LOS require broader system-level interventions. Ongoing efforts will focus on medication optimization for RESTORE patients as well as addressing discharge planning barriers to further reduce LOS and improve outcomes for RESTORE patients at CUH."],"dc:format":["application/pdf"],"dc:identifier":["https://hdl.handle.net/2152.5/10838","1596185264"],"dc:language":["en"],"dc:subject":["Delirium","Hip Fractures","Length of Stay","Orthopedic Procedures","Postoperative Complications","Quality Improvement"],"dc:title":["Addressing Delirium in Hip Fracture Patients to Reduce Post-Operative Length of Stay"],"dc:type":["Thesis","text"]},"updated_at":"2026-07-24T05:52:22Z"}