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Molendijk-van Nieuwenhuyzen K, Belt-van Opstal R, Hakvoort L, Dikken J. Exploring geriatric trauma unit experiences through patients' eyes: a qualitative study. BMC Geriatr 2024; 24:476. [PMID: 38816688 PMCID: PMC11140891 DOI: 10.1186/s12877-024-05023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
INTRODUCTION The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization. METHODS This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed. RESULTS The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit. CONCLUSION Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.
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Affiliation(s)
| | | | | | - Jeroen Dikken
- De Haagse Hogeschool, Faculteit Gezondheid, Voeding & Sport, Johanna Westerdijkplein 75, 2521 EN, The Hague, The Netherlands
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Ferrah N, Kennedy B, Beck B, Ibrahim J, Gabbe B, Cameron P. A scoping review of models of care for the management of older trauma patients. Injury 2024; 55:111200. [PMID: 38035863 DOI: 10.1016/j.injury.2023.111200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION The number of older people hospitalised with major trauma is rapidly increasing. New models of care have emerged, such as co-management, and trauma centres dedicated to delivering geriatric trauma care. The aim of this scoping review was to explore in-hospital models of care for older adults who experience physical trauma. PATIENTS AND METHODS The search was conducted in accordance with the PRISMA- SC (preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews) reporting guidelines. The National Heart Lung, and Blood Institute (NIH) study quality assessment tool was used to evaluate risk of bias in before and after non-randomised experimental studies. RESULTS Of 2127 records returned from the database search, 43 papers were included. We identified five types of care models investigated in the reviewed studies: centralised trauma management, consultation services, co-management, patient care protocols, and alert and triage systems. The majority of patients were admitted under a specialised trauma service, intervention teams were for the most part multidisciplinary, and follow-up of patients post-discharge was seldom reported. Consultation services more often had advanced care and discharge planning as treatment objectives. In contrast, patient care protocol and alert systems commonly had management of anticoagulation as a treatment objective. Overall, the impact of the five models of care on patient outcomes was mixed. DISCUSSION Given the variability in patient characteristics and capabilities of health services, models of care need to be matched to the local profile of older trauma patients. However, some standards should be incorporated into a care model, including identifying goals of care, medication review and follow up post-discharge.
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Affiliation(s)
- Noha Ferrah
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia.
| | - Briohny Kennedy
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Department of Forensic Medicine, Monash University, The Victorian Institute of Forensic Medicine, Victoria Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Faculty of Medicine, Laval University, Quebec City, Canada
| | - Joseph Ibrahim
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Department of Forensic Medicine, Monash University, The Victorian Institute of Forensic Medicine, Victoria Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Health Data Research UK, Swansea University Medical School, UK
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Emergency and Trauma Centre, The Alfred Hospital, Victoria, Australia
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Lee SA, Joo YJ, Chang YR. Perceptions regarding the multidisciplinary treatment of patients with severe trauma in Korea: a survey of trauma specialists. JOURNAL OF TRAUMA AND INJURY 2023; 36:322-328. [PMID: 39381570 PMCID: PMC11309246 DOI: 10.20408/jti.2023.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2024] Open
Abstract
Purpose Patients with multiple trauma necessitate assistance from a wide range of departments and professions for their successful reintegration into society. Historically, the primary focus of trauma treatment in Korea has been on reducing mortality rates. This study was conducted with the objective of evaluating the current state of multidisciplinary treatment for patients with severe trauma in Korea. Based on the insights of trauma specialists (i.e., medical professionals), we aim to suggest potential improvements. Methods An online questionnaire was conducted among 871 surgical specialists who were members of the Korean Society of Traumatology. The questionnaire covered participant demographics, current multidisciplinary practices, perceived challenges in collaboration with rehabilitation, psychiatry, and anesthesiology departments, and the perceived necessity for multidisciplinary treatment. Results Out of the 41 hospitals with which participants were affiliated, only nine conducted multidisciplinary meetings or rounds with nonsurgical departments. The process of transferring patients to rehabilitation facilities was not widespread, and delays in these transfers were frequently observed. Financial constraints were identified by the respondents as a significant barrier to multidisciplinary collaboration. Despite these hurdles, the majority of respondents acknowledged the importance of multidisciplinary treatment, especially in relation to rehabilitation, psychiatry, and anesthesiology involvement. Conclusions This survey showed that medical staff specializing in trauma care perceive several issues stemming from the absence of a multidisciplinary system for patient-centered care in Korea. There is a need to develop an effective multidisciplinary treatment system to facilitate the recovery of trauma patients.
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Affiliation(s)
- Shin Ae Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Trauma Center, Seoul National University Hospital, Seoul, Korea
| | - Yeon Jin Joo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Ye Rim Chang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Trauma Center, Seoul National University Hospital, Seoul, Korea
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Kishawi SK, Adomshick VJ, Halkiadakis PN, Wilson K, Petitt JC, Brown LR, Claridge JA, Ho VP. Development of Imaging Criteria for Geriatric Blunt Trauma Patients. J Surg Res 2023; 283:879-888. [PMID: 36915016 PMCID: PMC11299230 DOI: 10.1016/j.jss.2022.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. METHODS Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. RESULTS We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. CONCLUSIONS Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.
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Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Victoria J Adomshick
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Penelope N Halkiadakis
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Keira Wilson
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Jordan C Petitt
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio.
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Translator use not associated with longer time to pain medication in initial evaluation of low-severity geriatric trauma. Am J Emerg Med 2022; 60:62-64. [PMID: 35905603 DOI: 10.1016/j.ajem.2022.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/17/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Determine whether geriatric victims of blunt trauma who preferred to communicate in a language other than English waited longer for pain medication or received more imaging studies than English-speaking patients with the same age and injuries. Secondary outcomes were the type of medication administered and number of imaging studies. METHODS We conducted a retrospective analysis of all trauma activations to a single academic urban medical center from January 2019 to October 2019. We included all hemodynamically stable patients older than 65, with head or torso trauma after a low energy injury, and on at least one medication that was an anti-coagulant, anti-platelet, or chemotherapeutic. RESULTS We identified 1,153 unique patients (17, 379 radiologic studies) performed from January 2019 to October 2019, with a median of 5 (4-6) radiologic studies per patient. We excluded 419 patients for whom the language used was not reported (n = 7), no imaging was not reported (n = 16), or no medication was recorded as given (n = 409), leaving 734 patients for further analysis. Of those 734 patients, 460 preferred to communicate in English, 84 in Mandarin Chinese, 64 in Spanish, 37 in Cantonese Chinese, and 35 in Korean, and 29 in Russian. Across all languages patient age and Injury Severity Score (ISS) were comparable. Those who preferred to communicate in Spanish, Russian, or Korean were more likely to be female than those who preferred English, Mandarin, or Cantonese, but this tendency was not statistically significant (χ2-test; p = 0.051, 0.15 after Bonferroni correction). We did not find a statistically significant association between preferred language and time to medication, fraction of opioids used as first-line pain medication, or number of imaging studies performed. Across all patients, the most common medications administered were acetaminophen (524/734, 71%), any opioid (111/734, 15%), followed by local infiltration or nerve block with lidocaine (49/734, 6.7%). CONCLUSIONS A retrospective analysis of patients with low-risk blunt trauma found no relationship between preferred language, time to pain medication, use of opioids or number of imaging studies.
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Huntington CR, Kao AM, Sing RF, Ross SW, Christmas AB, Prasad T, Lincourt AE, Kasten KR, Heniford BT. Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients. Am Surg 2021:31348211046886. [PMID: 34555960 DOI: 10.1177/00031348211046886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/OBJECTIVES Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. METHODS Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. RESULTS Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. CONCLUSION Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.
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Affiliation(s)
- Ciara R Huntington
- Department of Surgery, 2351St. Luke's Regional Medical Center, Boise, Idaho, USA
| | - Angela M Kao
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- 22442Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, USA
| | - Samuel W Ross
- 22442Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, USA
| | - A Britt Christmas
- 22442Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Amy E Lincourt
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Kevin R Kasten
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review. Ann Surg 2021; 273:e239-e246. [PMID: 30985368 DOI: 10.1097/sla.0000000000003313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). BACKGROUND At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines. METHODS A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0. RESULTS Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report. CONCLUSIONS Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.
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Benham DA, Rooney AS, Calvo RY, Carr MJ, Diaz JA, Sise CB, Bansal V, Sise MJ, Martin MJ. The rising tide of methamphetamine use in elderly trauma patients. Am J Surg 2021; 221:1246-1251. [PMID: 33707080 DOI: 10.1016/j.amjsurg.2021.02.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Methamphetamine (METH) is associated with an elevated risk of injury and the outcomes in the elderly remain unclear. We analyzed METH's impact in elderly trauma patients. METHODS Retrospective analysis (2009-2018) of trauma patients at a Level I trauma center. Elderly patients were defined as age ≥55. Substance use was identified by blood alcohol test and urine drug screen. Cox proportional hazard model was used to assess patient and injury characteristics with mortality. RESULTS Of 15,770 patient encounters with substance use testing, 5278 (34%) were elderly. Elderly METH use quadrupled over time (2%-8%; p < 0.01). Elderly METH + patients were more likely to require surgical intervention (35% vs. 17%), mechanical ventilation (15% vs. 7%), and a longer hospitalization (6.5 vs. 3.6 days) compared with elderly substance negative. Multivariate analysis showed increasing age, ventilator use, and injury severity were associated with mortality (ps < 0.01); METH was not related to mortality. CONCLUSION Substance use in elderly trauma patients increased significantly. METH use in elderly trauma patients is a risk factor for significantly greater resource utilization.
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Affiliation(s)
- Derek A Benham
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Alexandra S Rooney
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Richard Y Calvo
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Matthew J Carr
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Joseph A Diaz
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - C Beth Sise
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Vishal Bansal
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Michael J Sise
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
| | - Matthew J Martin
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
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Snyder JA, Rabideau AC, Schuerer DJE. Geriatric Trauma Service: to Consult or Not to Consult? CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-020-00211-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Francis AA, Wall JEM, Stone A, Dewane MP, Dyke A, Gregg SC. The Impact of Interdisciplinary Care on Cost Reduction in a Geriatric Trauma Population. J Emerg Trauma Shock 2020; 13:286-295. [PMID: 33897146 PMCID: PMC8047963 DOI: 10.4103/jets.jets_151_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/24/2020] [Accepted: 05/08/2020] [Indexed: 11/16/2022] Open
Abstract
The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS).
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Affiliation(s)
- Andrew A Francis
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Joyce E M Wall
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Andrew Stone
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Michael P Dewane
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Ann Dyke
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Shea C Gregg
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
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Fernandez FB, Ong A, Martin AP, Schwab CW, Wasser T, Butts CA, McNicholas AR, Muller AL, Barbera CF, Trupp R, Sigal AP. Success Of An Expedited Emergency Department Triage Evaluation System For Geriatric Trauma Patients Not Meeting Trauma Activation Criteria. Open Access Emerg Med 2019; 11:241-247. [PMID: 31754315 PMCID: PMC6825467 DOI: 10.2147/oaem.s212617] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/07/2019] [Indexed: 11/23/2022] Open
Abstract
Background Geriatric patients are at increased risk of injury following low-energy mechanisms and are less tolerant of injury. Current criteria for trauma team activation (TTA) often miss these injuries. We evaluated a novel triage process for an expedited Emergency Medicine Physician evaluation protocol (T3) for at-risk geriatric sub-populations not meeting trauma team activation (TTA) criteria. Methods Retrospective review of injured patients (≥65 years) from a Level II Trauma Center with an Injury Severity Score (ISS < 16), prior to (Pre-T3, Jan 2007-Oct 2009), and after (Post-T3, Jan 2010-Oct 2012), implementation of T3, as well as a contemporary period (CP, Jan 2013-Oct 2015). Demographics, physiologic variables, and timeliness of care were measured. Rates of ICU admission, operative procedures and lengths of stay and in-hospital mortality were compared for all periods. Logistic regression analysis determined variables independently associated with mortality. Results Post-T3, 49.2% of geriatric registry patients underwent T3 with a reduction in key time intervals. Median time to evaluation (42.1 mins vs 61.7 min, p<0.001), median time to CT (161.3 mins vs 212.9 mins, p<0.001) and EDLOS (364.6 mins vs 451.5 mins, p=0.023) were all reduced compared to non-expedited evaluations. There was no change in mortality after the implementation of the protocol. Conclusion The T3 protocol expedited patient evaluation of at-risk geriatric patients that would not otherwise meet TTA criteria. The new process met the goals of the American College of Surgeons Trauma Quality Improvement Program while conserving resources.
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Affiliation(s)
| | - Adrian Ong
- Trauma and Surgical Critical Care Reading Hospital, Reading, PA, USA
| | - Anthony P Martin
- Trauma and Surgical Critical Care Reading Hospital, Reading, PA, USA
| | - C William Schwab
- Trauma and Surgical Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tom Wasser
- Complete Statistical Services, Macungie, PA, USA
| | | | | | - Alison L Muller
- Trauma and Surgical Critical Care Reading Hospital, Reading, PA, USA
| | - Charles F Barbera
- Department of Emergency Medicine, Reading Hospital, Reading, PA, USA
| | - Rachael Trupp
- Department of Emergency Medicine, Reading Hospital, Reading, PA, USA
| | - Adam P Sigal
- Department of Emergency Medicine, Reading Hospital, Reading, PA, USA
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de Vries R, Reininga IHF, de Graaf MW, Heineman E, El Moumni M, Wendt KW. Older polytrauma: Mortality and complications. Injury 2019; 50:1440-1447. [PMID: 31285055 DOI: 10.1016/j.injury.2019.06.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Older adults enduring a polytrauma have an increased mortality risk. Apart from age, the role of other predisposing factors on mortality are mainly described for the total polytrauma population. This study aimed to describe the mortality pattern of older polytrauma patients, its associated risk factors, and the role and etiology of in-hospital complications. METHODS An eight-year retrospective cohort was constructed from 380 polytrauma patients aged ≥65 in a Dutch level 1 trauma center and linked to the national trauma database (DTR). Demographics, injury characteristics, comorbidity, clinical characteristics, in-hospital mortality, mortality etiology and complications scored according to the Clavien-Dindo classification were analyzed. Primary outcome was the identification of risk factors associated with in-hospital mortality, followed by identification of in-hospital complications and their nature. RESULTS Overall in-hospital mortality was 36.3%, rising significantly with age. For patients aged ≥85 in-hospital mortality was 60.8%. Polytrauma patients aged ≥75 showed a peak of late-onset deaths one week following trauma. Age, a Glasgow coma score ≤8, coagulopathy, acidosis, injury severity score and the presence of a large subdural hematoma were significant risk factors influencing in-hospital mortality. Respiratory failure was the most prevalent severe and fatal complication. The proportion of fatal complications grew significantly with age (p < 0.01). CONCLUSIONS Age is strongly associated with in-hospital mortality in polytraumatized elderly. Coagulopathy, acidosis, a low Glasgow coma score, presence of a large subdural hematoma and injury severity score were independently of age associated with an increased mortality. Patients older than 75 years showed a unique trimodal distribution of mortality with a late onset one week following the initial trauma. Elderly were more susceptible for fatal complications. Respiratory failure was the most prevalent severe and fatal complication. Aggressive monitoring and treatment of the pulmonary status is therefore of utmost importance.
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Affiliation(s)
- Rob de Vries
- Department of Trauma Surgery, University Medical Centre Groningen (UMCG), Groningen, the Netherlands.
| | - Inge H F Reininga
- Department of Trauma Surgery, University Medical Centre Groningen (UMCG), Groningen, the Netherlands; Emergency Care Network Northern Netherlands, AZNN, Nothern Netherlands Trauma Registry, Groningen, the Netherlands.
| | - Max W de Graaf
- Department of Trauma Surgery, University Medical Centre Groningen (UMCG), Groningen, the Netherlands.
| | - Erik Heineman
- Department of Surgery, University Medical Centre Groningen (UMCG), Groningen, the Netherlands.
| | - Mostafa El Moumni
- Department of Trauma Surgery, University Medical Centre Groningen (UMCG), Groningen, the Netherlands.
| | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Centre Groningen (UMCG), Groningen, the Netherlands.
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Curtis E, Romanowski K, Sen S, Hill A, Cocanour C. Frailty score on admission predicts mortality and discharge disposition in elderly trauma patients over the age of 65 y. J Surg Res 2018; 230:13-19. [DOI: 10.1016/j.jss.2018.04.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/12/2018] [Accepted: 04/06/2018] [Indexed: 01/09/2023]
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Wooster M, Stassi A, Hill J, Kurtz J, Bonta M, Spalding MC. End-of-Life Decision-Making for Patients With Geriatric Trauma Cared for in a Trauma Intensive Care Unit. Am J Hosp Palliat Care 2018; 35:1063-1068. [PMID: 29366336 DOI: 10.1177/1049909117752670] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The geriatric trauma population is growing and fraught with poor physiological response to injury and high mortality rates. Our primary hypothesis analyzed how prehospital and in-hospital characteristics affect decision-making regarding continued life support (CLS) versus withdrawal of care (WOC). Our secondary hypothesis analyzed adherence to end-of-life decisions regarding code status, living wills, and advanced directives. MATERIALS AND METHODS We performed a retrospective review of patients with geriatric trauma at a level I and level II trauma center from January 1, 2007, to December 31, 2014. Two hundred seventy-four patients met inclusion criteria with 144 patients undergoing CLS and 130 WOC. RESULTS A total of 13 269 patients with geriatric trauma were analyzed. Insurance type and injury severity score (ISS) were found to be significant predictors of WOC ( P = .013/.045). Withdrawal of care patients had shorter time to palliative consultation and those with geriatrics consultation were 16.1 times more likely to undergo CLS ( P = .026). Twenty-seven (33%) patients who underwent CLS and 31 (24%) patients who underwent WOC had a living will, advanced directive, or DNR order ( P = .93). CONCLUSIONS Of the many hypothesized predictors of WOC, ISS was the only tangible independent predictor of WOC. We observed an apparent disconnect between the patient's wishes via living wills or advanced directives "in a terminal condition" and fulfillment during EOL decision-making that speaks to the complex nature of EOL decisions and further supports the need for a multidisciplinary approach.
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Affiliation(s)
- Meghan Wooster
- 1 Department of Surgery, Indiana University, Indianapolis, IN, USA
| | - Alyssa Stassi
- 2 Department of Surgery, Palmetto Health Richland, Columbia, SC, USA
| | - Joshua Hill
- 3 Department of Surgery, Grant Medical Center, Columbus, OH, USA
| | - James Kurtz
- 4 Heritage College of Osteopathic Medicine, Ohio University, Doctors Hospital, Columbus, OH, USA
| | - Marco Bonta
- 5 Department of Surgery, Riverside Methodist Medical Hospital, Columbus, OH, USA
| | - M Chance Spalding
- 3 Department of Surgery, Grant Medical Center, Columbus, OH, USA
- 4 Heritage College of Osteopathic Medicine, Ohio University, Doctors Hospital, Columbus, OH, USA
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Kunitake RC, Kornblith LZ, Cohen MJ, Callcut RA. Trauma Early Mortality Prediction Tool (TEMPT) for assessing 28-day mortality. Trauma Surg Acute Care Open 2018; 3:e000131. [PMID: 29766125 PMCID: PMC5887834 DOI: 10.1136/tsaco-2017-000131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/05/2017] [Accepted: 11/14/2017] [Indexed: 01/08/2023] Open
Abstract
Background Prior mortality prediction models have incorporated severity of anatomic injury quantified by Abbreviated Injury Severity Score (AIS). Using a prospective cohort, a new score independent of AIS was developed using clinical and laboratory markers present on emergency department presentation to predict 28-day mortality. Methods All patients (n=1427) enrolled in an ongoing prospective cohort study were included. Demographic, laboratory, and clinical data were recorded on admission. True random number generator technique divided the cohort into derivation (n=707) and validation groups (n=720). Using Youden indices, threshold values were selected for each potential predictor in the derivation cohort. Logistic regression was used to identify independent predictors. Significant variables were equally weighted to create a new mortality prediction score, the Trauma Early Mortality Prediction Tool (TEMPT) score. Area under the curve (AUC) was tested in the validation group. Pairwise comparison of Trauma Injury Severity Score (TRISS), Revised Trauma Score, Glasgow Coma Scale, and Injury Severity Score were tested against the TEMPT score. Results There was no difference between baseline characteristics between derivation and validation groups. In multiple logistic regression, a model with presence of traumatic brain injury, increased age, elevated systolic blood pressure, decreased base excess, prolonged partial thromboplastin time, increased international normalized ratio (INR), and decreased temperature accurately predicted mortality at 28 days (AUC 0.93, 95% CI 0.90 to 0.96, P<0.001). In the validation cohort, this score, termed TEMPT, predicted 28-day mortality with an AUC 0.94 (95% CI 0.92 to 0.97). The TEMPT score preformed similarly to the revised TRISS score for severely injured patients and was highly predictive in those having mild to moderate injury. Discussion TEMPT is a simple AIS-independent mortality prediction tool applicable very early following injury. TEMPT provides an AIS-independent score that could be used for early identification of those at risk of doing poorly following even minor injury. Level of evidence Level II.
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Affiliation(s)
- Ryan C Kunitake
- Department of Surgery, University of California, San Francisco, California, USA
| | - Lucy Z Kornblith
- Department of Surgery, University of California, San Francisco, California, USA
| | - Mitchell Jay Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Rachael A Callcut
- Department of Surgery, University of California, San Francisco, California, USA
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Abstract
This article describes geriatric trauma and commonly associated difficulties emphasizing both the epidemiology and assessment of geriatric trauma. There is little data guiding decisions for trauma patients 65 years or older, as there are many unique characteristics to the geriatric population, including comorbidities, medications, and the aging physiology. The geriatric population in the United States has been steadily climbing for the last 20 years and is projected to continue on this trend. Although each patient presents differently, there remains a need for the consistent utilization of standard guidelines to help dictate care for geriatric patients, particularly for patients not receiving care at a trauma center. This review uses a case study about an elderly woman with many comorbidities, followed by a comprehensive discussion of geriatric trauma and the challenges that result from a lack of guideline utilization to direct management.
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Fletcher B, Bradburn E, Baker C, Collier B, Hamill M, Shaver K. Pretrauma Functional Independence Measure Score Predicts Survival in Geriatric Trauma. Am Surg 2017. [DOI: 10.1177/000313481708300619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Functional Independence Measure (FIM) is used by rehabilitation professionals to access disability. The FIM score combines both motor and cognitive parameters to assess a patient's level of required assistance in performing activities of daily living (ADL). The geriatric trauma patient is becoming an increasingly important cohort for trauma services. FIM has been shown to predict discharge outcomes and those at high risk for falls. We hypothesized pretrauma FIM scores may predict survival in the geriatric trauma population. This was a retrospective study of patients 65 years and older that were admitted to our Level I trauma center from July 1, 2006 to July 1, 2012. A total 941 patients underwent stepwise regression to identify those factors predicting survival. Age, Injury Severity Score, revised trauma score, body mass index, and pretrauma FIM scores (12-point scale) were studied. The primary outcome was survival. Statistical significance reached at P value <0.05. Multiple logistic regression analysis was then performed. A total of 1315 patients were identified and complete data were available on 941 patients. Mean age was 78 (SD ± 8.2), mean Injury Severity Score was 13(SD ± 8.7), and mean body mass index was 26. Overall mortality was 11 per cent. The odds ratio of survival was 3.532 (95% confidence interval = 2.191–5.718) times greater for every 1-point increase in the preadmission FIM expression score. Glasgow Coma Scale, revised trauma score, gender, and pretrauma FIM expression scores were predictive of survival in the geriatric trauma patient. Pretrauma FIM expression can be used to predict survival in the elderly trauma victim. Further study is needed to establish the role of FIM as part of trauma scoring systems.
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Affiliation(s)
- Brian Fletcher
- Department of General Surgery, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Eric Bradburn
- Department of General Surgery, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Christopher Baker
- Department of General Surgery, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Bryan Collier
- Department of General Surgery, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Mark Hamill
- Department of General Surgery, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Katherine Shaver
- Department of General Surgery, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
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Abstract
PURPOSE OF REVIEW The geriatric population is the fastest growing segment of the population, and geriatric trauma patients are increasingly common. Caring for this population has unique challenges. The goal of the review is to identify factors that may help in the care of geriatric patients suffering from genitourinary trauma. RECENT FINDINGS Multiple factors lead to inferior outcomes in patients with geriatric trauma including failure to rescue, treatment in lower volume trauma centers, and undertriage of geriatric patients. Improvement in geriatric trauma outcomes occurs with the use of dedicated geriatric consult teams. The surgical management of genitourinary injuries in the geriatric population remains unchanged. SUMMARY Interventions for geriatric patients differ from younger populations. Direct changes in overall management of the geriatric population lead to improved outcomes. The treatment of geriatric trauma patients with genitourinary injuries is similar to a younger cohort. The lack of recent studies in clinical outcomes in this population has been identified as a gap in knowledge that will require future research to answer.
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Abstract
Across the world, the population is aging. Adults 65 years and older make up one of the fastest growing segments of the US population. Trauma is a disease process that affects all age groups. The mortality and morbidity that result from an injury can be influenced by many factors including age, physical condition, and comorbidities. The management of the elderly trauma patient can present some unique challenges. This paper addresses the differences that occur in the management of elderly patient who has been injured. This paper also includes a discussion of how to prevent injury in the elderly.
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Post-trauma mortality increase at age 60: a cutoff for defining elderly? Am J Surg 2016; 212:781-785. [PMID: 27038794 DOI: 10.1016/j.amjsurg.2015.12.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/06/2015] [Accepted: 12/02/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND There has been an increasing emphasis on identifying elderly trauma patients. However, definitions based solely on age vary widely, ranging from age 55 to 80 years, hampering optimal trauma management for older patients. The goal of this study was to develop an objective, data-driven definition for "elderly" in trauma care by evaluating mortality risk as a function of age. METHODS We conducted a retrospective analysis of 872,861 adult (≥18 years) patients from the National Trauma Data Bank's National Sample Program from 2003 to 2010. The primary outcome was risk-adjusted in-hospital mortality determined using multivariate logistic regression. Contribution of age to mortality was investigated through step-wise regression and percent of R2 attributable to age. We searched for straight-line trends in mortality rate at each age using the spline function of Statistical Analysis Software. RESULTS Statistically significant increases in mortality rate were noted at ages 37, 60, and 78. Age was found to contribute 10% to mortality compared with greater than 80% for Glasgow coma scale and injury severity score combined. CONCLUSIONS Our findings suggest using age 60 years as a data-driven definition of "elderly" in trauma.
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Bhattacharya B, Davis KA. Nuances in the Care of Emergent Splenic Injury in the Elderly Patient. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0153-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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