Impact of geriatric consultations on clinical outcomes of elderly trauma patients: A retrospective analysis

Interprofessional interventions that impact collaboration and quality of care across inpatient trauma care continuum: A scoping review

INTRODUCTION

Despite the recognized importance of interprofessional collaboration (IPC) in trauma care, healthcare professionals often work in silos. Interprofessional (IP) interventions are crucial for optimizing IPC and delivering high-quality care across clinical contexts, yet their effectiveness throughout the inpatient trauma care continuum is not well understood. Thus, this review aimed to examine the literature on the effectiveness of IP interventions on collaboration processes and related outcomes in inpatient trauma care.

METHODS

We conducted a scoping review following Joanna Briggs Institute's methodology. We searched six databases for studies from the last decade on IP interventions in inpatient trauma care. Two independent reviewers categorized IP interventions (education, practice, organization) and extracted their impact on IPC processes and related outcomes (team performance, patient, organization).

RESULTS

Of the 17,397 studies screened, 148 met the inclusion criteria. Most were cohort designs (72%), conducted in level I trauma centers (57%) and emergency departments (51%), and involved surgeons (56%) and nurses (53%). Studies focused on IP organization interventions (51%), such as clinical pathways; IP practice interventions (35%), such as trauma team activation protocols; and IP education interventions (14%) including multi-method education. IP practice interventions most effectively improved team performance results, while IP education interventions primarily improved IPC processes. Positive patient outcomes were limited, with few studies examining organizational effects.

CONCLUSIONS

Significant advancements are still required in IP interventions and trauma care research. Future studies should rigorously explore the effectiveness of interventions throughout the inpatient trauma care continuum and focus on developing robust measures for patient and organizational outcomes.

Impact of inpatient geriatrics consultation on hospital outcomes in older adults with trauma

BACKGROUND

Older adults presenting with trauma have worse outcomes than younger adults. Starting in 2016, we provided geriatrics consultation (GC) to older adults admitted to the trauma service. We aimed to analyze the impact of GC on patient outcomes.

METHODS

We performed a retrospective pre-post study and year-matched cohort study. We identified patients from the trauma registry at our level 1 trauma center. In the pre-post study, we compared patients who received GC (2016-2022) with controls (2011-2015). In the cohort study (2016-2022), we compared patients who received GC with controls. We matched for age, race, sex, and injury severity score (ISS) in both studies, as well as admission year in the cohort study. Outcome variables included mortality (in-hospital, 30-day, 90-day), length of stay (LOS), discharge disposition, and hospital readmission rates (30-day, 90-day).

RESULTS

We analyzed 1968 patients in the pre-post study and 2544 patients in the cohort study. Patients were similar in age, race, and sex. GC patients had a slightly higher ISS score and a higher rate of ICU stay. Delirium occurrence was lower among GC patients. GC patients had lower in-hospital mortality compared to controls (pre-post OR 0.27, p < 0.001; cohort OR 0.31, p < 0.001) and increased LOS (6 days vs 4 days, p < 0.001; both studies). GC patients in the cohort study also had lower 30- and 90-day mortality (OR 0.52 and 0.65, p < 0.01) and were less likely to return home (OR 0.81, p < 0.01); similar trends, though not statistically significant, were noted in the pre-post study. Lower readmission rates (statistically non-significant) were noted in the GC group across both studies.

CONCLUSIONS

GC in older adults with trauma has proven benefit with reduced mortality and a trend toward lower readmission rates but was associated with increased LOS and higher rates of discharge to skilled facility.

GIFTS: Geriatric Intensive Functional Therapy Sessions-for the older trauma patient

BACKGROUND

Considering resources for comprehensive geriatric care, it would be beneficial for geriatric trauma patients (GTPs) and medical patients to be comanaged in one program focusing on ancillary therapeutics (AT): physical therapy, occupational therapy, speech language pathology, respiratory therapy, and sleep wake hygiene. This pilot study describes outcomes of GTPs in a hospital-wide program focused on geriatric-specific AT.

METHODS

Geriatric trauma patients and geriatric patients were screened by program coordinator for enrollment at one Level II trauma center from August 2021 to December 2022. Enrolled patients (EPs) were admitted to trauma or medicine floors and received repetitive AT with attention to sleep wake hygiene throughout hospitalization and compared with similar nonenrolled patients (NEPs). Excluded patients had any of the following: indication of geriatric syndrome with a fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) score of 5, no frailty with a FRAIL score of 0, comfort focused plans, or arrived from skilled care. Retrospective chart review of demographics and outcomes was completed for both EPs and NEPs.

RESULTS

A total of 224 EPs (28 trauma [TR]) were compared with 574 NEPs (148 TR). Enrolled patients showed shorter length of stay (mean, 3.8 vs. 6.1; p = 0.0001), less delirium (3.1% vs. 9.6%, p = 0.00222), less time to ambulation (13 hours vs. 39 hours, p = 0.0005), and higher likelihood to discharge home (56% vs. 27%, p < 0.0001) as compared with NEPs. The median FRAIL score was 3 for both groups. Enrolled medical patients ambulated the soonest at 11 average hours, compared with 23 hours for enrolled trauma patients and 39 hours for NEPs. There were zero delirium events among enrolled trauma patients; 25% was found among nonenrolled trauma patients ( p = 0.00288).

CONCLUSION

Despite a small trauma cohort, results support feasibility to include GTPs in hospital-wide programs with geriatric-specific AT. Mobility and cognitive strategies may improve opportunities to avoid delirium, decrease length of stay, and influence more frequent disposition to home.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

A scoping review of models of care for the management of older trauma patients

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.

Identification of Seniors at Risk Score to Determine Geriatric Evaluations on Trauma Patients With Hip Fractures

BACKGROUND

Trauma centers are confronted with rising numbers of geriatric trauma patients at high risk for adverse outcomes. Geriatric screening is advocated but not standardized within trauma centers.

OBJECTIVE

This study aims to describe the impact of Identification of Seniors at Risk (ISAR) screening on patient outcomes and geriatric evaluations.

METHODS

This study used a pre-/postdesign to assess the impact of ISAR screening on patient outcomes and geriatric evaluations in trauma patients 60 years and older, comparing the periods before (2014-2016) and after (2017-2019) screening implementation.

RESULTS

Charts for 1,142 patients were reviewed. Comparing pre- to post-ISAR groups, the post-ISAR group with geriatric evaluations were older (M = 82.06, SD = 9.51 vs. M = 83.64, SD = 8.69; p = .026) with higher Injury Severity Scores (M = 9.22, SD = 0.69 vs. M = 9.38, SD = 0.92; p = .001). There was no significant difference in length of stay, intensive care unit length of stay, readmission rate, hospice consults, or inhospital mortality. Inhospital mortality (n = 8/380, 2.11% vs. n = 4/434, 0.92%) and length of stay in hours (M = 136.49, SD = 67.09 vs. M = 132.53, SD = 69.06) down-trended in the postgroup with geriatric evaluation.

CONCLUSION

Resources and care coordination efforts can be directed toward specific geriatric screening scores to achieve optimal outcomes. Varying results were found related to outcomes of geriatric evaluations prompting future research.

Burns in the elderly: a nationwide study on management and clinical outcomes

Background

In modern-day burn care, advanced age remains an important predictor for mortality among burn victims. In this study, we compared the complete treatment trajectory (including pre-hospital and surgical treatment) and the outcomes between an elderly burn population and a younger adult burn population.

Methods

In this nationwide study, data from the Dutch Burn Repository were used. This is a uniform national registration for Dutch specialized burn care. All adult patients that were admitted to one of the three Dutch burn centres from the period 2009 to 2015 were included in the analysis. Burn patients were considered as elderly when ≥65 years of age, and were then further subdivided into three age categories: 65-74, 75-85 and 85+ years. Younger adults in the age category 18-64 years were used as the reference group.Surgical management was studied comprehensively and included timing of surgery, the number of procedures and details on the surgical technique, especially the technique used for debridement and the grafting technique that was applied.For the comparison of clinical outcome, the following parameters were included: mortality, wound infections, length of stay/TBSA (total body surface area) burned, discharge disposition and secondary reconstructions.

Results

During the study period, 3155 adult patients were included (elderly, n = 505). Burn severity, reflected by the median TBSA, varied between 3.2-4.0% and was comparable, but aetiology and pre-hospital care were different between elderly and the younger adult reference group.Surgical treatment was initiated significantly faster in elderly burn patients (p < 0.001). Less selective techniques for surgical debridement were used in the elderly burns patients (hydrosurgery, 42.0% vs 23.5-22.6%), and on the other hand more avulsion (5.3% vs 7.3-17.6%) and primary wound closure (6.7% vs 24.5%). The most frequently used grafting technique was meshed skin grafts (79.2-88.6%); this was not related to age.Mortality increased rapidly with a higher age and showed a high peak in the 85+ category (23.8%). Furthermore, considerable differences were found in hospital discharge disposition between the elderly and the reference group.

Conclusions

In conclusion, elderly burn patients who require specialized burn care are vulnerable and medically challenging. Differences in aetiology, comorbidity, physiology and the management prior to admission possibly affect the initial surgical management and result in significantly worse outcomes in elderly. Elderly patients need optimal, timely and specialized burn care to enhance survival after burn injuries.

Do elderly trauma patients receive the required treatment? Epidemiology and outcome of geriatric trauma patients treated at different levels of trauma care

PURPOSE

In an ageing society, geriatric trauma displays an increasing challenge in trauma care. Due to comorbidities and reduced physiologic reserves, these patients might benefit from an immediate specialised care. The current study aims to clarify the prevalence and outcome of geriatric trauma depending on the level of the primary trauma centre.

METHODS

Data sets of 124,641 patients entered in the TR-DGU between 2009 and 2016 were included. Geriatric trauma was defined above 65 years and ISS ≥ 9. Analysing the prevalence, the age structure of all trauma cases registered in 2014 was compared to demographic data of the German Federal Statistical Office. Differences in injury pattern, in-hospital care and outcome between the primary levels of care were analysed.

RESULTS

In comparison to their share of population, geriatric patients are highly overrepresented in the TR-DGU. Despite minor injury mechanisms, severe head injuries are common. A tendency to under-triage can be observed, as level II and III trauma centres receive a higher percentage of older patients. Nevertheless, there is no effect on the mortality. 10% of these patients require an early transfer to a higher levelled trauma centres mainly due to severe head and spine injuries. Surprisingly, pre-clinical available signs such as GCS or blood pressure were not altered in these patients.

CONCLUSION

Patients above the age of 65 years represent a second group with high risk for traumatic injuries besides younger adults. Despite low-energy trauma mechanisms, these patients are prone to suffer from severe injuries, which require specialised care. Current admission practice appears adequate, as pre-clinical available symptoms did not correlate with injuries that demanded an early inter-hospital transfer. Specialised geriatric triage scores might further improve admission practice.

Multidisciplinary Patient Management Improves Mortality in Geriatric Trauma Patients

Improvement in the care of the traumatically injured patient should be a goal at all trauma centers. One purpose of the data generated by the Trauma Quality Improvement Program is to provide insight which will lead to quality improvement initiatives and to promote intrinsic improvement on a center by center basis. The primary objective of this study was to measure the efficacy of instituting a multidisciplinary Trauma Medicine (T-MED) program to improve geriatric mortality at Ventura County Medical Center (VCMC). Trauma Quality Improvement Program data at VCMC before October 2013 demonstrated poor performance in treating geriatric patients. To attempt to improve outcomes, a multidisciplinary T-MED program was instituted in October 2013, which included a mandatory consultation and collaborative management with hospitalist medicine physicians for all trauma patients 65 years of age or older. The T-MED program increased focus on preexisting conditions, medication management, and discharge planning, including rehabilitation and continuity of care. Institution of a T-MED program at VCMC resulted in significant improvement in mortality rates for geriatric trauma patients.

Higher Quality, Lower Cost with an Innovative Geriatrics Consultation Service

OBJECTIVES

To design a value-driven, interprofessional inpatient geriatric consultation program coordinated with systems-level changes and studied outcomes and costs.

DESIGN

Propensity-matched case-control study of older adults hospitalized at an academic medical center (AMC) who did or did not receive geriatric consultation.

SETTING

Single tertiary-care AMC in Portland, Oregon.

PARTICIPANTS

Adults aged 70 and older who received an inpatient geriatric consultation (n=464) and propensity-matched controls admitted before development of the consultation program (n=2,381). Pre- and postintervention controls were also incorporated into cost difference-in-difference analyses.

MEASUREMENTS

Daily charges, total charges, length of stay (LOS), 30-day readmission, intensive care unit (ICU) days, Foley catheter days, total medication doses per day, high-risk medication doses per day, advance directive and Physician Orders for Life Sustaining Treatment (POLST) documentation, restraint orders, discharge to home, and mortality.

RESULTS

On average, individuals who received a geriatric consultation had $611 lower charges per day than those without a consultation (p=.02). They spent on average 0.36 fewer days in the ICU (p<.001). They were less likely to have restraint orders (20.0% vs 27.9%, p<0.001), more likely to have a POLST (58.2% vs 44.6%, p<.001), and more likely to be discharged to home (33.4% vs 28.2%, p=.03). They received fewer doses of antipsychotics, benzodiazepines, and antiemetics (10, 5, and 7 fewer doses per 100 patient-days, respectively) and had lower in-hospital mortality (2.4% vs 4%, p=.01). There was no difference in hospital LOS or 30-day readmission.

CONCLUSION

Our consultation program resulted in significant reductions in daily charges, ICU days, potentially inappropriate medication use, and use of physical restraints and increased end-of-life planning. This model has potential for dissemination to other institutions operating in resource-scarce, value-driven settings.

Trauma Consults by Geriatricians: Looking Into the Black Box

The conceptual framework, targeting of older adults, and content of a targeted geriatric trauma consult (GTC) performed by geriatricians at a Level 1 trauma center are highlighted. The GTC is designed to optimize patient care through comprehensive assessment and to interrupt the disablement process. In a performance improvement study, fellowship-trained and certified geriatricians conducted the GTC in 98 patients ranging in age from 68 to 100 years. Most common recommendations by the geriatricians were for transitions of care (e.g., home health, skilled nursing facility, hospice), changes in medications (e.g., antihypertensives, antidepressants/antipsychotics), advanced care planning, and specialist referral. Targeted GTC performed by a geriatrician is an efficient approach to comanagement of complex older trauma patients, in contrast to mandated geriatric team consultation. In settings of value-based care, GTC by a geriatrician has potential to reduce patient disability and health care costs compared with usual care of older trauma patients.