Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients

Development and implementation of a geriatric nursing program at an academic medical center

Brigham and Women's Hospital, a leader in geriatric surgery, was awarded Geriatric Surgery Verification by the American College of Surgeons. This award demonstrates its expertise in meeting the specialized needs of older adults in the perioperative period to optimize their surgical outcomes and experience. Among the program's standards is implementing the geriatric nurse champion role and education in alignment with the Nurses Improving Care for Healthsystem Elders (NICHE) practice model. In this month's NICHE column, nurse leaders from Brigham and Women's Hospital describe its path to achieving Geriatric Surgery Verification and implementing the NICHE practice model in the perioperative setting.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee

Background

Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation.

Methods

We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified.

Results

Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings.

Conclusion

Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

'Our Voices Aren't Being Heard': A qualitative descriptive study of nurses' perceptions of interprofessional collaboration in care supporting older people's functioning during a hospital stay

INTRODUCTION

Older people admitted to hospital are highly susceptible to functional decline and related complications. Care supporting their functioning is complex and requires healthcare professionals working in concert, with nurses playing a central role. Yet, little is known about nurses' perceptions of interprofessional collaboration (IPC) in care supporting functioning in acutely admitted older people. To fill this knowledge gap, we elucidate the perspectives of nurses in Ontario, Canada, on IPC in care supporting older people's functioning during a hospital stay.

METHODS

We employed a qualitative methodology in conjunction with a qualitative descriptive design. Thirteen focus groups were held with a purposeful, criterion-based sample of 57 acute care nurses practising in a range of acute care settings (e.g. Emergency, General Medicine, General Surgery, Intensive Care, Coronary Care). Data were thematically analysed.

RESULTS

We identified two overarching themes: (1) IPC is improving, but nurses are excluded from decision-making and (2) nurse advocacy causes friction with other professionals. The first theme captures nurses' perception that IPC in older people's care is improving, but nurses are marginalised in interprofessional decision-making. As a result, nurses perceive that their knowledge is devalued, and their contributions to care supporting older people's functioning are undermined. The second theme underlines a tension between interprofessional team practices and patient- and family-centred care, while also demonstrating nurses' increasing willingness to act as patient and family advocates.

CONCLUSIONS

Findings can be used to enhance IPC in care supporting the functioning of acutely hospitalised older people. To improve IPC, clinical and administrative leaders should cultivate more egalitarian team relationships that encourage nurses to contribute to decision-making and advocate on behalf of older patients and their families.

Initiatives Targeting Health Care Professionals: A Systematic Review of Knowledge Translation Pain Assessment and Management Studies Focusing on Older Adults

OBJECTIVES

Pain is often undertreated in older adult populations due to factors, such as insufficient continuing education and health care resources. Initiatives to increase knowledge about pain assessment and management are crucial for the incorporation of research evidence into practice. Knowledge translation (KT) studies on pain management for older adults and relevant knowledge users have been conducted; however, the wide variety of KT program formats and outcomes underscores a need to evaluate and systematically report on the relevant literature.

MATERIALS AND METHODS

Using a systematic review methodology, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycInfo, and Web of Science databases were searched from inception to June 2023. Pain-related KT programs targeted towards older adults, their informal caregivers, and health care professionals were examined. Initiatives focusing on health care professionals are the focus of this review. Initiatives focusing on older adults are reported in a companion article.

RESULTS

From an initial 21,669 search results, 172 studies met our inclusion criteria. These studies varied widely in focus and delivery format but the majority were associated with significant risk of bias. In this report, we are focusing on 124 studies targeting health care professionals; 48 studies involving initiatives targeting older adults are reported in a companion article. Moreover, most programs were classified as knowledge mobilization studies without an implementation component. Across all studies, knowledge user satisfaction with the initiative and the suitability of the material presented were most commonly assessed. Patient outcomes, however, were underemphasized in the literature.

CONCLUSION

Patient and clinical outcomes must be a focus of future research to fully conceptualize the success of KT programs for older adult individuals. Without implementation plans, disseminated knowledge does not tend to translate effectively into practice.

Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures

Background

Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures.

Methods

All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding.

Results

A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001].

Conclusion

There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

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.

Investigating the effects of frailty on six-month outcomes in older trauma patients admitted to UK major trauma centres: a multi-centre follow up study

BACKGROUND

Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission.

METHODS

This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up.

RESULTS

Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (β-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (β -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (β -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01).

CONCLUSIONS

Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning.

Impact of medication intensification on 30-day hospital readmissions in a geriatric trauma population: A multicenter cohort study

BACKGROUND

Fall-related injuries are a significant health issue that occur in 25% of older adults and account for a significant number of trauma-related hospitalizations. Although medication intensification may increase the risk of hospital readmissions in non-trauma patients, data on a geriatric trauma population are lacking.

OBJECTIVE

The primary objective was to evaluate the effect of medication intensification on 30-day hospital readmissions in geriatric patients hospitalized for fall-related injuries.

METHODS

This multicenter, retrospective cohort study included patients with geriatric who presented to one of three trauma centers within a large, health-system between January 1, 2018 and December 31, 2020. Patients at least 65 years old admitted with a fall-related injury were eligible for inclusion. Patients were grouped according to medication changes at discharge, which included intensified and non-intensified groups. Medication intensification included increased dose(s) or initiation of new agents. The primary outcome was the 30-day hospital readmission rate.

RESULTS

Of the 870 patients included (median [interquartile range, IQR] age, 82 [74-89] years, 522 (60%) female, and 220 (25%) with a previous fall), there were 471 (54%) and 399 (46%) patients in the intensified and non-intensified groups, respectively. The intensified group had a higher 30-day hospital readmission rate (21% intensified vs. 16% non-intensified, p = 0.043; number needed to harm 20) based on an unweighted analysis. According to a weighted propensity score logistic regression, medication intensification was associated with higher 30-day hospital readmissions (24% [95% confidence interval [CI] 19-31%] intensified vs. 15% [95% CI 11-20%] non-intensified, p = 0.018). These results were consistent within competing risk models accounting for death (cause-specific model: hazard ratio [HR] 1.63 [95% CI 1.07-2.49], p = 0.023; Fine-Gray model: HR 1.64 [95% CI 1.07-2.50], p = 0.022).

CONCLUSIONS

In a geriatric trauma population hospitalized after a fall, intensification of medications may pose an increased risk of 30-day hospital readmission.

Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?

INTRODUCTION

It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.

STUDY DESIGN

Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days.

RESULTS

110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05).

CONCLUSION

Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.

Trauma in the elderly: a bilateral rectus sheath haematoma

Life expectancy has more than doubled in the last century, and a new cohort of elderly and increasingly frail patients is presenting to emergency departments with new clinical challenges. When this patient cohort presents after injury, all aspects of clinical practice have to be recalibrated to provide safe and appropriate care. The prevalence of chronic disease, levels of organ failure, multiple comorbidities, greater use of anticoagulation and incidence of recurrent low- and high-impact trauma may delay and obscure diagnosis and, ultimately, increase mortality.Older age is a risk factor for rectus sheath haematoma (RSH), which is haemorrhage into the potential space surrounding the rectus abdominis muscle/s. It is a rare presentation following trauma but can provide diagnostic challenges and be fatal. Even more rare is bilateral RSH with only 12 reported in the literature since 1981.This case report describes bilateral RSH presenting in an elderly woman following a fall and the consequences of seemingly minor trauma in the elderly.

Development and Validation of a Model to Quantify Injury Severity in Real Time

Importance

Quantifying injury severity is integral to trauma care benchmarking, decision-making, and research, yet the most prevalent metric to quantify injury severity-Injury Severity Score (ISS)- is impractical to use in real time.

Objective

To develop and validate a practical model that uses a limited number of injury patterns to quantify injury severity in real time through 3 intuitive outcomes.

Design, Setting, and Participants

In this cohort study for prediction model development and validation, training, development, and internal validation cohorts comprised 223 545, 74 514, and 74 514 admission encounters, respectively, of adults (age ≥18 years) with a primary diagnosis of traumatic injury hospitalized more than 2 days (2017-2018 National Inpatient Sample). The external validation cohort comprised 3855 adults admitted to a level I trauma center who met criteria for the 2 highest of the institution's 3 trauma activation levels.

Main Outcomes and Measures

Three outcomes were hospital length of stay, probability of discharge disposition to a facility, and probability of inpatient mortality. The prediction performance metric for length of stay was mean absolute error. Prediction performance metrics for discharge disposition and inpatient mortality were average precision, precision, recall, specificity, F1 score, and area under the receiver operating characteristic curve (AUROC). Calibration was evaluated using calibration plots. Shapley addictive explanations analysis and bee swarm plots facilitated model explainability analysis.

Results

The Length of Stay, Disposition, Mortality (LDM) Injury Index (the model) comprised a multitask deep learning model trained, developed, and internally validated on a data set of 372 573 traumatic injury encounters (mean [SD] age = 68.7 [19.3] years, 56.6% female). The model used 176 potential injuries to output 3 interpretable outcomes: the predicted hospital length of stay, probability of discharge to a facility, and probability of inpatient mortality. For the external validation set, the ISS predicted length of stay with mean absolute error was 4.16 (95% CI, 4.13-4.20) days. Compared with the ISS, the model had comparable external validation set discrimination performance (facility discharge AUROC: 0.67 [95% CI, 0.67-0.68] vs 0.65 [95% CI, 0.65-0.66]; recall: 0.59 [95% CI, 0.58-0.61] vs 0.59 [95% CI, 0.58-0.60]; specificity: 0.66 [95% CI, 0.66-0.66] vs 0.62 [95%CI, 0.60-0.63]; mortality AUROC: 0.83 [95% CI, 0.81-0.84] vs 0.82 [95% CI, 0.82-0.82]; recall: 0.74 [95% CI, 0.72-0.77] vs 0.75 [95% CI, 0.75-0.76]; specificity: 0.81 [95% CI, 0.81-0.81] vs 0.76 [95% CI, 0.75-0.77]). The model had excellent calibration for predicting facility discharge disposition, but overestimated inpatient mortality. Explainability analysis found the inputs influencing model predictions matched intuition.

Conclusions and Relevance

In this cohort study using a limited number of injury patterns, the model quantified injury severity using 3 intuitive outcomes. Further study is required to evaluate the model at scale.

Reliability and validity of the Chinese version of the trauma-specific frailty index (TSFI) for geriatric trauma patients

BACKGROUND

Pre-traumatic frailty in geriatric trauma patients has caught attention from emergency medical workers and the assessment of it thus become one of the important aspects of risk management. Several tools are available to identify frailty, but limited tools have been validated for geriatric trauma patients in China to assess pre-traumatic frailty.The aim of this study is to translate the Trauma-Specific Frailty Index(TSFI) into Chinese, and to evaluate the reliability and validity of the translated version in geriatric trauma patients.

METHODS

A cross-sectional study was conducted. The TSFI was translated with using the Brislin model, that included forward and backward translation. A total of 184 geriatric trauma patients were recruited by a convenience sampling between October and December 2020 in Hospital of Chengdu University of Traditional Chinese Medicine, Sichuan. Using reliability or internal consistency tests assessed with Cronbach's alpha coefficient, split-half reliability and test-retest reliability. Content validity and construct validity analysis were both performed. Sensitivity, specificity and maximum Youden index(YI) were used to determine the optimal cut-off value. The screening performance was examined by Kappa value.

RESULTS

The total study population included 184 subjects, of which 8 participants were excluded, resulting in a study sample size of 176 elderly trauma patients (the completion rate was 95.7%). The Chinese version of Trauma-Specific Frailty Index(C-TSFI) have 15 items with 5 dimensions. Cronbach's alpha coefficient of the C-TSFI was 0.861, Cronbach's alpha coefficient of dimensions ranged from 0.837 to 0.875, the split-half reliability of the C-TSFI were 0.894 and 0.880 respectively, test-retest reliability ranged from 0.692 to 0.862. The correlation coefficient between items and the C-TSFI ranged from 0.439 to 0.761. The content validity index for items (I-CVI) of the C-TSFI scale was 0.86~1.00, and the scale of content validity index (S-CVI) was 0.93. The area under curve (AUC) of the C-TSFI was 0.932 (95%CI 0.904-0.96, P < 0.05), the maximum YI was 0.725, the sensitivity was 80.2%, the specificity was 92.3%, and the critical value was 0.31. Kappa value was 0.682 (P < 0.05).

CONCLUSIONS

The Chinese version of TSFI could be used as a general assessment tool in geriatric trauma patients, and both its reliability and validity have been demonstrated.

Effects of non-pharmacologic prevention on delirium in critically ill patients: A network meta-analysis

BACKGROUND

Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients.

AIM

This review aimed to evaluate the efficacy of non-pharmacological interventions and determine what combination of these is effective in preventing delirium among Intensive Care Unit patients.

STUDY DESIGN

A systematic review and meta-analysis. This review follows the guidelines of the Preferred Reporting Items for Systematic reviews and Meta Analysis statements for Network Meta-Analysis (PRISMA-NMA). Data sources included the Cumulative Index to Nursing & Allied Health Literature., MEDLINE, and Cochrane library databases. The integrated data were investigated with odds ratio (OR) and 95% confidence interval (95% CI), using the random-effects Mantel-Haenszel model. Data were considered significant when p < 0.05. Furthermore, to reveal what combination of care is effective, we performed a network meta-analysis estimated OR, 95% CI.

RESULTS

We identified three randomized controlled trials and eight controlled before-after trials (11 in total, with 2549 participants). The pooled data from 11 trials of multicomponent intervention had a significant effect on delirium prevention (OR 0.58, 95% CI 0.44-0.76, p < 0.001). As a result of network meta-analysis, two bundles were effective compared to the control group in reducing the incidence of delirium: a) the combination of sleep promotion (SP), cognitive stimulation (CS), early mobilization (EM), pain control (PC), and assessment (AS) (OR 0.47, 95% CI 0.35-0.64, p < 0.002), and b) the combination of SP and CS (OR 0.46, 95% CI 0.28-0.75, p < 0.001).

CONCLUSION

This study revealed that non-pharmacological interventions, particularly multicomponent interventions, helped to prevent delirium in critically ill patients. In the network meta-analysis, the most effective care combination for reducing incidence of delirium was found to be multicomponent intervention, which comprises SP-CS-EM-PC-AS, and SP-CS.

RELEVANCE TO CLINICAL PRACTICE

These findings reveal an efficient combination of multicomponent interventions for preventing delirium, which may be a very important prerequisite in planning care programs in the future.

Explainable Machine Learning to Bring Database to the Bedside: Development and Validation of the TROUT (Trauma fRailty OUTcomes) Index, a Point-of-Care Tool to Prognosticate Outcomes After Traumatic Injury Based on Frailty

OBJECTIVE

Exemplify an explainable machine learning framework to bring database to the bedside; develop and validate a point-of-care frailty assessment tool to prognosticate outcomes after injury.

BACKGROUND

A geriatric trauma frailty index that captures only baseline conditions, is readily-implementable, and validated nationwide remains underexplored. We hypothesized Trauma fRailty OUTcomes (TROUT) Index could prognosticate major adverse outcomes with minimal implementation barriers.

METHODS

We developed TROUT index according to Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis guidelines. Using nationwide US admission encounters of patients aged ≥65 years (2016-2017; 10% development, 90% validation cohorts), unsupervised and supervised machine learning algorithms identified baseline conditions that contribute most to adverse outcomes. These conditions were aggregated into TROUT Index scores (0-100) that delineate 3 frailty risk strata. After associative [between frailty risk strata and outcomes, adjusted for age, sex, and injury severity (as effect modifier)] and calibration analysis, we designed a mobile application to facilitate point-of-care implementation.

RESULTS

Our study population comprised 1.6 million survey-weighted admission encounters. Fourteen baseline conditions and 1 mechanism of injury constituted the TROUT Index. Among the validation cohort, increasing frailty risk (low=reference group, moderate, high) was associated with stepwise increased adjusted odds of mortality {odds ratio [OR] [95% confidence interval (CI)]: 2.6 [2.4-2.8], 4.3 [4.0-4.7]}, prolonged hospitalization [OR (95% CI)]: 1.4 (1.4-1.5), 1.8 (1.8-1.9)], disposition to a facility [OR (95% CI): 1.49 (1.4-1.5), 1.8 (1.7-1.8)], and mechanical ventilation [OR (95% CI): 2.3 (1.9-2.7), 3.6 (3.0-4.5)]. Calibration analysis found positive correlations between higher TROUT Index scores and all adverse outcomes. We built a mobile application ("TROUT Index") and shared code publicly.

CONCLUSION

The TROUT Index is an interpretable, point-of-care tool to quantify and integrate frailty within clinical decision-making among injured patients. The TROUT Index is not a stand-alone tool to predict outcomes after injury; our tool should be considered in conjunction with injury pattern, clinical management, and within institution-specific workflows. A practical mobile application and publicly available code can facilitate future implementation and external validation studies.

Frailty, Acute Brain Dysfunction, and Posthospitalization Disability Outcomes in Critically Ill Older Adults

BACKGROUND

Identifying potentially modifiable factors that mediate adverse outcomes in frail adults with critical illness may facilitate development of interventions to improve intensive care unit (ICU) survivorship.

OBJECTIVES

To estimate the relationship between frailty, acute brain dysfunction (as reflected by delirium or persistent coma), and 6-month disability outcomes.

METHODS

Older adults (aged ≥50 years) admitted to the ICU were enrolled prospectively. Frailty was identified with the Clinical Frailty Scale. Delirium and coma were assessed daily with the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale, respectively. Disability outcomes (death and severe physical disability [defined as new dependence in 5 or more activities of daily living]) were assessed by telephone within 6 months after discharge.

RESULTS

In 302 older adults (mean [SD] age, 67.2 [10.8] y), both frail and vulnerable patients had a higher risk for acute brain dysfunction (adjusted odds ratio [AOR], 2.9 [95% CI, 1.5-5.6], and 2.0 [95% CI, 1.0-4.1], respectively) compared with fit patients. Both frailty and acute brain dysfunction were independently associated with death or severe disability at 6 months (AOR, 3.3 [95% CI, 1.6-6.5] and 2.4 [95% CI, 1.4 -4.0], respectively). The average proportion of the frailty effect mediated by acute brain dysfunction was estimated to be 12.6% (95% CI, 2.1%-23.1%; P = .02).

CONCLUSION

Frailty and acute brain dysfunction were important independent predictors of disability outcomes in older adults with critical illness. Acute brain dysfunction may be an important mediator of increased risk for physical disability outcomes after critical illness.

Long-term health-related quality of life and independence among older survivors of serious injury

BACKGROUND

Little is known about the recovery experiences of older trauma intensive care unit (TICU) survivors and the relationship between geriatric trauma care and long-term functional ability and health-related quality of life (HRQOL).

METHODS

We conducted a prospective cohort study of 218 patients (age, ≥65 years) admitted to a Level 1 regional trauma center TICU before versus after implementation of a geriatric care bundle with protocolized geriatrics consultations (Geri-T). Survivors or their proxies were interviewed approximately 1 year after hospitalization. Outcomes included the Katz Index of Independence in Activities of Daily Living (ADLs), Lawton Instrumental Activities of Daily Living (IADLs), and EQ-5D-5L HRQOL survey. Two investigator-developed questions regarding recovery experiences were included. Differences in outcomes among survivors admitted before versus after Geri-T were analyzed using multivariable linear regression. Responses to questions about recovery experiences were qualitatively assessed using content analysis.

RESULTS

We reached 67% (146/218) of hospital survivors or their proxies across both groups; 126 patients were still alive and completed the survey. Mean age was 76 (SD, 8), 36% were female, and 90% were independent with ADLs preinjury. At follow-up, independence with ADLs was 76% and IADLs was 63%. The mean EQ-5D-5L index score was 0.78 (SD, 0.18). Most patients (65%) reported having not returned to preinjury functional status. Neither functional ability or HRQOL differed significantly among patients admitted before versus after Geri-T. Content analysis of open-ended questions revealed themes of activity limitations, persistent pain, and cognitive dysfunction.

CONCLUSION

Nearly one-fifth of TICU survivors experienced loss of ADL function 1 year after injury, and most reported having not returned to preinjury functional status. Nonetheless, patient-reported HRQOL was comparable to age-adjusted norms. Geri-T was not associated with differences in HRQOL or functional ability. Survivors reported persistent difficulty with activities beyond those of daily living, pain, and cognition.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level III.

Geriatric Trauma and Frailty

Geriatric trauma is increasing in the United States. The care of patients with geriatric trauma is complex due to age-related changes and comorbidities. Patients with geriatric trauma have increased risk of poor outcomes compared with younger patients with trauma, and the highest risk groups are those who have frailty. These patients require special care considerations. Multidisciplinary care can improve outcomes in frail patients with geriatric trauma.

Delirium Prevention and Management in Frail Surgical Patients

Delirium, an acute, fluctuating impairment in cognition and awareness, is one of the most common causes of postoperative brain dysfunction. It is associated with increased hospital length of stay, health care costs, and mortality. There is no FDA-approved treatment of delirium, and management relies on symptomatic control. Several preventative techniques have been proposed, including the choice of anesthetic agent, preoperative testing, and intraoperative monitoring. Frailty, a state of increased vulnerability to adverse events, is an independent and potentially modifiable risk factor for the development of delirium. Diligent preoperative screening techniques and implementation of prevention strategies could help improve outcomes in high-risk patients.

Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review

OBJECTIVE

To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma.

SETTING

Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched.

INCLUDED ARTICLES

Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone.

METHODS

Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken.

OUTCOME MEASURES

Any outcomes reported for patients, staff or care system.

RESULTS

17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury.

CONCLUSIONS

This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895.

Evaluation of interdisciplinary care pathway implementation in older elective surgery patients

BACKGROUND

The American College of Surgeons Geriatric Surgery Verification Program outlines best practices for surgical care in older adults. These recommendations have guided institutions to create workflows to better support needs specific to older surgical patients. This qualitative study explored clinician experiences to understand influences on implementation of frailty screening and an interdisciplinary care pathway in older elective colorectal surgery and neurosurgery patients.

STUDY DESIGN

Semi-structured in-person and video-based interviews were conducted from July 2021 to March 2022 with clinicians caring for patients ≥70 years on the colorectal surgery and neurosurgery services. Interviews addressed familiarity with and beliefs about the intervention, intervention alignment with routine workflow and workflow adaptations, and barriers and facilitators to performing the intervention. Interviews were analyzed using the consolidated framework for implementation research (CFIR) to find themes related to ongoing implementation.

RESULTS

Thirty-two clinicians participated (56.3% female, 58.8% White). Fifteen relevant CFIR constructs were identified. Key themes to implementation success included strong participant belief in effectiveness of the intervention and its advantage over standard care; the importance of training, reference materials, and champions; and the need for institution-level investment in resources to amplify the impact of the intervention on patients and expand the capacity to address their needs.

CONCLUSION

Systematic evaluation found implementation of frailty screening and an interdisciplinary care pathway in elective colorectal surgery and neurosurgery patients to be supported by participating clinicians, yet sustainability of the intervention and further adoption across surgical services to better meet the needs of older patients would necessitate organizational resource allocation.

Frailty and comorbidity predict 30 day postoperative outcomes, independent of anatomical site of fracture

INTRODUCTION

Fragility fractures are a major threat to geriatric patients. However, it is unclear whether this patient population's inherent frailty and comorbidity or the physiologic insult caused by the fracture and its surgery contribute more to undesirable patient outcomes. Hence, this study examines if frailty and comorbidity can predict 30 day postoperative outcomes while the effects of multiple fracture sites are accounted for.

METHODS

A retrospective review of patients ≥ 65 years of age in the National Surgical Quality Improvement Program who underwent surgical treatment between 2013 and 2017 was performed. A total of 52,497 patients were included in the final analysis, including fracture cases of the extremities, limbs, and hip. Demographics, several metrics of preoperative health, temporal variables, and fracture location were tested in bivariate analysis of 30 day postoperative mortality, length of stay in hospital, discharge outcome, and complications. Significant variables were considered for multivariate logistic regression models for each outcome.

RESULTS

Frailty, comorbidity, and time to surgery were found to be the significant predictors in multivariate analysis of each 30 day postoperative outcome, independent of the effects of fracture site (p < 0.05). Examination of 30 day mortality found that American Society of Anesthesiologists Class ≥ 3 (2.30 Odds Ratio), modified Frailty Index > 0 (1.37 OR), Charleston Comorbidity Index ≥ 6 (1.63 OR), and time to surgery (1.45 OR) were especially important (all p < 0.05). Additionally, the worst outcomes were associated with fractures of the pelvis/hip and femur/knee, including 30 day mortality (5.90 and 5.12 OR, respectively; both p < 0.05).

CONCLUSION

The effects of the preoperative health were found to be independent of patient demographics and fracture site. Additionally, specific high-risk fracture sites are significant predictors of outcome, supporting the need to prioritize these patients. Clinical care pathways for geriatric patients may benefit from emphasis on these high-risk fractures and preoperative patient health.

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial

BACKGROUND

The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients.

METHODS

This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission.

RESULTS

A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05).

CONCLUSION

External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Models of acute care for injured older patients-Australia and New Zealand practice

INTRODUCTION

The epidemiology of injured patients has changed, with an increasing predominance of severe injury and deaths in older (65 years and above) patients after low falls. There is little evidence of the models of care that optimise outcomes for injured older patients. This study aims to describe clinician perspectives of existing models of acute care for injured older patients in Australia and New Zealand.

METHODS

This cross-sectional online survey of healthcare professionals (HCP) managing injured older patients in Australia or New Zealand hospitals was conducted between November 2nd and December 12th, 2020. Recruitment was via survey link and snowball sampling to professional organisations and special interest groups via email and social media. HCP were asked, using a Likert scale, how likely four typical case vignettes were to be admitted to one of twelve options for ongoing care. Additional questions explored usual care components.

RESULTS

Participants (n=157) were predominantly Australian medical professionals in a major trauma service (MTS) or metropolitan hospital. The most common age defining "geriatric" was aged 65 years and older (43%). HCP described variability in the models and components of acute care for older injured patients in Australia and New Zealand. As a component of care, cognitive, delirium and frailty screening are occurring (60%, 61%, 46%) with HCP from non-major trauma services (non-MTS) reporting frailty and cognitive impairment screening more likely to occur in the emergency department (ED). Access to an acute pain service was more likely in a MTS. Participants described poor likelihood of a geriatrician (highest 16%) or physician (highest 12%) review in ED CONCLUSION: Despite a low response rate, HCP in Australia and New Zealand describe variability in acute care pathways for injured older patients. Given the change in epidemiology of injury towards older patients with low force mechanisms, models of acute injury care should be evaluated to define a cost-effective model and components of care that optimise patient-centred outcomes relevant to injured older patients. HCP described some factors they perceive to determine care, and outcomes of variability, offering guidance for future research and resource allocation in the Australia and New Zealand trauma system.

Conceptualization of frailty in rehabilitation interventions with adults: a scoping review

Purpose: We aimed to synthesize the literature that considered frailty in the evaluation of rehabilitation interventions for adults (aged ≥18) by answering: (1) how is frailty defined in rehabilitation intervention research?; (2) how is frailty operationalized in rehabilitation intervention research?; (3) what are the characteristics of rehabilitation interventions for frail adults and what frailty related outcomes are assessed?Materials and methods: A scoping review was conducted. Data were analyzed using descriptive statistics and qualitative content analysis.Results: 53 articles met the inclusion criteria. Most studies were conducted in Europe and involved randomized control trials. The included studies reported on rehabilitation interventions that only included individuals aged 50 or older. Thirteen studies used Fried's definition of frailty, but most (n = 27) did not use any definition. Many studies did not differentiate between the conceptualization (e.g., definition) and operationalization (e.g., use of inclusion/exclusion criteria, outcome measures) of frailty. Most interventions focused on exercise. Instrumental activities of daily living reported most frequently as outcomes (n = 11).Conclusions: There is an absence of consistent definitions of frailty in rehabilitation interventions and current definitions tend to focus on physical functioning. The authors suggest rehabilitation researchers consider an expanded definition of frailty informed by the International Classification of Functioning, Disability and Health framework.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals should use an expanded definition of frailty, informed by the International Classification of Functioning, Disability and Health framework, should include physical, mental, personal, environmental, and social factors to decrease, delay, or prevent frailty in adults.Rehabilitation professionals should consider a broader operationalization of frailty that is not dependent on age and physical functioning.Rehabilitation professionals that consider a broader conceptualization of frailty should tailor interventions to the specific needs of frail adults.

Provision of acute care pathways for older major trauma patients in the UK

BACKGROUND

The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known.

OBJECTIVE

The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK.

METHODS

A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each.

RESULTS

Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age.

CONCLUSIONS

This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases

BACKGROUND

Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized.

OBJECTIVE

To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort.

METHODS

We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention.

RESULTS

A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention.

CONCLUSION

For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.

Frailty in mid-life predicts outcome following trauma

PURPOSE

Midlife adults (50-64 y) are at risk for falls and subsequent injury; yet current guidance on fall screening only pertains to older adults (> 65 y). Herein, we evaluated whether frailty was predictive of readmission for falls in midlife trauma patients.

STUDY DESIGN

This was a retrospective cohort study of trauma midlife patients admitted for traumatic injuries from 2010 to 2015. Demographics, injury data, fall history, and post-index readmission for falls were collected from medical records. Frailty scores were calculated retrospectively using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS). The association between frailty and outcomes was assessed. p < 0.05 was considered significant.

RESULTS

A total of 326 midlife patients were included, 54% were considered fit, 33.7% pre-frail, and 12.3% frail. Compared to their fit and pre-frail counterparts, frail patients were more likely to be female (67.5% vs. 46.3% vs. 36.3%, p < 0.001), have a history of fall (22.5% vs. 15.5% vs. 6.2%, p < 0.001), and to have suffered a ground level fall on index admission (52.5% vs. 20% vs. 5.7%, p < 0.001). Controlling for age, BMI, gender, race, and fall history, frailty was associated with readmission of midlife adults for falls (OR = 1.82 [1.23-2.69]; p = 0.003) and discharge to skilled nursing facilities (OR = 26.86 [8.03-89.81], p < 0.001).

CONCLUSIONS

Pre-injury frailty may be an effective tool to predict risk of readmission for fall and discharge disposition in midlife trauma patients.

Frailty independently predicts unfavorable discharge in non-operative traumatic brain injury: A retrospective single-institution cohort study

BACKGROUND

Frailty is associated with adverse outcomes in traumatically injured geriatric patients but has not been well-studied in geriatric Traumatic Brain Injury (TBI).

OBJECTIVE

To assess relationships between frailty and outcomes after TBI.

METHODS

The records of all patients aged 70 or older admitted from home to the neurosurgical service of a single institution for non-operative TBI between January 2020 and July 2021 were retrospectively reviewed. The primary outcome was adverse discharge disposition (either in-hospital expiration or discharge to skilled nursing facility (SNF), hospice, or home with hospice). Secondary outcomes included major inpatient complication, 30-day readmission, and length of stay.

RESULTS

100 patients were included, 90% of whom presented with Glasgow Coma Score (GCS) 14-15. The mean length of stay was 3.78 days. 7% had an in-hospital complication, and 44% had an unfavorable discharge destination. 49% of patients attended follow-up within 3 months. The rate of readmission within 30 days was 13%. Patients were characterized as low frailty (FRAIL score 0-1, n = 35, 35%) or high frailty (FRAIL score 2-5, n = 65, 65%). In multivariate analysis controlling for age and other factors, frailty category (aOR 2.63, 95CI [1.02, 7.14], p = 0.005) was significantly associated with unfavorable discharge. Frailty was not associated with increased readmission rate, LOS, or rate of complications on uncontrolled univariate analyses.

CONCLUSION

Frailty is associated with increased odds of unfavorable discharge disposition for geriatric patients admitted with TBI.

A proposal for virtual, telephone-based preoperative cognitive assessment in older adults undergoing elective surgery

OBJECTIVE

To assess the feasibility of administering the MoCA 5-minute test/Telephone (T-MoCA), an abbreviated version of the Montreal Cognitive Assessment to older adults perioperatively DESIGN: A feasibility study including patients aged ≥ 70 years scheduled for surgery from December 2020 to March 2021 SETTING: Preoperative virtual clinic PATIENTS: Patients ≥70 years undergoing major elective surgery INTERVENTION: A study investigator called eligible patients prior to surgery, obtained consent, and completed the preoperative cognitive assessment. Follow-up assessment was completed 1-month postoperatively, and participating clinicians were surveyed at the completion of the study.

MEASUREMENTS

An attention test, T-MoCA, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and Generalized Anxiety Disorder 2-item (GAD-2) MAIN RESULTS: Overall, 37/40 (92.5%) patients completed the pre- and post-operative assessments. The cohort was 50% female, white (97.5%), with a median age of 76 years (interquartile range (IQR) 73-79), and education level was higher than high school in 82.5% of patients. Preoperatively, the median number of medications was 8 (IQR 7-11), 27/40 (67.5%) had medications with anticholinergic effects, and 6/40 (15%) had benzodiazepines. Median completion time of the phone assessment was 10 min (IQR 8.25-12) and 4 min (IQR 3-5) for the T-MoCA with a median T-MoCA score of 13 (IQR 12-14). Most patients (37/40) completed the post-operative assessment, and 6/37 (16.2%) reported they had experienced a change in memory or attention post-operatively. Clinician's survey reported ease and feasibility in performing T-MoCA as a preoperative cognitive evaluation.

CONCLUSION

Preoperative cognitive assessment of older adults using T-MoCA over the phone is easy to perform by clinicians and had a high completion rate by patients. This test is feasible for virtual assessments. Further research is needed to better define validity and correlation with postoperative outcomes.

Comprehensive geriatric assessment for older orthopedic patients and analysis of risk factors for postoperative complications

Background

The comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool to reduce perioperative complications of geriatric patients, however there is no universally accepted standardization of CGA for orthopedic surgery. In this study, a novel CGA strategy was applied to evaluate the conditions of older patients undergoing orthopedic surgery from a broad view and to identify potential risk factors for postoperative complications.

Methods

A prospective cohort study was conducted from March 2019 to December 2020.The study enrolled patients (age > 75 years) for elective or confined orthopedic surgery. All patients were treated by a multidisciplinary team. A structured CGA was conducted to identify high-risk older patients and to facilitate coordinated multidisciplinary team care by a geriatric team. The basic patient characteristics, CGA results, postoperative complication and mortality rates were collected. Multivariate logistic regression analysis was used to identify risk factors for postoperative complications.

Results

A total of 214 patients with an age of 81.07 ± 4.78 (range, 75–100) years were prospectively enrolled in this study. In total, 66 (30.8%) complications were registered, including one death from myocardial infarction (mortality rate, 0.5%). Poor Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were accompanied by frailty, worse perioperative risk, pain, and nutritional status. Poor ADL was also associated with higher risks of falling, polypharmacy, and cardiac and respiration complications. Poor IADL was associated with a higher risk of cardiac and respiration complications. Higher stroke risk was accompanied by higher risks of cardiac complications, delirium, and hemorrhage. Worse American Society of Anesthesiologists (ASA) score was associated with worse ADL, IADL, frailty, and higher delirium risk. Multivariate logistic regression analysis showed that spinal fusion (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.65 to 0.83; p = 0.0214), blood loss(OR, 1.68; 95% CI, 1.31 to 2.01; p = 0.0168), ADL (severe dysfunction or worse) (OR, 1.45; 95% CI, 1.16 to 1.81; p = 0.0413), IADL (serious dependence) (OR, 1.08; 95% CI, 1.33 to 1.63; p = 0.0436), renal function (chronic kidney disease (CKD) ≥ stage 3a) (OR, 2.01; 95% CI, 1.54 to 2.55; p = 0.0133), and malnutrition(OR, 2.11; 95% CI, 1.74 to 2.56; p = 0.0101) were independent risk factors for postoperative complications.

Conclusion

The CGA process reduces patient mortality and increases safety in older orthopedic surgery patients. Spinal fusion, blood loss, ADL (severe dysfunction or worse), IADL (serious dependence), renal function (CKD ≥ stage 3a) and nutrition mini nutritional assessment (MNA) (malnourished) were independent risk factors of postoperative complications following orthopaedic surgery in older patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03328-5.

A national study of 23 major trauma centres to investigate the effect of a geriatrician assessment on clinical outcomes in older people admitted with serious injury in England (FiTR 2): a multicentre observational cohort study

BACKGROUND

Older people are at the greatest risk of poor outcomes after serious injury. Evidence is limited for the benefit of assessment by a geriatrician in trauma care. We aimed to determine the effect of geriatrician assessment on clinical outcomes for older people admitted to hospital with serious injury.

METHODS

In this multicentre observational study (FiTR 2), we extracted prospectively collected data on older people (aged ≥65 years) admitted to the 23 major trauma centres in England over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. We examined the effect of a geriatrician assessment within 72 h of admission on the primary outcome of inpatient mortality in older people admitted to hospital with serious injury, with patients censored at discharge. We analysed data using a multi-level Cox regression model and estimated adjusted hazard ratios (aHRs).

FINDINGS

Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records held by TARN, of whom 35 490 were included in these analyses. Median age was 81·4 years (IQR 74·1-87·6), 19 468 (54·9%) were female, and 16 022 (45·1%) were male. 28 208 (79·5%) patients had experienced a fall from less than 2 m. 16 504 (46·5%) people received a geriatrician assessment. 4419 (12·5%) patients died during hospital stay, with a median time from admission to death of 6 days (IQR 2-14). Of those who died, 1660 (37·6%) had received a geriatrician assessment and 2759 (62·4%) had not (aHR 0·43 [95% CI 0·40-0·46]; p<0·0001).

INTERPRETATION

Geriatrician assessment was associated with a reduced risk of death for seriously injured older people. These data support routine provision of geriatrician assessment in trauma care. Future research should explore the key components of a geriatrician assessment paired with a health economic evaluation.

FUNDING

None.

Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury

Importance

Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.

Objective

To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury.

Design, Setting, and Participants

A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation.

Intervention

The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team.

Main Outcomes and Measures

The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.

Results

Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P < .001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P = .03).

Conclusions and Relevance

In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.

Geriatric surgical service interventions in older emergency general surgery patients: Preliminary results

BACKGROUND

Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients.

METHODS

We prospectively identified patients ≥75 years admitted to the EGS service at an urban tertiary care hospital from January 2020-March 2021 who screened positive for frailty (FRAIL score ≥3 [scale 0-5, higher being worse]) or with cognitive impairment. A pilot geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, conducted a comprehensive geriatric assessment and modified Rockwood Frailty Index calculation for each eligible patient. Patient, hospital admission, and geriatric consultation characteristics were collected via chart review.

RESULTS

Fifty consecutive patients (median age 82 years [IQR 78-90], 56% female) received geriatric consultation (median time 3 days [IQR 1-6] from admission). The most common admission diagnosis was bowel obstruction (32%). Sixty-four percent of patients underwent ≥1 surgical procedure. Using the Frailty Index, 64% were moderately or severely frail. Interventions most frequently performed by the geriatric team included delirium prevention and management (66%), consideration of swallowing function (52%), individualized pain management (50%), and facilitation of serious illness conversations (58%).

CONCLUSIONS

Geriatric service involvement addresses a high burden of both geriatric and palliative care needs in older EGS patients. Geriatric recommendations may direct interventions for surgical education in fundamental geriatric and palliative care knowledge to maximize geriatric resources for the most high-risk patients.

Models of Care in Geriatric Intensive Care—A Scoping Review on the Optimal Structure of Care for Critically Ill Older Adults Admitted in an ICU

A growing proportion of critically ill patients admitted in ICUs are older adults. The need for improving care provided to older adults in critical care settings to optimize functional status and quality of life for survivors is acknowledged, but the optimal model of care remains unknown. We aimed to identify and describe reported models of care.

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review

BACKGROUND

Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients.

METHODS

A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003).

RESULTS

Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41.

CONCLUSION

Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice.

LEVEL OF EVIDENCE

Systematic review, Level II.

The patient's voice matters: The impact of advance directives on elderly trauma patients

BACKGROUND

Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (ADs) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of preinjury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality.

METHODS

A multicenter retrospective review was conducted on patients older than 65 years with traumatic injury between 2017 and 2019. Three Level I trauma centers and one Level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted.

RESULTS

There were 6,135 patients identified; 751 (12.2%) had a preinjury AD. Patients in the AD+ group were older (86 vs. 77 years, p < 0.0001), more likely to be women (67.0% vs. 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients, and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs. 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs. 39.6%, p = 0.251). A preinjury AD was identified as an independent predictor of mortality, but not a predictor of WOC.

CONCLUSION

Despite a high WOC rate in patients older than 65 years, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

Rib Fracture Frailty Index: A risk stratification tool for geriatric patients with multiple rib fractures

BACKGROUND

Rib fractures are consequential injuries for geriatric patients (age, ≥65 years). Although age and injury patterns drive many rib fracture management decisions, the impact of frailty-which baseline conditions affect rib fracture-specific outcomes-remains unclear for geriatric patients. We aimed to develop and validate the Rib Fracture Frailty (RFF) Index, a practical risk stratification tool specific for geriatric patients with rib fractures. We hypothesized that a compact list of frailty markers can accurately risk stratify clinical outcomes after rib fractures.

METHODS

We queried nationwide US admission encounters of geriatric patients admitted with multiple rib fractures from 2016 to 2017. Partitioning around medoids clustering identified a development subcohort with previously validated frailty characteristics. Ridge regression with penalty for multicollinearity aggregated baseline conditions most prevalent in this frail subcohort into RFF scores. Regression models with adjustment for injury severity, sex, and age assessed associations between frailty risk categories (low, medium, and high) and inpatient outcomes among validation cohorts (odds ratio [95% confidence interval]). We report results according to Transparent Reporting of Multivariable Prediction Model for Individual Prognosis guidelines.

RESULTS

Development cohort (n = 55,540) cluster analysis delineated 13 baseline conditions constituting the RFF Index. Among external validation cohort (n = 77,710), increasing frailty risk (low [reference group], moderate, high) was associated with stepwise worsening adjusted odds of mortality (1.5 [1.2-1.7], 3.5 [3.0-4.0]), intubation (2.4 [1.5-3.9], 4.7 [3.1-7.5]), hospitalization ≥5 days (1.4 [1.3-1.5], 1.8 [1.7-2.0]), and disposition to home (0.6 [0.5-0.6], 0.4 [0.3-0.4]). Locally weighted scatterplot smoothing showed correlations between increasing RFF scores and worse outcomes.

CONCLUSION

The RFF Index is a practical frailty risk stratification tool for geriatric patients with multiple rib fractures. The mobile app we developed may facilitate rapid implementation and further validation of RFF Index at the bedside.

LEVEL OF EVIDENCE

Prognostic study, level III.

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers.

METHODS

Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence.

RESULTS

Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16).

CONCLUSION

In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury.

LEVEL OF EVIDENCE

Therapeutic, level IV; Epidemiologic, level III.

Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis

BACKGROUND

Delirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes that can last long term. Therefore, the importance of prevention is undeniable and adopting new models of care for at-risk patients should be prioritised.

OBJECTIVES

This systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium in acutely unwell hospitalised patients.

METHODS

MEDLINE, EMBASE, PsycINFO, OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO.

RESULTS

A total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of 0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies). Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio = 0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention (risk ratio = 0.29, 95% CI: 0.09 to 0.87).

CONCLUSIONS

Non-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.

Impact of a geriatric consultation service on outcomes in older trauma patients: a before-after study

PURPOSE

Early geriatric involvement is recommended for older trauma patients. We wished to determine the impact of geriatric consultation on mortality, hospital length of stay and discharge disposition in older patients who were admitted to our Level 1 trauma unit.

METHODS

We completed a health records review of trauma unit patients, age ≥ 75 years old with Injury Severity Score (ISS) ≥ 12, before (11/2015-10/2017) and after (11/2017-10/2019) implementation of a geriatric trauma consultation initiative. Primary outcomes were mortality, hospital length of stay and discharge destination. Secondary objectives were adherence to the geriatric trauma consult process and identification of geriatric-specific issues. A multivariable analysis controlling for age, gender, multi-morbidity and ISS was undertaken.

RESULTS

157 patients pre-implementation and 172 post-implementation with mean age 83.8 years and 53.8% females were included. Geriatric consultation had no impact on in-hospital mortality [OR 0.70 (95% CI 0.31-1.58)] or length of stay [ß 0.68 (95%CI - 1.35-2.72)]. Patients who received a geriatric consultation were more likely to be discharged home (OR 2.01 (95% CI 1.24-3.24). The adherence to consultation process was 99.4%. Mobility, pain and cognitive impairment were the most common geriatric concerns, identified in 76.6, 61.1 and 50.0% of older trauma patients, respectively.

CONCLUSION

Older trauma patients that receive geriatric trauma consultation are more likely to be discharged home. Collaboration between trauma and geriatric specialists is beneficial and may lead to meaningful improvements in outcomes for older trauma patients.

Effectiveness of Interprofessional Consultation-Based Interventions for Delirium: A Scoping Review

BACKGROUND

Interprofessional geriatric consultation teams and multicomponent interventions are established models for delirium care. They are combined in interprofessional consultative delirium team interventions; however, insight into this novel approach is lacking.

OBJECTIVE

To describe the effectiveness and core components of consultation-based interventions for delirium.

METHOD

Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, and ProQuest. Data on core intervention components, outcomes, facilitators, and barriers were extracted.

RESULTS

10 studies were included. Core intervention components were systematic delirium screening, ongoing consultation, implementation of non-pharmacologic and pharmacological interventions, and staff education. Of the included studies, 1/6 found a significant reduction in delirium incidence, 1/2 a reduction in delirium duration, and 2/3 found a reduction in falls. Facilitators and barriers to implementation were discussed.

CONCLUSION

There was consistency in team structure and core components, however intervention operationalization and effectiveness varied widely. There is some evidence that this model is effective for reducing delirium and its sequelae.

Older trauma patients are at high risk of delirium, especially those with underlying dementia or baseline frailty

BACKGROUND

Given the increasing numbers of older patients presenting with trauma, and the potential influence of delirium on outcomes, we sought to investigate the proportion of such patients who were diagnosed with delirium during their stay-and patient factors associated therewith-and the potential associations between delirium and hospital length of stay (LOS). We hypothesized that delirium would be common, associated with certain patient characteristics, and associated with long hospital LOS (highest quartile).

METHODS

We conducted a retrospective observational cohort study of all trauma patients aged ≥65 years presenting in September to October 2019, interrogating medical records and the institutional trauma database. The primary outcome measure was occurrence of delirium.

RESULTS

Among 99 eligible patients, delirium was common, documented in 23% (23 of 99). On multivariable analysis, adjusting for age, frailty and history of dementia, frailty (OR 4.09, 95% CI 1.08 to 15.53, p=0.04) and dementia (OR 5.23, 95% CI 1.38 to 19.90, p=0.02) were independently associated with likelihood of delirium. Standardized assessment tools were underused, with only 34% (34 of 99) screened within 4 hours of arrival. On univariate logistic regression analysis, having an episode of delirium was associated with long LOS (highest quartile), OR of 5.29 (95% CI 1.92 to 14.56, p<0.001). In the final multivariable model, adjusting for any (non-delirium) in-hospital complication, delirium was independently associated with long LOS (≥16 days; OR 4.81, p=0.005).

DISCUSSION

In this study, delirium was common. History of dementia and baseline frailty were associated with increased risk. Delirium was independently associated with long LOS. However, many patients did not undergo standardized screening at admission. Early identification and targeted management of older patients at risk of delirium may reduce incidence and improve care of this vulnerable cohort. These data are hypothesis generating, but support the need for initiatives which improve delirium care, acknowledging the complex interplay between frailty and other geriatric syndromes in the older trauma patients.

LEVEL OF EVIDENCE

III.

Feasibility and accuracy of ED frailty identification in older trauma patients: a prospective multi-centre study

BACKGROUND

The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres.

METHODS

Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools.

RESULTS

We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI.

CONCLUSIONS

This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS.

TRIAL REGISTRATION

ISRCTN, ISRCTN10671514 . Registered 22 October 2019.

Socially conscious surgical care must prioritize older adults

TOPIC

A commentary on social justice issues in geriatric surgery FUTURE DIRECTIONS: Recognizing social determinants of health and racism as a contributing mechanism for inequities in the care of older adult surgical patients KNOWLEDGE GAPS: Identifying the role of the surgeon in achieving health equity for older adults PURPOSE: Increase recognition of opportunities for antiracist care in everyday surgical practice, including shared decision-making and palliative care STATE OF THE ART: Patient treatment goals documented in their own words. Social needs screening in older adult surgical patients TECHNOLOGY GAPS: Platform for clear documentation of surgical treatments offered and patient treatment goals, social determinants of health and social risk factors, and collaborative treatment and discharge plans discussed across multidisciplinary, elder-friendly teams.

Sex differences in long-term outcomes after traumatic injury: A mediation analysis

BACKGROUND

We sought to examine the association and potential mediators between sex and long-term trauma outcomes.

METHODS

Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis.

RESULTS

2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes.

CONCLUSIONS

There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.

Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center

BACKGROUND

Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019; Engelhardt et al., 2018).

METHODS

We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more.

RESULTS

Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements.

CONCLUSION

Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective.