1
|
Ferrah N, Kennedy B, Beck B, Ibrahim J, Gabbe B, Cameron P. A scoping review of models of care for the management of older trauma patients. Injury 2024; 55:111200. [PMID: 38035863 DOI: 10.1016/j.injury.2023.111200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION The number of older people hospitalised with major trauma is rapidly increasing. New models of care have emerged, such as co-management, and trauma centres dedicated to delivering geriatric trauma care. The aim of this scoping review was to explore in-hospital models of care for older adults who experience physical trauma. PATIENTS AND METHODS The search was conducted in accordance with the PRISMA- SC (preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews) reporting guidelines. The National Heart Lung, and Blood Institute (NIH) study quality assessment tool was used to evaluate risk of bias in before and after non-randomised experimental studies. RESULTS Of 2127 records returned from the database search, 43 papers were included. We identified five types of care models investigated in the reviewed studies: centralised trauma management, consultation services, co-management, patient care protocols, and alert and triage systems. The majority of patients were admitted under a specialised trauma service, intervention teams were for the most part multidisciplinary, and follow-up of patients post-discharge was seldom reported. Consultation services more often had advanced care and discharge planning as treatment objectives. In contrast, patient care protocol and alert systems commonly had management of anticoagulation as a treatment objective. Overall, the impact of the five models of care on patient outcomes was mixed. DISCUSSION Given the variability in patient characteristics and capabilities of health services, models of care need to be matched to the local profile of older trauma patients. However, some standards should be incorporated into a care model, including identifying goals of care, medication review and follow up post-discharge.
Collapse
Affiliation(s)
- Noha Ferrah
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia.
| | - Briohny Kennedy
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Department of Forensic Medicine, Monash University, The Victorian Institute of Forensic Medicine, Victoria Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Faculty of Medicine, Laval University, Quebec City, Canada
| | - Joseph Ibrahim
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Department of Forensic Medicine, Monash University, The Victorian Institute of Forensic Medicine, Victoria Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Health Data Research UK, Swansea University Medical School, UK
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Victoria Australia; Emergency and Trauma Centre, The Alfred Hospital, Victoria, Australia
| |
Collapse
|
2
|
Raymond K, Sterling A, Roberts M, Holland III RW, Galwankar S, Mishra RK, Agrawal A. Analysis of traumatic intracranial hemorrhage and delayed traumatic intracranial hemorrhage in patients with isolated head injury on anticoagulation and antiplatelet therapy. J Neurosci Rural Pract 2023; 14:686-691. [PMID: 38059222 PMCID: PMC10696333 DOI: 10.25259/jnrp_270_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/03/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives Anticoagulants and antiplatelet (ACAP) agents are increasingly and frequently used, especially in the elderly. The present study was carried out to assess the prevalence of delayed traumatic intracranial hemorrhage (dtICH) after a normal result on an initial head computed tomography (CT) in adults who were taking ACAP medication. Materials and Methods The present retrospective included all adult patients who arrived in the emergency department between January 2017 and January 2021 with a history of fall from the patient's own height, while being on ACAP medication with an isolated head injury. The Institutional Review Board approved the study with a waiver of consent. The primary outcome measures were prevalence of dtICH in patients who had initial normal CT scan brain and were on ACAP medication. Results There were 2137 patients on ACAP medication, of which 1062 were male, and 1075 were of the female gender. The mean age of the patients was 82.1 years. About 8.2% had positive first CT scans (176/2137), while 0.023 (27/1149) had dtICH. The most common positive finding on the CT scan was subarachnoid hemorrhage followed by subdural hemorrhage. Male gender positively correlated with increased risk for first CT being positive (P = 0.033). Patient's with comorbidity of cirrhosis and chemotherapy had higher risk of dtICH (P = 0.47, 0.011). Conclusion There was a very low (0.023%) prevalence of dtICH. Dual therapy or Coumadin therapy made up the majority of tICH. Cirrhosis and chemotherapy were associated with the risk of a repeat CT scan being positive with an initial CT scan negative.
Collapse
Affiliation(s)
- Kevin Raymond
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Alexander Sterling
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Mary Roberts
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Reuben W. Holland III
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - S Galwankar
- Department of Emergency Medicine, Sarasota Memorial Hospital, Sarasota, Florida, United States
| | - Rakesh Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Amit Agrawal
- Department of Neurosurgery , All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| |
Collapse
|
3
|
Trauma Response for Elderly Anticoagulated Patients: An Initiative to Reduce Trauma Resource Utilization in the Emergency Department. J Trauma Nurs 2021; 28:159-165. [PMID: 33949350 DOI: 10.1097/jtn.0000000000000577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury. OBJECTIVE The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population. METHODS A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests. RESULTS An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51). CONCLUSION The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.
Collapse
|
4
|
Eichinger M, Robb HDP, Scurr C, Tucker H, Heschl S, Peck G. Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review. Scand J Trauma Resusc Emerg Med 2021; 29:100. [PMID: 34301281 PMCID: PMC8305876 DOI: 10.1186/s13049-021-00922-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group. METHODS AND FINDINGS A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review. CONCLUSIONS Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.
Collapse
Affiliation(s)
- Michael Eichinger
- Major Trauma and Cutrale Perioperative and Ageing Group, Imperial College Healthcare NHS Trust, London, UK
| | - Henry Douglas Pow Robb
- Academic Clinical Fellow in General Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Cosmo Scurr
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | | | - Stefan Heschl
- Department of Cardiac, Thoracic and Vascular Anaesthesiology and Intensive Care, Medical University Hospital, Graz, Austria
| | - George Peck
- Cutrale Peri-operative and Ageing Group, Imperial College London, London, UK
| |
Collapse
|
5
|
Francis AA, Wall JEM, Stone A, Dewane MP, Dyke A, Gregg SC. The Impact of Interdisciplinary Care on Cost Reduction in a Geriatric Trauma Population. J Emerg Trauma Shock 2020; 13:286-295. [PMID: 33897146 PMCID: PMC8047963 DOI: 10.4103/jets.jets_151_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/24/2020] [Accepted: 05/08/2020] [Indexed: 11/16/2022] Open
Abstract
The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS).
Collapse
Affiliation(s)
- Andrew A Francis
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Joyce E M Wall
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Andrew Stone
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Michael P Dewane
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Ann Dyke
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| | - Shea C Gregg
- Department of Surgery, Yale New Haven Health-Bridgeport Hospital, Bridgeport, CT, USA
| |
Collapse
|
6
|
Travers B, Jones S, Bastani A, Opsommer M, Beydoun A, Karabon P, Donaldson D. Assessing geriatric patients with head injury in the emergency department using the novel level III trauma protocol. Am J Emerg Med 2020; 45:149-153. [PMID: 33229252 DOI: 10.1016/j.ajem.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/17/2020] [Accepted: 11/14/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Intracranial injury in elderly patients presenting with minor head trauma is often overlooked in the emergency department (ED). Our suburban community-based level II trauma hospital developed and implemented the level III trauma protocol (L3TP) in January 2016 to better evaluate and diagnose intracranial injury in elderly patients presenting with minor head trauma after a fall. The L3TP requires that the ED physician immediately assess all patients meeting the following criteria 1) Age ≥ 65 years old. 2) Currently taking any anticoagulant or antiplatelet agents. 3) Presenting in the ED with a potential head injury after a fall. The ED physician determines if these high-risk patients require emergent imaging, obviating the need for trauma team activation unless an intracranial hemorrhage (ICH) is found. The purpose of this study was to assess the impact of the novel L3TP on resource utilization and patient outcome. METHODS Our retrospective cohort study included patients who met the L3TP inclusion criteria and had an ICH diagnosed by non-contrast computed tomography (CT). We compared patients triaged by the L3TP (January to December 2017) to patients triaged before the L3TP was implemented (January to August 2015) in order to assess the impact of the L3TP on resource utilization and patient outcome. The data was analyzed using two independent samples t-tests and Chi-square tests. RESULTS Patients triaged by the L3TP had a significantly shorter average length of time from arrival in the ED to CT (level III trauma 0.64 h vs control 2.37 h, (d = 1.73; 95% CI = 1.42, 2.04), p ≤ 0.0001) and ED length of stay (level III trauma 2.55 h vs control 4.72 h, (d = 2.17; 95% CI = 1.21, 3.13), p ≤ 0.0001). There was insufficient evidence to conclude that there was any difference in health outcomes between the control and level III trauma groups. CONCLUSION The L3TP is an effective and resource efficient protocol that quickly identifies ICH in elderly patients without activating the trauma team for every elderly patient presenting to the ED with a potential head injury after a fall.
Collapse
Affiliation(s)
- Benjamin Travers
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
| | - Shanna Jones
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Aveh Bastani
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Michael Opsommer
- Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Ali Beydoun
- Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - David Donaldson
- Department of Emergency Medicine, Beaumont Hospital System, Troy, MI, USA
| |
Collapse
|
7
|
|
8
|
Callahan ZM, Gadomski SP, Koganti D, Patel PH, Beekley AC, Williams P, Donnelly J, Cohen MJ, Marks JA. Geriatric patients on antithrombotic therapy as a criterion for trauma team activation leads to over triage. Am J Surg 2019; 219:43-48. [PMID: 31030991 DOI: 10.1016/j.amjsurg.2019.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/29/2019] [Accepted: 04/16/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma. METHODS Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups. RESULTS After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P = 0.21). CONCLUSIONS Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.
Collapse
Affiliation(s)
- Zachary M Callahan
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Stephen P Gadomski
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Deepika Koganti
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Pankaj H Patel
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Alec C Beekley
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Patricia Williams
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Julie Donnelly
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Murray J Cohen
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| | - Joshua A Marks
- Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA.
| |
Collapse
|