Improving a Mature Palliative Care Program at a Level I Trauma Center

Frailty Screening in Geriatric Trauma: A Pilot Feasibility Study

BACKGROUND

Frailty in older adult trauma patients is associated with increased complications and worsened outcomes. Frailty screening can help guide care. Yet, trauma center assessment of frailty is relatively new, can be challenging to implement, and is not yet standard practice.

OBJECTIVES

The purpose of this pilot feasibility study is to assess the impact of implementing frailty screening for older adult trauma patients and to evaluate the effect of frailty screening on palliative care consultation, inhospital complications, hospital length of stay, and discharge disposition.

METHODS

We conducted a 3-month (July 2019 to September 2019) prospective observational pilot feasibility study of geriatric trauma patients 65 years and older presenting to a Level I trauma center. The Trauma-Specific Frailty Index score was completed within 24 hr of patient admission. Inferential statistics were used to assess the relationships.

RESULTS

Fifty subjects were included. Between frail and nonfrail patient groups, there was no significant correlation between mean Trauma-Specific Frailty Index score and palliative care consultation, χ2(1,N=50) = 2.32, p = .149; inpatient complications, χ2(1,N=50) = 0.000, p = 1.000; hospital length of stay, t(48) = 0.95, p = .345; or discharge disposition (receiver operating characteristic curve, p = .337). There was a significant negative relationship between Trauma-Specific Frailty Index Scores and Injury Severity Scores, t(15) = 2.33, p = .035.

CONCLUSION

This pilot study demonstrates that frailty screening can be implemented to help guide older adult trauma care but is not without challenges. Barriers to frailty screening should be addressed to ensure trauma team engagement. Additional research with a larger sample size is warranted to explore the benefits of frailty screening in guiding care.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

BACKGROUND

We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting.

METHODS

PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively.

RESULTS

A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear.

CONCLUSION

The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.