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Tyree S, Fischer K, Stephens D, Burton MC, Pagali S. Impact of inpatient geriatrics consultation on hospital outcomes in older adults with trauma. J Am Geriatr Soc 2024. [PMID: 38769752 DOI: 10.1111/jgs.18977] [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: 02/05/2024] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Older adults presenting with trauma have worse outcomes than younger adults. Starting in 2016, we provided geriatrics consultation (GC) to older adults admitted to the trauma service. We aimed to analyze the impact of GC on patient outcomes. METHODS We performed a retrospective pre-post study and year-matched cohort study. We identified patients from the trauma registry at our level 1 trauma center. In the pre-post study, we compared patients who received GC (2016-2022) with controls (2011-2015). In the cohort study (2016-2022), we compared patients who received GC with controls. We matched for age, race, sex, and injury severity score (ISS) in both studies, as well as admission year in the cohort study. Outcome variables included mortality (in-hospital, 30-day, 90-day), length of stay (LOS), discharge disposition, and hospital readmission rates (30-day, 90-day). RESULTS We analyzed 1968 patients in the pre-post study and 2544 patients in the cohort study. Patients were similar in age, race, and sex. GC patients had a slightly higher ISS score and a higher rate of ICU stay. Delirium occurrence was lower among GC patients. GC patients had lower in-hospital mortality compared to controls (pre-post OR 0.27, p < 0.001; cohort OR 0.31, p < 0.001) and increased LOS (6 days vs 4 days, p < 0.001; both studies). GC patients in the cohort study also had lower 30- and 90-day mortality (OR 0.52 and 0.65, p < 0.01) and were less likely to return home (OR 0.81, p < 0.01); similar trends, though not statistically significant, were noted in the pre-post study. Lower readmission rates (statistically non-significant) were noted in the GC group across both studies. CONCLUSIONS GC in older adults with trauma has proven benefit with reduced mortality and a trend toward lower readmission rates but was associated with increased LOS and higher rates of discharge to skilled facility.
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Affiliation(s)
- Sara Tyree
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Karen Fischer
- Department of Medicine Research Hub, Mayo Clinic, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Stephens
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - M Caroline Burton
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sandeep Pagali
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Geriatrics and Gerontology, Mayo Clinic, Rochester, Minnesota, USA
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Lodge M, Aitken R, Chong YH, Thillainadesan J. Development of a minimum clinical dataset for preoperative comprehensive geriatric assessment using a modified Delphi technique. Australas J Ageing 2024. [PMID: 38754868 DOI: 10.1111/ajag.13334] [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: 02/29/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To construct a standardised, consensus-guided minimum clinical dataset (MCDS) for preoperative comprehensive geriatric assessment and optimisation (CGA) in Australia and Aotearoa New Zealand. METHODS We conducted a review of the international perioperative literature to identify CGA domains and tools for potential inclusion in the MCDS. We invited members of the Australian and New Zealand Society for Geriatric Medicine to participate in a Delphi study to obtain consensus on MCDS tools. Participants were asked to rate proposed tools using Likert scales (when >2 tools) or make a binary choice between two proposed tools. Consensus was considered to be achieved when there was at least 75% concordance between the two rounds amongst the participants, and at least one variable attaining over 50% of participants' votes. Domains that did not achieve consensus in Round 1 were carried over to Round 2. RESULTS There were 73 participants in Round 1 of the Delphi study and 47 participants in Round 2. Consensus was achieved on tool/s recommended for every MCDS domain: Clinical Frailty Scale (frailty); sMMSE, RUDAS, MoCA (cognition); 4AT (delirium); timed-up-and-go (physical function); GDS-15 (mood); Barthel Index (functional status); and MUST (malnutrition). CONCLUSIONS We recommend clinicians delivering preoperative CGA consider the use of the MCDS we have constructed when assessing older people contemplating surgery, as part of a multicomponent and multidisciplinary approach to optimising perioperative outcomes.
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Affiliation(s)
- Margot Lodge
- Alfred Health, Melbourne, Victoria, Australia
- National Centre for Healthy Ageing, Melbourne, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rachel Aitken
- Department of Aged Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Yih Harng Chong
- Te Whatu Ora (Waitemata District), Auckland, New Zealand
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Janani Thillainadesan
- Department of Geriatric Medicine, Centre for Education and Research on Ageing, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Lodge ME, Dhesi J, Shipway DJ, Braude P, Meilak C, Partridge J, Andrew NE, Srikanth V, Ayton DR, Moran C. The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study. BMC Health Serv Res 2024; 24:345. [PMID: 38491431 PMCID: PMC10943911 DOI: 10.1186/s12913-024-10844-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/08/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK. METHODS A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR). RESULTS Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services. CONCLUSIONS Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.
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Affiliation(s)
- Margot E Lodge
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - David Jh Shipway
- CLARITY (Collaborative Ageing Research) group, North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
| | - Philip Braude
- CLARITY (Collaborative Ageing Research) group, North Bristol NHS Trust, Bristol, UK
| | - Catherine Meilak
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Judith Partridge
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Nadine E Andrew
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
| | - Velandai Srikanth
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Peninsula Health, Frankston, Australia
| | - Darshini R Ayton
- National Centre for Healthy Ageing, Melbourne, Australia.
- Health and Social Care Unit, Monash University, Melbourne, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Chris Moran
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
- Peninsula Health, Frankston, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Merrick M, Grange R, Rudd S, Shipway D. Evaluation and Treatment of Acute Trauma Pain in Older Adults. Drugs Aging 2023; 40:869-880. [PMID: 37563445 DOI: 10.1007/s40266-023-01052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/12/2023]
Abstract
In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.
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Affiliation(s)
- Minnie Merrick
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Robert Grange
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Sarah Rudd
- Library and Knowledge Service, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK.
- University of Bristol, Bristol, UK.
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Jarman H, Crouch R, Halter M, Peck G, Cole E. Provision of acute care pathways for older major trauma patients in the UK. BMC Geriatr 2022; 22:915. [PMID: 36447158 PMCID: PMC9706856 DOI: 10.1186/s12877-022-03615-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Heather Jarman
- grid.451349.eEmergency Department Clinical Research Group, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK
| | - Robert Crouch
- grid.430506.40000 0004 0465 4079Emergency Department, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD UK
| | - Mary Halter
- grid.451349.eEmergency Department Clinical Research Group, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT UK
| | - George Peck
- grid.426467.50000 0001 2108 8951Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London, W2 1NY UK
| | - Elaine Cole
- grid.4868.20000 0001 2171 1133Queen Mary University of London, 4 Newark Street, London, E1 2EA UK
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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. THE LANCET. HEALTHY LONGEVITY 2022; 3:e549-e557. [PMID: 36102764 DOI: 10.1016/s2666-7568(22)00144-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 02/07/2023] Open
Abstract
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.
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