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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.
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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
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Ferrah N, Parker C, Ibrahim J, Gabbe B, Cameron P. A qualitative descriptive study exploring clinicians' perspectives of the management of older trauma care in rural Australia. BMC Health Serv Res 2023; 23:704. [PMID: 37381004 DOI: 10.1186/s12913-023-09545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 05/14/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND For older trauma patients who sustain trauma in rural areas, the risk of adverse outcomes associated with advancing age, is compounded by the challenges encountered in rural healthcare such as geographic isolation, lack of resources, and accessibility. Little is known of the experience and challenges faced by rural clinicians who manage trauma in older adults. An understanding of stakeholders' views is paramount to the effective development and implementation of a trauma system inclusive of rural communities. The aim of this descriptive qualitative study was to explore the perspectives of clinicians who provide care to older trauma patients in rural settings. METHOD We conducted semi-structured interviews of health professionals (medical doctors, nurses, paramedics, and allied health professionals) who provide care to older trauma patients in rural Queensland, Australia. A thematic analysis consisting of both inductive and deductive coding approaches, was used to identify and develop themes from interviews. RESULTS Fifteen participants took part in the interviews. Three key themes were identified: enablers of trauma care, barriers, and changes to improve trauma care of older people. The resilience of rural residents, and breadth of experience of rural clinicians were strengths identified by participants. The perceived systemic lack of resources, both material and in the workforce, and fragmentation of the health system across the state were barriers to the provision of trauma care to older rural patients. Some changes proposed by participants included tailored education programs that would be taught in rural centres, a dedicated case coordinator for older trauma patients from rural areas, and a centralised system designed to streamline the management of older trauma patients coming from rural regions. CONCLUSIONS Rural clinicians are important stakeholders who should be included in discussions on adapting trauma guidelines to the rural setting. In this study, participants formulated pertinent and concrete recommendations that should be weighed against the current evidence, and tested in rural centres.
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Affiliation(s)
- Noha Ferrah
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC, 3004, Australia.
| | - Catriona Parker
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC, 3004, Australia
| | - Joseph Ibrahim
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC, 3004, Australia
- Department of Forensic Medicine, Monash University, The Victorian Institute of Forensic Medicine, Southbank, VIC, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC, 3004, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC, 3004, Australia
- Health Data Research UK, Swansea University Medical School, Swansea, Wales
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Sigal A, Butts CA, Deaner T, Wasser T, Bailey B, Bindra M, Muller A, Martin AP, Ong A. Potentially Inappropriate Medications are Associated With Geriatric Trauma Recidivism. J Surg Res 2023; 283:581-585. [PMID: 36442257 DOI: 10.1016/j.jss.2022.10.029] [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: 04/12/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The American Geriatric Society has identified polypharmacy and categories of potentially inappropriate medication (PIM) that should be avoided in the elderly. These medications can potentially cause an increased risk of falls and traumatic events. MATERIALS AND METHODS We conducted a retrospective study on elderly patients with traumatic injuries at a Level 1 trauma center. We compared patients having only one traumatic event and those with one or more traumatic events with the presence of prescriptions for PIMs. RESULTS Identified high risk categories of anticoagulant and antiplatelet agents (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.28), psychiatric and neurologic agents (OR 1.32, 95% CI 1.22-1.43), as well as medication with anticholinergic properties (OR 1.14, 95% CI 1.03-1.27) were associated with an increased risk of recurrent trauma. CONCLUSIONS We can quantify the risk of recurrent trauma with certain categories of PIM. Medication reconciliation and shared decision-making regarding the continued use of these medications may positively impact trauma recidivism.
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Affiliation(s)
- Adam Sigal
- Department of Emergency Medicine, Reading Hospital, West Reading, Pennsylvania.
| | - Christopher A Butts
- Division of Trauma, Acute Care and Surgical Critical Care, Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Traci Deaner
- Department of Emergency Medicine, Reading Hospital, West Reading, Pennsylvania
| | - Tom Wasser
- Department of Emergency Medicine, Reading Hospital, West Reading, Pennsylvania
| | - Blake Bailey
- Department of Emergency Medicine, Reading Hospital, West Reading, Pennsylvania
| | - Monisha Bindra
- Department of Emergency Medicine, Reading Hospital, West Reading, Pennsylvania
| | - Alison Muller
- Division of Trauma, Acute Care and Surgical Critical Care, Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Anthony P Martin
- Division of Trauma, Acute Care and Surgical Critical Care, Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Adrian Ong
- Division of Trauma, Acute Care and Surgical Critical Care, Department of Surgery, Reading Hospital, West Reading, Pennsylvania
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Yeates EO, Grigorian A, Kuza CM, Nguyen NT, Inaba K, Dolich M, Nahmias J. The DEPARTS Score: A Novel Tool for Predicting Discharge Disposition in Geriatric Trauma Patients. Am Surg 2023; 89:447-451. [PMID: 34240654 DOI: 10.1177/00031348211029843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Geriatric trauma patients (GTPs) represent a high-risk population for needing post-acute care, such as skilled nursing facilities (SNFs) and long-term acute care hospitals (LTACs), due to a combination of traumatic injuries and baseline functional health. As there is currently no well-established tool for predicting these needs, we aimed to create a scoring tool that predicts disposition to SNFs/LTACs in GTPs. METHODS The adult 2017 Trauma Quality Improvement Program database was divided at random into two equal sized sets (derivation and validation sets) of GTPs >65 years old. First, multiple logistic regression models were created to determine risk factors for discharge to a SNF/LTAC in admitted GTPs. Second, the weighted average and relative impact of each independent predictor was used to derive a DEPARTS (Discharge of Elderly Patients After Recent Trauma to SNF/LTAC) score. We then validated the score using the area under the receiver-operating curve (AROC). RESULTS Of 66 479 patients in the derivation set, 36 944 (55.6%) were discharged to a SNF/LTAC. Number of comorbidities, fall mechanism, spinal cord injury, long bone fracture, and major surgery were each independent predictors for discharge to SNF/LTAC, and a DEPARTS score was derived with scores ranging from 0 to 19. The AROC for this was .74. In the validation set, 66 477 patients also had a SNF/LTAC discharge rate of 55.7%, and the AROC was .74. DISCUSSION The DEPARTS score is a good predictor of SNF/LTAC discharge for GTPs. Future prospective studies are warranted to validate its accuracy and clinical utility in preventing delays in discharge.
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Affiliation(s)
- Eric O Yeates
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA.,Department of Surgery, 8564University of Southern California, CA, USA
| | - Catherine M Kuza
- Department of Anesthesiology, 8564University of Southern California, Los Angeles, CA, USA
| | - Ninh T Nguyen
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - Kenji Inaba
- Department of Surgery, 8564University of Southern California, CA, USA
| | - Matthew Dolich
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
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Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial. J Trauma Acute Care Surg 2023; 94:36-44. [PMID: 36279368 DOI: 10.1097/ta.0000000000003817] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Joseph B, Saljuqi AT, Phuong J, Shipper E, Braverman MA, Bixby PJ, Price MA, Barraco RD, Cooper Z, Jarman M, Lack W, Lueckel S, Pivalizza E, Bulger E. Developing a National Trauma Research Action Plan: Results from the geriatric research gap Delphi survey. J Trauma Acute Care Surg 2022; 93:209-219. [PMID: 35393380 DOI: 10.1097/ta.0000000000003626] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treating older trauma patients requires a focus on the confluence of age-related physiological changes and the impact of the injury itself. Therefore, the primary way to improve the care of geriatric trauma patients is through the development of universal, systematic multidisciplinary research. To achieve this, the Coalition for National Trauma Research has developed the National Trauma Research Action Plan that has generated a comprehensive research agenda spanning the continuum of geriatric trauma care from prehospital to rehabilitation. METHODS Experts in geriatric trauma care and research were recruited to identify current gaps in clinical geriatric research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines ensuring heterogeneity and generalizability. On subsequent surveys, participants were asked to rank the priority of each research question on a nine-point Likert scale, categorized to represent low-, medium-, and high-priority items. The consensus was defined as more than 60% of panelists agreeing on the priority category. RESULTS A total of 24 subject matter experts generated questions in 109 key topic areas. After editing for duplication, 514 questions were included in the priority ranking. By round 3, 362 questions (70%) reached 60% consensus. Of these, 161 (44%) were high, 198 (55%) medium, and 3 (1%) low priority. CONCLUSION Among the questions prioritized as high priority, questions related to three types of injuries (i.e., rib fracture, traumatic brain injury, and lower extremity injury) occurred with the greatest frequency. Among the 25 highest priority questions, the key topics with the highest frequency were pain management, frailty, and anticoagulation-related interventions. The most common types of research proposed were interventional clinical trials and comparative effectiveness studies, outcome research, and health care systems research.
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Affiliation(s)
- Bellal Joseph
- From the Department of Surgery (B.J., A.T.S.), University of Arizona, College of Medicine, Tucson, Arizona; Department of Biomedical Informatics and Medical Education (J.P., E.S.), The University of Washington, Seattle, Washington; Coalition for National Trauma Research (M.A.B., P.J.B., M.A.P.), San Antonio, Texas; University of South Florida Morsani College of Medicine-Lehigh Valley Campus (R.D.B.), Allentown, Pennsylvania; Brigham & Women's Hospital (Z.C., M.J.), Boston, Massachusetts; Department of Surgery (W.L., E.B.), The Department of Surgery, Trauma and Surgical Critical Care Division (S.L.), Brown University, Providence, Rhode Island; Department of Anesthesiology (E.P.), UTHealth Houston McGovern Medical School, Houston, Texas; Department of Surgery, The Division of Trauma and Critical care (R.D.B.), Lehigh Valley Hospital and Health Network, University of South Florida Morsani College of Medicine (USF-MCOM), Lehigh Valley Campus, Allentown, PA
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Jarman MP, Jin G, Weissman JS, Ash AS, Tjia J, Salim A, Haider A, Cooper Z. Association of Trauma Center Designation With Postdischarge Survival Among Older Adults With Injuries. JAMA Netw Open 2022; 5:e222448. [PMID: 35294541 PMCID: PMC8928003 DOI: 10.1001/jamanetworkopen.2022.2448] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/12/2022] [Indexed: 01/14/2023] Open
Abstract
Importance Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population. Objective To examine whether 30- and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level. Design, Setting, and Participants This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type. Exposure Admitting hospital's trauma center level. Main Outcomes and Measures Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models. Results A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]). Conclusions and Relevance These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.
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Affiliation(s)
- Molly P. Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ginger Jin
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Arlene S. Ash
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worchester
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worchester
| | - Ali Salim
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Medical College, The Aga Khan University, Karachi, Pakistan
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Lacey J, d’Arville A, Walker M, Hendel S, Lancman B. Considerations for the Older Trauma Patient. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00510-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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.
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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
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Lampron J, Khoury L, Moors J, Nemnom MJ, Figueira S, Podinic I, Eagles D. Impact of a geriatric consultation service on outcomes in older trauma patients: a before-after study. Eur J Trauma Emerg Surg 2021; 48:2859-2865. [PMID: 34146122 DOI: 10.1007/s00068-021-01724-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/05/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jacinthe Lampron
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lara Khoury
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Joy Moors
- Department of Geriatrics, The Ottawa Hospital, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sonshire Figueira
- Ottawa Regional Trauma Program, The Ottawa Hospital, Ottawa, ON, Canada
| | - Irina Podinic
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, ON, F658aK1Y 4E9, Canada.
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O'Mara L, Palm K, Castillo-Angeles M, Bryant E, Moberg E, Armstrong K, Patel N, Tulebaev S, McDonald M, Tsitos D, Cooper Z. Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center. J Trauma Nurs 2021; 28:59-66. [PMID: 33417405 DOI: 10.1097/jtn.0000000000000546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Lynne O'Mara
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery (Mss O'Mara, Palm, Armstrong, Patel, and McDonald and Drs Castillo-Angeles and Cooper), Center for Surgery and Public Health (Ms Moberg and Dr Cooper), Division of Aging, Department of Medicine (Dr Tulebaev), and Department of Nursing (Ms Tsitos), Brigham and Women's Hospital, Boston, Massachusetts; and Rush Medical School, Chicago, Illinois (Ms Bryant)
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McLaughlin CJ, Fornadley JM, Fields K, Armen S, Laufenberg L. Biodebridement in the Surgical Intensive Care Unit: Unique Therapy for Unique Patients. Am Surg 2020; 88:1330-1333. [PMID: 32816534 DOI: 10.1177/0003134820943115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute care surgery has evolved to encompass the advanced management of complex nonhealing wounds. Biodebridement has the potential to improve the care of chronic wounds for acute care surgery patients, particularly for patients in the surgical intensive care unit (SICU) with hospital-acquired pressure injuries. A case report of biodebridement using larval maggot therapy in the SICU is presented to illustrate real-world application and progression in wound healing. A review of current research involving biodebridement was conducted. A septuagenarian gentleman sustained a fall resulting in cervical spine fractures with neurological deficits. The patient had a prolonged hospital course in the SICU, complicated by myocardial infarction, respiratory failure requiring tracheostomy, and development of a Stage IV sacral pressure ulcer. The wound base was sharply debrided several times and became refractory to conventional mechanical/chemical debridement techniques. The patient had a prohibitively high risk for the operating room but remained too sensate for further effective bedside debridement. Biodebridement was utilized to create a viable wound base, with improved appearance noted within 2 weeks. A review of the current literature shows biodebridement has numerous benefits in the management of chronic wounds. Biodebridement is a unique therapy that possesses great value for select patients in the SICU. In particular, patients who are too high risk for further operative intervention, but too sensate for ongoing bedside debridement and dressing changes, benefit significantly from this underutilized approach. Further research is needed to solidify the place of biodebridement in the surgical management of chronic nonhealing wounds.
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Affiliation(s)
- Christopher J McLaughlin
- 12310 Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Jeffrey M Fornadley
- 12310 Department of Surgery, Division of Plastic and Reconstructive Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Kim Fields
- 12311 Department of Nursing, Division of Wound, Ostomy, & Continence Nursing, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Scott Armen
- 12310 Division of Trauma, Critical Care, and Acute Care Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Lacee Laufenberg
- 12310 Division of Trauma, Critical Care, and Acute Care Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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13
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A systematic review and meta-analysis evaluating geriatric consultation on older trauma patients. J Trauma Acute Care Surg 2019; 88:446-453. [DOI: 10.1097/ta.0000000000002571] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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14
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Bridges LC, Christie AB, Awad HH, Sigman EJ, Christie DB, Ackermann RJ. Geriatric Trauma Screening Tool: Preinjury Functional Status Dictates Intensive Care Unit Discharge Disposition. Am Surg 2019. [DOI: 10.1177/000313481908500828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Older adults account for an increasing percentage of trauma patients and have worse outcomes when compared with younger populations. Simple prediction tools are needed to designate risk categories among these patients. The Geriatric Trauma Screening Tool (GTST) was developed to risk stratify older adults admitted to the ICU at a Level 1 trauma center. One hundred fifty patients aged ≥ 65 years were prospectively screened for high-risk (HR) injuries, comorbidities, and pre-hospital function using the GTST. Patients who screened for HR were more likely to have an unfavorable disposition than non-HR patients. HR patients had significantly longer ICU and hospital length of stays when compared with non-HR patients. In addition, patients with prior functional impairment were at higher risk for an unfavorable discharge disposition than their counterparts. Implementation of the GTST predicted discharge disposition in geriatric trauma patients admitted to the ICU. Pre-injury functional status was a better predictor of discharge disposition than either the types of HR injuries or the presence of comorbidities. Risk stratification of geriatric trauma patients allows for early engagement of patients and caregivers regarding transitions of care as well as more efficient utilization of hospital resources.
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Affiliation(s)
| | - Amy B. Christie
- Department of Critical Care, Medical Center Navicent Health, Macon, Georgia
| | - Hamza H. Awad
- Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Erika J. Sigman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | | | - Richard J. Ackermann
- Division of Geriatrics, Department of Family Medicine, Medical Center Navicent Health, Macon, Georgia
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15
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Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes. J Trauma Acute Care Surg 2019; 84:864-875. [PMID: 29389841 DOI: 10.1097/ta.0000000000001829] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes. METHODS We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters. RESULTS We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes. CONCLUSION Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients. LEVEL OF EVIDENCE Prognostic and epidemiological, level IV.
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16
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Brown KL, Ashcraft AS. Comfort or Care: Why Do We Have to Choose? Implementing a Geriatric Trauma Palliative Care Program. J Trauma Nurs 2019; 26:2-9. [DOI: 10.1097/jtn.0000000000000410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Forman DE, Zieman SJ. "Doc, I Think My Meds Are Killing Me! Please Help…": Transdisciplinary Forces Unite to Refocus Pharmacotherapy for Older Adults. J Am Geriatr Soc 2018; 67:205-207. [PMID: 30536783 DOI: 10.1111/jgs.15706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 10/22/2018] [Accepted: 10/28/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel E Forman
- Chair, Section of Geriatric Cardiology, Divisions of Geriatrics and the Heart and Vascular Institute, University of Pittsburgh Medical Center, Professor of Medicine, University of Pittsburgh.,Physician Scientist, Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System
| | - Susan J Zieman
- Medical Officer, Geriatrics Branch, Division of Geriatrics and Clinical Gerontology, National Institute on Aging/National Institutes of Health
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18
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Mccusker A, Khan M, Kulvatunyou N, Zeeshan M, Sakran JV, Hayek H, O'Keeffe T, Hamidi M, Tang A, Joseph B. Sarcopenia defined by a computed tomography estimate of the psoas muscle area does not predict frailty in geriatric trauma patients. Am J Surg 2018; 218:261-265. [PMID: 30122406 DOI: 10.1016/j.amjsurg.2018.07.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The aim of our study was to assess the correlation between frailty & sarcopenia and impact of each condition on outcomes in geriatric trauma patients. METHODS We performed a four-year (2013-2016) secondary analysis of our prospectively maintained frailty database and included all trauma patients age ≥65 y who had CT-abdomen. Trauma-Specific-Frailty-Index (TSFI) was used to calculate frailty. Patients were classified as non-frail or frail. Sarcopenia was defined as the lowest sex-specific-quartile of total-psoas-index (TPI). Outcome measures included in-hospital complications, mortality and adverse disposition. RESULTS 325 patients were included in the study, 36% (n = 117) were frail and 24.9% (n = 81) had sarcopenia. There was a weak correlation between frailty and sarcopenia (R2 = 0.04). The overall rate of complications and mortality was 19.4% and 7.7% respectively. On regression analysis, after controlling for possible confounding variables and frailty status, sarcopenia was associated with adverse disposition (OR:1.41,p = 0.01). However, it was not associated with in-hospital complications (OR:1.21,p = 0.54) or in-hospital mortality (OR:1.12,p = 0.73). CONCLUSION Sarcopenia as an individual marker might not be an effective screening tool for risk assessment in geriatric-trauma patients. Frailty assessment should be a part of risk assessment and prognostication.
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Affiliation(s)
- Ashley Mccusker
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Muhammad Khan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Haya Hayek
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
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Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients. J Trauma Acute Care Surg 2018; 85:167-173. [DOI: 10.1097/ta.0000000000001931] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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20
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Increased hospice enrollment and decreased neurosurgical interventions without changes in mortality for older Medicare patients with moderate to severe traumatic brain injury. Am J Surg 2018. [DOI: 10.1016/j.amjsurg.2018.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Wong H, Lovett N, Curry N, Shah K, Stanworth SJ. Antithrombotics in trauma: management strategies in the older patients. J Blood Med 2017; 8:165-174. [PMID: 29042825 PMCID: PMC5633276 DOI: 10.2147/jbm.s125209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The ageing population has resulted in a change in the demographics of trauma, and older adult trauma now accounts for a growing number of trauma admissions. The management of older adult trauma can be particularly challenging, and exhibits differences to that of the younger age groups affected by trauma. Frailty syndromes are closely related with falls, which are the leading cause of major trauma in older adults. Comorbid disease and antithrombotic use are more common in the older population. Physiological changes that occur with ageing can alter the expected clinical presentation of older persons after injury and their susceptibility to injury. Following major trauma, definitive control of hemorrhage remains essential for improving outcomes. In the initial assessment of an injured patient, it is important to consider whether the patient is taking anticoagulants or antiplatelets and if measures to promote hemostasis such as reversal are indicated. After hemostasis is achieved and bleeding has stopped, longer-term decisions to recommence antithrombotic agents can be challenging, especially in older people. In this review, we discuss one aspect of management for the older trauma patients in greater detail, that is, acute and longer-term management of antithrombotic therapy. As we consider the health needs of an ageing population, rise in elderly trauma and increasing use of antithrombotic therapy, the need for research in this area becomes more pressing to establish best practice and evidence-based care.
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Affiliation(s)
- Henna Wong
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust.,Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme
| | - Nicola Lovett
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust
| | - Nicola Curry
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust
| | - Ku Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme
| | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust.,Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme.,Department of Haematology, NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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22
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Chico-Fernández M, Llompart-Pou JA, Sánchez-Casado M, Ballesteros-Sanz MÁ. Severe traumatic disease register in Spain. Med Intensiva 2017; 41:324-325. [PMID: 28465072 DOI: 10.1016/j.medin.2017.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Affiliation(s)
- M Chico-Fernández
- UCI de Trauma y Emergencias (UCITE), Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España.
| | - J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Islas Baleares, España
| | - M Sánchez-Casado
- Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, España
| | - M Á Ballesteros-Sanz
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
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23
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Llompart-Pou JA, Pérez-Bárcena J, Chico-Fernández M, Sánchez-Casado M, Raurich JM. Severe trauma in the geriatric population. World J Crit Care Med 2017; 6:99-106. [PMID: 28529911 PMCID: PMC5415855 DOI: 10.5492/wjccm.v6.i2.99] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.
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