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Egodage T, Ho VP, Bongiovanni T, Knight-Davis J, Adams SD, Digiacomo J, Swezey E, Posluszny J, Ahmed N, Prabhakaran K, Ratnasekera A, Putnam AT, Behbahaninia M, Hornor M, Cohan C, Joseph B. Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee. Trauma Surg Acute Care Open 2024; 9:e001395. [PMID: 39021732 PMCID: PMC11253746 DOI: 10.1136/tsaco-2024-001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
Background Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation. Methods We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified. Results Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings. Conclusion Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.
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Affiliation(s)
- Tanya Egodage
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Vanessa P Ho
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Tasce Bongiovanni
- Surgery, University of San Francisco, San Francisco, California, USA
| | | | - Sasha D Adams
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Jody Digiacomo
- Nassau University Medical Center, East Meadow, New York, USA
| | | | | | - Nasim Ahmed
- Surgery, Division of Trauma, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Kartik Prabhakaran
- Surgery, Westchester Medical Center Health Network, Valhalla, New York, USA
| | | | | | | | - Melissa Hornor
- Surgery, Loyola University Chicago, Maywood, Illinois, USA
| | - Caitlin Cohan
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bellal Joseph
- The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [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: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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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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Toure A, Tadi R, Meagher M, Brown CT, Lam H, LaRosa S, Saint-Fort L, Syed H, Harshaw N, Moore K, Sohail N, Perea LL. There's No Place Like Home: Delirium as a Barrier in Geriatric Trauma. J Surg Res 2024; 293:89-94. [PMID: 37734296 DOI: 10.1016/j.jss.2023.08.014] [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: 03/07/2023] [Revised: 07/13/2023] [Accepted: 08/08/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Delirium is associated with a three-fold increase in frequency of 6-mo mortality following intensive care unit admission. Outside of mortality, it has been linked with severe morbidity including long-term cognitive decline, loss of autonomy, and increased risk of institutionalization. There is a paucity of literature regarding delirium and geriatric trauma patients. The aim of our study is to determine predictive factors of delirium in geriatric trauma patients. METHODS This is a retrospective review of all geriatric (>65 y) trauma patients with a documented frailty score at a Level I Trauma Center from 1/2019 to 9/2021. Univariate and multivariate logistic regressions were performed. Geriatric patients with delirium (D) and those without delirium (ND) were compared. Patients were excluded if they did not have a documented frailty score or died before admission. RESULTS One thousand three hundred and seventeen patients met criteria; 40 (3%) patients developed delirium. Neither age nor gender was different between the two groups. Frailty scores were not different between the two groups. Patients with documented delirium had a higher incidence of a positive drug screen on admission (85% versus 62.2%, P = 0.0034), higher median injury severity score (10 versus 9, P = 0.0088), and longer hospital (7 d versus 3 d, P < 0.001) and intensive care unit (1 d versus 0 d, P < 0.001) length of stay (LOS) than their ND counterparts. The D group had a higher frequency of benzodiazepine (47.5% versus 19.3%, P < 0.001) and narcotic use (77.5% versus 56.5%, P = 0.0085). Tethers nor bedrest orders were significantly associated with delirium. Incidence of urinary tract infection (12.5% versus 1%, P < 0.001) and restraint use (P < 0.001) were significantly associated with increased risk of delirium. Additionally, those with a diagnosis of delirium were more often discharged to a skilled nursing facility than those in the ND group (45% versus 30.8%, P = 0.0006). CONCLUSIONS We aimed to identify key predictive factors of delirium in our study population and found that certain factors correlated with higher frequencies of delirium in our geriatric trauma patients. Preadmission and early controlled substance use were significantly associated with delirium, as were the presence of urinary tract infection and extended intensive care unit LOS. By recognizing some of these modifiable factors, LOS may decrease while increasing the likelihood of discharge home.
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Affiliation(s)
- Abdoulaziz Toure
- Department of Surgery, Arnot Ogden Medical Center, Elmira, New York
| | - Roshan Tadi
- Department of Surgery, Arnot Ogden Medical Center, Elmira, New York
| | - Mitchell Meagher
- Department of Surgery, Arnot Ogden Medical Center, Elmira, New York
| | - Catherine Ting Brown
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Hoi Lam
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Samantha LaRosa
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Launick Saint-Fort
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Huda Syed
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Nathaniel Harshaw
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Katherine Moore
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Neelofer Sohail
- Department of Geriatric Medicine, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Lindsey L Perea
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania.
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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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Spencer AL, Nunn AM, Miller PR, Russell GB, Carmichael SP, Neri KE, Marterre B. The value of compassion: Healthcare savings of palliative care consults in trauma. Injury 2023; 54:249-255. [PMID: 36307268 PMCID: PMC11210453 DOI: 10.1016/j.injury.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. STUDY DESIGN We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. RESULTS 140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01). Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01). Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01). Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01). Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group. Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01). Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). CONCLUSION Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.
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Affiliation(s)
- Audrey L Spencer
- Department of Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Room 5411, Tower 4, Tucson, AZ 85724, United States of America.
| | - Andrew M Nunn
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Preston R Miller
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Gregory B Russell
- Department of Biostatistics & Data Science, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Samuel P Carmichael
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Kristina E Neri
- Wake Forest University School of Medicine, Bowman Gray Center for Medical Education, 475 Vine Street, Winston-Salem, NC 27101, United States of America.
| | - Buddy Marterre
- Departments of Surgery & Internal Medicine, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
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Katlic MR. All Surgeons Should Be Palliative Care Surgeons. JAMA Surg 2022; 157:1132-1133. [PMID: 36260364 DOI: 10.1001/jamasurg.2022.4725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Mark R Katlic
- Sinai Center for Geriatric Surgery, LifeBridge Health System, Baltimore, Maryland
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Pierce JG, Ricon R, Rukmangadhan S, Kim M, Rajasekar G, Nuño M, Curtis E, Humphries M. Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US. JAMA Surg 2022; 157:1125-1132. [PMID: 36260298 PMCID: PMC9582969 DOI: 10.1001/jamasurg.2022.4718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/17/2022] [Indexed: 01/11/2023]
Abstract
Importance The American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encourage trauma service clinicians to deliver palliative care in parallel with life-sustaining treatment and recommend goals of care (GOC) discussions within 72 hours of admission for patients with serious illness. Objective To measure adherence to TQIP guidelines-recommended GOC discussions for trauma patients with serious illness, treated at a level I trauma center in the US. Design, Setting, and Participants This retrospective cohort study included 674 adults admitted to a trauma service center for 3 or more days between December 2019 and June 2020. The medical records of 486 patients who met the criteria for serious illness using a consensus definition adapted to the National Trauma Data Bank were reviewed for the presence of a GOC discussion. Patients were divided into 2 cohorts based on admission before or after the guidelines were incorporated into the institutional practice guidelines on March 1, 2020. Main Outcomes and Measures The primary outcomes were GOC completion within 72 hours of admission and during the overall hospitalization. Patient and clinical factors associated with GOC completion were assessed. Other palliative care processes measured included palliative care consultation, prior advance care planning document, and do-not-resuscitate code status. Additional end-of-life processes (ie, comfort care and inpatient hospice) were measured in a subset with inpatient mortality. Results Of 674 patients meeting the review criteria, 486 (72.1%) met at least 1 definition of serious illness (mean [SD] age, 60.9 [21.3] years; mean [SD] Injury Severity Score, 16.9 [12.3]). Of these patients, 328 (67.5%) were male and 266 (54.7%) were White. Among the seriously ill patients, 92 (18.9%) had evidence of GOC completion within 72 hours of admission and 124 (25.5%) during the overall hospitalization. No differences were observed between patients admitted before and after institutional guideline publication in GOC completion within 72 hours (19.0% [47 of 248 patients] vs 18.9% [45 of 238]; P = .99) or during the overall hospitalization (26.2% [65 of 248 patients] vs 24.8% [59 of 238]; P = .72). After adjusting for age, GOC completion was found to be associated with the presence of mechanical ventilation (odds ratio [OR], 6.42; 95% CI, 3.49-11.81) and meeting multiple serious illness criteria (OR, 4.07; 95% CI, 2.25-7.38). Conclusions and Relevance The findings of this cohort study suggest that, despite the presence of national guidelines, GOC discussions for patients with serious illness were documented infrequently. This study suggests a need for system-level interventions to ensure best practices and may inform strategies to measure and improve trauma service quality in palliative care.
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Affiliation(s)
| | | | | | | | - Ganesh Rajasekar
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| | - Miriam Nuño
- Department of Public Health Sciences, University of California, Davis
| | - Eleanor Curtis
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| | - Misty Humphries
- Department of Surgery, University of California, Davis Medical Center, Sacramento
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9
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Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention. J Am Coll Surg 2022; 235:278-284. [PMID: 35839403 DOI: 10.1097/xcs.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older trauma patients present with poor preinjury functional status and more comorbidities. Advances in care have increased the chance of survival from previously fatal injuries with many left debilitated with chronic critical illness and severe disability. Palliative care (PC) is ideally suited to address the goals of care and symptom management in this critically ill population. A retrospective chart review was done to identify the impact of PC consults on hospital length of stay (LOS), ICU LOS, and surgical decisions. STUDY DESIGN A Level 1 Trauma Center Registry was used to identify adult patients who were provided PC consultation in a selected 3-year time period. These PC patients were matched with non-PC trauma patients on the basis of age, sex, race, Glasgow Coma Scale, and Injury Severity Score. Chi-square tests and Student's t-tests were used to analyze categorical and continuous variables, respectively. Any p value >0.05 was considered statistically significant. RESULTS PC patients were less likely to receive a percutaneous endoscopic gastric tube or tracheostomy. PC patients spent less time on ventilator support, spent less time in the ICU, and had a shorter hospital stay. PC consultation was requested 16.48 days into the patient's hospital stay. Approximately 82% of consults were to assist with goals of care. CONCLUSION Specialist PC team involvement in the care of the trauma ICU patients may have a beneficial impact on hospital LOS, ICU LOS, and surgical care rendered. Earlier consultation during hospitalization may lead to higher rates of goal-directed care and improved patient satisfaction.
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10
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Park C, Bharija A, Mesias M, Mitchell A, Krishna P, Storr-Street N, Brown A, Martin M, Lu AC, Staudenmayer KL. Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury. JAMA Surg 2022; 157:676-683. [PMID: 35675065 PMCID: PMC9178494 DOI: 10.1001/jamasurg.2022.1556] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/13/2022] [Indexed: 12/19/2022]
Abstract
Importance Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored. Objective To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury. Design, Setting, and Participants A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation. Intervention The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team. Main Outcomes and Measures The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed. Results Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P < .001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P = .03). Conclusions and Relevance In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.
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Affiliation(s)
- Caroline Park
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Ankur Bharija
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
- Geriatrics, Linus Health, Waltham, Massachusetts
| | - Matthew Mesias
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Ann Mitchell
- Patient Care Services, Professional Practice, Stanford, California
| | | | - Nannette Storr-Street
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Alyssa Brown
- Department of Rehabilitation, Stanford University, Stanford, California
| | - Marina Martin
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Amy C. Lu
- Department of Quality Administration, University of California, San Francisco
| | - Kristan L. Staudenmayer
- Division of General Surgery, Department of Surgery, Stanford School of Medicine, Stanford, California
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11
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Anderson PM, Vollmann P, Weißenberger M, Rudert M. Total hip arthroplasty in geriatric patients – a single-center experience. SICOT J 2022; 8:12. [PMID: 35380534 PMCID: PMC8982179 DOI: 10.1051/sicotj/2022011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/07/2022] [Indexed: 11/15/2022] Open
Abstract
Background: As advanced age often leads to accumulating comorbidities, geriatric patients are endangered by serious events during total hip arthroplasty. This study was conducted to explore whether or not the benefit in terms of health-related quality of life (HRQoL) was comparable to younger patients. Methods: At a single academic center, 100 patients meeting the following inclusion criteria were retrospectively recruited: (1) primary arthritis of the hip leading to THA; (2) age 80 years or older at the time of surgery; (3) follow up of at least 12 months. For comparison, two further groups were recruited in the same manner, differing only in the age criterion: 100 patients aged 60–69 and 100 patients aged 70–79 at the time of hip replacement. The primary outcome was compared using the WOMAC and the EQ-5D score. The secondary outcome was determined by rates of orthopedic and non-orthopedic complications. Intragroup comparisons of the PROMS were performed by the non-parametric Wilcoxon test for paired samples. For intergroup comparisons of the PROMS, the Kruskal–Wallis-test was performed. Concerning categorial data, intergroup comparisons were performed by the Chi-Square test. The level of significance was set at 0.05. Results: Concerning the WOMAC score, neither the absolute values at 12 months after THA (p = 0.176) nor the amount of change relative to the values before surgery (p = 0.308) differed significantly between the 3 groups. Concerning the EQ-5D index the absolute values at 12 months after THA differed significantly (p = 0.008). Rates of orthopedic complications did not differ significantly (p = 0.631). Rates of non-orthopedic complications increased significantly with rising age (p = 0.033). Conclusions: Compared to younger patients, geriatric patients after THA have an equal improvement in hip-specific and general HRQoL. While rates of orthopedic complications are comparable too, non-orthopedic complications occur more frequently.
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Affiliation(s)
- Philip Mark Anderson
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
- Corresponding author:
| | - Peter Vollmann
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
| | - Manuel Weißenberger
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
| | - Maximilian Rudert
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
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12
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Karam BS, Patnaik R, Murphy P, deRoon-Cassini TA, Trevino C, Hemmila MR, Haines K, Puzio TJ, Charles A, Tignanelli C, Morris R. Improving mortality in older adult trauma patients: Are we doing better? J Trauma Acute Care Surg 2022; 92:413-421. [PMID: 34554138 DOI: 10.1097/ta.0000000000003406] [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 Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care. MATERIALS AND METHODS This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality. RESULTS There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49). CONCLUSION Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Basil S Karam
- From the Department of Surgery (B.S.K., R.P., P.M., T.A.d.-C., Co.T., R.M.), Comprehensive Injury Center (T.A.d.-C.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (M.R.H.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (K.H.), Duke University, Durham, North Carolina; Department of Surgery (T.J.P.), University of Texas Health Science Center, Houston, Texas; Department of Surgery (A.C.), School of Public Health (A.C.), University of North Carolina, Chapel Hill, North Carolina; Department of Surgery (Ch.T.), Institute for Health Informatics (Ch.T.), University of Minnesota, Minneapolis; and Department of Surgery (Ch.T.), North Memorial Health Hospital, Robbinsdale, Minnesota
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13
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Schuijt HJ, Lehmann LS, Javedan H, von Keudell AG, Weaver MJ. A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures. J Bone Joint Surg Am 2021; 103:e72. [PMID: 33974580 DOI: 10.2106/jbjs.20.02149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.
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Affiliation(s)
- Henk Jan Schuijt
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Soleymani Lehmann
- Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Houman Javedan
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Arvind G von Keudell
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael John Weaver
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Boston, Massachusetts
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14
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Sokas C, Herrera-Escobar JP, Klepp T, Stanek E, Kaafarani H, Salim A, Nehra D, Cooper Z. Impact of chronic illness on functional outcomes and quality of life among injured older adults. Injury 2021; 52:2638-2644. [PMID: 33823987 DOI: 10.1016/j.injury.2021.03.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma care for injured older adults is complicated by pre-existing chronic illness. We examined the association between chronic illness and post-injury function, healthcare utilization and quality of life. METHODS Trauma patients ≥65 years with an Injury Severity Score (ISS) ≥9 discharged from one of three level-1 trauma centers were interviewed 6-12 months post-discharge. Patients were asked about new functional limitations, injury-related emergency department (ED) visits or readmission, and health-related quality of life (HRQoL). Trauma registry data was used to determine presence of seven chronic illnesses. Adjusted regression models examined associations between increasing number of chronic illness (0, 1, ≥2) and outcomes. RESULTS Of 1,379 patients, 46.5% had at least one chronic illness. In adjusted analysis, any chronic illness was associated with higher odds of new functional limitation (1 chronic illness, OR1.54, CI: 1.20-1.97; ≥2, OR1.69, CI: 1.16-2.48) and worse physical health-related QoL (1 chronic illness adj. mean diff= -4.0, CI: -5.6 to -2.5; ≥2 adj. mean diff.= -4.4, CI: -7.3 to -1.4, p<0.01). Mental health post-injury was consistent with population norms across all groups. CONCLUSION Presence of any chronic illness in older adults is associated with new functional limitations and worse physical HRQoL post-injury, but unchanged mental health. Focused interventions are needed to support long-term recovery.
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Affiliation(s)
- Claire Sokas
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, MA USA.
| | | | - Timothy Klepp
- Boston University, School of Medicine, Boston, MA USA
| | - Ewelina Stanek
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, MA USA
| | - Haytham Kaafarani
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
| | - Ali Salim
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, MA USA; Harvard Medical School, Boston, MA, USA
| | | | - Zara Cooper
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, MA USA; Harvard Medical School, Boston, MA, USA
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15
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Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
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Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Makish A, Priestap F, Vogt KN, Parry NG, Sibbald R, Ball I. Medical assistance in dying and the trauma patient. J Trauma Acute Care Surg 2021; 90:e155-e157. [PMID: 34016933 DOI: 10.1097/ta.0000000000003130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Amy Makish
- From the London Health Sciences Centre Trauma Program (A.M., F.P., I.B.) London, ON Canada; Department of Surgery (K.N.V., N.G.P.), Western University, London, ON Canada; Division of General Surgery (K.N.V., N.G.P.), London Health Sciences Centre Trauma Program, London, ON Canada; Ethics Program (R.S.), London Health Sciences Centre, London, ON Canada; and Department of Medicine (I.B.) and Department of Epidemiology and Biostatistics (I.B.), Western University, London, ON Canada
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17
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Hakkenbrak N, Zuidema W, Rikken Q, Halm J, Dorn T, Reijnders U, Giannakopoulos G. Mortality after falls in Amsterdam; Data from a retrospective cross sectional study. FORENSIC SCIENCE INTERNATIONAL: REPORTS 2020. [DOI: 10.1016/j.fsir.2020.100061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Esquibel BM, Waller CJ, Borgert AJ, Kallies KJ, Harter TD, Cogbill TH. The role of palliative care in acute trauma: When is it appropriate? Am J Surg 2020; 220:1456-1461. [PMID: 33051066 DOI: 10.1016/j.amjsurg.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/21/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.
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Affiliation(s)
- Brendon M Esquibel
- General Surgery Residency, Department of Medical Education, Gundersen Health System, La Crosse, WI, USA
| | - Christine J Waller
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Thomas D Harter
- Department of Bioethics and Humanities, Gundersen Health System, La Crosse, WI, USA
| | - Thomas H Cogbill
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
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19
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Maxwell CA, Mixon AS, Conner E, Phillippi JC. Receptivity of Hospitalized Older Adults and Family Caregivers to Prognostic Information about Aging, Injury, and Frailty: A Qualitative Study. Int J Nurs Stud 2020; 109:103602. [PMID: 32534291 DOI: 10.1016/j.ijnurstu.2020.103602] [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: 09/19/2019] [Revised: 01/20/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is the leading prognosticator for poor outcomes and palliative care among older adults. Delivery of negative prognostic information entails potentially difficult conversations about decline and death. OBJECTIVE The study aims were to: 1) examine hospitalized older adults' and family caregivers' receptivity to general (vs. individualized) prognostic information about frailty, injury, and one-year outcomes; and 2) determine information needs based on prognostic information. DESIGN Provision of general prognostic information followed by semi-structured interview questions. We deductively analyzed qualitative data within the context of problematic integration theory. SETTING An academic medical center in the Southeast region of the U.S. PARTICIPANTS Purposive sampling was utilized to obtain a distribution of patients across the frailty continuum (non-frail [N=10], pre-frail [N=9], frail [9=6]). Twenty-five older adults (≥ age 65) hospitalized for a primary injury (e.g. fall) and 15 family caregivers of hospitalized patients were enrolled. METHODS Hospitalized older patients and family caregivers were shown prognostic information about one-year outcomes of injured older adults in the form of simple pictographs. Semi-structured interview questions were administered immediately afterwards. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Demographic and medical information data were used to contextualize the responses during analysis. RESULTS Overall, participants (patients [56%], caregivers [73%]) were open to receiving prognostic information. A small number of family caregivers (N=3) expressed reservations about the frankness of the information and suggested delivery through a softer approach or not at all. Qualitative data was coded using categories and constructs of problematic integration theory. Four codes (personalizing the evidence, vivid understanding, downhill spiral, realities of aging) reflected probabilistic and evaluative orientation categories of problematic integration theory. One code (fatalism vs. hope) represented manifestations of ambivalence and ambiguity in the theory; and another code (exceptionalism) represented divergence and impossibility. Two codes (role of thought processes, importance of faith) reflected forms of resolutions as described in problematic integration theory. Information needs based on prognostic information revealed four additional codes: give it to me straight, what can I do? what can I expect? and how can I prevent decline? A consistently reported desire of both patients and caregivers was for honesty and hope from providers. CONCLUSION This study supports the use of general prognostic information in conversations about aging, injury, frailty and patient outcomes. Incorporating prognostic information into communication aids can facilitate shared decision making before end-of-life is imminent.
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Affiliation(s)
- Cathy A Maxwell
- Vanderbilt University School of Nursing, 461 21st Ave. South, Nashville, TN 37240.
| | - Amanda S Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System.
| | - Elizabeth Conner
- University of Tennessee Health Science Center, College of Medicine, 910 Madison Ave. Suite 1031, Memphis, TN 38163.
| | - Julia C Phillippi
- Vanderbilt University School of Nursing, 461 21st Ave. South, Nashville, TN 37240.
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Lee KC, Udelsman BV, Streid J, Chang DC, Salim A, Livingston DH, Lindvall C, Cooper Z. Natural Language Processing Accurately Measures Adherence to Best Practice Guidelines for Palliative Care in Trauma. J Pain Symptom Manage 2020; 59:225-232.e2. [PMID: 31562891 DOI: 10.1016/j.jpainsymman.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive. OBJECTIVES To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review. METHODS Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery. RESULTS There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay. CONCLUSION NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ali Salim
- Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David H Livingston
- Division of Trauma and Surgical Critical Care, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Farhat I, Moore L, Porgo TV, Patton MP, Tardif PA, Truchon C, Berthelot S, Stelfox HT, Gabbe BJ, Lauzier F, Turgeon AF, Clément J. Resource use for older people hospitalised due to injury in a Canadian integrated trauma system: a retrospective multicenter cohort study. Age Ageing 2019; 48:867-874. [PMID: 31437268 DOI: 10.1093/ageing/afz097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/02/2019] [Accepted: 06/21/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Injuries represent one of the leading causes of preventable morbidity and mortality. For countries with ageing populations, admissions of injured older patients are increasing exponentially. Yet, we know little about hospital resource use for injured older patients. Our primary objective was to evaluate inter-hospital variation in the risk-adjusted resource use for injured older patients. Secondary objectives were to identify the determinants of resource use and evaluate its association with clinical outcomes. METHODS We conducted a multicenter retrospective cohort study of injured older patients (≥65 years) admitted to any trauma centres in the province of Quebec (2013-2016, N = 33,184). Resource use was estimated using activity-based costing and modelled with multilevel linear models. We conducted separate subgroup analyses for patients with trauma and fragility fractures. RESULTS Risk-adjusted resource use varied significantly across trauma centres, more for older patients with fragility fractures (intra-class correlation coefficients [ICC] = 0.093, 95% CI [0.079, 0.102]) than with trauma (ICC = 0.047, 95% CI = 0.035-0.051). Risk-adjusted resource use increased with age, and the number of comorbidities, and varied with discharge destination (P < 0.001). Higher hospital resource use was associated with higher incidence of complications for trauma (Pearson correlation coefficient [r] = 0.5, 95% CI = 0.3-0.7) and fragility fractures (r = 0.5, 95% CI = 0.3-0.7) and with higher mortality for fragility fractures (r = 0.4, 95% CI = 0.2-0.6). CONCLUSIONS We observed significant inter-hospital variations in resource use for injured older patients. Hospitals with higher resource use did not have better clinical outcomes. Hospital resource use may not always positively impact patient care and outcomes. Future studies should evaluate mechanisms, by which hospital resource use impacts care.
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Affiliation(s)
- Imen Farhat
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Teegwendé Valérie Porgo
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Marie-Pier Patton
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Pier-Alexandre Tardif
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Catherine Truchon
- Institut National d’Excellence en Santé et en Services Sociaux (INESSS), Québec, QC, Canada
| | - Simon Berthelot
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
- Department of family medicine and emergency medicine, Université Laval, Québec, QC, Canada
| | - Henry T Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - François Lauzier
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
- Department of Medicine, Université Laval, Québec, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence – Soins intensifs (Trauma – Emergency – Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Julien Clément
- Institut National d’Excellence en Santé et en Services Sociaux (INESSS), Québec, QC, Canada
- Department of Surgery, Université Laval, Québec, QC, Canada
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22
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Evaluating the outcomes of blunt thoracic trauma in elderly patients following a fall from a ground level: higher level care institution vs. lower level care institution. Eur J Trauma Emerg Surg 2019; 47:955-963. [PMID: 31583421 DOI: 10.1007/s00068-019-01230-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of the study is to evaluate the outcomes of higher level care institutions of elderly patients who sustained a thoracic injury after a ground-level fall (GLF). HYPOTHESIS Higher level care institutions have a better survival. METHODS The National Trauma Data Bank (NTDB) data set of 2012-2014 was accessed for the study. All patients, 65 years of age and older, who experienced a GLF and sustained a thoracic injury, were included in the study. Patient demography, injury characteristics including injury severity score (ISS), Glasgow coma scale (GCS) motor score, comorbidities, and patient outcomes were compared between the higher level care institution [American College of Surgeon (ACS) level I and level II trauma centers) and lower level care institution (ACS level III and level IV and unranked-trauma centers). On univariate analysis, some significant patient characteristic differences were found; therefore, propensity score matching and paired analyses were performed. All P values are two sided, and a P value < 0.05 was considered statistically significant. RESULTS Out of the 15,256 patients who satisfied the inclusion criteria, approximately 52% (7994) of patients were treated at a higher level care institution. On univariate analysis, significant differences were found between the lower level care institution and higher level care institution regarding male gender (44.2% vs.46%, P = 0.03), ISS median [interquartile] (9 [5-12] vs. 9 [5-13], P < 0.001), history of alcohol abuse (4.2% vs. 5.3%, P = 0.007), dementia (8.7% vs. 9.8%, P = 0.02), bleeding disorder or history of anticoagulation use (17% vs. 18.4%, P = 0.03), obesity (5% vs. 6.6%, P < 0.001), and abbreviated injury scale (AIS) thorax (2 [1-3] vs. 3 [2-3], P < 0.001). After propensity score matching, the majority of the characteristics were balanced with few exceptions, including ISS, AIS ≥ 3 head and abdomen, and P values < 0.05. The overall in-hospital mortality was not significantly different between the higher level care institution vs. the lower level care institution (4.4% vs. 3.9%, P = 0.14). The median hospital length of stay and 95% confidence interval between both groups was (5 [5, 5] and 5 [5, 5], P = 0.72). CONCLUSION Treating elderly patients with blunt chest trauma in higher level care institutions failed to show any benefit in overall survival or hospital length of stay. LEVEL OF EVIDENCE IV. STUDY TYPE Observational cohort.
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Abstract
A common fallacy prevalent in surgical culture is for surgical intervention and palliation to be regarded as mutually exclusive or sequential strategies in the trajectory of surgical illness. Modern surgeons play a complex role as both providers and gatekeepers in meeting the palliative needs of their patients. Surgical palliative care is ideally delivered by surgical teams as a component of routine surgical care, and includes management of physical and psychosocial symptoms, basic communication about prognosis and treatment options, and identification of patient goals and values. Specialty palliative care services may be accessed through a through a variety of models.
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Affiliation(s)
- Ana Berlin
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 5-562, New York, NY 10032, USA; Department of Medicine, Division of Hematology/Oncology, Adult Palliative Medicine Service, Columbia University Medical Center, New York, NY, USA.
| | - Teresa Johelen Carleton
- Tucson Medical Center Palliative Care, Tucson Medical Center, 5301 E. Grant Road, Tucson, AZ 85712, USA; University of Arizona Phoenix, Phoenix, AZ, USA
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