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Geriatric Trauma

Proactive geriatric trauma consultation model.
by

Camilla Wong

on 18 September 2013

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Transcript of Geriatric Trauma

Proactive Geriatric Trauma Consultation:
The trauma is not the only problem.

Challenges of the Geriatric Trauma Patient
demographic imperative

atypical presentation and atypical responses

it is not only about the injury

hazards of hospitalization are a reality

Comprehensive Geriatric
Assessment (CGA)
A comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a co-ordinated and integrated plan for management and longitudinal follow-up.

Comprehensive Geriatric Assessment
Implementation
1. Provision of structured, medical, functional, cognitive and psychosocial evaluation to improve clinical outcomes;

2. Prevention of age-specific complications related to co-morbid disease, hazards of hospitalization, or potentially inappropriate medications; and

3. Development of recommendations to the trauma team regarding appropriate discharge planning.

Evaluation
geriatric issues addressed
recommendation adherence rate
subspecialty consultation requests
geriatric-specific in-hospital complications
trauma quality indicators
discharge destination

systematic case finding

early involvement, within x hours of admission

prevention of geriatric syndromes

implementation of recommendations (writing orders)

early attention to discharge planning

Implementation: eligibility criteria
all patients aged 60 and over admitted to the Trauma service

patients are identified by the Trauma Registry and Quality Coordinator and communicated to the GTCS team every business morning

The GTCS Team
geriatrician

advance practice nurse in geriatrics

medical trainees
The Intervention: CGA
cognition
mood
mobilization and falls risk
restraint use
continence
decubitus ulcer
sensory impairment
nutrition
pain
medication review
other medical complications
discharge planning
Timing of the Intervention: Proactive
A comprehensive geriatric assessment is performed within 72 hours of admission to the Trauma service.

The intensity and frequency of follow-up is individualized.
Communication, communication, communication
recommendations are communicated in written form (dictated transcription and written orders) and supplemented with verbal communication

weekly attendance at interdisciplinary Trauma team rounds

The GTCS resulted in less consultations to Medicine and Psychiatry.
There were fewer consultation requests made to Internal Medicine (N = 31 vs. N = 18, P = 0.04) and Psychiatry in the post-GTCS group (N = 33 vs. N = 18, P = 0.02), but not to other subspecialties.
Proactive geriatric trauma consultation was associated with decreased incident delirium and discharge to nursing home.
There was no difference in trauma quality indicators, but a trend towards decreased length of stay.
Frequency of geriatric issues addressed.
The trauma team adhered to most recommendations.
Adherence rate by the Trauma team to recommendations made by the GTCS was 93.2%.
Comprehensive geriatric assessment (CGA) is effective for inpatients.
more likely to be “living at home” at 6 months (OR 1.25, 95% CI 1.11 to 1.42; P=0.000)

less likely to be institutionalized (OR 0.79, 95% CI 0.69 to 0.88, P<0.0001)

less likely to suffer death or deterioration (OR 0.76, 95% CI 0.64 to 0.90; P=0.001)

more likely to experience improved cognitive function (OR 1.11, 95% CI 0.20 to 2.01 (P=0.02)


PROACTIVE geriatric consultation improves outcomes.
decreased delirium rates among hip fracture patients

shorter lengths of stay in patients admitted to a hospitalist service

reduction in medical complications in elective orthopedic patients

J Am Geriatr Soc. 2001;49(5):516-22.
J Am Geriatr Soc. 2009;57(11):2139-45.
Age Ageing. 2007;36(2):190-6.
Cochrane Database of Systematic Reviews 2011
Geriatric patients stay long enough to lose function.
one third of older adults develop a new disability in an ADL during hospitalization

half of these are unable to recover function
J Am Ger Soc 1993;41:1353-60.
Ann Intern Med 1993;118:219-223.
Ann Intern Med 1993;118:219-223.
The risk of death is NOT significantly lower among older patients treated at trauma centers than those treated at non-trauma centers.

It's not just about the injury in geriatric patients.
the Injury Severity Score (ISS) does not fully capture the potential for mortality in older adults

the ISS does not predict discharge placement
J Am Geriatr Soc 2002;50:215-222.
J Am Geriatr Soc 1991;39:8S-16S.
Case fatality rates are highest among those 75+
more pre-existing conditions

altered responses to apparently minor injuries

atypical physiologic signs of injury

more serious injuries for same mechanism of injury

Ann Surg. 2012;256(6):1098-101
Ann Surg. 2012 ;256(6):1098-101
Ann Surg. 2012 ;256(6):1098-101
Ann Surg. 2012 ;256(6):1098-101
Ann Surg. 2012 ;256(6):1098-101
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The Intervention: CGA
Camilla Wong, MD FRCPC MHSc
PROACTIVE
Trauma
National Trauma Registry 2011 Report

Cases defined based on an Injury Severity Score (ISS) > 12 and using external cause of injury inclusion and exclusion criteria.
Falls are the leading cause of trauma in the elderly.
Causes of trauma in the elderly:

1. falls (74%)

2. motor vehicle collisions (20%)

3. other causes of blunt injury (3%)
National Trauma Registry 2011 Report
Future Directions
sustainability evaluation at St. Michael's Hospital
referral process mapping and optimization at St. Michael's Hospital
prospective, interrupted time-series implementation and evaluation at Sunnybrook Hospital
implementation at Royal Columbian Hospital, BC
multi-site RCT
Limitations
single institution

retrospective analysis

before and after design

lack of adjusted analyses
Acknowledgments
Barbara Haas
Magda Lenartowicz
Amanda McFarlan
Avery Nathens
Meredith Parkovnick
Lee Ringer
Anne Stephens
Sharon Straus
Marisa Zorzitto

Methods
was a before (March 2005–August 2007) and after (September 2007–March 2010) case series, N = 238 and N = 248, respectively

inclusion criteria: all patients 60 years or older admitted to the Trauma service

exclusion criteria: dead on arrival, died in emergency department

retrospective chart and trauma database abstraction

incident delirium identified with a validated chart abstraction tool
Before implementation 3.8% (n = 9) received a CGA vs 59.4% (n = 146) after implementation.
Ann Surg. 2012;256(6):1098-101.
Ann Surg. 2012;256(6):1098-101.
Ann Surg. 2012;256(6):1098-101.
Ann Surg. 2012;256(6):1098-101.
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