Tag Archives: elderly

Detecting Rib Fractures In The Elderly

It’s well known that our elders do less well than younger folks after injury. The number of complications is higher, there tends to be more loss of independence during recovery, and mortality is increased. This is not only true of high energy trauma like car crashes, but also much lower energy events such as a fall from standing.

Rib fractures are common after falls in the elderly and contribute to significant morbidity if not treated adequately. Traditionally, they are identified through a combination of physical exam and chest x-ray. Unfortunately, only half of rib fractures are visible on x-ray. It falls to the physical exam to detect the rest.

A group at Beth Israel Hospital in Boston explored the utility of using chest CT in an attempt to determine if this would result in more appropriate and cost-efficient care in the elderly. They performed a retrospective study of 3 years of their own data on patients aged 65 or more presenting after a mechanical fall and receiving a rib fracture diagnosis. Imaging was ordered at the discretion of the physician. A total of 330 patients were elderly, fell, and had both chest x-ray and chest CT obtained. This was a very elderly group, with a mean age of 84 years!

Here are the factoids:

  • Rib fractures were seen on chest x-ray in 40 patients (12%) and on CT in an additional 56 ; 234 patients had no fractures on either
  • When fractures were seen on both studies, CT identified a median of 2 more fractures than chest x-ray
  • Patients with fractures not seen on chest x-ray were admitted significantly more often than those without fractures (91% vs 78%)
  • Mortality, admission to ICU, ICU length of stay, and hospital length of stay were not different if fractures were seen only on CT
  • CT scan identified new issues or clarified diagnoses suggested by chest x-ray in 14 cases, including one malignancy
  • Rib detail images were obtained in 13 patients and proved to be better than chest x-ray, but not quite as good as CT scan

Conclusion: use of CT for rib fracture diagnosis resulted in a few more admissions, but no change in hospital resource utilization, complications, or mortality.

Bottom line: Hmm…, read the paper closely. The authors conclude that more patients with CT-only identified rib fractures are admitted. But compared to what? Unfortunately, patients without rib fractures on CT. What about comparing to patients who had fractures seen on chest x-ray too? If that number is the same, then of what additional use is CT? Identifying a few incidentalomas?

Given that there is no change in the usual outcome measures listed here, it doesn’t seem like there is any additional benefit to adding CT. And I can see a lot of downsides: cost, radiation, and possible exposure to IV contrast. In my mind, there is still nothing that beats a good physical exam and a chest x-ray. Skip the CT scan. And don’t even think about ordering rib detail images! That’s so 1990s. And even if no rib fractures are seen on imaging, physical exam is the prime determinant for admitting your patient for aggressive pain management and pulmonary toilet.

Reference: Chest CT imaging utility for radiographically occult rib fractures in elderly fall-injured patients. J Trauma ePub ahead of print, Jan 23, 2019.

EAST 2019 #7: Falls Screening In The Elderly

Falls in our elderly population are one of the largest issues facing trauma centers in the US, if not world-wide. The sheer numbers, along with the significant morbidity and mortality experienced by this group is mind boggling. ACS verified trauma centers are encouraged to have geriatric specific practice guidelines to assist in optimal care of these patients, and falls prevention programs are common among them.

The Centers for Disease Control is promoting a program called the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. They provide a suite of tools and resources, and screening begins with a 12 point questionnaire (see links). This tool obviously takes a bit of time to administer, and time is precious. The research group at
Baystate Medical Center in Massachusetts postulated that giving the full screen may be a bit cumbersome.

They explored a possible simplification to the 12-point STEADI screen, reducing it to only 3 of the questions. They sought to determine whether this easier and more convenient screen might be as accurate as the full STEADI screen. They evaluated a group of 60 elderly patients use the abbreviated tool, and those who scored high were referred to a physical therapy for further assessment and intervention. The primary outcome was performance improvement on the Timed Up and Go test (TUG), a measure of the patient’s ability to get up from a chair, walk a fixed distance and back, then sit down again. Normal performance is < 12 seconds.

Here are the factoids:

  • The median age of the 60 study patients who were considered high risk was 77
  • Median TUG before interventions was 16 seconds
  • After physical therapy intervention, the time decreased significantly to 12.3 seconds

The authors concluded that the abbreviated screen could be used to effectively identify elderly patients at risk for falls.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

  • Show the audience the full STEADI questionnaire, and highlight the three questions used in your study. This was not specified in the abstract. Did the patients have to score positive on all three questions to qualify for intervention?
  • How much time difference is there in answering the full 12-question survey vs the abbreviated 3 question one? The full survey looks pretty simple to me.
  • Did you also administer the full screen to see the correlation with your subset of three questions? This could provide interesting information that could validate the brief screen. How many more receiving the full screen would have qualified for the intervention?
  • What exactly were the interventions that the therapists provided in PT? Were they the same for each patient? How do you think they improved the TUG score?
  • Did all 60 patients complete the program? Or were more enrolled and only 60 qualified for intervention?
  • Is the TUG score difference clinically significant? You showed statistical significance, but are these patients really less likely to fall? Did you collect any data of falls after completion of the intervention?

This is a timely and pertinent study. I look forward to hearing the nitty gritty at the conference.

Links:

  • The STEADI algorithm
  • The 12 point STEADI screen

Reference: Fall prevention initiative: A fall screening pilot study in the ambulatory setting. EAST 2019 Paper #21.

Pan Scanning for Elderly Falls?

The last abstract for the Clinical Congress of the American College of Surgeons that I will review deals with doing a so-called “pan-scan” for ground level falls. Apparently, patients at this center have been pan-scanned for years, and they wanted to determine if it was appropriate.

This was a retrospective trauma registry review of 9 years worth of ground level falls. Patients were divided into young (18-54 years) and old (55+ years) groups. They were included in the study if they received a pan-scan.

Here are the factoids:

  • Hospital admission rates (95%) and ICU admission rates (48%) were the same for young and old
  • ISS was a little higher in the older group (9 vs 12)
  • Here are the incidence and type of injuries detected:
Young (n=328) Old (n=257)
TBI 35% 40%
C-spine 2% 2%
Blunt Cereb-vasc inj * 20% 31%
Pneumothorax 14% 15%
Abdominal injury 4% 2%
Mortality * 3% 11%

 * = statistically significant

Bottom line: There is an ongoing argument, still, regarding pan-scan vs selective scanning. The pan-scanners argue that the increased risk (much of which is delayed or intangible) is worth the extra information. This study shows that the authors did not find much difference in injury diagnosis in young vs elderly patients, with the exception of blunt cerebrovascular injury.

Most elderly patients who fall sustain injuries to the head, spine (all of it), extremities and hips. The torso is largely spared, with the exception of ribs. In my opinion, chest CT is only for identification of aortic injury, which just can’t happen from falling over. Or even down stairs. And solid organ injury is also rare in this group.

Although the future risk from radiation in an elderly patient is probably low, the risk from the IV contrast needed to see the aorta or solid organs is significant in this group. And keep in mind the dangers of screening for a low probability diagnosis. You may find something that prompts invasive and potentially more dangerous investigations of something that may never have caused a problem!

I recommend selective scanning of the head and cervical spine (if not clinically clearable), and selective conventional imaging of any other suspicious areas. If additional detail of the thoracic and/or lumbar spine are needed, specific spine CT imaging should be used without contrast.

Related posts:

Reference: Pan-scanning for ground level falls in the elderly: really? ACS Surgical Forum, trauma abstracts, 2016.

Adding A Hospitalist To The Trauma Service

Hospitals are increasingly relying on a hospitalist model to deliver care to inpatients on medical services. These medical generalists are usually trained in general internal medicine, family medicine, or pediatrics and provide general hospital-based care. Specialists, both medical and surgical, may be consulted when needed.

In most higher level trauma centers in the US (I and II), major trauma patients are admitted to a surgical service (Trauma), and other nonsurgical specialists are consulted based on the needs of the patients and the competencies of the surgeons managing the patients. As our population ages, more and more elderly patients are admitted for traumatic injury, with more and more complex medical comorbidities.

Is there a benefit to adding medical expertise to the trauma service? A few studies have now looked at this, and I will review them over the next few days. The Level I trauma center at Christiana Care in Wilmington, Delaware embedded a trauma hospitalist (THOSP) in the trauma service. They participated in the care of trauma patients with coronary artery disease, CHF, arrhythmias, chronic diseases of the lung or kidneys, stroke, diabetes, or those taking anticoagulants.

The THOSP was consulted on appropriate patients upon admission, or during admission if one of the conditions was discovered later. They attended morning and afternoon sign-outs, and weekly multidisciplinary rounds. A total of 566 patients with hospitalist involvement were matched to controls, and ultimately 469 patients were studied.

Here are the factoids:

  • Addition of the THOSP resulted in a 1 day increase in hospital length of stay
  • Trauma readmissions decreased significantly from 2.4% to 0.6%
  • The number of upgrades to ICU status doubled, but ICU LOS remained the same
  • Mortality decreased significantly from 2.9% to 0.4%
  • The incidence of renal failure decreased significantly
  • Non-significant decreases in cardiovascular events, DVT/PE and sepsis were also noted
  • There was no difference in the number of medical specialty consults placed (cardiology, endocrinology, neurology, nephrology)

Bottom line: This paper shows some positive impact, along with some puzzling mixed results. The decrease in mortality and many complications is very positive. Was the increase in ICU transfers due to a different care philosophy in medical vs surgical personnel? And the failure to decrease the number of specialty consults was very disappointing to me. I would expect that having additional medical expertise on the team should make a difference there.

Was the THOSP really “embedded” if they were not involved in the regular daily rounds? In this case, they were present only for handoffs and for weekly multidisciplinary rounds. I believe that having them on the rounding team daily would be of huge benefit, allowing the surgeons and hospitalists to learn from each other. Plus, there should be a benefit to the residents in a Level I center, helping them broaden their ability to care for these complicated patients.

Reference: Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions. J Trauma 81(1):178-183, 2016.

The Medical Orthopaedic Trauma Service

Our population is aging, and falls continue to be a leading cause of injury and morbidity in the elderly. Unfortunately, many elders have significant medical conditions that make them more likely to suffer unfortunate complications from their injuries and the procedures that repair them.

More and more hospitals around the world are applying a more multidisciplinary approach than the traditional model. One example is the Medical Orthopaedic Trauma Service (MOTS) at New York-Presbyterian Hospital/Weill Cornell Medical Center. Any elderly patient who has suffered a fracture is seen in the ED by both an emergency physician and a hospitalist from the MOTS team. Once in the hospital, the hospitalist and orthopaedic surgeon try to determine the reason for the fall, assess for risk factors such as osteoporosis, provide comprehensive medical management, provide pain control, and of course, fix the fracture.

This medical center published a paper looking at their success with this model. They retrospectively reviewed 306 patients with femur fractures involving the greater trochanter. They looked at complications, length of stay, readmission rate and post-discharge mortality. No change in length of stay was noted, but there were significantly fewer complications, specifically catheter associated urinary tract infections and arrhythmias. The readmission rate was somewhat shorter in the MOTS group, but did not quite achieve significance with regression analysis.

Bottom line: This type of multidisciplinary approach to these fragile patients makes sense. Hospitalists, especially those with geriatric experience, can have a significant impact on the safety and outcomes of these patients. But even beyond this, all trauma professionals need to look for and correct the reasons for the fall, not just fix the bones and send our elders home. This responsibility starts in the field with prehospital providers, and continues with hospital through the entire inpatient stay.

Related post:

Reference: The medical orthopaedic service (MOTS): an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures. J Orthopaedic Trauma 26(6):379-383, 2012.