Tag Archives: elderly

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.

Anticoagulants And The Elderly: Are They Being Appropriately Treated?

About 2.3 million people, or a bit less than 1% of the US population, have atrial fibrillation. This condition is commonly managed with anticoagulants to reduce the risk of stroke. Unfortunately, the elderly represent a large subset of those with a-fib. And the older we get, the more likely we are to fall. About half of those over 80 will fall once a year.

Are all of these elderly patients being treated with anticoagulants appropriately? Several scoring systems have been developed that allow us to predict the likelihood of ischemic stroke. Looking at it another way, they allow us to judge the appropriateness of using an anticoagulant to prevent such an event.

The original CHADS2 score was developed using retrospective Medicare data in the US. The newer CHA2DS2-VASC score used prospective data from multiple countries. However, the accuracy is about the same as the original CHADS2 score. But because the newer system has three more variables, it adds a few more people to the high-risk group who should receive an anticoagulant.

The higher the CHA2DS2-VASC score, the more likely one is to have an ischemic stroke. The threshold to justify anticoagulation seems to vary a bit, with some saying >1 and others going with >2. Here’s a chart that shows how the stroke risk increases.


Stroke risk per year with CHA2DS2-VASC score

Whereas CHA2DS2-VASC predicts the risk of clotting (ischemic stroke), the HAS-BLED score looks at the risk of bleeding. It includes clinical conditions, labile INR, and concomitant use of NSAIDs, aspirin or alcohol, but not a history of falls.

Proper management of atrial fibrillation in the elderly must carefully balance both of these risks to reduce potential harm as much as possible. A HAS-BLED score of >3 indicates a need to clinically review the risk-benefit ratio of anticoagulation. It does not provide an absolute threshold to stop it.

A group at Henry Ford Hospital in Detroit, a Level I trauma center, retrospectively reviewed their experience with patients who fell while taking an anticoagulant for atrial fibrillation. They calculated CHA2DS2-VASC and HAS-BLED for each and evaluated the appropriateness of their anticoagulation regimen.

Here are the factoids:

  • A total of 242 patients were reviewed, and the average age was 78
  • The average CHA2DS2-VASC score was 5, and the average HAS-BLED was 3
  • Only 1.6% were considered to be receiving an anticoagulant inappropriately (CHA2DS2-VASC 0 or 1)
  • Nearly 9% of patients were dead 30 days after the fall

Bottom line: The authors found that their population was appropriately anticoagulated. But they also noted that the morbidity and mortality risk was high, and was independent of age and comorbidities.

There are tools available to help us judge whether an elderly patient should be taking an anticoagulant for atrial fibrillation. The tool for predicting bleeding risk, however, is not as good for trauma patients. It ignores the added risk from falling, which is very common in the elderly.

Every patient admitted to the trauma service after a fall should have a critical assessment of their need for anticoagulation. The specific drug they are taking (reversible vs irreversible) should also be examined. If there is any question regarding appropriateness, the primary care provider should be contacted personally to discuss and modify their drug regimen. Don’t just rely on them reading the hospital discharge summary. Falls can be and are frequently fatal, just not immediately. Inappropriate use of anticoagulants can certainly contribute to this problem, so do your part to reduce that risk.

Related links and posts:

Reference: Falls, anticoagulation, and the elderly: are we inappropriately treating atrial fibrillation in this high-risk population? JACS 225(4S1):S53-S54, 2017.

Syncope Workup in Trauma Patients – Updated With CPG

Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.

Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay.

A total of 14% of trauma patients had syncope as a possible contributor to their injury. The investigators found that the following tests were typically ordered in these patients:

  • Carotid ultrasound (96%)
  • 2D Echo (96%)
  • Cardiac enzymes (81%)
  • Cardiology consult (23%)
  • Neurology consult (11%)
  • EEG (7%)
  • MRI (6%)

Most of this testing was normal. About 3% of cardiac enzymes were abnormal, as were 5% of carotid imaging and 4% of echocardiograms.

Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.

Is it possible to determine a subset of this population that may show a higher yield for this screening? Surgeons at Temple University in Philadelphia found that there was little utility in using carotid duplex studies. They did note that patients with a history of heart disease were more likely to have an abnormal EKG, and that an abnormal EKG predicted an abnormal echo. Overall, only patients with a history of significant cardiac comorbidity, older age, and higher ISS had findings requiring intervention.

Bottom line: Don’t just reflexively order a syncope workup when there is a question of this problem. Think about it first, because the majority of these studies are nonproductive. They are not needed routinely in trauma patients with “syncope” as a contributing factor.  Obtain a good cardiac history, and if indicated, order an EKG and go from there. See the practice guideline proposed by the Temple group below. And be sure to include the patients primary doctor in the loop!

References:

  1. Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary. J Trauma 70(2):428-432, 2011.
  2. Syncope workup: Greater yield in select trauma population. Intl J Surg, accepted for publication June 27, 2017.

Geriatric Week 6: Effect Of An In-Hospital Falls Prevention Program

The Centers for Disease Control (CDC) has developed a neatly packaged falls prevention program that clinicians can apply to their elderly patients. Of course, there’s a cute acronym (STEADI = Stopping Elderly Accidents, Deaths, and Injuries), and a lot of slickly packaged reference material. The trauma group at Parkland wondered if the application of this outpatient program on an inpatient population would be helpful.

They looked at elderly patients (age>65) who were admitted for falls. The patients went through STEADI evaluation and interventions, and were compared with a group of historical controls from the prior year.

Here are the factoids:

  • 218 patients went through the STEADI process, and were compared with 194 controls
  • The usual demographics appeared to be the same in both groups
  • The fall rate in-hospital was 4.1% for both groups (!)
  • The fall recidivism rate (fell after discharge) was also the same (2.8% STEADI vs 2.1% controls)

STEADI consists of a number of assessments, including looking for medical conditions and medications that may

impair mobility, visual problems, gait and balance testing, footwear evaluation, cognitive screening, and home evaluation. This program was modified by the authors for inpatient use, although the exact modifications were not listed in the abstract.

Bottom line: The application of the CDC STEADI program did not appear to affect falls in-hospital or those after discharge. The authors question whether maintaining the resources ($) to implement this program is justified. The paper does raise that question, but it is not clear what modifications were made to the full program to tailor it to an inpatient population. The fact that nearly 1 in 20 elderly patients are falling in the hospital is concerning, with or without STEADI. What the abstract does confirm is that elderly falls are a huge problem. The CDC notes that 1 in every 3 patients age 65 and older will fall each year! Further evaluation of STEADI and other similar programs is essential to decrease the morbidity and mortality of falls in this age group.

Reference: UnSTEADI: Implementation of the CDC fall prevention program does not prevent in-hospital falls or reduce fall recidivism rates. Presented at EAST 2015, Paper 16.