Tag Archives: geriatric trauma

Geriatric Week 1: How We Take Care Of Our Elders

Time for some philosophy again. A paper in Neurology released ahead of print confirms something I’m seeing more and more often. Specifically, hospitals can be bad for you, particularly if you are elderly.

The trauma population that we all see is aging with the overall population. Being older predisposes one to injuries that are more likely to require hospitalization. And unfortunately, being in the hospital can have adverse effects. I’m not just talking about the usual culprits such as medical errors or exposure to resistant bacteria.

The Chicago Health and Aging Project has been tracking a group of elders as they age, and has been making a number of interesting observations. Most recently, they have released information on a correlation between cognitive decline and hospitalization. They tracked nearly 1900 people, of whom 1335 ending up in the hospital for one reason or another (not just trauma). They found that there is a baseline rate of global cognitive decline with age (surprise!). Unfortunately, this rate of decline accelerated 2.4 times in the hospitalized group. Episodic memory scores declined 3.3 times faster, and executive function declined 1.7 times faster. And declines tended to be more pronounced in patients who had more severe illness, longer hospital stay, or advanced age.

There are some issues with the study. It is large, but it is a correlation study nonetheless. Are the effects due to something that happens in the hospital, or are they caused by something not evaluated by the study? It’s also not clear to me whether the declines noted are clinically significant in the daily lives of the people studied, or are just a number on some scale.

Bottom line: Some of the “benign” things that we do to patients in the hospital can have a big impact on their functional outcome. Always remember that they are more fragile than the young trauma patients we take care of. That extra fluid bolus, or dose of morphine, exposure to IV contrast, or noisy neighbor that keeps them from sleeping can make a real difference in how they do. Always consider that everything you do to them might kill them. Then seriously reconsider whether you really, really need to order it at all.

Reference: Cognitive decline after hospitalization in a community population of older persons. Neurology, 78(13):950-956, 2012.

Next Week: Trauma In The Elderly

All of next week, I’ll be writing about a topic that is becoming more and more important: geriatric trauma. Our population is aging, and the number of older patients being admitted to trauma centers is exploding.

Here are the topics to be covered:

  • How We Take Care Of Our Elders
  • Thoughts On Geriatric Trauma
  • Elderly Trauma And The Frailty Index
  • The Medical Orthopaedic Trauma Service
  • Falls In The Elderly: The Consequences
  • Effect Of an In-Hospital Falls Prevention Program

And please feel free to leave comments and suggest future topics!

Impact Of A Geriatric Trauma Service

I previously wrote about the impact of adding a hospitalist to the trauma service to improve care of geriatric trauma patients. Method Dallas Medical Center created a specific geriatric trauma service, which they called the G-60 service, in 2009. They published their data after one year of experience in 2012.

All patients 60 years of age and older with injuries <48 hours old were admitted to a specific hospital unit. All admitted patients were seen immediately by the trauma surgeon and a hospitalist. Other involved services included rehab, palliative care, PT and OT, pharmacy, nutrition, respiratory therapy, and social work, as needed. The hospitalist was also tasked with expedited clearance for surgical procedures.

Time-to-care goals included G-60 service activation and ED evaluation within 30 minutes, admission to the G-60 unit within 4 hours, operative procedures (if needed) within 36 hours, and discharge within 5 days if appropriate. Multidisciplinary rounds with the full complement of personnel were held twice weekly.

A total of 393 patients were admitted to the G-60 service over a period of one year. A control group of 280 patients from the year before implementation were used for comparison.

Here are the factoids:

  • Mechanism of injury was blunt 98% of the time, as expected. Most were falls, and the frequency increased from 68% to 75% after implementation of G-60.
  • ICU admission rate remained steady at about 20%
  • Significant time-to-care decreases were seen in all 4 categories. ED length of stay decreased by 2 hours, and time to OR decreased by more than half a day.
  • Hospital length to stay decreased from 7 to 5 days, and ICU LOS decreased from 5 to 3 days. Both were statistically and financially significant.
  • There were significant decreases in the incidence of complications, including UTI, renal failure, CHF, ventilator associated pneumonia, and respiratory failure.
  • There was no change in DVT or PE rates.

Bottom line: Implementation of a multidisciplinary trauma service that addresses the special problems of injured elderly patients improves outcomes, and would appear to save a lot of money. I have observed a very obvious age shift in the trauma population at my own trauma center, and I know quite a few other trauma medical directors who are seeing the same thing. We are all going to need to develop the equivalent of a G-60 service to improve outcomes and reduce the financial challenges of taking care of these patients. However, using age 60 as the threshold will miss a number of elders who might benefit. Frailty measures and common sense will need to be taken into account to make sure all appropriate patients can benefit from this type of service.

Reference: Geriatric trauma service: A one-year experience. J Trauma 72(1):119-122, 2012.

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.

Tomorrow: The G-60 Geriatric Trauma Service 

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

Rib Fractures In The Elderly

Just like children are not small adults, elderly patients are not just old adults. As I mentioned yesterday, mortality increases significantly as we get older such that the same injury is much more likely to kill an elder.

Rib fractures are no exception. A 10 year retrospective cohort study looked at the management and mortality of this problem in patients 65 and older at Harborview in Seattle. When comparing young and old patients with the same number of fractures and injury severity, death and pneumonia were twice as likely in the elderly (22% vs 10% mortality, 31% vs 17% pneumonia). Ventilator days and hospital/ICU length of stay was significantly longer, too. Mortality increased by 19% and pneumonia increased by 27% for each additional rib fracture in the elderly.

Here are some practical tips for management of rib fractures in the elderly:

  • Admit any older patient with even a single rib fracture for pain management and pulmonary toilet
  • Treat their pain well, but watch the narcotics! Consider an epidural if indicated, but monitor carefully.
  • Keep your patient out of bed as much as possible. Chairs are good, walking is better.
  • Encourage coughing and other pulmonary toilet techniques
  • Do not discharge until they pass the “eyeball” test. This means that they have to look well enough to go home and participate in their usual activities. They should be walking around at their usual speed and agility. It does no good to discharge and lay in bed or on the couch. They’ll be back dying of pneumonia before you know it.
  • A general rule of thumb: Length of stay is generally n+1 days, where n is the number of rib fractures (isolated injury). Be wary of trying to send someone home sooner than this.

Related posts:

Reference: Rib fractures in the elderly. J Trauma 48(6):1040-1046, 2000.

Thanks to Scott Weingart, author of the EMCrit Blog (www.emcrit.org) for suggesting this topic!